Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Table 1 Diagnostic value of endoscopic ultrasonography in chronic pancreatitis

Author	No. of pts	No. of EUS criteria	Threshold for CP diagnosis	Comparison	Sn	Sp	PPV	NPV	Acc
Wiersema et al[4]	69	11	> 3 = dg	EUS vs ERCP	100	79
				EUS vs ERCP + secretin test	70	33
				EUS vs ERCP + history	90	66
Catalano et al[2]	80	11	1-2 mild	EUS vs secretin test	84	78
			3-5 moderate	EUS vs ERCP	86.1	95.4
			> 5 severe	EUS vs ERCP + secretin test	84.2	97.6
Sahai et al[8]	126	9	> 2 for any CP	EUS vs ERCP			> 85	< 85
			< 3 = fibrosis
			> 6 = severe				> 85
Conwell et al[14]	56	9	4-5 = equivocal	EUS vs ePFT	36	94	93	41
			> 6 = definite		26	100	100	39
Stevens et al[13]	83	9	3-5 = dg	EUS vs ERCP	68	79	83	62
			6-9 = severe
Stevens et al[10]	100	9	> 4	Radial EUS vs ePFT	68	95			84
				Linear EUS vs ePFT	44	95			74
Stevens et al[12]	50	9	> 4	EUS vs secretin ePFT	71	92
				EUS vs CCK ePFT	63	85
Zimmermann et al[23]	21	9	> 4	EUS vs histology (surgery)	78	73
Varadarajulu et al[24]	21	9	> 4	EUS vs histology1 (surgery)	90	85.7			88.1
Chong et al[25]	71	9	> 3 = dg	EUS vs histology1 (surgery)	83.3	80
			> 4 = severe fibrosis
Bhutani et al[22]	11	9	> 3	EUS vs histology (autopsy)

¹Non-calcific chronic pancreatitis. ePFT: Endoscopic pancreatic function test; EUS: Endoscopic ultrasonography; ERCP: Endoscopic retrograde cholangiopancreatography; Sn: Sensitivity; Sp: Specificity; Acc: Accuracy; CCK: Cholecystokinin; PPV: Positive predictive value; NPV: Negative predictive value.

Table 2 Correspondence between standard endoscopic ultrasonography criteria and pathologic features in chronic pancreatitis (adapted from Sahai AV 2002[21])

Standard EUS criteria	Pathologic features
Parenchymal criteria
Hyperechoic foci	Small calcifications
Hyperechoic strands	Fibrosis
Lobularity	Edema or fibrosis
Cysts	Pseudocysts
Calcifications	Calcifications
Ductal criteria
MPD dilatation	MPD dilatation
MPD irregularity	MPD irregular
Hyperechoic MPD walls	Ductal fibrosis or edema
Visible side branches	Dilated secondary branches

EUS: Endoscopic ultrasonography; MPD: Main pancreatic duct.

Table 3 Rosemont consensus definitions

Rank	Features		Definition	Location
	Parenchymal features
1	Major A	Hyperechoic foci with shadowing	Echogenic structures ≥ 2 mm in length and width that shadow	Body and tail only
2	Major B	Lobularity with honeycombing	Well-circumscribed, ≥ 5 mm structures with enhancing rims and relatively echo-poor centers, with ≥ 3 lobules	Body and tail only
	Minor	Lobularity with honeycombing	Well-circumscribed, ≥ 5 mm structures with enhancing rims and relatively echo-poor centers, with non-contiguous lobules	Body and tail only
3	Minor	Hyperechoic foci without shadowing	Echogenic structures ≥ 2 mm in length and width with no shadowing	Body and tail only
4	Minor	Cysts	Anechoic, rounded/elliptical structures with or without septations	Head, body and tail only
5	Minor	Stranding	Hyperechoic lines ≥ 3 mm in length in at least two different directions with respect to the imaged plane	Body and tail only
	Ductal features
1	Major A	MPD calculi	Echogenic structures within the MPD with acoustic shadowing	Head, body and tail only
2	Minor	Irregularity of MPD contour	Uneven or irregular outline and ectatic course	Body and tail only
3	Minor	Dilated side branches	3 or more tubular anechoic structures each measuring ≥ 1 mm in width, budding from MPD	Body and tail only
4	Minor	MPD dilation	≥ 3.5 mm in body or > 1.5 mm in tail	Body and tail only
5	Minor	Hyperechoic duct margin	Echogenic, distinct structure greater than 50%of the entire MPD	Body and tail only

MPD: Main pancreatic duct.

Table 4 Rosemont diagnostic stratification

Stratum	Criteria
Consistent with CP	1 major feature A + ≥ 3 minor features
	1 major feature A + major feature B
	2 major feature
Suggestive of CP	1 major feature A + < 3 minor features
	1 major feature B + ≥ 3 minor features
	≥ 5 minor features (any)
Indeterminate for CP	3 or 4 minor features major feature B alone or with < 3 minor features
Normal	≤ 2 minor features1

¹Excludes cysts, dilated main pancreatic duct, hyperechoic non-shadowing foci, dilated side branch. CP: Chronic pancreatitis.