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Critical Review of Diagnostic Methods Used in Chronic Pancreatic Disease

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Critical Review of Diagnostic Methods Used in Chronic Pancreatic Disease REVIEW Critical review of diagnostic methods used in chronic pancreatic disease IVAN TBECK MD PHD FRCPC FACP FACG HIS REVIEW DEALS WITH THE IT BECK. Critical review of diagnostic methods used in chronic pancreatic disease. Can J Gastroenterol 1995;9(1):51-60. This paper provides a balanced assessment of the vari- T diagnostic modalities used to in- ous pancreatic function tests and imaging techniques used in the differential diagnosis of vestigate chronic pancreatic disease chronic pancreatic disease. Function tests that study the digestive capacity of the pancreas and the methods employed to differen- (fat absorption of dietary lipids, fluorescein- or radiolabelled fats, bentiromide test, etc) tiate chronic pancreatitis from carci- have high specificity, but very low sensitivity. This is because 90% of pancreas has to be noma of the pancreas. Other destroyed before steatorrhea or creatorrhea occurs. Tests that directly measure pancreatic conditions that lead to pancreatic in- bicarbonate and protein secretion (secretin test, etc) are more accurate and may detect sufficiency without pancreatitis or can- pancreatic dysfunction even before anatomical changes occur. Measurement of pancre- cer (such as cystic fibrosis, primary atic enzymes in serum or urine, or the decreased decline of serum amino acids during their pancreatic atrophy of childhood, adult incorporation into pancreatic enzymes, are not sufficiently sensitive or specific to help di- pancreatic lipomatosis or isolated agnose pancreatic disease. Sensitive and specific tumour markers are not yet available. lipase-colipase deficiency, etc) will not Thus screening tests are not cost-effective – if they are negative, they do not exclude pan- creatic disease; and if positive, they have to be confirmed by more specific tests. Imaging be discussed although these conditions techniques are the most commonly used methods of investigation. The usefulness of ab- may also lead to abnormal pancreatic dominal survey films, barium studies, percutaneous transhepatic cholangiography, endo- function tests. The subject of the pres- scopic retrograde cholangiopancreatography (ERCP), ultrasonography, computed ent paper was reviewed in more detail tomographic scan, magnetic resonance imaging and endoscopic ultrasonography is criti- by the author two years ago (1). The cally reviewed. Most of the radiological methods can be combined with cytology or biopsy. present paper is a more general over- Histology demonstrating malignancy establishes this diagnosis, but negative biopsies do view and a critical assessment of the not exclude malignant tumours. Presently only ERCP and endoscopic ultrasound can diag- methods used and an update on recent nose cancers sufficiently early to allow for possible ‘curative’ surgery, and only endoscopic developments. ultrasound is capable to stage tumours for the assessment of resectability. The clinical features of chronic pan- Key Words: Computed tomographic scan, Endoscopic retrograde cholangiopancreatography, creatitis and carcinoma are shown in Endoscopic ultrasonography, Imaging techniques, Pancreatic biopsies, Pancreatic function tests, Figures 1 and 2. The common denomi- Secretin test, Tumour markers nator of both diseases is replacement of functioning parenchyma and the duct Analyse critique des méthodes diagnostiques utilisées dans la system with nonfunctioning tissue: in- pancréatite chronique flammatory tissue and fibrosis in RÉSUMÉ : Cet article présente une évaluation équilibrée des diverses épreuves de fonc- chronic pancreatitis, and tumour in tion du pancréas et des techniques d’imagerie utilisées pour le diagnostic différentiel de la cancer of the pancreas. The clinical pancréatite chronique. Les épreuves de fonction qui portent sur la capacité digestive du symptoms, biochemical abnormalities pancréas (absorption des graisses d’origine alimentaire, fluorescéine ou graisses radio- and anatomical distortions in both marquées, épreuve au bentiromide, etc.) s’accompagnent d’un degré élevé de spécificité, conditions are due to ductal obstruc- mais d’une très faible sensibilité. Cela est dû au fait que 90 % du pancréas doit être détruit tion, diminished parenchymal or avant que ne survienne la stéatorrhée ou la créatorrhée. Les épreuves qui visent une me- ductal-cell function and the presence sure directe des bicarbonates du pancréas et la sécrétion protéique (test de la sécrétine, of mass lesions. Except in the case of voir page suivante functioning islet cell tumours (which Queen’s University, Kingston, Ontario are not the subject of this review), dif- Correspondence and reprints: Dr IT Beck, Division of Gastroenterology, Department of