Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cappeliez, O.
Right arrow Articles by Matos, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cappeliez, O.
Right arrow Articles by Matos, C.
(Radiology. 2000;215:358-364.)
© RSNA, 2000

Gastrointestinal Imaging

Chronic Pancreatitis: Evaluation of Pancreatic Exocrine Function with MR Pancreatography after Secretin Stimulation1

Olivier Cappeliez, MD, Myriam Delhaye, MD, Jacques Devière, MD, Olivier Le Moine, MD, Thierry Metens, PhD, Nicole Nicaise, MD, Michel Cremer, MD, Julien Stryuven, MD and Celso Matos, MD

1 From the Departments of Radiology (O.C., T.M., N.N., J.S., C.M.) and Gastroenterology (M.D., J.D., O.L.M., M.C.), Hôpital Erasme, Université Libre de Bruxelles, 808 Route de Lennik, B-1070 Brussels, Belgium. Received June 7, 1999; revision requested July 29; revision received September 14; accepted September 24. Address correspondence to C.M. (e-mail: cmatos@ulb.ac.be).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To compare duodenal filling seen at magnetic resonance (MR) pancreatography after secretin stimulation and biochemical parameters determined with the intraductal secretin test (IDST) for evaluation of pancreatic exocrine function.

MATERIALS AND METHODS: MR pancreatography after secretin stimulation and IDST were performed in 41 patients with chronic pancreatitis (group 1) and eight patients with other pancreatic disease (group 2). A control group (group 3, n = 28) underwent MR pancreatography after secretin stimulation only. MR pancreatograms were acquired before and every 30 seconds for 10 minutes after secretin injection. Duodenal filling was graded from least amount of filling (grade 1) to normal filling (grade 3) on the last MR pancreatogram. Pancreatic exocrine function was determined at IDST. Main pancreatic ductal diameter was compared between groups 1 and 3.

RESULTS: All ductal diameters were significantly larger in group 1 (P < .001). The maximal diameter variation after secretin stimulation was significantly higher in the control group (P = .001). Pancreatic exocrine function parameters determined at IDST were significantly lower in patients with grade 1 duodenal filling than in those with grade 2 or 3 (P < .05). Maximal bicarbonate concentration alone was independently associated with all grades of duodenal filling (P = .007). The sensitivity and specificity of reduced duodenal filling for assessment of reduced pancreatic exocrine function were 72% and 87%, respectively.

CONCLUSION: Duodenal filling grade determined at MR pancreatography after secretin stimulation allows specific estimation of pancreatic exocrine function.

Index terms: Endoscopic retrograde cholangiopancreatography (ERCP), 770.1222 • Pancreas, function, 770.91, 774.91 • Pancreas, MR, 770.121411 • Pancreatitis, 770.2913 • Secretin


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
The diagnosis of chronic pancreatitis is based on both the evaluation of the functional integrity of the gland and the typical morphologic changes in pancreatic ducts seen at endoscopic retrograde pancreatography (ERP), as defined according to the Cambridge classification (1). Ductal abnormalities detected at ERP, however, may not be closely related to the degree of pancreatic functional impairment. Discrepancies between morphology and function are found in 12%–29% of cases (2–5).

There are two principal kinds of pancreatic function tests. The secretin test, which involves collection of duodenal juice after secretin stimulation of the pancreas, is the reference standard method for functional investigation (6). The secretin test is invasive, time-consuming, and expensive, and its performance is restricted to specialized centers. The other method is the intraductal secretin test, which involves collection of pure pancreatic juice (PPJ) after endoscopic retrograde cannulation of the main pancreatic duct during ERP. The intraductal secretin test is a refinement of and can substitute for the standard secretin test (7–9). The intraductal secretin test also is invasive, with potential morbidity. Indirect function tests, although noninvasive, lack sensitivity and specificity especially for the diagnosis of early chronic pancreatitis. In these cases, both morphologic and functional studies are necessary for detection of slight abnormalities identified with an individual method (10).

