Association between quality-of-life metrics in patients with chronic pancreatitis

Classification of Pancreatitis: Problems and Prospects.- A. Acute Pancreatitis.- Morphology of Acute Pancreatitis in Relation to Etiology and Pathogenesis.- Clinical Presentation and Course of Acute Pancreatitis.- I. Imaging Procedures.- Ultrasound in the Diagnosis and Grading of Acute Pancreatitis.- Computed Tomography in Acute Pancreatitis: Diagnosis, Staging, and Detection of Complications.- Diagnosis of Infected Pancreatic Necrosis.- Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis: Indications and Limitations.- II. Functional Methods.- Appropriate Use of Serum Pancreatic Enzymes for the Diagnosis of Acute Pancreatitis.- Identification of the Etiological Factor in Acute Pancreatitis.- Exocrine Pancreatic Function During and Following Acute Pancreatitis.- Endocrine Pancreatic Function During and Following Acute Pancreatitis.- III. Prognostic Evaluation.- Pathophysiological Determinants of Severity of Acute Pancreatitis.- Clinical Value of Multifactorial Classification in the Prognostic Evaluation of Acute Pancreatitis.- Biochemical Markers in the Early Prognostic Evaluation of Acute Pancreatitis.- Prognostic Evaluation of Acute Pancreatitis: When- and How-Consequences for Clinical Management.- Diagnostic and Prognostic Evaluation of Graft Pancreatitis.- IV. Guidelines.- Acute Pancreatitis: Diagnostic Guidelines for General Practitioners, Clinicians in Community Hospitals and in Specialized Centers.- B. Chronic Pancreatitis.- I. Chronic Pancreatitis: Clinical Features.- Pathomorphological Feature of Chronic Pancreatitis.- Pathophysiological Events in Chronic Pancreatitis: The Current Concept.- Clinical Presentation and Course of Chronic Pancreatitis.- Painless Versus Painful Chronic Pancreatitis.- II. Imaging Procedures.- Role of Ultrasonography in the Diagnosis, Staging and Detection of Complications of Chronic Pancreatitis.- Diagnosis and Staging of Chronic Pancreatitis by Computed Tomography.- Diagnosis and Staging of Chronic Pancreatitis by Endoscopic Retrograde Cholangiopancreatography.- Radiologic Imaging of Chronic Pancreatitis.- Role of Pancreatic Duct Drainage for Evaluation of Pancreatic Pain.- What Does the Surgeon Need in the Preoperative Evaluation of Chronic Pancreatitis?.- III. Function Tests.- Neuroendocrine Abnormalities of Upper Gut Function in Chronic Pancreatitis: Lessons for Physiology and Pathophysiology.- Direct Pancreatic Function Tests in the Diagnosis and Staging of Chronic Pancreatitis.- Oral Pancreatic Function Tests in the Diagnosis and Staging of Chronic Pancreatitis.- Present and Future of Breath Tests in the Diagnosis of Pancreatic Insufficiency.- Value of Serum Pancreatic Enzymes in the Diagnosis of Chronic Pancreatitis.- New Fecal Tests in the Diagnosis of Exocrine Pancreatic Insufficiency.- Extracellular Matrix in Pancreatic Diseases.- Endocrine Pancreatic Function in the Diagnosis and Staging of Chronic Pancreatitis.- IV. Chronic Pancreatitis: Guidelines.- Diagnostic Standards for Chronic Pancreatitis.- Standards in Surgical Treatment of Chronic Pancreatitis.- C. Pancreatic Cancer.- Langerhans Islets Are the Origin of Ductal-Type Adenocarcinoma.- I. Imaging Procedures.- Ultrasound and Endoscopic Ultrasound in the Diagnosis of Pancreatic Tumors.- Computed Tomography and Magnetic Resonance Imaging in Pancreatic Cancer.- Endoscopic Retrograde Cholangiopancreatography in the Diagnosis of Pancreatic Tumors.- Role of Laparoscopy and Laparoscopic Ultrasound in Pancreatic Cancer.- Intraportal Ultrasonography for Evaluation of Resectability in Pancreatic Cancer.- II. Other Diagnostic Procedures.- Serological Diagnosis of Pancreatic Cancer.- Role of Cytology in the Diagnosis of Pancreatic Tumors.- Scintigraphic Procedures in the Detection of Pancreatic Tumors: Role of Fluorodeoxyglucose Positron Emission Tomography.- III. Molecular Biology.- Clinical Applicability of Molecular Procedures in the Diagnosis of Pancreatic Cancer.- IV. Guidelines.- Pancreatic Cancer: Diagnostic Guidelines for General Practitioners and Clinicians in Community Hospitals and Specialized Centers.

