Chronic pancreatitis:Pain and computed tomography/magnetic resonance imaging findings

Chronic pancreatitis(CP)is a fibroinflammatory disease characterized by irreversible destruction of pancreatic tissue.With the development of the disease,it may lead to exocrine and/or endocrine insufficiency.CP is one of the common diseases that cause abdominal pain,which will not get permanent spontaneous relief as the disease evolves.The American College of Gastroenterology clinical guidelines recommend computed tomography or magnetic resonance imaging as the first-line examination for the diagnosis of CP.CP common imaging findings include pancreatic atrophy,irregular dilatation of the pancreatic duct,calcification of pancreatic parenchyma,pancreatic duct stones,etc.In clinical practice,whether any correlations between CP-induced abdominal pain patterns(no pain/constant/intermittent pain)and corresponding imaging findings present are not well known.Therefore,this review aims to comprehensively sort out and analyze the relevant information by collecting lots of literature on this field,so as to construct a cross-bridge between the clinical manifestations and imaging manifestations of CP patients.Also,it provides an imaging basis and foundation for the classification and diagnosis of abdominal pain types in clinical CP patients.

Chronic pancreatitis as a driving factor for pancreatic cancer:An epidemiological understanding

The retrospective study by Lew et al(2022)examined the rising hospitalization rates for chronic pancreatitis(CP)and its association with pancreatic ductal adenocarcinoma(PDAC),revealing significant ethno-racial disparities and risk factors.Overweight black men aged 40-59 years and white men over 40 years with higher incomes showed an elevated risk of PDAC among CP patients.The study,which included 14.2 million admissions from 2016-2017,found that 2.6%of adult patients were diagnosed with CP,with white males being the majority.Multivariate regression analysis identified men,black individuals,those aged 40-59 years,and individuals with a body mass index(BMI)between 25 and 29.9 as having an increased risk for CP.Moreover,0.78%of CP patients also had PDAC,with older age and BMI being significant risk factors for developing PDAC in CP patients.The study also highlighted disparities in healthcare access and utilization among different socioeconomic and ethno-racial groups,which may impact the risk and outcomes of CP and PDAC.

Pain in chronic pancreatitis:What can we do today?

The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis(CP).In this context,pain represents the most common and debilitating symptom,and it deeply affects patient’s quality of life.Multiple rating scales(unidimensional,bidimensional and multidimensional)have been proposed to quantify CP pain.However,it represents the result of complex mechanisms,involving genetic,neuropathic and neurogenic factors.Considering all these aspects,the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner.First,a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients.The second step,after medical approach,is endoscopic therapy,especially for complicated CP.In case of failure,tailored surgery represents the third step and decompressive or resection procedures can be chosen.In conclusion,CP pain’s management is challenging considering all these complex aspects and the lack of international protocols.

Dietary Green Tea Extract and Antioxidants Improve Insulin Secretory Functions of Pancreatic β-Cells in Mild and Severe Experimental Rodent Model of Chronic Pancreatitis

Chronic pancreatitis (CP) is a progressive inflammatory disorder of the pancreas. It is predominantly idiopathic (with an unknown cause) in India and mostly due to alcohol in the West. Diabetes that occur secondary to chronic pancreatitis (T3c Diabetes) is often brittle, and is difficult to attain normoglycemia with conventional treatment requiring multiple doses of insulin. Mild and severe model of CP was induced in mice by repeated intraperitoneal injections of cerulein and L-arginine respectively with an intent to study islet dysfunction and develop therapeutic strategy in animal models of CP. Dietary intervention of epigallocatechin-3-gallate (EGCG) was tested in both the models of CP for its beneficial effects on insulin secretory functions. Pancreata collected upon euthanasia were used to study alterations in the morphology of pancreatic parenchyma and inflammation by staining with H&E and fibrotic changes by Masson’s trichrome and picrosirius staining. Insulin secretory functions of islets were evaluated to test the efficacy of the dietary intervention on β-cell functions. Intraperitoneal glucose tolerance test was performed to monitor the glucose homeostasis before and after the dietary intervention. Both the models resulted in CP with dispersed acini, inflammation and fibrosis. The loss of acini and extent of fibrosis was more in L-arginine model. 2-fold improvement in glucose-stimulated insulin secretory functions of islets was observed with 0.5% EGCG dietary intervention in cerulein model of CP and 1.6-fold in L-arginine model of CP. A further improvement in insulin secretion by 3.2-fold was observed with additional dietary supplements like N-acetyl cysteine, curcumin in combination with EGCG. Our results thus demonstrate and highlight the therapeutic potential of dietary green tea (EGCG) supplementation in reversing islet dysfunction and improving glucose homeostasis in experimental chronic pancreatitis in mice.

