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.

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.

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.

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.

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.

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.

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.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children:A multicenter randomized controlled trial

BACKGROUND Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography(ERCP).Currently,there is no suitable treatment for post-ERCP pancreatitis(PEP)prophylaxis.Few studies have prospectively evaluated interventions to prevent PEP in children.AIM To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.METHODS This multicenter,randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria.Patients were randomly divided into the external use of mirabilite group(external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP)and blank group.The primary outcome was the incidence of PEP.The secondary outcomes included the severity of PEP,abdominal pain scores,levels of serum inflammatory markers[tumor necrosis factor-alpha(TNF-α)and serum interleukin-10(IL-10)],and intestinal barrier function markers[diamine oxidase(DAO),D-lactic acid,and endotoxin].Additionally,the side effects of topical mirabilite were investigated.RESULTSA total of 234 patients were enrolled,including 117 in the external use of mirabilite group and theother 117 in the blank group.The pre-procedure and procedure-related factors were notsignificantly different between the two groups.The incidence of PEP in the external use ofmirabilite group was significantly lower than that in the blank group(7.7%vs 26.5%,P<0.001).The severity of PEP decreased in the mirabilite group(P=0.023).At 24 h after the procedure,thevisual analog scale score in the external use of mirabilite group was lower than that in the blankgroup(P=0.001).Compared with those in the blank group,the TNF-αexpressions weresignificantly lower and the IL-10 expressions were significantly higher at 24 h after the procedurein the external use of mirabilite group(P=0.032 and P=0.011,respectively).There were nosignificant differences in serum DAO,D-lactic acid,and endotoxin levels before and after ERCPbetween the two groups.No adverse effects of mirabilite were observed.CONCLUSIONExternal use of mirabilite reduced the PEP occurrence.It significantly alleviated post-proceduralpain and reduced inflammatory response.Our results favor the external use of mirabilite toprevent PEP in children.

Incidence and mortality of acute and chronic pancreatitis in the Netherlands:A nationwide record-linked cohort study for the years 1995-2005

AIM:To analyze trends in incidence and mortality of acute pancreatitis(AP) and chronic pancreatitis(CP) in the Netherlands and for international standard populations.METHODS:A nationwide cohort is identified through record linkage of hospital data for AP and CP,accumulated from three nationwide Dutch registries:the hospital discharge register,the population register,and the death certificate register.Sex-and age-group specific incidence rates of AP and CP are defined for the period 2000-2005 and mortality rates of AP and CP for the period 1995-2005.Additionally,incidence and mortality rates over time are reported for Dutch and international(European and World Health Organization) standard populations.RESULTS:Incidence of AP per 100000 persons per year increased between 2000 and 2005 from 13.2(95%CI:12.6-13.8) to 14.7(95%CI:14.1-15.3).Incidence of AP for males increased from 13.8(95%CI:12.9-14.7) to 15.2(95%CI:14.3-16.1),for females from 12.7(95%CI:11.9-13.5) to 14.2(95%CI:13.4-15.1).Irregular patterns over time emerged for CP.Overall mean incidence per 100000 persons per year was 1.77,for males 2.16,and for females 1.4.Mortality for AP fluctuated during 1995-2005 between 6.9 and 11.7 per million persons per year and was almost similar for males and females.Concerning CP,mortality for males fluctuated between 1.1(95%CI:0.6-2.3) and 4.0(95%CI:2.8-5.8),for females between 0.7(95%CI:0.3-1.6) and 2.0(95%CI:1.2-3.2).Incidence and mortality of AP and CP increased markedly with age.Standardized rates were lowest for World Health Organization standard population.CONCLUSION:Incidence of AP steadily increased while incidence of CP fluctuated.Mortality for both AP and CP remained fairly stable.Patient burden and health care costs probably will increase because of an ageing Dutch population.

Diagnosis and treatment of diabetes mellitus in chronic pancreatitis

Diabetes secondary to pancreatic diseases is commonly referred to as pancreatogenic diabetes or type 3c diabetes mellitus.It is a clinically relevant condition with a prevalence of 5%-10%among all diabetic subjects in Western populations.In nearly 80%of all type 3c diabetes mellitus cases,chronic pancreatitis seems to be the underlying disease.The prevalence and clinical importance of diabetes secondary to chronic pancreatitis has certainly been underestimated and underappreciated so far.In contrast to the management of type 1 or type2 diabetes mellitus,the endocrinopathy in type 3c is very complex.The course of the disease is complicated by additional present comorbidities such as maldigestion and concomitant qualitative malnutrition.General awareness that patients with known and/or clinically overt chronic pancreatitis will develop type 3c diabetes mellitus(up to 90%of all cases)is rather good.However,in a patient first presenting with diabetes mellitus,chronic pancreatitis as a potential causative condition is seldom considered.Thus many patients are misdiagnosed.The failure to correctly diagnose type 3 diabetes mellitus leads to a failure to implement an appropriate medical therapy.In patients with type 3c diabetes mellitus treating exocrine pancreatic insufficiency,preventing or treating a lack of fat-soluble vitamins(especially vitamin D)and restoring impaired fat hydrolysis and incretin secretion are key-features of medical therapy.