Classification of Pancreatitis: Problems and Prospects.- A. Acute Pancreatitis.- Morphology of Acute Pancreatitis in Relation to Etiology and Pathogenesis.- Clinical Presentation and Course of Acute Pancreatitis.- I. Imaging Procedures.- Ultrasound in the Diagnosis and Grading of Acute Pancreatitis.- Computed Tomography in Acute Pancreatitis: Diagnosis, Staging, and Detection of Complications.- Diagnosis of Infected Pancreatic Necrosis.- Endoscopic Retrograde Cholangiopancreatography in Acute Pancreatitis: Indications and Limitations.- II. Functional Methods.- Appropriate Use of Serum Pancreatic Enzymes for the Diagnosis of Acute Pancreatitis.- Identification of the Etiological Factor in Acute Pancreatitis.- Exocrine Pancreatic Function During and Following Acute Pancreatitis.- Endocrine Pancreatic Function During and Following Acute Pancreatitis.- III. Prognostic Evaluation.- Pathophysiological Determinants of Severity of Acute Pancreatitis.- Clinical Value of Multifactorial Classification in the Prognostic Evaluation of Acute Pancreatitis.- Biochemical Markers in the Early Prognostic Evaluation of Acute Pancreatitis.- Prognostic Evaluation of Acute Pancreatitis: When- and How-Consequences for Clinical Management.- Diagnostic and Prognostic Evaluation of Graft Pancreatitis.- IV. Guidelines.- Acute Pancreatitis: Diagnostic Guidelines for General Practitioners, Clinicians in Community Hospitals and in Specialized Centers.- B. Chronic Pancreatitis.- I. Chronic Pancreatitis: Clinical Features.- Pathomorphological Feature of Chronic Pancreatitis.- Pathophysiological Events in Chronic Pancreatitis: The Current Concept.- Clinical Presentation and Course of Chronic Pancreatitis.- Painless Versus Painful Chronic Pancreatitis.- II. Imaging Procedures.- Role of Ultrasonography in the Diagnosis, Staging and Detection of Complications of Chronic Pancreatitis.- Diagnosis and Staging of Chronic Pancreatitis by Computed Tomography.- Diagnosis and Staging of Chronic Pancreatitis by Endoscopic Retrograde Cholangiopancreatography.- Radiologic Imaging of Chronic Pancreatitis.- Role of Pancreatic Duct Drainage for Evaluation of Pancreatic Pain.- What Does the Surgeon Need in the Preoperative Evaluation of Chronic Pancreatitis?.- III. Function Tests.- Neuroendocrine Abnormalities of Upper Gut Function in Chronic Pancreatitis: Lessons for Physiology and Pathophysiology.- Direct Pancreatic Function Tests in the Diagnosis and Staging of Chronic Pancreatitis.- Oral Pancreatic Function Tests in the Diagnosis and Staging of Chronic Pancreatitis.- Present and Future of Breath Tests in the Diagnosis of Pancreatic Insufficiency.- Value of Serum Pancreatic Enzymes in the Diagnosis of Chronic Pancreatitis.- New Fecal Tests in the Diagnosis of Exocrine Pancreatic Insufficiency.- Extracellular Matrix in Pancreatic Diseases.- Endocrine Pancreatic Function in the Diagnosis and Staging of Chronic Pancreatitis.- IV. Chronic Pancreatitis: Guidelines.- Diagnostic Standards for Chronic Pancreatitis.- Standards in Surgical Treatment of Chronic Pancreatitis.- C. Pancreatic Cancer.- Langerhans Islets Are the Origin of Ductal-Type Adenocarcinoma.- I. Imaging Procedures.- Ultrasound and Endoscopic Ultrasound in the Diagnosis of Pancreatic Tumors.- Computed Tomography and Magnetic Resonance Imaging in Pancreatic Cancer.- Endoscopic Retrograde Cholangiopancreatography in the Diagnosis of Pancreatic Tumors.- Role of Laparoscopy and Laparoscopic Ultrasound in Pancreatic Cancer.- Intraportal Ultrasonography for Evaluation of Resectability in Pancreatic Cancer.- II. Other Diagnostic Procedures.- Serological Diagnosis of Pancreatic Cancer.- Role of Cytology in the Diagnosis of Pancreatic Tumors.- Scintigraphic Procedures in the Detection of Pancreatic Tumors: Role of Fluorodeoxyglucose Positron Emission Tomography.- III. Molecular Biology.- Clinical Applicability of Molecular Procedures in the Diagnosis of Pancreatic Cancer.- IV. Guidelines.- Pancreatic Cancer: Diagnostic Guidelines for General Practitioners and Clinicians in Community Hospitals and Specialized Centers.

