Pancreatitis (Chronic, Suspected)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients with suspected chronic pancreatitis.

Lead Researcher: Sian Chin, Arjun Shivananda

Experts & Contributors: Hannes Basson, Ravinder Dhillon, Martin Marshall, Duncan Ramsay, Gagandeep Sandhu

Editorial Panel: Core membership
Link to Editorial Panel

Date reviewed: April 2018

Date Published: February 2019

Image 1a and1b (Computed Tomography): Atrophic and heavily calcified (arrow) pancreas reflecting chronic pancreatitis.

Chronic Pancreatitis

Image 1a and1b (Computed Tomography): Atrophic and heavily calcified (arrow) pancreas reflecting chronic pancreatitis.

Chronic Pancreatitis

Suggested approach for structural imaging in the diagnosis of chronic pancreatitis:

  • Ultrasound is the initial imaging of choice for investigation of biliary tree to assess for gallstone disease
  • CT is moderately accurate in diagnosis of suspected chronic pancreatitis and is the first line investigation of choice
  • Other modalities, such as magnetic resonance cholangiopancreatography (MRCP), secretin augmented MRCP (sMRCP) and endoscopic ultrasound (EUS) can provide further diagnostic information relatively non-invasively and can help guide interventional management
  • CT, MRI, EUS and ERCP have comparably high diagnostic accuracy so the choice of imaging modality may be made based on invasiveness, local availability, experience and costs 1
  • In the event that structural imaging (with CT, MRCP and EUS) is equivocal, then ePFT is recommended as the next investigation of choice. This is because of its high negative predictive value (97%), and when combined with EUS it allows reliable exclusion of early chronic pancreatitis 2
  • Endoscopic retrograde cholangiopancreatography (ERCP) is rarely recommended solely for diagnosis as MRCP and sMRCP are non-invasive alternatives with comparable accuracy. ERCP should be reserved for situations where non-invasive modalities are not available or therapeutic intervention is required for pancreatic pain and suspected main pancreatic duct obstruction, based on MRCP or EUS 3