Today, diagnostic ERP is challenged by magnetic resonance (MR) cholangiopancreatography, which is a noninvasive diagnostic alternative to ERP for the morphologic evaluation of normal and diseased pancreatic ducts (11–14). Recent technical issues with regard to MR cholangiopancreatography include monitoring of pancreatic flow dynamics and duodenal filling after pancreatic hormonal stimulation with secretin. This is made possible by the advent of single-shot heavily T2-weighted MR sequences. This technique improves depiction of the pancreatic ducts and may allow estimation of pancreatic exocrine reserve (15). Therefore, the aim of this study was to compare duodenal filling as measured on MR pancreatograms obtained 10 minutes after secretin injection with biochemical parameters in PPJ collected during the intraductal secretin test.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Patient Population
Between September 1996 and February 1999, a total of 49 consecutive patients (15 female and 34 male patients) aged 11–78 years (mean age ± SD, 49 years ± 14) who had undergone both MR pancreatography after secretin stimulation and ERP with collection of PPJ were included in the study (Table 1). The patients were classified into two groups. Group 1 comprised 41 patients (12 female and 29 male patients; age range 11–78 years; mean age, 46 years ± 13) with chronic pancreatitis, including 13 with mild changes, three with moderate changes, and 25 with severe changes, as defined by the Cambridge criteria (1). Group 2 comprised eight patients (three women and five men; age range, 43–77 years; mean age, 61 years ± 11) without chronic pancreatitis, including four with intraductal papillary mucinous tumor, one with acute recurrent pancreatitis, two suspected of having sphincter of Oddi dysfunction, and one with steatorrhea but no pancreatic disease. For the purpose of the study, 28 patients (16 women and 12 men; age range, 25–81 years; mean age, 51 years ± 16) without pancreatic disease were included in a control group (group 3). Group 3 comprised consecutive patients who had undergone routine MR cholangiopancreatography after secretin stimulation for evaluation of the biliary ducts. They had no pancreatic symptoms or risk factors and normal serum levels of pancreatic hydrolase.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Final Diagnoses in the Patient Population
 
MR Pancreatography after Secretin Stimulation
All patients gave informed consent after explanation of the complete examination procedure. The examinations were performed in accordance with the recommendations of our institutional review board. Patients were asked to fast for at least 3 hours before the examination.

MR studies were performed with a clinical 1.5-T MR imager (Gyroscan ACS NT; Philips Medical Systems, Best, the Netherlands) equipped with a quadrature body coil (n = 35) or an abdominal phased-array coil (n = 42), according to coil availability. The patient was placed in the supine position for imaging. MR pancreatography was performed within one breath hold by using a single-shot turbo spin-echo T2-weighted sequence ({infty}/1,050–1,200 [repetition time msec/effective echo time msec]; echo train length, 276–296; section thickness, 40–50 mm; matrix, 150 x 256; field of view, 260 mm; acquisition time, 3 seconds) before and after secretin stimulation. Patients were asked to hold their breath from just before the acquisition of each dynamic image until immediately after the acquisition. The actual breath hold duration was close to 4 seconds. To reduce the blurring that can occur on turbo spin-echo images because of the short T2 of liver tissue, the first 20 echoes were discarded for image construction. For the same reason, spectral fat suppression also was applied. Presaturation bands (thickness, 80 mm) were applied anteriorly and posteriorly to reduce artifacts. The projections were oriented in the coronal plane and included the entire main pancreatic duct up to its emergence at the papilla of Vater. No further postprocessing of images was needed. With these parameters, we obtained projective images that resembled direct pancreatograms obtained with ERP. To eliminate the signal intensity from overlapping fluid-containing bowel, 200 mL of a negative oral contrast agent consisting of superparamagnetic nanoparticles (ferumoxsil oral suspension, Lumirem; Laboratoire Guerbet, Roissy, France) was administered before dynamic MR imaging. The time between ingestion of ferumoxsil and acquisition of the dynamic MR images after secretin stimulation was less than 5 minutes. Antiperistaltic agents were not administered.