Incidence,prevalence,and comorbidities of chronic pancreatitis:A 7-year population-based study

BACKGROUND Chronic pancreatitis(CP)is a fibroinflammatory syndrome leading to reduced quality of life and shortened life expectancy.Population-based estimates of the incidence,prevalence,and comorbidities of CP in China are scarce.AIM To characterize the incidence,prevalence,and comorbidities of CP in Sichuan Province,China,with population-based data.METHODS Data on CP from 2015 to 2021 were obtained from the Health Information Center of Sichuan Province.During the study period,a total of 38090 individuals were diagnosed with CP in Sichuan Province.The yearly incidence rate and point prevalence rate(December 31,2021)of CP were calculated.The prevalence of comorbid conditions in CP patients was estimated.The annual number of CPrelated hospitalizations,hospital length of stay,and hospitalization costs for CP were evaluated.Yearly incidence rates were standardized for age by the direct method using the permanent population of Sichuan Province in the 2020 census as the standard population.An analysis of variance test for the linearity of scaled variables and the Cochran-Armitage trend test for categorical data were performed to investigate the yearly trends,and a two-sided test with P<0.05 was considered statistically significant.RESULTS The 38090 CP patients comprised 23280 males and 14810 females.The mean age of patients at CP diagnosis was 57.83 years,with male patients(55.87 years)being younger than female patients(60.11 years)(P<0.001).The mean incidence rate of CP during the study period was 6.81 per 100000 person-years,and the incidence of CP increased each year,from 4.03 per 100000 person-years in 2015 to 8.27 per 100000 person-years in 2021(P<0.001).The point prevalence rate of CP in 2021 was 45.52 per 100000 individuals for the total population,with rates of 55.04 per 100000 individuals for men and 35.78 per 100000 individuals for women(P<0.001).Individuals aged 65 years or older had the highest prevalence of CP(113.38 per 100000 individuals)(P<0.001).Diabetes(26.32%)was the most common comorbidity in CP patients.The number of CP-related hospitalizations increased from 3739 in 2015 to 11009 in 2021.The total costs for CP-related hospitalizations for CP patients over the study period were 667.96 million yuan,with an average of 17538 yuan per patient.CONCLUSION The yearly incidence of CP is increasing,and the overall CP hospitalization cost has increased by 1.4 times during the last 7 years,indicating that CP remains a heavy health burden.

Burden of bone disease in chronic pancreatitis:A systematic review and meta-analysis

