Kronik Pankreatitte Radyoloji
Özet
Kronik pankreatit (KP), tekrarlayan inflamasyonlar sonucu pankreasın endokrin ve ekzokrin fonksiyonlarını kalıcı olarak yitirmesine yol açan progresif bir hastalıktır. Tanı sürecinde klinik semptomların yanı sıra ultrasonografi (USG), bilgisayarlı tomografi (BT) ve manyetik rezonans görüntüleme (MRG) gibi yöntemler kritik rol oynar. USG; ucuz ve taşınabilir olmasıyla öne çıkarken, BT kalsifikasyonların tespitinde ve başlangıç değerlendirmesinde en sık kullanılan yöntemdir. MRG ve sekretinli MRKP (MRKP-S) ise özellikle erken evre duktal ve parankimal değişikliklerin saptanmasında BT'den daha duyarlıdır. Hastalığın radyolojik raporlamasında kalsifikasyon miktarı, kanal çapı düzensizliği ve parankimal atrofi gibi bulgular standartlaştırılmış sistemlerle (Cambridge veya NCI kriterleri) değerlendirilir. Ayrıca otoimmün pankreatit ve oluk pankreatiti gibi nadir formlar, görüntüleme özellikleriyle pankreas kanserinden ayırt edilmelidir. KP hastalarında pankreas adenokarsinomu riskinin belirgin şekilde artması, radyolojik takibin ve erken tanının önemini artırmaktadır. Modern görüntüleme teknikleri ve standart raporlama protokolleri sayesinde, hastalığın evrelemesi ve takibi yapılarak yaşam kalitesinin artırılması hedeflenmektedir.
Chronic pancreatitis (CP) is a progressive disease resulting in the permanent loss of endocrine and exocrine functions of the pancreas due to recurrent inflammation, where imaging methods such as ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) play a critical role in the diagnosis alongside clinical symptoms. While USG stands out for being inexpensive and portable, CT is the most commonly used initial method for detecting calcifications, and MRI, along with secretin-enhanced MRCP (S-MRCP), is more sensitive than CT in detecting early-stage ductal and parenchymal changes. Radiological reporting of the disease involves evaluating findings like calcification quantity, ductal irregularities, and parenchymal atrophy using standardized systems such as Cambridge or NCI criteria, while rare forms like autoimmune and groove pancreatitis must be distinguished from pancreatic cancer through specific imaging features. Given that the risk of pancreatic adenocarcinoma significantly increases in CP patients, the importance of radiological follow-up and early diagnosis is highlighted, with modern imaging techniques and standardized protocols aiming to improve disease staging, monitoring, and overall quality of life.
Referanslar
Conwell DL, Lee LS, Yadav D, et al. American Pancreatic Association practice guidelines in chronic pancreatitis evidence-based report on diagnostic guidelines. Pancreas. 2014;43(8): 1143–1162. doi:10.1097/MPA.0000000000000237
Singh VK, Yadav D, Garg PK. Diagnosis and Management of Chronic Pancreatitis: A Review. JAMA - Journal of the American Medical Association. 2019;322(24): 2422–2434. doi:10.1001/jama.2019.19411
Issa Y, Kempeneers MA, van Santvoort HC, et al. Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis. European Radiology. European Radiology; 2017;27(9): 3820–3844. doi:10.1007/s00330-016-4720-9
Gardner TB, Adler DG, Forsmark CE, et al. ACG Clinical Guideline: Chronic Pancreatitis. American Journal of Gastroenterology. 2020;115(3): 322–339. doi:10.14309/ajg.0000000000000535
Dimcevski G, Erchinger FG, Havre R, et al. Ultrasonography in diagnosing chronic pancreatitis: New aspects. World Journal of Gastroenterology. 2013;19(42): 7247–7257. doi:10.3748/wjg.v19.i42.7247
Remer EM, Baker ME. Imaging of chronic pancreatitis. Radiologic Clinics of North America. 2002;40(6): 1229–1242. doi:10.1016/S0033-8389(02)00044-1
Graziani R, Tapparelli M, Malagò R, et al. The various imaging aspects of chronic pancreatitis. Journal of the Pancreas. 2005;6(1): 73–88.