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Editorial for "Multiparametric MRI Scoring System of the Pancreas for the Diagnosis of Chronic Pancreatitis"C hronic pancreatitis (CP) is a recurrent, multifactorial, fibroinflammatory disease that results in pancreatic fibrosis and insufficiency, recurrent pain, and shorter life expectancy.While robust data on prevalence are rare, population data from the United States, Spain, China, and Japan suggest that many hundreds of thousands if not more suffer from the disease, with increasing incidence worldwide. 1arly detection of CP is critical for management as later-stage disease is characterized by irreversible parenchymal fibrosis and loss of tissue.However, the diagnosis of earlystage CP is challenging due to nonspecific clinical symptoms and the inherent limitations of existing diagnostic tools.Calcifications on computed tomography (CT) and pancreatic ductal changes on magnetic resonance imaging (MRI) are established imaging biomarkers of CP but largely manifest late in the disease, 2 missing many of the early changes in the pancreatic parenchyma.Endoscopic ultrasound (EUS) may be effective in detecting some early changes of CP but is invasive with poorly defined diagnostic criteria. 3Scoring systems for both magnetic resonance cholangiopancreatography (MRCP; Cambridge classification) and EUS (Rosemont classification) have been established but may overlap with normal age-related changes to the pancreas, 3 leaving questions about their utility in early diagnosis. 2Thus, there is a clear need for novel noninvasive imaging-based diagnostic tools to detect early parenchymal changes of CP.In this issue of JMRI, Tirkes et al investigated a series of MRI-based imaging biomarkers in the detection of early CP changes, including two proposed models for CP scoring. 4hese data expand upon prior analysis of imaging from the MINIMAP cohort which have shown that semiquantitative models 5 and quantitative metrics 6 can differentiate between healthy controls and those with a diagnosis of CP.There is no widely accepted definition of early CP, 3 which makes evaluation of imaging biomarkers difficult.In the present study, the authors used a combination of clinical symptoms and established imaging biomarkers (Cambridge grade on CT or MRI) to establish cohorts of "suspected" CP and "definite" CP, in addition to the healthy controls.Univariate analysis showed that three simple pancreatic parenchyma metrics

Introduction: Background: Chronic pancreatitis is a debilitating, progressive, and irreversible disorder characterized by a cycle of inflammation and fibrosis. The etiology of chronic pancreatitis is broad and ranges from genetic to anatomic factors. Chronic pancreatitis is also a painful disorder with numerous patients using narcotics for relief. We aimed to study the clinical outcomes of patients with chronic pancreatitis with a concomitant diagnosis of cannabis use in comparison to patients with chronic pancreatitis who do not use cannabis. Methods: The NIS database was queried for the years 2015-2019. Adult patients ( >age 18) with a diagnosis of cannabis use and chronic pancreatitis versus those with chronic pancreatitis only as a principal discharge diagnosis were identified using ICD-10 codes. The primary outcome was inpatient mortality. Secondary outcomes were hospital length of stay (LOS) and total hospital charges (TOTHC). Statistical analysis was performed using STATA. Results: We identified 153,407 patients who had chronic pancreatitis, of which 8,985 patients had a concomitant diagnosis of cannabis use. After propensity score matching, patients with a diagnosis of chronic pancreatitis and cannabis use had decreased mortality (OR 0.34, p< 0.0001, CI:0.27-0.45), decreased LOS ( -0.98 days, p< 0.0001, CI: 1.12 to -0.83) and decreased (TOTHC -$13,845, p< 0.0001, CI: -$15,954 to -11,736) compared to patients with only a diagnosis of chronic pancreatitis. Conclusion: Patients with chronic pancreatitis who use cannabis interestingly had lower mortality, LOS, and TOTHC compared to patients with chronic pancreatitis who do not use cannabis. This is an important study that demonstrates that cannabis use is not detrimental and can be effective in controlling symptoms and improving outcomes in certain patient populations. Further randomized controlled trials are necessary to further illustrate our results.