A set of images was acquired before secretin stimulation, which enabled optimal positioning of the imaged section. After intravenous bolus administration of secretin (Sekretolin; Hoechst, Frankfurt am Main, Germany) at a dose of 1 clinical unit (0.00029 mg) per kilogram of body weight, acquisition of the optimal section was repeated every 30 seconds. This dynamic procedure was conducted during 10 minutes.

Intraductal Secretin Test
The intraductal secretin test was always performed within 4 weeks (mean, 11 days; range, 1–28 days) of MR pancreatography after secretin stimulation. A 6-F nasopancreatic catheter with multiple side holes (NPDS; Wilson-Cook, Winston-Salem, NC) was inserted into the main pancreatic duct over a guide wire. The endoscope was then removed, and PPJ was collected continuously in 10 1-minute samples during 10 minutes after intravenous bolus injection of secretin with the same dose as for the MR studies. The maximal secretory volume per minute and the total secretory volume after 10 minutes, as well as maximal bicarbonate concentration and maximal bicarbonate output, were determined with the PPJ samples. Lower limits for PPJ parameters were established as the mean minus 1.5 SDs: for maximal secretory volume, 4.1 mL/min; for maximal bicarbonate concentration, 124 mEq/L; for maximal bicarbonate output, 525 mEq/min (7); and for total secretory volume, 28.6 mL/10 min (8). A weighted linear combination of maximal bicarbonate concentration (MBC) and output (MBO) after secretin stimulation was used to calculate pancreatic exocrine function expressed as a percentage of normal function (7): [(0.03 x MBC) + (0.0026 x MBO)] x 16.4.

Image Analysis
The MR images obtained after secretin stimulation were reviewed by a radiologist (O.C.) who did not participate in image acquisition and who was blinded to clinical, intraductal secretin test, and ERP data. The baseline and maximal diameters of the main pancreatic duct, the delay to reach maximal diameter, and the diameter at 10 minutes were measured to monitor variations in ductal size after secretin stimulation. Measurements of the duct were performed by using an electronic caliper on the screen of an independent diagnostic workstation (Gyroscan NT Diagnostic Workstation, Philips Medical Systems). The diameters were obtained at the same location before and after secretin injection. The variations in main pancreatic ductal diameter between baseline and maximal values and between baseline and final values were calculated and expressed as percentages. On the last image of the dynamic study, duodenal filling was graded visually as follows: grade 1 was assigned when the filling remained limited to the duodenal bulb; grade 2, when pancreatic juice filled the bulb and the duodenum up to the genu inferius; and grade 3, when the bulb and the duodenum were filled beyond the genu inferius (Fig 1). Grades 1 and 2 were considered to represent reduced duodenal filling capacity. Visualization of side branches on MR pancreatograms was not recorded because the final diagnosis of chronic pancreatitis was dependent on ERP findings.



View larger version (109K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. Coronal single-shot turbo spin-echo MR pancreatograms ({infty}/1,050; echo train length of 296; section thickness, 40 mm) obtained before (top left) and at 4 (top right), 6 (bottom left), and 10 (bottom right) minutes after secretin injection. Progressive filling of the duodenum (arrowheads) with pancreatic juice, from the bulb to the genu inferius, is shown. The main pancreatic duct (arrows) is better depicted after secretin administration.

