American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines

Conwell, Darwin L. MD, MS*; Lee, Linda S. MD; Yadav, Dhiraj MD; Longnecker, Daniel S. MD§; Miller, Frank H. MD; Mortele, Koenraad J. MD; Levy, Michael J. MD#; Kwon, Richard MD**; Lieb, John G. MD††; Stevens, Tyler MD‡‡; Toskes, Phillip P. MD§§; Gardner, Timothy B. MD§; Gelrud, Andres MD∥∥; Wu, Bechien U. MD¶¶; Forsmark, Christopher E. MD§§; Vege, Santhi S. MD#

doi: 10.1097/MPA.0000000000000237
Original Article

Abstract: The diagnosis of chronic pancreatitis remains challenging in early stages of the disease. This report defines the diagnostic criteria useful in the assessment of patients with suspected and established chronic pancreatitis. All current diagnostic procedures are reviewed, and evidence-based statements are provided about their utility and limitations. Diagnostic criteria for chronic pancreatitis are classified as definitive, probable, or insufficient evidence. A diagnostic (STEP-wise; survey, tomography, endoscopy, and pancreas function testing) algorithm is proposed that proceeds from a noninvasive to a more invasive approach. This algorithm maximizes specificity (low false-positive rate) in subjects with chronic abdominal pain and equivocal imaging changes. Furthermore, a nomenclature is suggested to further characterize patients with established chronic pancreatitis based on TIGAR-O (toxic, idiopathic, genetic, autoimmune, recurrent, and obstructive) etiology, gland morphology (Cambridge criteria), and physiologic state (exocrine, endocrine function) for uniformity across future multicenter research collaborations. This guideline will serve as a baseline manuscript that will be modified as new evidence becomes available and our knowledge of chronic pancreatitis improves.

From the *Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH; †Division of Gastroenterology, Hepatology, and Endoscopy, Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA; ‡Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; §Department of Pathology, The Geisel School of Medicine at Dartmouth, Hanover, NH; ║Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL; ¶Department of Radiology, Beth Israel Deaconness Hospital, Harvard Medical School, Boston, MA; #Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN; **Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI; ††Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; ‡‡Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; §§Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Florida, Gainesville, FL; ║║Department of Gastroenterology, University of Chicago, Chicago, IL; and ¶¶Division of Gastroenterology, Department of Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.

Received for publication June 17, 2014; accepted September 19, 2014.

Reprints: Darwin L. Conwell, MD, MS, Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, 288A Faculty Office Tower, 410 W, 10th Ave, 2nd Floor, Columbus, Ohio 43210 (e-mail: darwin.conwell@osumc.edu).

The authors declare no conflict of interest.

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© 2014 by Lippincott Williams & Wilkins.