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Issa Y, Kempeneers MA, van Santvoort HC, Bollen TL, Bipat S, Boermeester MA. Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis. Eur Radiol. 2017;27(9):3820-44. (Review article). View the reference
  2. Albashir S, Bronner MP, Parsi MA, Walsh RM, Stevens T. Endoscopic ultrasound, secretin endoscopic pancreatic function test, and histology: correlation in chronic pancreatitis. Am J Gastroenterol. 2010;105(11):2498-503. (Level III evidence). View the reference
  3. Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, et al. American pancreatic association practice guidelines in chronic pancreatitis: evidence-based report on diagnostic guidelines. Pancreas. 2014;43(8):1143-62. (Guideline). View the reference
  4. Weltman DI, Zeman RK. Acute diseases of the gallbladder and biliary ducts. Radiol Clin North Am. 1994;32(5):933-50. (Review article). View the reference
  5. Bastid C, Sahel J, Filho M, Sarles H. Diameter of the main pancreatic duct in chronic calcifying pancreatitis. Measurement by ultrasonography versus pancreatography. Pancreas. 1990;5(5):524-7. (Level III evidence). View the reference
  6. Niederau C, Grendell JH. Diagnosis of chronic pancreatitis. Gastroenterology. 1985;88(6):1973-95. (Level III evidence). View the reference
  7. Siddiqi AJ, Miller F. Chronic pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR. 2007;28(5):384-94. (Review article). View the reference
  8. Rosso E, Alexakis N, Ghaneh P, Lombard M, Smart HL, Evans J, et al. Pancreatic pseudocyst in chronic pancreatitis: endoscopic and surgical treatment. Dig Surg. 2003;20(5):397-406. (Review article). View the reference
  9. Sze KC, Pirola RC, Apte MV, Wilson JS. Current options for the diagnosis of chronic pancreatitis. Expert Rev Mol Diagn. 2014;14(2):199-215. (Review article). View the reference
  10. Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology. 1989;171(2):353-7. (Level III evidence). View the reference
  11. Perez-Johnston R, Sainani NI, Sahani DV. Imaging of chronic pancreatitis (including groove and autoimmune pancreatitis). Radiol Clin North Am. 2012;50(3):447-66. (Review article). View the reference
  12. Pungpapong S, Wallace MB, Woodward TA, Noh KW, Raimondo M. Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis: a prospective comparison study. J Clin Gastroenterol. 2007;41(1):88-93. (Level III evidence). View the reference
  13. Remer EM, Baker ME. Imaging of chronic pancreatitis. Radiol Clin North Am. 2002;40(6):1229-42, v. (Review article). View the reference
  14. Sanyal R, Stevens T, Novak E, Veniero JC. Secretin-enhanced MRCP: review of technique and application with proposal for quantification of exocrine function. AJR Am J Roentgenol. 2012;198(1):124-32. (Level II evidence).View the reference
  15. Manfredi R, Perandini S, Mantovani W, Frulloni L, Faccioli N, Pozzi Mucelli R. Quantitative MRCP assessment of pancreatic exocrine reserve and its correlation with faecal elastase-1 in patients with chronic pancreatitis. La Radiologia medica. 2012;117(2):282-92. (Level III evidence). View the reference
  16. Balci NC, Smith A, Momtahen AJ, Alkaade S, Fattahi R, Tariq S, et al. MRI and S-MRCP findings in patients with suspected chronic pancreatitis: correlation with endoscopic pancreatic function testing (ePFT). J Magn Reson Imaging. 2010;31(3):601-6. (Level III evidence).View the reference
  17. Fukukura Y, Fujiyoshi F, Sasaki M, Nakajo M. Pancreatic duct: morphologic evaluation with MR cholangiopancreatography after secretin stimulation. Radiology. 2002;222(3):674-80. (Level II evidence). View the reference
  18. Hellerhoff KJ, Helmberger H, 3rd, Rosch T, Settles MR, Link TM, Rummeny EJ. Dynamic MR pancreatography after secretin administration: image quality and diagnostic accuracy. AJR Am J Roentgenol. 2002;179(1):121-9. (Level III evidence). View the reference
  19. Sica GT, Braver J, Cooney MJ, Miller FH, Chai JL, Adams DF. Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis. Radiology. 1999;210(3):605-10. (Level III-IV evidence). View the reference
  20. Takehara Y, Ichijo K, Tooyama N, Kodaira N, Yamamoto H, Tatami M, et al. Breath-hold MR cholangiopancreatography with a long-echo-train fast spin-echo sequence and a surface coil in chronic pancreatitis. Radiology. 1994;192(1):73-8. (Level III evidence). View the reference
  21. Catalano MF, Lahoti S, Geenen JE, Hogan WJ. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis. Gastrointest Endosc. 1998;48(1):11-7. (Level II-III evidence). View the reference
  22. Nattermann C, Goldschmidt AJ, Dancygier H. Endosonography in chronic pancreatitis--a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography. Endoscopy. 1993;25(9):565-70. (Level II-III evidence). View the reference