 
Statistical Analyses
The Student t test was used to compare dynamic variations in the diameter of the main pancreatic duct between patients with chronic pancreatitis and control patients. The analysis of variance with the Bonferroni correction was performed to analyze differences between PPJ parameters for each duodenal filling grade (Bonferroni threshold: P < .05). Logistic regression was used to determine which variables were independently associated with duodenal filling grade. The Student t test was used to analyze differences between mild and moderate or severe chronic pancreatitis changes at ERP according to duodenal filling grade. The odds ratio, sensitivity, specificity, and positive and negative predictive values of reduced duodenal filling seen at MR pancreatography after secretin stimulation were calculated to help detect reduced pancreatic exocrine function.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Dynamic Variations in Main Pancreatic Ductal Diameter
The diameter of the main pancreatic duct as measured on MR pancreatograms obtained before and after secretin stimulation was compared between patients in group 1 and those in group 3 (Table 2). Data on baseline diameter, maximal diameter, diameter at 10 minutes, and time to reach maximal diameter were available for all control patients and for 35 of 41 patients with chronic pancreatitis. Six of the latter patients were excluded from this analysis because the main pancreatic duct was not measurable on all 20 images due to motion artifact. All main pancreatic ductal diameter measurements over time and the time to reach the maximal diameter were significantly higher in chronic pancreatitis patients when compared with those in control patients (P <= .001). During the 1st minutes after secretin administration, the main pancreatic duct undergoes enlargement, which is followed by a return to near its baseline diameter as pancreatic juice fills the duodenum. The percentage of variation from baseline to maximal diameter was significantly higher in control patients (+66.5%) than in patients with chronic pancreatitis (+32.2%) (P = .001). The percentage of variation between baseline diameter and that at 10 minutes after secretin injection was not significantly different between patients with chronic pancreatitis (+9.9%) and control patients (-0.9%). Variations in main pancreatic ductal diameter were not compared between groups 1 and 2 owing to the small number of patients in group 2 (n = 8) with pancreatic disease for whom ductal diameter after secretin stimulation could differ from that in group 3 patients without pancreatic disease.


View this table:
[in this window]
[in a new window]

  		TABLE 2. Variations in Main Pancreatic Ductal Diameter: Group 1 versus Group 3
 
Duodenal Filling and PPJ Analysis
PPJ parameters and duodenal filling as graded at 10 minutes after secretin administration were available in all group 1 and group 2 patients (n = 49). By considering the mean values for each PPJ parameter according to the duodenal filling grade (Table 3), univariate analysis results revealed that each of the parameters of PPJ analysis was significantly lower in patients with grade 1 duodenal filling than the parameters in patients with grade 2 or 3 duodenal filling (P < .05). Multivariate analysis results revealed that only maximal bicarbonate concentration in PPJ was independently associated with all grades of duodenal filling (P = .007).


View this table:
[in this window]
[in a new window]

  		TABLE 3. PPJ Parameters according to Grade of Duodenal Filling
 
Duodenal Filling and Severity of Chronic Pancreatitis
Among the 41 patients with chronic pancreatitis (group 1), we found no statistically significant differences for grade of duodenal filling as determined at MR pancreatography after secretin stimulation between mild (n = 13) and moderate or severe (n = 28) morphologic changes as determined at ERP (Fig 2).



View larger version (18K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. Bar graph shows the distribution of duodenal filling grade between patients with mild chronic pancreatitis (CP) (n = 13) and those with moderate (Mod.) or severe (Sev.) chronic pancreatitis (n = 28). White bars = duodenal filling grade 1, gray bars = duodenal filling grade 2, black bars = duodenal filling grade 3. Data are reported as a percentage of patients in each group. No statistically significant difference was found between duodenal filling grade as determined at MR pancreatography and morphologic changes as seen at ERP.