Background: The diagnosis of chronic pancreatitis (CP) in the early stages is often problematic. Endoscopic retrograde pancreatography (ERP), secretin test and computed tomography are not sensitive enough to detect the early stages of CP. The aim of this study was to investigate the features of CP in endoscopic ultrasonography (EUS) in patients with unexplained abdominal pain and/or suspected CP. Methods: Thirty‐four consecutive patients in whom CP was suspected after reviewing their history, abdominal ultrasonography and upper gastrointestinal endoscopy findings underwent EUS. Endoscopic ultrasonography was performed by an author who was aware of the history but blinded to the ERP results. Nineteen patients underwent ERP. Endoscopic ultrasonography was used to evaluate parenchymal changes (echogenic foci, echo pattern, prominent interlobular septa, lobularity, cyst and cavities) and ductal changes (dilatation, echogenicity of duct wall, irregularity, side branch ectasia, tortuousity). Results: Nine patients were found to be normal with regard to EUS examination. Abnormal studies for EUS were 25, while for ERP they were 17. The agreement between ERP and EUS was 100% in the 14 patients with moderate and severe disease. The diagnosis of early or mild CP was established with EUS in 11 patients. Endoscopic retrograde pancreatography, which was performed in five of the patient groups with mild disease, was normal in two patients and showed mild changes in three patients. Conclusions: Endoscopic ultrasonography may contribute to establishing the diagnosis and severity of CP found by ERP. Prospective randomized studies and long‐term follow up of patients are needed in order to determine the role of EUS in the diagnosis of early CP.

Chronic pancreatitis (CP) arise from diverse etiologies and can result in significant morbidities, such as pain, exocrine and endocrine insufficiency, and even mortality, with occurrence of unresectable pancreatic cancer. These features may be part of the clinical presentation at diagnosis or develop later. Although considerable progress has been made in terms of understanding the etiopathogenesis, clinical course, and treatment outcomes, significant gaps remain in our knowledge. Even in the area of diagnostic criteria and disease classification, though core elements, especially in advanced disease, are common, differences exist.1 In 2016, a multi-society group published a proposal for a new mechanistic definition of CP and conceptual model of disease initiation and progression to serve as the foundation for future research on reaching a consensus to a mechanistic definition, diagnostic criteria, and disease classification in terms of subtypes, severity, and prognosis.2 In this issue of JGH, two important issues with significant impact on the quality of life of CP patients are explored. Olesen et al. examined the factors associated with the presence and type of pain in CP.3 Liu et al. analyzed risk factors associated with the development of diabetes mellitus (DM) in idiopathic CP (ICP) and created a predictive nomogram.4 These results are important to help us better understand the disease process and clinical course of CP. Olesen et al. performed a cross-sectional, multicenter study based on data derived from the Scandinavian Baltic Pancreatic Club database, with CP defined according to the M-ANNHEIM classification system, to determine the prevalence of pain, risk factors for pain, and associations between pain risk factors and type of pain (intermittent vs constant pain).3 A total of 1384 patients with CP were enrolled. The prevalence of pain was 57.9%. Multivariate analysis confirmed the independence and significance of the associations for pain and age at diagnosis, current status of smoking, alcohol consumption, exocrine pancreatic insufficiency, pancreatic duct changes, pseudocyst, and duodenal stenosis. Constant pain was more frequently reported in moderate and heavy smokers, whereas alcohol was associated with intermittent pain. The strength of the study is the well-defined large patient population. These findings underline the complexity of pain and specifically emphasize the importance of smoking and alcohol cessation. Given the study design, there are intrinsic limitations such as inability to attribute causality, possibility of recall bias, and inability to provide more detailed information such as pain intensity and whether the findings can be extrapolated