Radiol Oncol 1997; 31: 273-6.
Endoscopic retrograde pancreatography in the diagnosis of
chronic pancreatitis
Milivoj Rubinic
Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka,
Croatia
The importance of endoscopic cholangiopancreatography (ERCP) in the diagnosis of chronic pancreatitis is the basic topic of the paper. The method is considerably more sensitive than any other radiological, especially noninvasive method used in diagnostics. Especially thanks to this combined endoscopis radiological method, chronic pancreatitis is at present classified in three groups. Thus, it is possible to make exact plans for the further treatment, which may be either medical (endoscopical), or surgical. An analysis is here made of 370 patients with whom chronic pancreatitis was established by this method. Of this number 286 (77 %) were men, and84(23 %)women. Most of the patients were between 40 and 50 years of age, their number being 204 (55 %). Here they appear classified into three groups according to the mentioned classification method. The group of mild chronic pancreatitis includes 154 (42%) patients, 123 (33 %) patients show moderate changes, and 93 (25 %) patients have marked changes. It is important to point out that 211 (74 %) of 286 patients in their case history mentioned the consumption of alcohol and nicotine for more than five years.
Key words: pancreatitis-diagnosis, cholangiopancreatography, endoscopic retrograde: chronic disease
Introduction
Endoscopic retrograde Cholangiopancreatography (ERCP), a combined radiological method, was introduced into clinical practice 25 years ago and became a routine procedure in the diagnostics of biliopancreatic system complaints.'"4 It has since taken a special place in the diagnostics of chronic pancreatitis, where it is much more sensitive than any other noninvasive radiological method such as ultrasound and computerized tomography.5"8
Except in the appraisal of the severity of chronic pancreatitis on the basis of changes in its ductal system, it also serves to the planning of any further treatment, which may be either medical (endoscop-
Correspondence to: Prof. dr. Milivoj Rubinic, Internal Clinic-Gastroenterology, Kresimirova 42, 51000 Rijeka, Croatia.
UDC: 616.37-002.1-072.1
ical), or surgical.9"1" The aim of the paper is to illustrate: the value of ERCP in the diagnostics of chronic pancreatitis and to make an analysis of the results obtained.
Material and methods
An analysis of 370 successful ERCPs in which chronic pancreatitis had been established was made. The indication was made on the basis of the patients' case history, clinical picture, lab reports, and the pancreas ultrasound examination of all patients was carried out as well. ERCP was made a technique as it was described and adopted by a great number of authors. In this case the special attention was given to the pre-ERCP control to detect pre-filling changes of parenchima, such as calcification before the central film examination.2"5'7'"
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Ruhinic M
Figure I. Mild changes chronic pannv.iiius. Norma! ductus pancreaticus (P) and > 3 changes lateral duct (arrow).
Figure 2. Moderate changes chronic pancreatitis. Dilatation of ductus pancreaticus (P) and 3 changes lateral duct (arrow).
'Figure 3. Mark«! changes chronic pancreatitis. The same as Figure 2 with extremly dilatation of ductus pancreaticus (P and arrow).
All ERCP findings have been classified by using the international system of 1984 (Table I)12 which is ilustrated at Figures 1, 2, 3,
men analysed, the case history of 211 (74%) included a record of the consumption of these harmful agents.
Results
Of 370 successfully made ERCPs, where chronic pancreatitis had been found, 286 (77 %) were men, and 84 (23 %) women. The average age of all patients analysed was under 40, 93 (25 %); between 40 and 50 were 204 (55 %) patients, and 73 (20 %) patients were above 50, By using the above mentioned classification the group of mild changes comprised 154 (42%) patients, the group of moderate changes 123 (33 %) patients, and the most severely affected group of marked changes 93 (25 %) patients. In this last group it is of interest to mention that it comprised 81 (87%) men, and only 12 (13 %) women, all of them alcohol and nicotine consumers for five years of more. And of all the 286
Discussion
Chronic pancreatitis in its mild form presents a difficult diagnostic problem.s-In its severe form, with or without complications, the diffilculty is increased by a very serious therapeutic problem. But it is exactly through the ERCP that today we have also numerous nonsurgical possibilities in the treatment of this disease at our disposal.14"'8 Another important fact to be pointed out is, thanks to this method, that the classification of chronic pancreatitis has been effected into three forms, which in turn is important for the treatment of this disease."'12
To make the endoscopic treatment of this disease easier, there exist today also other classifications at our disposal, although they are rarely used.16 This paper deals with the analysis of 370 ERCPs in
Endoscopic retrograde pancreatography in the diagnosis of chronic pancreatitis
275
Table 1. Classification of chronic pancreatitis.12
Terminology	Main pancreatic	Number
duct	of dameged
branches of pancreatic
_duct
unchanged	none
unchanged	< 3
unchanged	3 or > 3
pathologicaly
changed	> 3
pathologicaly
changed*_> 3
* With one, or more than one criteria: big cyst, obstruction, marked dilatation or marked changes of organ shape.
which chronic pancreatitis has been established. It is evident that in 77 % of the cases men are predominant, which is the result of the more frequent use of noxious agents such as alcohol and nicotine. It has been further noticed that the disease occurs at the most reproducible stage, and that is between 40 and 50 years of age. Similar data have been established also by other authors.11'
The internationally accepted classification has been used also in this paper, in which 42 % cases of mild, 33 % cases of medium, and 25 % cases of severe chronic pancreatitis have been found. It is not possible to compare these data with the pertinent literature, as the severity of the disease is dependent upon the duration of the period of time during which the noxious agents have been consumed, the type of alcohol and nicotine, and a number of other external and internal factors.20"22 It is sometimes difficult to make or solve the differential diagnosis of pancreas carcinoma regardless the series of methods used, noninvasive radiological or invasive endoscopic ones.23"25 And to conclude with, it is exactly thanks to the ERCP combined endoscopic radiological method that chronic inflamatory pancreas diseases can be established at an early stage, to differentiate this method from other radiological non-invasive examinations. In severe cases of the disease, besides for making a strictly correct diagnosis, the method offers also at present wide therapeutic possibilities.
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