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Diagnostic Approach

  • Mario Tadić
  • Tajana Štoos-Veić
  • Ivica Grgurević
Chapter
Part of the Clinical Gastroenterology book series (CG)

Abstract

The diagnostic approach for pancreatic disease must rely on a combination of laboratory tests, imaging studies, and clinical symptoms. However, the symptoms of pancreatic diseases are often absent for a long time. Establishing a diagnosis at an early stage of the disease can improve outcomes by providing adequate treatment modalities and preventing complications. Pancreatic enzyme tests in body fluids have proven their value in evaluation of pancreatic disease but have some limitations. Pancreatic function tests detect diffuse pancreatic disease and reveal early deterioration of pancreatic exocrine function before the clinical characteristics such as maldigestion or steatorrhea occur. Advances in technologies have given the ability to visualize changes in pancreatic structure using available imaging procedures. However, detecting pancreatic disease in its early stages is still a difficult task. In this chapter, we discuss the diagnostic approach to pancreatic disease, and the advantages and disadvantages of available diagnostic methods, identifying gaps for each method to increase diagnostic accuracy of early-stage pancreatic disease.

Keywords

Pancreatitis Pancreatic cancer Exocrine insufficiency Pancreatic imaging Transabdominal ultrasound Endoscopic ultrasound (EUS) EUS-FNA (endoscopic ultrasound-guided fine needle aspiration) Computed tomography (CT) Secretin-enhanced MRCP (magnetic resonance cholangiopancreatography) 