to non-Caucasian populations. Liu et al. utilized data from a single center CP database in Shanghai, China, that was set up retrospectively but maintained prospectively to determine the incidence of DM. The authors also attempted to identify risk factors for DM and develop a nomogram for prediction of DM in patients with ICP.4 Although the M-ANNHEIM classification system was not used, unlike in the study by Olesen et al., specific morphologic features and complications were systematically captured. A total of 1633 patients were enrolled. The median follow-up duration was 9.8 years. DM was found in 26.3% of patients after the onset of CP. Adult status at onset of ICP, biliary stricture at/before diagnosis of CP, steatorrhea at/before diagnosis of CP, and complex pathologic changes in the main pancreatic duct were identified as risk factors for DM development in these patients. The nomogram demonstrated good accuracy in estimating the risk of DM, with a C index of 0.674. The obvious strengths of this study are the novelty in terms of creation of a nomogram, the large sample size, and amount of data available prospectively. Nonetheless, not all factors related to the development of DM were included in the analysis, and it was difficult to distinguish between pancreatogenic DM and type 2 DM. Currently, a definite diagnosis of CP is usually achieved at a late disease stage, and the focus of management is then directed towards the detection of and management of complications, such as pain relief, replacement therapies for exocrine and endocrine pancreatic deficiencies, and surgical resection in context of cancer and unremitting pain. These two papers provide important data to further our knowledge in the clinical course of established CP. They address the clinically important issues of lifestyle adjustment in pain management and the need for screening of DM. There is a need to be able to diagnose CP at an early stage and initiate treatment to limit disease progression and minimize complications. An international working group supported by four major pancreas societies sought to develop a consensus definition and diagnostic criteria for early CP. However, no consensus could be reached for a definition or diagnostic criteria of early CP. However consensus was achieved in other areas, such as the use of the term “early” to describe a disease state with preserved pancreatic function and potentially reversible features rather than disease duration, the importance of genetic variants as important risk factors for early CP, the role of environmental risk factors to provide evidence to support the diagnosis of early CP, and the need to differentiate CP from other disorders with overlapping morphological and functional features. The conclusion was that new approaches to the accurate diagnosis of early CP would require development and validation of a mechanistic definition that considers risk factors, biomarkers, clinical context, and new models of disease.5 There is also a need to better stratify patients for prognostication and to guide surveillance for CP related complications. The study by Liu et al. addressed DM development. The M-ANNHEIM classification system provides a comprehensive etiologic, morphologic, and functional description.1 However, it is not consistently applied in clinical practice. A recent study correlated clinical, laboratory, and imaging data with the number of hospital readmissions and in-hospital days to develop a three-stage chronic pancreatitis prognosis score (COPPS), which was based on a composite of pain (numeric rating scale), level of glycosylated hemoglobin A1c, level of C-reactive protein, body mass index, and platelet count. COPPS helped to determine the risk for readmission to hospital and potential length of hospital stay.6 CP increases the risk of pancreatic cancer. However, in the absence of hereditary predisposition, it remains unclear which subgroup of CP patients would benefit from surveillance.7, 8 Well-designed multicenter prospective longitudinal cohort studies with a large sample size of well-characterized CP patients are needed to better understand the true natural history of CP and develop predictive nomograms, and one such study is currently underway.9 Despite ongoing multi-society efforts to systematically address diagnostic and therapeutic challenges in CP,3, 7, 9, 10 important gaps in knowledge remain. The search for the Holy Grail continues.

