The Rosemont Criteria: A Diagnostic Tool for Chronic Pancreatitis
The Rosemont criteria are endoscopic ultrasound (EUS) criteria used to diagnose chronic pancreatitis, particularly in cases where conventional imaging techniques may not show definitive changes. 1
Background and Development
The Rosemont criteria were established in 2009 through a consensus study involving 32 internationally recognized endosonographers who anonymously voted on terminology, rank order, and categorization of EUS features for chronic pancreatitis. The criteria were developed to address inconsistencies in EUS terminology and diagnostic approaches that made it difficult to reproduce findings and apply them consistently in clinical practice. 1
Structure of the Rosemont Classification
The Rosemont criteria categorize EUS findings into major and minor criteria:
Major Criteria:
- Hyperechoic foci with shadowing and main pancreatic duct calculi
- Lobularity with honeycombing
Minor Criteria:
- Pancreatic cysts
- Dilated main pancreatic duct ≥3.5 mm
- Irregular pancreatic duct contour
- Dilated side branches ≥1 mm
- Hyperechoic duct wall
- Strands
- Non-shadowing hyperechoic foci
- Lobularity with non-contiguous lobules
Diagnostic Categories
Based on the presence of these criteria, patients are classified into one of four categories:
- Consistent with chronic pancreatitis
- Suggestive of chronic pancreatitis
- Indeterminate for chronic pancreatitis
- Normal pancreas
Clinical Utility and Validation
The Rosemont criteria have been evaluated in several studies:
When compared to histopathology (the gold standard), the Rosemont classification showed strong predictive value for chronic pancreatitis in patients with features "suggestive" of CP, with 96.2% of such patients having evidence of CP on histopathology. 2
However, the "normal" Rosemont classification had poor correlation in excluding CP, as 55.5% of patients classified as "normal" still had CP on histopathology. 2
The interobserver agreement (IOA) for the Rosemont criteria in diagnosing chronic pancreatitis is moderate (k = 0.46), similar to conventional criteria (k = 0.53). 3
Advantages Over Standard Criteria
The Rosemont classification may be particularly useful in patients with high suspicion of chronic pancreatitis who have fewer than 4 standard criteria but with more significant findings such as parenchymal lithiasis, lobularity, or ductal calcifications. 4
Limitations
- Lack of a universally accepted reference standard for chronic pancreatitis makes validation challenging
- Moderate interobserver agreement suggests some subjectivity in interpretation
- Poor performance in excluding chronic pancreatitis when EUS findings are classified as "normal"
Clinical Application
The Rosemont criteria can be used independently of patient characteristics (age, sex, BMI) and environmental factors (smoking and alcohol exposure), making them broadly applicable across different patient populations. 2
For clinicians evaluating patients with suspected chronic pancreatitis, the Rosemont criteria provide a standardized approach to interpreting EUS findings, particularly valuable when conventional imaging is inconclusive or in non-calcific chronic pancreatitis where changes may be more subtle.
Pitfalls to Avoid
- Do not rely solely on Rosemont "normal" classification to exclude chronic pancreatitis, as this has been shown to have poor correlation with histopathology
- Remember that EUS findings should be interpreted in the context of clinical symptoms and other diagnostic tests
- Be aware that interobserver variability exists, so correlation with clinical findings remains important
The Rosemont criteria represent an important advancement in standardizing the EUS-based diagnosis of chronic pancreatitis, though they should be considered as part of a comprehensive diagnostic approach rather than a definitive standalone test.