BACKGROUND Bone disease is an under-recognized cause of morbidity in chronic pancreatitis(CP).Over the past decade,publications of original studies on bone disease in CP has warranted synthesis of the evidence to ascertain the true burden of the problem.AIM To quantify the prevalence of osteopenia,osteoporosis,and fragility fractures in CP patients and investigate the associated clinical features and outcomes.METHODS A systematic search identified studies investigating bone disease in CP patients from Cochrane Library,Embase,Google Scholar,Ovid Medline,PubMed,Scopus,and Web of Science,from inception until October 2022.The outcomes included prevalence of osteopenia,osteoporosis,and fragility fractures,which were metaanalyzed using a random-effects model and underwent metaregression to delineate association with baseline clinical features.RESULTS Twenty-one studies were included for systematic review and 18 studies were included for meta-analysis.The pooled prevalence of osteopenia and osteoporosis in CP patients was 41.2%(95%CI:35.2%-47.3%)and 20.9%(95%CI:14.9%-27.6%),respectively.The pooled prevalence of fragility fractures described among CP was 5.9%(95%CI:3.9%-8.4%).Metaregression revealed significant association of pancreatic enzyme replacement therapy(PERT)use with prevalence of osteoporosis[coefficient:1.7(95%CI:0.6-2.8);P<0.0001].We observed no associations with mean age,sex distribution,body mass index,alcohol or smoking exposure,diabetes with prevalence of osteopenia,osteoporosis or fragility fractures.Paucity of data on systemic inflammation,CP severity,and bone mineralization parameters precluded a formal metaanalysis.CONCLUSION This meta-analysis confirms significant bone disease in patients with CP.Other than PERT use,we observed no patient or study-specific factor to be significantly associated with CP-related bone disease.Further studies are needed to identify confounders,at-risk population,and to understand the mechanisms of CP-related bone disease and the implications of treatment response.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life.Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention.Traditionally surgery is reserved for patients who do not improve with other interventions.However,recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function.Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders,minimally invasive surgery for chronic pancreatitis is slow to evolve.Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis.With this background,the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis.A Pub Med search of all relevant articles was performed using the appropriate keywords,parentheses,and Boolean operators.Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy,considered an adequate procedure only in a small proportion of patients.The pancreatic head is the pacemaker of pain,so adequate decompression is critical for long-term pain relief.Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection.With improvements in laparoscopic instrumentation and technological advances,minimally invasive surgery for chronic pancreatitis is gaining momentum.However,more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Non-pharmacological pain palliation methods in chronic pancreatitis

Chronic pancreatitis(CP)is a condition characterized by persistent and often severe pain resulting from the inflammatory disease of the pancreas.While pharmacological treatments play a significant role in palliative pain management,some patients require non-pharmacological methods.This review article focuses on non-pharmacological approaches used to alleviate pain in CP.The article examines non-pharmacological palliation options,including surgery,endoscopic approaches,neurostimulation techniques,acupuncture,and other alternative medicine methods.The effectiveness of each method is evaluated,taking into consideration patient compliance and side effects.Additionally,this article emphasizes the importance of personalized pain management in CP and underscores the need for a multidisciplinary approach.It aims to summarize the existing knowledge on the use of non-pharmacological palliation methods to improve the quality of life for patients with CP.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.

Pancreatic cancer,autoimmune or chronic pancreatitis,beyond tissue diagnosis:Collateral imaging and clinical characteristics may differentiate them

Pancreatic ductal adenocarcinoma(PDAC)is one of the most lethal malignancies and is developing into the 2nd leading cause of cancer-related death.Often,the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses,such as autoimmune pancreatitis(AIP)and massforming chronic pancreatitis(MFCP),making its diagnosis challenging.Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications.Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses;however,the diagnostic accuracy is imperfect.Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis.It is not unusual that after a thorough diagnostic evaluation,the clinician is confronted with a pancreatic mass with uncertain diagnosis.In those cases,a re-evaluation must be entertained,preferably by an experienced multispecialty team including radiologists,pathologists,gastroenterologists,and surgeons,looking for disease-specific clinical,imaging,and histological hallmarks or collateral evidence that could favor a specific diagnosis.Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP,PDAC,and MFCP and to highlight those disease-specific clinical,radiological,serological,and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.

Coexistent alcohol-related cirrhosis and chronic pancreatitis have a comparable phenotype to either disease alone:A comparative retrospective analysis

