From the Guidelines
The best imaging tool for chronic pancreatitis with elevated serum lipase (312 U/L) and chronically elevated carcinoembryonic antigen (CEA) at 5.0 ng/mL is MRI with magnetic resonance cholangiopancreatography (MRCP), as it provides detailed images of the pancreas and pancreatic ducts, and is preferred for its sensitivity and ability to identify communication between a pancreatic cystic neoplasm and the pancreatic duct system 1.
Key Considerations
- The elevated lipase suggests ongoing pancreatic inflammation, while the chronically elevated CEA, though nonspecific, warrants thorough imaging to rule out pancreatic malignancy which can sometimes develop in the setting of chronic pancreatitis.
- MRI with MRCP is an excellent choice for evaluating the pancreatic ducts and identifying characteristic findings of chronic pancreatitis such as calcifications, ductal dilation, and parenchymal atrophy.
- Contrast-enhanced CT scan, ideally a pancreatic protocol CT, is an alternative option, but MRI with MRCP is preferred due to its sensitivity and ability to identify communication between a pancreatic cystic neoplasm and the pancreatic duct system 1.
Imaging Modalities
- MRI with MRCP: provides detailed images of the pancreas and pancreatic ducts, and is preferred for its sensitivity and ability to identify communication between a pancreatic cystic neoplasm and the pancreatic duct system 1.
- Contrast-enhanced CT scan: an alternative option, but may not provide the same level of detail as MRI with MRCP.
- Endoscopic ultrasound (EUS): may be recommended as a follow-up if the CT or MRI findings are inconclusive, as it can detect subtle pancreatic changes and allow for tissue sampling if needed.
Clinical Scenarios
- In cases where the identification of calcification is important, or for tumour staging, or for diagnosing postoperative recurrent disease, multimodality imaging should be considered 1.
- The use of CT should be considered in clinical situations where the detection of parenchymal, mural or central calcification is important, especially when differentiating pseudocysts associated with chronic pancreatitis from pancreatic cystic neoplasms 1.
From the Research
Imaging Tools for Chronic Pancreatitis
The following imaging tools can be used to diagnose chronic pancreatitis:
- Abdominal ultrasound (US)
- Computerized tomography (CT)
- Endoscopic ultrasound (EUS)
- Magnetic resonance imaging (MRI)
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP) 2
Comparison of Imaging Tools
Studies have compared the accuracy of different imaging tools for diagnosing chronic pancreatitis:
- EUS and MRCP have been shown to be highly accurate and complementary when used together 3
- MRI and MRCP play an important role in diagnosing chronic pancreatitis by imaging pancreatic parenchyma and ducts 4
- Multi-detector CT (MDCT) is a cornerstone for evaluating chronic pancreatitis, but has limitations and is reserved for providing morphological information 4
- Secretin-stimulated MRCP and technological innovations in magnetic resonance may improve diagnostic accuracy 5
Advanced Imaging Techniques
Advanced imaging techniques, such as:
- Quantitative MR imaging
- Radiomics and artificial intelligence
- Secretin-stimulated diffusion-weighted magnetic resonance imaging (DW-MRI) may provide quantitative metrics for determining the presence and severity of acinar cell loss and aid in the diagnosis of chronic pancreatitis 4, 5
Diagnosis of Chronic Pancreatitis
The diagnosis of chronic pancreatitis can be made using a combination of imaging tools and clinical criteria:
- EUS and MRCP can be used to diagnose chronic pancreatitis with high sensitivity and specificity 3
- MRI and MRCP can be used to image pancreatic parenchyma and ducts, and to detect subtle parenchymal changes in the setting of chronic pancreatitis 2, 4
- Secretin-stimulated DW-MRI may help to detect mild or early pancreatitis 5