This study evaluated the new criteria for the diagnosis of chronic pancreatitis (CP) with endoscopic retrograde pancreatography (ERP) proposed by the Japan Pancreas Society in 1995 by comparing it with the older criteria of the Japanese Society of Gastroenterology proposed in 1983. No significant differences were noted between the two when the diagnostic sensitivity of ERP was considered in calcifying CP. Among 54 patients of noncalcifying CP (group I) with ERP diagnosis of moderate or advanced pancreatitis by the previous criteria, only one of 22 with the localized type was definite CP. The remaining 21 were ruled out as either definite or probable CP, and six were classified as having chronic obstructive pancreatitis based on the new criteria. In contrast, a diagnosis of definite CP was made not only for all the 32 patients with CP (group I) of diffuse type but also in 11 cases of CP (group II) with diffuse minimal pancreatitis showing irregular dilatation of the side branches with scattered distribution throughout the gland. In a series of 15 follow-up patients with CP (group II) having initial ERP diagnosis of minimal pancreatitis, CP group I developed in three of five cases of diffuse minimal pancreatitis, which is consistent with definite CP by the new criteria, whereas progression to this group of CP was found in none of the 10 patients with localized minimal pancreatitis. These results indicate that although localized CP is excluded from CP, the incidence of diffuse noncalcifying CP diagnosed by ERCP was increased with the new criteria, and detecting radiologic features with diffuse irregular dilatation of the branch ducts based on these criteria may lead to early diagnosis of CP.

The aim of the study was to understand the association of frequent opioid use with disease phenotype and pain pattern and burden in children and adolescents with acute recurrent (ARP) or chronic pancreatitis (CP). Cross-sectional study of children <19 years with ARP or CP, at enrollment into the INSPPIRE cohort. We categorized patients as opioid "frequent use" (daily/weekly) or "nonfrequent use" (monthly or less, or no opioids), based on patient and parent self-report. Of 427 children with ARP or CP, 17% reported frequent opioid use. More children with CP (65%) reported frequent opioid use than with ARP (41%, P = 0.0002). In multivariate analysis, frequent opioid use was associated with older age at diagnosis (odds ratio [OR] 1.67 per 5 years, 95% confidence interval [CI] 1.13-2.47, P = 0.01), exocrine insufficiency (OR 2.44, 95% CI 1.13-5.24, P = 0.02), constant/severe pain (OR 4.14, 95% CI 2.06-8.34, P < 0.0001), and higher average pain impact score across all 6 functional domains (OR 1.62 per 1-point increase, 95% CI 1.28-2.06, P < 0.0001). Children with frequent opioid use also reported more missed school days, hospitalizations, and emergency room visits in the past year than children with no frequent use (P < 0.0002 for each). Participants in the US West and Midwest accounted for 83% of frequent opioid users but only 56% of the total cohort. In children with CP or ARP, frequent opioid use is associated with constant pain, more healthcare use, and higher levels of pain interference with functioning. Longitudinal and prospective research is needed to identify risk factors for frequent opioid use and to evaluate nonopioid interventions for reducing pain and disability in these children.