BACKGROUND Alcohol use disorder is a prevalent disease in the United States.It is a well-demonstrated cause of recurrent and long-standing liver and pancreatic injury which can lead to alcohol-related liver cirrhosis(ALC)and chronic pancreatitis(ACP).ALC and ACP are associated with significant healthcare utilization,cost burden,and mortality.The prevalence of coexistent disease(CD)ranges widely in the literature and the intersection between ALC and ACP is inconsistently charac-terized.As such,the clinical profile of coexistent ALC and ACP remains poorly understood.We hypothesized that patients with CD have a worse phenotype when compared to single organ disease.AIM To compare the clinical profile and outcomes of patients with CD from those with ALC or ACP Only.METHODS In this retrospective comparative analysis,we reviewed international classi-fication of disease 9/10 codes and electronic health records of adult patients with verified ALC Only(n=135),ACP Only(n=87),and CD(n=133)who received care at UPMC Presbyterian-Shadyside Hospital.ALC was defined by histology,imaging or clinical evidence of cirrhosis or hepatic decompensation.ACP was defined by imaging findings of pancreatic calcifications,moderate-severe pancreatic duct dilatation,irregularity or atrophy.We compared demographics,pertinent clinical variables,healthcare utilization,and mortality for patients with CD with those who had single organ disease.RESULTS Compared to CD or ACP Only,patients with ALC Only were more likely to be older,Caucasian,have higher body mass index,and Hepatitis B or C infection.CD patients(vs ALC Only)were less likely to have imaging evidence of cirrhosis and portal hypertension despite possessing similar MELD-Na and Child C scores at the most recent contact.CD patients(vs ACP Only)were less likely to have acute or recurrent acute pancreatitis,diabetes mellitus,insulin use,oral pancreatic enzyme therapy,and need for endoscopic therapy or pancreatic surgery.The number of hospitalizations in patients with CD were similar to ACP Only but significantly higher than ALC Only.The overall mortality in patients with CD was similar to ALC Only but trended to be higher than ACP Only(P=0.10).CONCLUSION CD does not have a worse phenotype compared with single organ disease.The dominant phenotype in CD is similar to ALC Only which should be the focus in longitudinal follow-up.

Dietary intake in patients with chronic pancreatitis:A systematic review and meta-analysis

BACKGROUND A progressive reduction in the secretion of pancreatic enzymes in patients with chronic pancreatitis(CP)results in malabsorption and ultimate malnutrition.However,the pathogenesis of malnutrition is multifactorial and other factors such as chronic inflammation,alcohol excess and poor dietary intake all contribute.Patients may restrict their dietary intake due to poor appetite or to avoid gastrointestinal symptoms and abdominal pain.Whilst up to half of patients with chronic pancreatitis are reportedly malnourished,the dietary intake of patients with CP is relatively understudied and has not been systematically reviewed to date.AIM To perform a systematic review and meta-analysis of the dietary intakes of patients with CP compared to healthy controls,and to compare the dietary intake of patients with alcohol-related CP and non-alcohol-related CP.METHODS A systematic literature search was performed using EMBASE,MEDLINE,and Cochrane review on studies published between 1946 and August 30th,2019.Adult subjects with a diagnosis of CP who had undergone dietary assessment were included in the systematic review(qualitative analysis).Studies on patients with other pancreatic diseases or who had undergone pancreatic surgery were not included.Studies comparing the dietary intake of patients with CP to that of healthy controls were included in the meta-analysis(quantitative analysis).Metaanalysis was performed using Review Manager 5.3.Newcastle Ottawa Scale(NOS)was used to assess quality of studies.RESULTS Of 6715 studies retrieved in the search,23 were eligible for qualitative analysis while 12 were eligible for quantitative analysis.In the meta-analysis,the total energy(calorie)intake of patients with CP was similar to that of healthy controls[mean difference(MD):171.3;95%confidence interval(CI):-226.01,568.5;P=0.4],however patients with CP consumed significantly fewer non-alcohol calories than controls[MD:-694.1;95%CI:-1256.1,(-132.1);P=0.02].CP patients consumed more protein,but carbohydrate and fat intakes did not differ significantly.Those with alcohol-related CP consumed more mean(standard deviation)calories than CP patients with a non-alcohol aetiology[2642(1090)kcal and 1372(394)kcal,respectively,P=0.046],as well as more protein,fat,but not carbohydrate.CONCLUSION Although patients with CP had similar calorie intake to controls,studies that analysed the contribution of alcohol to energy intake showed that patients with CP consumed fewer non-alcohol calories than healthy controls.A high calorie intake,made up to a large degree by alcohol,may in part contribute to poor nutritional status in CP.

Follow-up of patients with pseudotumoral chronic pancreatitis: Outcome and surveillance

AIM: To follow up patients with pseudotumoral chronic pancreatitis (PCP) to assess their outcome and identify an optimal surveillance interval.