References

  1. 1.
    Ghaneh P, Costello E, Neoptolemos JP. Biology and management of pancreatic cancer. Gut. 2007;56:1134–52.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016;375(20):1972–81.CrossRefPubMedGoogle Scholar
  3. 3.
    Issa Y, et al. Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study. HPB. 2017;19:978.  https://doi.org/10.1016/j.hpb.2017.07.006.CrossRefPubMedGoogle Scholar
  4. 4.
    Anaizi A, Hart PA, Conwell DL. Diagnosing chronic pancreatitis. Dig Dis Sci. 2017;62:1713–20.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Ramsey ML, Conwell DL, Hart PA. Complications of chronic pancreatitis. Dig Dis Sci. 2017;62(7):1745–50.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Fonseca V, Berger LA, Beckett AG, Dandona P. Size of pancreas in diabetes mellitus: a study based on ultrasound. Br Med J. 1985;291:1240–1.CrossRefGoogle Scholar
  7. 7.
    Della Corte C, Mosca A, Majo F, et al. Nonalcoholic fatty pancreas disease and nonalcoholic fatty liver disease: more than ectopic fat. Clin Endocrinol. 2015;83:656–62.CrossRefGoogle Scholar
  8. 8.
    Jeong HT, Lee MS, Kim MJ. Quantitative analysis of pancreatic echogenicity on transabdominal sonography: correlations with metabolic syndrome. J Clin Ultrasound. 2015;43:98–108.CrossRefPubMedGoogle Scholar
  9. 9.
    Li D. Diabetes and pancreatic cancer. Mol Carcinog. 2012;51(1):64–74.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Buscarini E, Greco S. Transabdominal ultrasonography of the pancreas. In: D’Onofrio M, editor. Ultrasonography of the pancreas. Milan: Springer; 2012.Google Scholar
  11. 11.
    Rickes S, Unkrodt K, Neye H, Okran KW, Wermke W. Differentiation of pancreatic tumours by conventional ultrasound, unenhanced and echo-enhanced power Doppler sonography. Scand J Gastroenterol. 2002;37:1313–20.CrossRefPubMedGoogle Scholar
  12. 12.
    Kitano M, Kudo M, Maekawa K, Suetomi Y, Sakamoto H, Fukuta N, et al. Dynamic imaging of pancreatic diseases by contrast enhanced coded phase inversion harmonic ultrasonography. Gut. 2004;53:854–9.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Park MK, Jo J, Kwon H, Cho JH. Oh JY, Noh MH, Nam KJ. Usefulness of acoustic radiation force impulse elastography in the differential diagnosis of benign and malignant solid pancreatic lesions. Ultrasonography. 2014;33:26–33.CrossRefPubMedGoogle Scholar
  14. 14.
    Kawada N, Tanaka S, Uehara H, Ohkawa K, Yamai T, Takada R, Shiroeda H, Arisawa T, Tomita Y. Potential use of point shear wave elastography for the pancreas: a single center prospective study. Eur J Radiol. 2014;83:620–4.CrossRefPubMedGoogle Scholar
  15. 15.
    Kawada N, Tanaka S. Elastography for the pancreas: current status and future perspective. World J Gastroenterol. 2016;22(14):3712–24.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Zamboni GA, Ambrosetti MC, D’Onofrio M, Pozzi Mucelli R. Ultrasonography of the pancreas. Radiol Clin N Am. 2012;50:395–406.CrossRefPubMedGoogle Scholar
  17. 17.
    Catalano MF, Sahai A, Levy M, Romagnuolo J, Wiersema M, Brugge W, Freeman M, Yamao K, Canto M, Hernandez LV. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointest Endosc. 2009;69:1251–61.CrossRefPubMedGoogle Scholar
  18. 18.
    Bolondi L, Priori P, Gullo L, et al. Relationship between morphological changes detected by ultrasonography and pancreatic exocrine function in chronic pancreatitis. Pancreas. 1987;2(2):222–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Coté GA, Smith J, Sherman S, Kelly K. Technologies for imaging the normal and diseased pancreas. Gastroenterology. 2013;144(6):1262–71.CrossRefPubMedGoogle Scholar
  20. 20.
    Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223(3):603–13.CrossRefPubMedGoogle Scholar
  21. 21.
    Valls C, et al. Dual-phase helical CT of pancreatic adenocarcinoma: assessment of resectability before surgery. AJR Am J Roentgenol. 2002;178:821–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Cassinotto C, Chong J, Zogopoulos G, Reinhold C, Chiche L, Lafourcade JP, Cuggia A, Terrebonne E, Dohan A, Gallix B. Resectable pancreatic adenocarcinoma: role of CT quantitative imaging biomarkers for predicting pathology and patient outcomes. Eur J Radiol. 2017;90:152–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Sherman S, Freeman ML, Tarnasky PR, Wilcox CM, Kulkarni A, Aisen AM, Jacoby D, Kozarek RA. Administration of secretin (RG1068) increases the sensitivity of detection of duct abnormalities by magnetic resonance cholangiopancreatography in patients with pancreatitis. Gastroenterology. 2014;147(3):646–54.CrossRefPubMedGoogle Scholar
  24. 24.
    Manfredi R, Pozzi Mucelli R. Secretin-enhanced MR imaging of the pancreas. Radiology. 2016;279(1):29–43.CrossRefPubMedGoogle Scholar
  25. 25.
    Dimastromatteo J, Brentnall T, Kelly KA. Imaging in pancreatic disease. Nat Rev Gastroenterol Hepatol. 2017;14(2):97–109.CrossRefPubMedGoogle Scholar
  26. 26.
    Sato A, Irisawa A, Bhutani MS, Shibukawa G, Yamabe A, Fujisawa M, Igarashi R, Arakawa N, Yoshida Y, Abe Y, Maki T, Hoshi K, Ohira H. Significance of normal appearance on endoscopic ultrasonography in the diagnosis of early chronic pancreatitis. Endosc Ultrasound. 2017;0:0.  https://doi.org/10.4103/2303-9027.209870.CrossRefGoogle Scholar
  27. 27.
    Bhutiani N, et al. Assessing the value of endoscopic ultrasound in predicting symptom severity and long-term clinical course in chronic pancreatitis. HPB. 2017;19:868.  https://doi.org/10.1016/j.hpb.2017.05.012.CrossRefPubMedGoogle Scholar
  28. 28.
    Storm AC, Lee LS. Endoscopic ultrasound-guided techniques for diagnosing pancreatic mass lesions: can we do better? World J Gastroenterol. 2016;22(39):8658–69.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Adler D, Schmidt CM, Al-Haddad M, Barthel JS, Ljung BM, Merchant NB, Romagnuolo J, Shaaban AM, Simeone D, Pitman MB, Layfield LJ. Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: the Papanicolaou Society of Cytopathology Guidelines. Cytojournal. 2014;11(Suppl 1):1.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Tadic M, Stoos-Veic T, Kusec R. Endoscopic ultrasound guided fine needle aspiration and useful ancillary methods. World J Gastroenterol. 2014;20(39):14292–300.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Pitman MB, Layfield LJ. The Papanicolaou Society of Cytopathology system for reporting pancreatobiliary cytology: definitions, criteria and explanatory notes. Cham: Springer; 2015.Google Scholar