  23. Wiersema MJ, Hawes RH, Lehman GA, Kochman ML, Sherman S, Kopecky KK. Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin. Endoscopy. 1993;25(9):555-64. (Level II-III evidence). View the reference
  24. Zimmerman MJ, Mishra G, Lewin D, Hawes RH, Coyle W, Adams DA, et al. Comparison of EUS findings with histopathology in chronic pancreatitis. Gastrointest Endosc. 1997;45(4):AB185. (Level III evidence). View the reference
  25. Bhutani MS, Arantes VN, Verma D, Moezzi J, Suryaprasad S, Kapadia AS, et al. Histopathologic correlation of endoscopic ultrasound findings of chronic pancreatitis in human autopsies. Pancreas. 2009;38(7):820-4. (Level III evidence). View the reference
  26. Varadarajulu S, Eltoum I, Tamhane A, Eloubeidi MA. Histopathologic correlates of noncalcific chronic pancreatitis by EUS: a prospective tissue characterization study. Gastrointest Endosc. 2007;66(3):501-9. (Level II evidence). View the reference
  27. Wallace MB, Hawes RH. Endoscopic ultrasound in the evaluation and treatment of chronic pancreatitis. Pancreas. 2001;23(1):26-35. (Review article). View the reference
  28. Petrone MC, Arcidiacono PG, Perri F, Carrara S, Boemo C, Testoni PA. Chronic pancreatitis-like changes detected by endoscopic ultrasound in subjects without signs of pancreatic disease: do these indicate age-related changes, effects of xenobiotics, or early chronic pancreatitis? Pancreatology. 2010;10(5):597-602. (Level II evidence). View the reference
  29. Conwell DL, Wu BU. Chronic pancreatitis: making the diagnosis. Clin Gastroenterol Hepatol. 2012;10(10):1088-95. (Review article). View the reference
  30. Ketwaroo G, Brown A, Young B, Kheraj R, Sawhney M, Mortele KJ, et al. Defining the accuracy of secretin pancreatic function testing in patients with suspected early chronic pancreatitis. Am J Gastroenterol. 2013;108(8):1360-6. (Level III evidence). View the reference
  31. Pelley JR, Gordon SR, Gardner TB. Abnormal duodenal [HCO3-] following secretin stimulation develops sooner than endocrine insufficiency in minimal change chronic pancreatitis. Pancreas. 2012;41(3):481-4. (Level III evidence). View the reference
  32. Toouli J, Biankin AV, Oliver MR, Pearce CB, Wilson JS, Wray NH. Management of pancreatic exocrine insufficiency: Australasian pancreatic club recommendations. Med J Aust. 2010;193(8):461-7. (Guideline). View the reference
  33. Stevens T, Dumot JA, Parsi MA, Zuccaro G, Vargo JJ. Combined endoscopic ultrasound and secretin endoscopic pancreatic function test in patients evaluated for chronic pancreatitis. Dig Dis Sci. 2010;55(9):2681-7. (Level III evidence). View the reference
  34. Adler DG, Lichtenstein D, Baron TH, Davila R, Egan JV, Gan SL, et al. The role of endoscopy in patients with chronic pancreatitis. Gastrointest Endosc. 2006;63(7):933-7. (Review article). View the reference
  35. NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. NIH Consens State Sci Statements. 2002;19(1):1-26. (Guideline). View the reference
  36. Axon AT. Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. Cambridge classification. Radiol Clin North Am. 1989;27(1):39-50. (Review article). View the reference
  37. Bor R, Madácsy L, Fábián A, Szepes A, Szepes Z. Endoscopic retrograde pancreatography: When should we do it? World Journal of Gastrointestinal Endoscopy. 2015;7(11):1023-31. (Level II evidence). View the reference
  38. Lohr JM. What are the useful biological and functional markers of early-stage chronic pancreatitis? J Gastroenterol. 2007;42 Suppl 17:66-71. (Review article). View the reference
  39. Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterology & hepatology. 2013;9(8):496-504. (Review article). View the reference
  40. Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology. 1976;70(3):314-20. (Level II evidence). View the reference
  41. Johnson GK, Geenen JE, Bedford RA, Johanson J, Cass O, Sherman S, et al. A comparison of nonionic versus ionic contrast media: results of a prospective, multicenter study. Midwest Pancreaticobiliary Study Group. Gastrointest Endosc. 1995;42(4):312-6. (Level II-III evidence). View the reference
  42. Wang P, Li ZS, Liu F, Ren X, Lu NH, Fan ZN, et al. Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol. 2009;104(1):31-40. (Level II evidence). View the reference
  43. Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D, et al. Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39(9):793-801. (Level II evidence). View the reference

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Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Pancreas