Pancreatic carcinoma coexisting with chronic pancreatitis versus tumor-forming pancreatitis:Diagnostic utility of the time-signal intensity curve from dynamic contrast-enhanced MR imaging

AIM: To evaluate the ability of the time-signal intensity curve (TIC) of the pancreas obtained from dynamic contrast-enhanced magnetic resonance imaging (MRI) for differentiation of focal pancreatic masses, especially pancreatic carcinoma coexisting with chronic pancreatitis and tumor-forming pancreatitis. METHODS: Forty-eight consecutive patients who underwent surgery for a focal pancreatic mass, including pancreatic ductal carcinoma (n = 33), tumor-forming pancreatitis (n = 8), and islet cell tumor (n = 7), were reviewed. Five pancreatic carcinomas coexisted with longstanding chronic pancreatitis. The pancreatic TICs were obtained from the pancreatic mass and the pancreatic parenchyma both proximal and distal to the mass lesion in each patient, prior to surgery, and were classified into 4 types according to the time to a peak: 25 s and 1, 2, and 3 min after the bolus injection of contrast material, namely, type-Ⅰ, Ⅱ, Ⅲ, and Ⅳ, respectively, and were then compared to the corresponding histological pancreatic conditions. RESULTS: Pancreatic carcinomas demonstrated type-Ⅲ (n = 13) or Ⅳ (n = 20) TIC. Tumor-forming pancreatitis showed type-Ⅱ (n = 5) or Ⅲ (n = 3) TIC. All islet cell tumors revealed type-Ⅰ. The type-Ⅳ TIC was only recognized in pancreatic carcinoma, and the TIC of carcinoma always depicted the slowest rise to a peak among the 3 pancreatic TICs measured in each patient, even in patients with chronic pancreatitis.CONCLUSION: Pancreatic TIC from dynamic MRI provides reliable information for distinguishing pancreatic carcinoma from other pancreatic masses, and may enable us to avoid unnecessary pancreatic surgery and delays in making a correct diagnosis of pancreatic carcinoma, especially, in patients with longstanding chronic pancreatitis.

Evaluation of clinical relevance of examining K-ras, p16 and p53 mutations along with allelic losses at 9p and 18q in EUS-guided fine needle aspiration samples of patients with chronic pancreatitis and pancreatic cancer

AIM： To establish an optimum combination of molecular markers resulting in best overall diagnostic sensitivity and specificity for evaluation of suspicious pancreatic mass. METHODS： Endoscopic ultrasound （EUS）-guided fine needle aspiration cytology （FNA） was performed on 101 consecutive patients （63 males, 38 females, 60 ± 12 years; 81 with subsequently diagnosed pancreatic cancer, 20 with chronic pancreatitis） with focal pancreatic mass. Samples were evaluated on-site by an experienced cytopathologist. DNA was extracted from Giemsa stained cells selected by laser microdissection and the presence of K-ras, p53 and p16 somatic mutations was tested by cycling-gradient capillary electrophoresis （CGCE） and single-strand conformation polymorphism （SSCP） techniques. In addition, allelic losses of tumor suppressor genes p16 （INK4, CDKN2A） and DPC4 （MADH4, SMAD4） were detected by monitoring the loss of heterozygosity （LOH） at 9p and 18q, respectively. RESULTS： Sensitivity and specificity of EUS-guided FNA were 75% and 85%, positive and negative predictive value reached 100%. The remaining 26% samples were assigned as inconclusive. Testing of molecular markers revealed sensitivity and specificity of 70% and 100% for K-ras mutations （P 〈 0.001）, 24% and 90% for p53 mutations （NS）, 13% and 100% for p16 mutations （NS）, 85% and 64% for aUelic losses at 9p （P 〈 0.001） and 78% and 57% for allelic losses at 18q （P 〈 0.05）. When tests for different molecular markers were combined, the best results were obtained with K-ras ＋ LOH at 9p （92% and 64%, P 〈 0.001）, K-ras ＋ LOH at 18q （92% and 57%, P 〈 0.001）, and K-ras ＋ LOH 9q ＋ LOH 18q （96% and 43%, P 〈 0.001）. When the molecular markers were used as complements to FNA cytology to evaluate inconclusive samples only, the overall sensitivity of cancer detection was 100% in all patients enrolled in the study. CONCLUSION： EUS-guided FNA cytology combined with screening of K-ras mutations and allelic losses of tumor suppressors p16 and DPC4 represents a very sensitive approach in screening for pancreatic malignancy. Molecular markers may find its use particularly in cases where FNA cytology has been inconclusive.