Luetmer H, Stephens H, Ward M. Luetmer PH, Stephens DH, Ward EM. Chronic pancreatitis: reassessment with current CT. Radiology. 1989 May;171(2):353-7. doi: 10.1148/radiology.171.2.2704799. PMID: 2704799. 1989; 353–357.
Siddiqi AJ, Miller F. Chronic Pancreatitis: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Features. Seminars in Ultrasound, CT and MRI. 2007;28(5): 384–394. doi:10.1053/j.sult.2007.06.003
Tirkes T, Fogel EL, Sherman S, et al. Detection of exocrine dysfunction by MRI in patients with early chronic pancreatitis. Abdominal Radiology. Springer US; 2017;42(2): 544–551. doi:10.1007/s00261-016-0917-2
Tirkes T, Lin C, Fogel EL, et al. T1 mapping for diagnosis of mild chronic pancreatitis. Journal of Magnetic Resonance Imaging. 2017;45(4): 1171–1176. doi:10.1002/jmri.25428
Miller FH, Keppke AL, Dalal K, et al. MRI of Pancreatitis and Its Complications: Part 2, Chronic Pancreatitis. American Journal of Roentgenology. 2004;183(6): 1637–1644. doi:10.2214/ajr.183.6.01831637
Sanyal R, Stevens T, Novak E, et al. Secretin-enhanced MRCP: Review of technique and application with proposal for quantification of exocrine function. American Journal of Roentgenology. 2012;198(1): 124–132. doi:10.2214/AJR.10.5713
Bian Y, Wang L, Chen C, et al. Quantification of pancreatic exocrine function of chronic pancreatitis with secretin-enhanced MRCP. World Journal of Gastroenterology. 2013;19(41): 7177–7182. doi:10.3748/wjg.v19.i41.7177
Hansen TM, Nilsson M, Gram M, et al. Morphological and functional evaluation of chronic pancreatitis with magnetic resonance imaging. World Journal of Gastroenterology. 2013;19(42): 7241–7246. doi:10.3748/wjg.v19.i42.7241
Tirkes T, Shah ZK, Takahashi N, et al. Reporting standards for chronic pancreatitis by using CT, MRI, and MR cholangiopancreatography: The consortium for the study of chronic pancreatitis, diabetes, and pancreatic cancer. Radiology. 2019;290(1): 207–215. doi:10.1148/radiol.2018181353
Sandrasegaran K, Lin C, Akisik FM, et al. State-of-the-art pancreatic MRI. American Journal of Roentgenology. 2010;195(1): 42–53. doi:10.2214/AJR.10.4421
Donati F, Boraschi P, Gigoni R, et al. Secretin-stimulated MR cholangio-pancreatography in the evaluation of asymptomatic patients with non-specific pancreatic hyperenzymemia. European Journal of Radiology. Elsevier Ireland Ltd; 2010;75(2): e38–e44. doi:10.1016/j.ejrad.2009.11.008
Akisik MF, Aisen AM, Sandrasegaran K, et al. Assessment of chronic pancreatitis: Utility of diffusion-weighted MR imaging with secretin enhancement. Radiology. 2009;250(1): 103–109. doi:10.1148/radiol.2493080160
Axon ATR, Classen M, Cotton PB, et al. Occasional report Pancreatography in chronic pancreatitis : interational definitions. Gut. 1984;25(February): 1107–1112.
Lesniak RJ, Hohenwalter MD, Taylor AJ. Spectrum of causes of pancreatic calcifications. American Journal of Roentgenology. 2002;178(1): 79–86. doi:10.2214/ajr.178.1.1780079
Andersen PL, Madzak A, Olesen SS, et al. Quantification of parenchymal calcifications in chronic pancreatitis: relation to atrophy, ductal changes, fibrosis and clinical parameters. Scandinavian Journal of Gastroenterology. Informa UK Limited, trading as Taylor & Francis Group; 2018;53(2): 218–224. doi:10.1080/00365521.2017.1415372
Hadidi A. Pancreatic duct diameter: Sonographic measurement in normal subjects. Journal of Clinical Ultrasound. 1983;11(1): 17–22. doi:10.1002/jcu.1870110105
Ladas SD, Tassios PS, Giorgiotis K, et al. Pancreatic duct width: its significance as a diagnostic criterion for pancreatic disease. Hepato-gastroenterology. Greece; 1993;40(1): 52–55.