Background. Currently, the use of the principles of evidence-based medicine is an integral part of assessing the effectiveness and safety of modern technology for the diagnosis and treatment of any disease or clinical condition. Differential diagnosis of pancreatic cancer and chronic pancreatitis is one of the most controversial issues in surgical pancreatology. The reduced number of cases of resectable pancreatic cancer indicates the need to develop programs for the differentiation of these pathologies with the wide implementation of modern diagnostic methods. Purpose − to compare the results of diagnostic methods (which are standardly used in accordance with clinical guidelines for the diagnosis of chronic pancreatitis) based on evidence-based medicine and quantitative assessments of their specificity, sensitivity, and general accuracy in terms of the differential diagnosis of chronic pancreatitis and pancreatic cancer in order to determine the most significant results for the differentiation of these pathologies. Materials and methods. The results of diagnostic methods were compared in 80 patients, among them 38 (47.5%) had pancreatic cancer, and 42 (52.5%) − chronic pancreatitis with predominant lesion of the pancreatic head. The patients underwent general clinical blood and urine tests, biochemical blood tests, and the following procedures and examinations available in the clinic: ultrasound examination of the abdominal organs, spiral computed tomography, fibrogastroduodenoscopy, endoscopic retrograde cholangiopancreatography, magnetic resonance imaging, CA 19-9 tumor marker test, ultrasound-guided percutaneous puncture of the pancreas, aspiration of pancreatic juice, urgent intraoperative biopsy, and histological examination of surgically resected areas of the pancreas. Based on the received data, we performed a comparison of their quality, accuracy, and informativeness. Results. Ultrasound imaging is a screening method for suspected pancreatic cancer, however, the overall accuracy, sensitivity, and specificity of the method are quite low (82.5%, 76.32%, 88.10%, respectively). When analyzing the qualitative characteristics of endoscopic retrograde cholangiopancreatography, the overall accuracy, sensitivity, and specificity indicators for the differential diagnosis of pancreatic cancer were 71%, 78.6%, and 63.3%, respectively. The interval assessment of the accuracy of the method of transcutaneous biopsy of the pancreas aimed at determining chronic pancreatitis was (34.9; 96.8)%; for pancreatic cancer – (8.5; 75.5)%. The interval assessment of the accuracy of the method of endoscopic aspiration of pancreatic juice for chronic pancreatitis was (6.8; 93.2)%; for pancreatic cancer – (19.4; 99.4)%. An increase in the level of CA 19-9 was found in 40.5% of patients (CI95% from 27.0% to 55.5%), while the average level was significantly higher in pancreatic cancer. The level of the CA 19-9 tumor marker depended on the size of the tumor and the spread of the process, and during the dynamic observation in the settings of treatment, it had a tendency to decrease, which indicated chronic pancreatitis. The significance of intraoperative morphological verification of the diagnosis of pancreatic cancer in histological examination was 98%, in cytological examination – 95.3%, in 4.7% urgent intraoperative biopsy was questionable. In all examinations, the surrounding tumor tissue showed a morphological pattern of chronic pancreatitis, in 36 (88%) cases – with foci of metaplasia and intraductal neoplasia of the epithelium, which can be considered as a background for the development of intraductal adenocarcinoma. At the same time, cancerous occlusion of the ducts led to their expansion above the point of narrowing with pronounced fibrous changes and inflammatory reaction of the stroma that was accompanied by widespread atrophy of the parenchyma. Conclusions. On the basis of evidence-based medicine, it was established that spiral computed tomography is the most informative method for the differential diagnosis of pancreatic cancer with chronic pancreatitis, with an overall accuracy of 92.2%, sensitivity of 89.2%, and specificity of 95%. The low qualitative indicators of ultrasound diagnostics can be increased due to its complex combination with the CA 19-9 tumor marker test with an overall accuracy of 92.3%, with sensitivity and specificity of 95% and 91%, respectively, which is significantly different from such indicators when the method was used separately (82.5%, 76.3%, and 88.1%, respectively). In the cases when the complex combination of endoscopic retrograde cholangiopancreatography with the measurement of the level of the CA 19-9 tumor marker was used, the overall accuracy of the method was 95.2%, with sensitivity of 95% and specificity of 95.5%, which is significantly different from such indicators obtained when the method was used separately (71%, 78.6% and 63.3%, respectively). Advances in modern imaging methods cannot replace histological examination as the «gold standard» for the correct determination of the morphological substrate of these pancreatic lesions.