Difficulty with diagnosis of malignant pancreatic neoplasms coexisting with chronic pancreatitis

Chronic pancreatitis is a relatively common disease. We encountered two different cases of belatedly demonstrated pancreatic carcinoma featuring underlying chronic pancreatitis. The first case was one that was highly suspected as that of a malignancy based upon imaging study, but unfortunately, it could not be confirmed by intra-operative cytology at that time. Following this, the surgeon elected to perform only conservative bypass surgery for obstructive biliary complication. Peritoneal carcinomatosis was later noted and the patient finally died. The second case, a malignant mucinous neoplasm,was falsely diagnosed as a pseudocyst, based upon the lesion's sonographic appearance and associated elevated serum amylase levels. After suffering repeated hemoptysis,the patient was found to exhibit lung metastasis and peritoneal seeding. We reviewed some of the literature,including those studies discussing chronic pancreatitis predisposing to a malignant change. These two case analyses illustrate clearly that the diagnosis for such conditions, which is simply based upon imagery or pathological considerations may end up being one of a mistaken malignancy. Some of our suggestions for the treatment of such malignancies as revealed herein include,total pancreatomy for univocal mass lesion, and needle aspiration of lesion-contained tissue for amylase, CA199and CEA levels for a suspicious cystic pancreatic mass.

Diagnostic criteria for autoimmune chronic pancreatitis revisited

Autoimmune chronic pancreatitis （AIP） is increasingly being recognized worldwidely, as knowledge of this entity builds up. Above all, AIP is a very attractive disease to clinicians in terms of its dramatic response to the oral steroid therapy in contrast to ordinary chronic pancreatitis. Although many characteristic findings of AIP have been described, definite diagnostic criteria have not been fully established. In the year 2002, the Japan Pancreas Society published the diagnostic criteria of AIP and many clinicians around the world use these criteria for the diagnosis of AIP. The diagnostic criteria proposed by the Japan Pancreas Society, however, are not completely satisfactory and some groups use their own criteria in reporting AIP. This review discusses several potential limitations of current diagnostic criteria for this increasingly recognized condition. The manuscript is organized to emphasize the need for convening a consensus to develop improved diagnostic criteria.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulf illed, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classif ication, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-f ine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or diff icult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.

Chronic pancreatitis,pancreatic adenocarcinoma and the black box in-between

Pancreatic cancer is a challenging disease for patients,doctors and researchers who for decades have searched for a cure for this deadly malignancy.Although existing mouse models of pancreatic cancer have shed light on the mecha-nistic basis of the neoplastic conversion of the pancreas,their impact in terms of offering new diagnostics and therapeu-tic modalities remains limited.Chronic pancreatitis is an inflammatory disease of the pancreas that is associated with a gradual damage of the organ and an increased risk of developing neoplastic lesions.In this review,we propose that detailed studies of chronic inflammatory processes in the pancreas will provide insights into the evolution of pancreatic cancer.This information may prove useful in the design of effective therapeutic strategies to battle the disease.

Diagnosis of mild chronic pancreatitis (Cambridge classification):Comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography

AIM： To investigate the usefulness of secretin injection- MRCP for the diagnosis of mild chronic pancreatitis.METHODS： Sixteen patients having mild chronic pancreatitis according to the Cambridge classification and 12 control subjects with no abnormal findings on the pancreatogram were examined for the diagnostic accuracy of secretin injection-MRCP regarding abnormal branch pancreatic ducts associated with mild chronic pancreatitis （Cambridge Classification）, using endoscopic retrograde cholangiopancreatography （ERCP） for comparison.RESULTS： The sensitivity and specificity for abnormal branch pancreatic ducts determined by two reviewers were respectively 55%-63% and 75%-83% in the head, 57%-64% and 82%-83% in the body, and 44%-44% and 72%-76% in the tail of the pancreas. The sensitivity and specificity for mild chronic pancreatitis were 56%-63% and 92%-92%, respectively. Interobserver agreement （K statistics） concerning the diagnosis of an abnormal branch pancreatic duct and of mild chronic pancreatitis was good to excellent.CONCLUSION： Secretin injection-MRCP might be useful for the diagnosis of mild chronic pancreatitis.