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The Current State of Diagnosis and Management of Chronic Pancreatitis

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The Current State of Diagnosis and Management of Chronic Pancreatitis DOI: https://doi.org/10.22516/25007440.301 Review articles The current state of diagnosis and management of chronic pancreatitis Lázaro Antonio Arango M., MD1*; Claudia Patricia Díaz T., MD2; Carlos Andrés Caicedo Q., MD3; Camilo Ángel Rodríguez, MD4 1. Physician, General Surgeon, Surgical Clinical Abstract Gastroenterologist, and Coordinator of the Surgical Clinical Gastroenterology Program at the Universidad Chronic pancreatitis (CP) is an inflammatory condition that leads to fibrosis, damage, and even destruction of de Caldas in Manizales, Colombia the pancreatic parenchyma and ducts. These permanent changes can alter pancreatic exocrine and endocri- 2. Physician, General Surgeon, Surgical Clinical ne functioning, cause biliary and pancreatic stenosis, lead to formation of pseudocysts and even increase the Gastroenterologist and Professor of Surgical Clinical Gastroenterology at the Universidad de Caldas in possibility of developing pancreatic cancer. The main clinical characteristic is pain which significantly alters Manizales, Colombia quality of life. To diagnose the CP, we have direct and indirect functional tests and the pancreatic structure test. 3. Physician, General Surgeon and Clinical The great challenge of these methods is early diagnosis, but this is difficult due to the subtlety of changes. Gastroenterologist at the Universidad de Caldas in Manizales, Colombia Once CP is diagnosed, management must be staggered. Medical management is the initial step which can be 4. General Practitioner from the Universidad de los followed by endoscopic management, surgical management, and for the most difficult cases a combination Andes in Bogotá, Colombia of these. The goal is to manage and understand the whole patient and illness to provide the best possible *Correspondence: Lázaro Antonio Arango, quality of life. This review article focuses on CP diagnosis and management in light of the currently available [email protected] evidence. ......................................... Keywords Received: 14/10/18 Chronic pancreatitis, diagnosis, treatment. Accepted: 04/09/19 INTRODUCTION Diagnosis requires evaluation of a patient’s clinical symp- toms, pancreatic function tests and imaging such as magne- Chronic pancreatitis (CP) is an inflammatory process in tic resonance imaging (MRI) and endoscopic ultrasound which the pancreatic parenchyma is altered and replaced (EUS). Diagnostic tests can be classified into functional by fibrous tissue. This permanently changes the pancreatic and structural. The latter evaluates the parenchyma and/ duct and parenchyma leading to endocrine and exocrine or duct anatomy. Functional tests can be direct or indirect. dysfunctions. (1, 2) In most patients, the main clinical cha- The latter has better diagnostic capacity when the disease is racteristic is pain. Other clinical characteristics depend on the in more advanced stages but has lower sensitivity for detec- degree of pancreatic endocrine and exocrine dysfunction. (3) ting early and moderate disease. (2, 4) This review will focus on diagnostic methods and therapeu- tic modalities for this entity. Improving each patient’s quality PANCREATIC FUNCTION TESTS of life depends on understanding the disease as a whole and comprehensive management on a case by case basis. Direct tests DIAGNOSIS Due to their expense, The cholecystokinin test and the secre- tin test are used almost exclusively at research centers due Advanced CP is more easily diagnosed than are mild to the expense of its execution. They consist of the measu- or moderate cases whose diagnosis can be challenging. rement of bicarbonate in the duodenal aspirate after stimu- 373 © 2019 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología lation with secretin or cholecystokinin (CCK). Pancreatic scans for detecting incipient parenchymal and ductal chan- exocrine dysfunction is indicated when bicarbonate levels ges and has better diagnostic sensitivity for early CP. (10) are below 75 mEq/L (5). These tests have high sensitivity The use of secretin increases the diagnostic potential of and specificity but because are invasive and expensive. (6) MRCP since it improves evaluation of ducts and of pan- creatic secretion into the duodenum. Imaging techniques Indirect tests including abdominal ultrasound allow us to evaluate ductal changes, pancreatic enlargement, calcifications, and peri- Indirect tests do not require hormonal stimulation of pan- pancreatic collections. (11) creatic secretion. Their diagnostic value is limited by their Today, endoscopic ultrasound (EUS) is the most sensi- low sensitivity and specificity for detecting alterations, tive diagnostic