Carbohydrate antigen 19-9 for differential diagnosis of pancreatic carcinoma and chronic pancreatitis

AIM: To evaluate the utility of carbohydrate antigen19-9(CA19-9) for differential diagnosis of pancreatic carcinoma and chronic pancreatitis.METHODS: We searched the literature for studies reporting the sensitivity, specificity, and other accuracy measures of serum CA19-9 levels for differentiating pancreatic carcinoma and chronic pancreatitis.Pooled analysis was performed using random-effects models, and receiver operating characteristic(ROC) curves were generated.Study quality was assessed using Standards for Reporting Diagnostic Accuracy and Quality Assessment for Studies of Diagnostic Accuracy tools.RESULTS: A total of 34 studies involving 3125 patients with pancreatic carcinoma and 2061 patients with chronic pancreatitis were included.Pooled analysis of the ability of CA19-9 level to differentiate pancreatic carcinoma and chronic pancreatitis showed the following effect estimates: sensitivity, 0.81(95%CI: 0.80-0.83); specificity, 0.81(95%CI: 0.79-0.82); positive likelihood ratio, 4.08(95%CI: 3.39-4.91); negative likelihood ratio, 0.24(95%CI: 0.21-0.28); and diagnostic odds ratio, 19.31(95%CI: 14.40-25.90).The area under the ROC curve was 0.88.No significant publication bias was detected.CONCLUSION: Elevated CA19-9 by itself is insufficient for differentiating pancreatic carcinoma and chronic pancreatitis, however, it increases suspicion of pancreatic carcinoma and may complement other clinical findings to improve diagnostic accuracy.

Pancreatic duct stones in patients with chronic pancreatitis:surgical outcomes

BACKGROUND: Pancreatic duct stone (PDS) is a common complication of chronic pancreatitis. Surgery is a common therapeutic option for PDS. In this study we assessed the surgical procedures for PDS in patients with chronic pancreatitis at our hospital. METHOD: Between January 2004 and September 2009, medical records from 35 patients diagnosed with PDS associated with chronic pancreatitis were retrospectively reviewed and the patients were followed up for up to 67 months. RESULTS: The 35 patients underwent ultrasonography, computed tomography, or both, with an overall accuracy rate of 85.7%. Of these patients, 31 underwent the modified Puestow procedure, 2 underwent the Whipple procedure, 1 underwent simple stone removal by duct incision, and 1 underwent pancreatic abscess drainage. Of the 35 patients, 28 were followed up for 4-67 months. There was no postoperative death before discharge or during follow-up. After the modified Puestow procedure, abdominal pain was reduced in patients with complete or incomplete stone clearance (P>0.05). Steatorrhea and diabetes mellitus developed in several patients during a long-term follow-up. CONCLUSIONS: Surgery, especially the modified Puestow procedure, is effective and safe for patients with PDS associated with chronic pancreatitis. Decompression of intraductal pressure rather than complete clearance of all stones predicts postoperative outcome.

Quantification of pancreatic exocrine function of chronic pancreatitis with secretin-enhanced MRCP

