What is the likely diagnosis if a patient has a heteroechoic pancreas, hyperechoic duct walls, and hyperechoic foci and strands on ultrasound?

Chronic Pancreatitis

The combination of heteroechoic (heterogeneous) pancreas, hyperechoic duct walls, and hyperechoic foci and strands on ultrasound is diagnostic of chronic pancreatitis.

EUS Features Diagnostic of Chronic Pancreatitis

The specific ultrasound findings you describe represent established EUS criteria for chronic pancreatitis:

• Hyperechoic foci and strands are among the nine validated EUS features used to diagnose chronic pancreatitis 1, 2
• Hyperechoic duct walls (margins) represent another key diagnostic criterion for chronic pancreatitis 1, 2
• Heteroechoic (heterogeneous) pancreatic parenchyma reflects the lobularity and structural changes characteristic of chronic pancreatitis 2, 3

Diagnostic Certainty Based on Number of Criteria

The diagnosis becomes increasingly certain based on how many EUS features are present:

• Early chronic pancreatitis is likely when more than 3 EUS criteria are present (positive predictive value >85%) 2, 3
• Moderate to severe chronic pancreatitis is likely when more than 5-6 criteria are present 2, 3
• The presence of hyperechoic foci with shadowing (calcifications) is the most predictive independent feature of chronic pancreatitis 1, 2

Rosemont Classification Framework

According to the consensus-based Rosemont criteria for EUS diagnosis of chronic pancreatitis:

• Major criteria include hyperechoic foci with shadowing (calculi) and lobularity with honeycombing 4, 5
• Minor criteria include hyperechoic duct walls, hyperechoic strands, nonshadowing hyperechoic foci, irregular duct contour, and dilated ducts 4
• Your described findings of hyperechoic duct walls, hyperechoic foci, and strands represent multiple minor criteria that collectively support the diagnosis 4

Clinical Context

Important caveat: While these EUS findings are highly suggestive of chronic pancreatitis, correlation with clinical presentation is essential:

• Look for typical symptoms including recurrent upper abdominal pain, history of alcohol abuse, or unexplained pancreatic enzyme elevations 6, 2
• Serum lipase may be elevated during acute exacerbations but can be normal in chronic disease 6
• The interobserver agreement among experienced endosonographers for chronic pancreatitis diagnosis is moderately good (kappa = 0.45), with best agreement for duct dilatation and lobularity 1