Management of Chronic Pancreatitis

Objective. Diagnosis of chronic pancreatitis is usually based on symptoms, ductal or parenchymal changes in imaging studies and function tests, but seldom on histology. Because the diagnosis of mild chronic pancreatitis is especially difficult, better tools to distinguish between chronic pancreatitis and normal pancreas are needed. Nowadays, cutting needles as thin as the widely used puncture needles are available. Using resected specimens, our aim was to evaluate whether these ultra-thin needles can take samples for histology that would allow verification of the diagnosis of chronic pancreatitis, with reference to a pancreatic wedge biopsy as the “gold standard”. Material and Methods. Fifty patients underwent pancreatic resection for various reasons. Two 20 G needle biopsies (outer diameter 0.8 mm, study biopsies) and a 5×5-mm wedge biopsy (reference biopsies) were taken from the same site of the specimen, avoiding possible neoplastic areas in the specimen. The samples were analyzed for the presence inflammation and fibrosis, both graded 0–3, as well as for any neoplastic changes without knowledge of the medical history, operative findings or final histology. Results. The reference biopsy showed normal tissue in 19 (38%) patients, chronic pancreatitis in 29 (58%) and only mild fibrosis (Grade 1) in 2 (4%) patients. In one patient the needle biopsy was insufficient for analysis. There was agreement between ultra-thin needle histology and the control specimen in 45/49 (92%) patients (correlation coefficient 0.9). Two biopsies of chronic pancreatitis and one mild fibrosis were misclassified as normal tissue, while one chronic pancreatitis biopsy was misclassified as an adenocarcinoma. The sensitivity of needle biopsy for chronic pancreatitis was 89%, specificity 100% and accuracy 94%. Conclusions. Ultra-thin needle histology correlates well with the pancreatic wedge biopsy. Thus, these encouraging results warrant further clinical studies of different grades and types of chronic pancreatitis.

The aim of this study was to define an optimum serum enzyme ratio for the diagnosis of chronic pancreatitis (CP) and for the evaluation of the stage of the disease. With this goal in mind, a simultaneous and interrelated analysis of different serum pancreatic enzymes was performed in 296 consecutive patients with clinically suspected CP. A total of 167 patients were finally diagnosed with CP and 129 with other digestive diseases (used as controls). Serum values of pancreatic amylase, lipase, immunoreactive trypsin, and their ratios were determined in every patient before final diagnosis was established. Stepwise logistic regression analysis was performed. As expected, abnormally low values of individual serum pancreatic enzymes in the diagnosis of CP were highly specific (92-98%) but very insensitive (20-32%). Their diagnostic usefulness was neither improved by calculation of their ratios nor by the use of multivariate logistic regression analysis. A low pancreatic amylase/lipase ratio correlated with advanced CP (p < 0.01), and had a high degree of accuracy (80.5%) in the evaluation of the stage of the disease (assessed by endoscopic retrograde pancreatography). In conclusion, while serum pancreatic enzymes have limited usefulness in the diagnosis of CP, the pancreatic amylase/lipase ratio could be a simple method for staging the disease.

EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis

Pancreatic cancer is characterized initially by non-specific abdominal symptoms followed by rapid tumor progression. Although chronic pancreatitis is a benign disorder, it can be one of the causative factors of pancreatic cancer. The level of the tumor marker carbohydrate antigen 19-9 (CA 19-9) in pancreatic cancer does not correlate with the stage of the neoplasm. Soluble interleukin 2 receptor (sIL-2R) is a cytokine that shows increased levels during some inflammatory processes and malignant disorders. Our aim in this study was to investigate whether sIL-2Ralpha levels can be used in association with CA 19-9 in the early diagnosis of pancreatic cancer and chronic pancreatitis. Serum samples were obtained from the blood of 21 pancreatic cancer patients without distant metastasis who were deemed inoperable, 16 chronic pancreatitis patients and 20 normal volunteers. We did not find any significant differences in CA 19-9 levels between normal controls and patients with chronic pancreatitis. There was a significant difference in the levels between the control group and the pancreatic cancer group (p = 0.003) and between patients with chronic pancreatitis and those with pancreatic cancer (p = 0.004). Although there was no significant difference in sIL-2Ralpha levels between the control group and the patient groups, we found a slight correlation between sIL-2Ralpha and CA 19-9 levels in the pancreatic cancer group (p = 0.003, r = 0.623) and a more marked correlation in the chronic pancreatitis group (p < 0.01, r = 0.751). According to our results, sIL-2Ralpha alone is not a good candidate marker in the diagnosis of pancreatic cancer; it can, however, be used in association with CA 19-9 for this purpose.