ferentiation between the two condi- Medicine, Hotel Dieu Hospital, Queen’s University, Kingston, Ontario K7L 5G2 tions may be very difficult (1-3). As Received for publication April 5, 1994. Accepted June 13, 1994 shown in Figures 3 and 4, cystic and CAN JGASTROENTEROL VOL 9NO 1JANUARY/FEBRUARY 1995 51 BECK LABORATORY TESTS etc.) sont plus précises et peuvent déceler une dysfonction pancréatique avant même que ne surviennent des changements anatomiques. La mesure des enzymes pancréatiques séri- (TABLE 1) ques ou urinaires ou l’atténuation de la baisse des amino-acides sériques durant leur incor- Pancreatic function tests poration aux enzymes pancréatiques ne sont pas suffisamment sensibles ni précises pour contribuer au diagnostic de la pancréatite. Les marqueurs tumoraux sensibles et spéci- Tests that assess digestive capacity of fiques se font encore attendre. Donc, les épreuves de dépistage ne sont pas économiques; si the pancreas (Table 2): Tests based on elles sont négatives, elles permettent d’exclure une maladie pancréatique; si elles sont measuring the digestive capacity of the positives, elles doivent encore être confirmées à l’aide d’autres tests plus spécifiques. Les pancreas are less sensitive than those techniques d’imagerie sont les méthodes d’investigation les plus fréquemment utilisées. that directly measure pancreatic secre- L’utilité des plaques simples de l’abdomen, des épreuves barytées, de la cholangiographie tion. This is because the normal pan- transhépatique percutanée, de la cholangiopancréatographie endoscopique rétrograde creas has considerable reserve capacity, (CPER), l’échographie, la scintigraphie, l’imagerie par résonnance magnétique et l’écho- and steatorrhea and creatorrhea be- graphie endoscopique sont passées en revue. La plupart des méthodes radiologiques peu- vent être combinées à la cytologie ou à la biopsie. L’histologie permet d’établir un come biochemically detectable only diagnostic de néoplasie le cas échéant, mais les biopsies négatives ne permettent pas d’ex- when lipase and trypsin secretion has clure les tumeurs malignes. À l’heure actuelle, seule la CPER et l’échographie endoscopique been reduced to less than 10% of nor- peuvent diagnostiquer les cancers suffisamment tôt pour permettre une chirurgie curative mal (5), and steatorrhea may not be de- possible et seule l’échographie endoscopique peut déterminer si la chirurgie est faisable. tectable until 75% of the pancreas has been resected. Thus, fecal fat studies are insensitive in mild chronic pancreatic disease. Fecal fat balance study: Steatorrhea occurs due to maldigestion (pancreatic disease) and to malabsorption (as a re- sult of many other conditions, includ- ing intestinal disease). Differentiation between the two can be achieved by the method described below. Fecal fat balance study before and during pancreatic replacement ther- apy: Steatorrhea due to pancreatic disease is diagnosed if fat absorption im- proves with oral ingestion of pancreatic enzymes. Gastric acid may lower duo- denal pH below the level that is opti- mal for lipase activity, and the simultaneous administration of enzymes and a H2 receptor antagonist Figure 1) Clinical and biochemical features caused by the anatomical changes of chronic pancreati- may further improve fat absorption tis. Reproduced with permission from reference 1 (6). Colipase, a factor needed for appro- solid tumours can occur in chronic demonstrate abnormal pancreatic priate lipase activity, plays an impor- pancreatitis as well as in benign and function (pancreatic function tests) tant role in fat digestion, and steator- malignant neoplasms (4). Further- and immunoassays for tumour markers rhea may occur in congenital isolated more, calcification can occur in to differentiate between benign and lipase-colipase deficiency (7). chronic pancreatitis and in several of malignant disease. The second cate- Screening tests for pancreatic maldi- the benign or malignant tumours. In gory consists of imaging and biopsy gestion: These tests, which study fat, addition, chronic pancreatitis is a risk techniques used to establish the ana- starch or peptide digestion, have been factor for pancreatic cancer (2,3). tomical basis for abnormal function. developed to simplify the cumbersome Once the suspicion of pancreatic Recent imaging techniques have re- fecal fat balance study. Most of them disease has been raised on clinical placed, to a great extent, the pancreatic are less sensitive and specific than the grounds, investigation is warranted to function tests, but evaluation and un- 72 h fecal fat excretion. determine whether chronic pancreatic derstanding of the usefulness of indi- Macroscopic and microscopic examination disease is present, and if so, whether vidual tests is important in the of stool: Considering the low sensitiv- this is chronic pancreatitis or carci- investigation
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