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Endoscopic ultrasonography to evaluate pancreatitis

Cleveland Clinic Journal of Medicine. 2012 March;79(3):202-206 | 10.3949/ccjm.79a.11092
March 1, 2012|Cleveland Clinic Journal of Medicine
Siwar Albashir, MD;Tyler Stevens, MD
Author and Disclosure Information

Siwar Albashir, MD
Department of Internal Medicine, Cleveland Clinic

Tyler Stevens, MD
Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic

Address: Tyler Stevens, MD, Digestive Disease Institute, A31, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail stevent@ccf.org

ABSTRACTEndoscopic ultrasonography (EUS) has become a well-accepted test in the workup of acute and chronic pancreatitis. However, further studies are needed to define its diagnostic role in patients with recurrent acute pancreatitis and minimal-change chronic pancreatitis.

KEY POINTS

  • EUS can identify the cause of acute pancreatitis when other imaging tests (computed tomography, transabdominal ultrasonography) are unrevealing.
  • EUS can safely and accurately detect bile duct stones and other causes of recurrent acute pancreatitis. It can also detect mild and severe structural features of chronic pancreatitis.
  • An endoscopic pancreatic function test may be a useful adjunct to EUS to detect mild exocrine insufficiency in early chronic pancreatitis.

ENDOSCOPIC ULTRASONOGRAPHY PLUS PANCREATIC FUNCTION TESTING

The best way to diagnose minimal-change chronic pancreatitis may be a combination of sensitive structural and functional testing. Although clinically apparent steatorrhea typically occurs late in the course of chronic pancreatitis, mild exocrine insufficiency may occur early and is detectable with hormone-stimulated pancreatic function testing. Therefore, pancreatic function tests are considered sensitive for diagnosing chronic pancreatitis.20,21,29

Endoscopic pancreatic function testing involves injecting secretin intravenously and then collecting duodenal aspirates through the endoscope. The duodenal fluid is analyzed for bicarbonate concentration as a measure of exocrine function.29

We have studied combined EUS and endoscopic pancreatic function testing in the diagnosis of chronic pancreatitis.16 The combination gives a simultaneous structural and functional assessment of the pancreas and may optimize sensitivity for detecting minimal-change chronic pancreatitis. In a small study, we found the combination had 100% sensitivity for noncalcific chronic pancreatitis compared with a histologic reference standard.16

Figure 2. Algorithm for diagnosis of minimal-change chronic pancreatitis.
EUS and endoscopic pancreatic function testing can be incorporated into the diagnostic strategy for patients with pancreatic-type abdominal pain. Our suggested algorithm is shown in Figure 2. We first perform computed tomography of the abdomen to look for calcifications, atrophy, and ductal dilation suggestive of severe chronic pancreatitis. However, even if computed tomography is negative, the patient may still have mild chronic pancreatitis. Therefore, we next perform EUS to look for mild parenchymal and ductal features indicating pancreatic fibrosis. If the findings on EUS are indeterminate, an endoscopic pancreatic function test is done in the same endoscopic session to confirm the diagnosis.

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