AIM:To obtain reference values for pancreatic flow output rate(PFR)and peak time(PT)in healthy volunteers and chronic pancreatitis(CP);to correlate quantification of secretin enhanced magnetic resonance cholangiopancreatography(SMRCP)of pancreatic fluid output following secretin with fecal elastase-1(FE-1)tests.METHODS:The present study includes 53 subjects comprised of 17 healthy individuals and 36 patients with CP from April 2011 to January 2013.The 36 patients with CP were divided into three groups of mild CP(n=14),moderate CP(n=19)and advanced CP(n=3)by M-ANNHEIM classification for CP..Fifty-three cases underwent FE-1 test and magnetic resonance imaging using 3.0 T-device(Signa EXCITE,GE Healthcare).Coronal T2-weighted single-shot turbo spin-echo,spiratory triggered,covering the papillae,duodenum and small bowel.MRCP was performed with a heavily T2-weighted fat-suppressed long TE HASTE sequence (thick slab 2D MRCP sequence),repeated every 2 min up to 11 min after 0.1 mL/kg secretin injection(Secrelux,Sanochemia,Germany).FE-1 test used sandwich enzyme-linked immunosorbent assay(ELISA)test(ScheBo.Tech,Germany).RESULTS:A good linear correlation showed between the calculated volume and the actual volume by Phantom experiments.Fifty-three paired Quantification of secretin enhanced magnetic resonance cholangiopancreatography(MRCPQ)and FE-1 data sets were analyzed.The mean FE-1 of 53 cases was 525.41±94.44μg/g for 17 healthy volunteers,464.95±136.13μg/g for mild CP,301.55±181.55μg/g for moderate CP,229.30±146.60μg/g for advanced CP.Also,there was statistically significant difference in FE-1(P=0.0001)between health and CP.The mean values of PFR and PT were 8.18±1.11 mL/min,5.76±1.71 min for normal;7.27±2.04 mL/min,7.71±2.55 min for mild CP;4.98±2.57 mL/min,9.10±3.00 min for moderate CP;4.13±1.83 mL/min,12.33±1.55 min for advanced CP.Further,statistically significant difference in PFR(P=0.0001)and PT(P=0.0001)was observed between health and CP.Besides,there was correlation(r=0.79)and consistency(K=0.6)between MRCPQ and ELISA Test.It was related between M-ANNHEIM classification and PFR(r=0.55),FE-1(r=0.57).CONCLUSION:SMRCP can provide a safe,non-invasive and efficient method to evaluate the exocrine function of the pancreas.

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.

Pathophysiology of chronic pancreatitis

Chronic pancreatitis(CP)is an inflammatory disease of the pancreas characterized by progressive fibrotic destruction of the pancreatic secretory parenchyma.Despite the heterogeneity in pathogenesis and involved risk factors,processes such as necrosis/apoptosis,inflammation or duct obstruction are involved.This fibrosing process ultimately leads to progressive loss of the lobular morphology and structure of the pancreas,deformation of the large ducts and severe changes in the arrangement and composition of the islets.These conditions lead to irreversible morphological and structural changes resulting in impairment of both exocrine and endocrine functions.The prevalence of the disease is largely dependent on culture and geography.The etiological risk-factors associated with CP are multiple and involve both genetic and environmental factors.Throughout this review the M-ANNHEIM classification system will be used,comprising a detailed description of risk factors such as:alcohol-consumption,nicotineconsumption,nutritional factors,hereditary factors,efferent duct factors,immunological factors and miscellaneous and rare metabolic factors.Increased knowledge of the different etiological factors may encourage the use of further advanced diagnostic tools,which potentially will help clinicians to diagnose CP at an earlier stage.However,in view of the multi factorial disease and the complex clinical picture,it is not surprising that treatment of patients with CP is challenging and often unsuccessful.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis(CP).For CP-related,uncomplicated,pancreatic pseudocysts(PPC),endoscopy is the first-choice therapeutic option.Recent advances have focused on endosonography-guided PPC transmural drainage,which tends to replace the conventional,duodenoscope-based coma immediately approach.Ancillary material is being tested to facilitate the endosonography-guided procedure.In this review,the most adequate techniques depending on PPC characteristics are presented along with supporting evidence.For CP-related biliary obstructions,endoscopy and surgery are valid therapeutic options.Patient co-morbidities(e.g.,portal cavernoma)and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option.Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures.In endoscopy,the gold standard technique consists of placing simultaneous,multiple,side-by-side,plastic stents for a oneyear period.Fully covered self-expandable metal stents are challenging this method and have provided 50%mid-term success.

Head mass in chronic pancreatitis: Inflammatory or malignant

Chronic pancreatitis increases the risk of developing pancreatic cancer. This often presents as a mass lesion in the head of pancreas. Mass lesion in the head of pancreas can also occur secondary to an inflammatory lesion. Recognising this is crucial to avoid unnecessary surgery. This is sometimes difficult as there is an overlap in clinical presentation and conventional computed tomography(CT) abdomen findings in inflammatory andmalignant mass. Advances in imaging technologies like endoscopic ultrasound in conjunction with techniques like fine needle aspiration, contrast enhancement and elastography as well as multidetector row CT, magnetic resonance imaging and positron emission tomography scanning have been shown to help in distinguishing inflammatory and malignant mass. Research is ongoing to develop molecular techniques to help characterise focal pancreatic mass lesions. This paper reviews the current status of imaging and molecular techniques in differentiating a benign mass lesion in chronic pancreatitis and from malignancy.