  32. 32.
    Layfield LJ, Ehya H, Filie AC, Hruban RH, Jhala N, Joseph L, Vielh P, Pitman MB. Utilization of ancillary studies in the cytologic diagnosis of biliary and pancreatic lesions: the Papanicolaou Society of Cytopathology Guidelines. Cytojournal. 2014;11(Suppl 1):4.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Iglesias-García J, Lindkvist B, Lariño-Noia J, Domínguez-Muñoz JE. The role of EUS in relation to other imaging modalities in the differential diagnosis between mass forming chronic pancreatitis, autoimmune pancreatitis and ductal pancreatic adenocarcinoma. Rev Esp Enferm Dig. 2012;104(6):315–21.CrossRefPubMedGoogle Scholar
  34. 34.
    Hollerbach S, Klamann A, Topalidis T, Schmiegel WH. Endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) cytology for diagnosis of chronic pancreatitis. Endoscopy. 2001;33(10):824–31.CrossRefPubMedGoogle Scholar
  35. 35.
    Stelow EB, Bardales RH, Lai R, Mallery S, Linzie BM, Crary GS, Stanley MW. The cytological spectrum of chronic pancreatitis. Diagn Cytopathol. 2005;32(2):65–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Boursi B, Finkelman B, Giantonio BJ, Haynes K, Rustgi AK, Rhim AD, Mamtani R, Yang YX. A clinical prediction model to assess risk for pancreatic cancer among patients with new-onset diabetes. Gastroenterology. 2017;152(4):840–50.CrossRefPubMedGoogle Scholar
  37. 37.
    Chen J, Yang R, Lu Y, Xia Y, Zhou H. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesion: a systematic review. J Cancer Res Clin Oncol. 2012;138(9):1433–41.CrossRefPubMedGoogle Scholar
  38. 38.
    Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol. 2009;40(5):612–23.CrossRefPubMedGoogle Scholar
  39. 39.
    Yao K, Wang Q, Jia J, Zhao HA. Competing endogenous RNA network identifies novel mRNA, miRNA and lncRNA markers for the prognosis of diabetic pancreatic cancer. Tumour Biol. 2017;39(6):1010428317707882.  https://doi.org/10.1177/1010428317707882.CrossRefPubMedGoogle Scholar
  40. 40.
    Bellizzi AM. Assigning site of origin in metastatic neuroendocrine neoplasms: a clinically significant application of diagnostic immunohistochemistry. Adv Anat Pathol. 2013;20(5):285–314.CrossRefPubMedGoogle Scholar
  41. 41.
    Mizuno S, Isayama H, Nakai Y. Prevalence of pancreatic cystic lesions is associated with diabetes mellitus and obesity: an analysis of 5296 individuals who underwent a preventive medical examination. Pancreas. 2017;46:801.  https://doi.org/10.1097/MPA.0000000000000833.CrossRefPubMedGoogle Scholar
  42. 42.
    Pitman MB. Pancreatic cyst fluid triage: a critical component of the preoperative evaluation of pancreatic cysts. Cancer Cytopathol. 2013;121(2):57–60.CrossRefPubMedGoogle Scholar
  43. 43.
    Tanaka M, Fernández-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K. International Association of Pancreatology. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12(3):183–97.CrossRefGoogle Scholar
  44. 44.
    Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology. 2017.  https://doi.org/10.1016/j.pan.2017.07.007.
  45. 45.
    Park WG, Mascarenhas R, Palaez-Luna M, Smyrk TC, O'Kane D, Clain JE, Levy MJ, Pearson RK, Petersen BT, Topazian MD, Vege SS, Chari ST. Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts. Pancreas. 2011;40(1):42–5.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Kadayifci A, Al-Haddad M, Atar M, Dewitt JM, Forcione DG, Sherman S, Casey BW, Fernandez-Del Castillo C, Schmidt CM, Pitman MB, Brugge WR. The value of KRAS mutation testing with CEA for the diagnosis of pancreatic mucinous cysts. Endosc Int Open. 2016;4(4):E391–6.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Conner JR, Mariño-Enríquez A, Mino-Kenudson M, Garcia E, Pitman MB, Sholl LM, Srivastava A, Doyle LA. Genomic characterization of low- and high-grade pancreatic mucinous cystic neoplasms reveals recurrent KRAS alterations in “high-risk” lesions. Pancreas. 2017;46(5):665–71.CrossRefPubMedGoogle Scholar
  48. 48.
    Scourtas A, Dudley JC, Brugge WR, Kadayifci A, Mino-Kenudson M, Pitman MB. Preoperative characteristics and cytological features of 136 histologically confirmed pancreatic mucinous cystic neoplasms. Cancer. 2017;125(3):169–77.Google Scholar
  49. 49.
    Volmar KE, Vollmer RT, Routbort MJ, Creager AJ. Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods. Cancer. 2006;108(4):231–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Chadwick BE, Layfield LJ, Witt BL, Schmidt RL, Cox RN, Adler DG. Significance of atypia in pancreatic and bile duct brushings: follow-up analysis of the categories atypical and suspicious for malignancy. Diagn Cytopathol. 2014;42(4):285–91.CrossRefPubMedGoogle Scholar
  51. 51.
    Dudley JC, Zheng Z, McDonald T, Le LP, Dias-Santagata D, Borger D, Batten J, Vernovsky K, Sweeney B, Arpin RN, Brugge WR, Forcione DG, Pitman MB, Iafrate AJ. Next-generation sequencing and fluorescence in situ hybridization have comparable performance characteristics in the analysis of Pancreaticobiliary brushings for malignancy. J Mol Diagn. 2016;18(1):124–30.CrossRefPubMedGoogle Scholar
  52. 52.
    Elek G, Gyökeres T, Schäfer E, Burai M, Pintér F, Pap A. Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy. Pathol Oncol Res. 2005;11(3):145–55.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mario Tadić
    • 1
    • 2
  • Tajana Štoos-Veić
    • 3
  • Ivica Grgurević
    • 1
    • 2
  1. 1.Department of Gastroenterology, Hepatology and Clinical NutritionUniversity of ZagrebZagrebCroatia
  2. 2.Faculty of Pharmacy and BiochemistryUniversity Hospital DubravaZagrebCroatia
  3. 3.Department of Pathology and CytologyUniversity Hospital DubravaZagrebCroatia

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