method,. It can be used to evaluate both the especially in early stages of the disease. (3) These tests pancreatic parenchyma and the ductal system and has the include measurement of serum trypsinogen, fecal fat, and/ ability to detect early and late changes in CP. (12-15) The or fecal elastase and a respiratory test. Traditional measure- purpose of EUS is to evaluate alterations of the parenchyma ments of endocrine function such as the glycated hemoglo- and pancreatic duct and to make early diagnoses. bin, fasting blood glucose, and oral glucose tolerance tests The literature lacks data to support any particular method require further study before they can be considered for of criteria based classification and diagnosis of chronic pan- diagnosis of chronic pancreatitis. (7) creatitis. There are many classifications and criteria which Measurements of serum trypsinogen below 20 ng/mL is evaluate issues including duct dilation, irregularity, and specific for advanced CP. Fecal fat measurement consists of enhancement, visualization of secondary ducts and calculi quantifying fat excreted fat for 72 hours by a patient limited as well hyperechoic foci, bands, lobularity and cysts in the to consumption of 100 g/day for at least 3 days before the parenchyma. The classification systems include the Lees- test. A finding of more than 7 g of fat/day indicates malab- Wiersema, Milwaukee, Japanese and Rosemont systems sorption. Like the serum trypsinogen test, the fecal fat test which classify findings as definitive or consistent, suggestive, has limited sensitivity for mild and moderate cases. Fecal indeterminate or inconclusive (normal) for CP. (13-16) elastase levels over 200 μg/g of fecal matter indicate slight Recently, the important concept of minimal endosonogra- possibility of exocrine pancreatic insufficiency. (8) phic changes which do not meet criteria for diagnosing pan- The carbon 13-labeled mixed triglyceride (MTG) breath creatitis has appeared. An article by Sheel explains the issue test is used for diagnosis of exocrine pancreatic insuffi- very well. It describes the diagnostic value of the Japanese ciency and has a sensitivity of 92% and specificity of 91%. and Rosemont criteria in patients with undetermined, When administered 6 hours after oral administration of suggestive, possible or early chronic pancreatitis and shows 250 mg of labeled MTG together with a meal with 16 g of that criteria that explain a patient’s symptoms are not always fat, a cumulative recovery rate of less than 29% indicates found. (16) A great majority of patients have pain and typical exocrine pancreatic insufficiency. (9) signs but have normal images even though discrete changes can be seen by EUS. It is important to assess the histories of PANCREATIC STRUCTURE TEST these patients for social issues, alcohol intake, cigarette smo- king, and family histories of disease. If possible, genetic stu- Diagnostic imaging is used for structural study of CP, but plain dies and endosonographic follow-up for at least 30 months abdominal radiography has a very low sensitivity because the should be conducted to observe which patients have true pancreatic calcifications characteristic CP can only be seen chronic pancreatitis, which patients heal, and which patients when the disease is already well advanced. In the past, endos- show improvement of EUS changes. Similarly, patients who copic retrograde cholangiopancreatography (ERCP) using have had acute pancreatitis should be followed up to deter- the Cambridge criteria for diagnosis of CP was considered to mine who will develop CP. (16) be the definitive method for evaluating changes in the pan- It is important to determine which EUS criteria help creatic duct. This invasive method, which has had associated diagnosis the most. In 1993, Wiersema et al. described a complications, has recently been displaced. (4) scale of the following nine diagnostic criteria. (17) Abdominal computed tomography (CT) is the first • Hyperechoic foci line in the diagnostic algorithm for patients suspected of • Fibrous tracts having CP. It is available and non-invasive nature but has • Lobularity low diagnostic yield in cases of mild to moderate CP. When • Cysts CT scans are inconclusive, Magnetic resonance cholangio- • Calculi pancreatography (MRCP) is indicated. It is superior to CT • Dilation of secondary branches 374 Rev Colomb Gastroenterol / 34 (4) 2019 Review articles • Irregularity of the pancreatic duct • Dilation of the Wirsung duct or stones within this duct • Hyperechogenic walls of the Wirsung duct . (Figure 2) • Fibrous bands (Figure 3) They gave all of these criteria equal diagnostic values. No opti- • Dilation of the Wirsung duct and enhancement of its mal cut-off point has been found, but it has been said that the walls (Figure 4) presence of four or more confirms the diagnosis.
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