Goda K, Sasaki E, Nagata K, et al. Pancreatic volume in type 1 and type 2 diabetes mellitus. Acta Diabetologica. 2001;38(3): 145–149. doi:10.1007/s005920170012
Balci NC, Smith A, Momtahen AJ, et al. MRI and S-MRCP findings in patients with suspected chronic pancreatitis: Correlation with endoscopic Pancreatic Function Testing (ePFT). Journal of Magnetic Resonance Imaging. 2010;31(3): 601–606. doi:10.1002/jmri.22085
Sato T, Ito K, Tamada T, et al. Age-related changes in normal adult pancreas: MR imaging evaluation. European Journal of Radiology. Elsevier Ireland Ltd; 2012;81(9): 2093–2098. doi:10.1016/j.ejrad.2011.07.014
Balci NC, Alkaade S, Magas L, et al. Suspected chronic pancreatitis with normal MRCP: Findings on MRI in correlation with secretin MRCP. Journal of Magnetic Resonance Imaging. 2008;27(1): 125–131. doi:10.1002/jmri.21241
Hardacre JM, Iacobuzio-Donahue CA, Sohn TA, et al. Results of Pancreaticoduodenectomy for Lymphoplasmacytic Sclerosing Pancreatitis. Annals of Surgery. 2003;237(6): 853–859. doi:10.1097/01.SLA.0000071516.54864.C1
Weber SM, Cubukcu-Dimopulo O, Palesty JA, et al. Lymphoplasmacytic sclerosing pancreatitis: Inflammatory mimic of pancreatic carcinoma. Journal of Gastrointestinal Surgery. 2003;7(1): 129–139. doi:10.1016/S1091-255X(02)00148-8
Hafezi-Nejad N, Singh VK, Fung C, et al. MR Imaging of Autoimmune Pancreatitis. Magnetic Resonance Imaging Clinics of North America. Elsevier Inc; 2018;26(3): 463–478. doi:10.1016/j.mric.2018.03.008
Kim JH, Byun JH, Lee SS, et al. Atypical manifestations of IgG4-related sclerosing disease in the abdomen: Imaging findings and pathologic correlations. American Journal of Roentgenology. 2013;200(1): 102–112. doi:10.2214/AJR.12.8783
Kawamoto S, Siegelman SS, Hruban RH, et al. Pancreatitis with Obstructive. 2004;(October): 915–921.
Exhibit E. ( Autoimmune Pancre- atitis ): Evaluation with Multidetector CT 1. RadioGraphics. 2008;28: 157–171. http://radiographics.rsna.org/content/28/1/157
Ichikawa T, Sou H, Araki T, et al. Duct-penetrating sign at MRCP: Usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology. 2001;221(1): 107–116. doi:10.1148/radiol.2211001157
Kim HJ, Kim YK, Jeong WK, et al. Pancreatic duct “Icicle sign” on MRI for distinguishing autoimmune pancreatitis from pancreatic ductal adenocarcinoma in the proximal pancreas. European Radiology. 2015;25(6): 1551–1560. doi:10.1007/s00330-014-3548-4
Raman SP, Salaria SN, Hruban RH, et al. Groove pancreatitis: Spectrum of imaging findings and radiology-pathology correlation. American Journal of Roentgenology. 2013;201(1): 29–39. doi:10.2214/AJR.12.9956
Triantopoulou C, Dervenis C, Giannakou N, et al. Groove pancreatitis: A diagnostic challenge. European Radiology. 2009;19(7): 1736–1743. doi:10.1007/s00330-009-1332-7
Hao L, Zeng XP, Xin L, et al. Incidence of and risk factors for pancreatic cancer in chronic pancreatitis: A cohort of 1656 patients. Digestive and Liver Disease. 2017;49(11): 1249–1256. doi:10.1016/j.dld.2017.07.001
Tamura K, Yu J, Hata T, et al. Mutations in the pancreatic secretory enzymes CPA1 and CPB1 are associated with pancreatic cancer. Proceedings of the National Academy of Sciences of the United States of America. 2018;115(18): 4767–4772. doi:10.1073/pnas.1720588115