 
Value of Duodenal Filling in Screening for Reduced Pancreatic Exocrine Function
We studied the value of an isolated reduction in duodenal filling (grades 1 and 2) as a screening criterion for reduced pancreatic exocrine function in groups 1 and 2 (Table 4). In 13 (76%) of 17 patients with reduced duodenal filling, the calculated pancreatic exocrine function was 50% or less. In 32 patients with normal duodenal filling, 27 (84%) had a calculated function of greater than 50% (Fig 3). The sensitivity, specificity, positive predictive value, and negative predictive value of reduced duodenal filling grade for prediction of reduced pancreatic exocrine function (<=50% of normal function) were 72% (13 of 18), 87% (27 of 31), 76% (13 of 17), and 84% (27 of 32), respectively, with a prevalence of 37% (18 of 49). Given the results listed in Table 4, the odds ratio for reduced duodenal filling was 17.6 for patients with a calculated function of 50% or less, relative to patients with a calculated function of greater than 50%.


View this table:
[in this window]
[in a new window]

  		TABLE 4. Distribution of Group 1 and Group 2 Patients according to Pancreatic Exocrine Function and Duodenal Filling Status
 


View larger version (27K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3. Scatterplot shows the distribution of patients for each duodenal filling (DF) grade according to the calculated pancreatic exocrine function as a percentage of normal function. Presence of a normal duodenal filling grade does not exclude impairment of pancreatic exocrine function. {diamondsuit} = mild chronic pancreatitis, {square} = moderate chronic pancreatitis, {triangleup} = severe chronic pancreatitis, {circ} = no chronic pancreatitis.

 

   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Until recently, the role of MR pancreatography in cases of chronic pancreatitis was limited to diagnosis and follow-up of advanced cases (11,14). Owing to spatial resolution that is lower than that of ERP, ductal abnormalities in cases of mild pancreatitis cannot be assessed at MR pancreatography. Side branches usually are depicted only when dilated. Moreover, the condition in which the pancreatic ductal system is demonstrated at MR pancreatography differs from that in which it is depicted during ERP. Indeed, in ERP, retrograde injection of contrast medium creates enlargement of the ducts, whereas in MR pancreatography, the physiologic or physiopathologic ductal liquid content is demonstrated.

Secretin administration helps improve the delineation of ductal morphology both in healthy individuals and in patients suspected of having chronic pancreatitis (15,16). As previously described in studies with ultrasonography (US), computed tomography (CT), and MR imaging (15,17–19), we monitored dynamic variations in main pancreatic ductal diameter after secretin stimulation. In accordance with previous results, we found measurable dilatation of the main pancreatic duct, observed mostly within 2–6 minutes of secretin injection. This is explained by a secretin-stimulated increase in fluid secretion by the ductal cells in the ductal system and by simultaneously increased tonus of the sphincter of Oddi during the first 5 minutes, which inhibits the release of fluid through the papilla of Vater (20). After that time, the tonus of the sphincter decreases, and the caliber of the main pancreatic duct returns to the baseline value as the pancreatic juice flows out through the papilla and progressively fills the duodenum. In this study, all main pancreatic ductal diameters measured on the dynamic MR studies were significantly higher in patients with chronic pancreatitis. Furthermore, the time to reach peak ductal diameter was longer, and the percentage increase in diameter was lower in patients with chronic pancreatitis than in control patients. This probably reflects the fibrotic process involving pancreatic parenchyma in patients with chronic pancreatitis. Although a long-lasting secretin-induced enlargement of the duct has been reported (21) in some patients with chronic pancreatitis, the difference in percentage increase in ductal diameter from before to 10 minutes after secretin stimulation between patients with chronic pancreatitis and control patients was not significant in our study.

The present study provides additional data regarding the relevance of duodenal filling observed during MR pancreatography after secretin stimulation. Until now, there has been only speculation that duodenal filling could be correlated with exocrine pancreatic function (15). Currently, the most valuable pancreatic function tests are the duodenal and intraductal secretin tests with sampling of duodenal juice or PPJ (8,9,22,23). With invasive techniques such as those, the best evaluation of the pancreatic exocrine function is given by measuring bicarbonate output and concentration in PPJ collected after secretin stimulation (7,9,24). In the present study, we found a significant difference in all PPJ parameters between duodenal filling grade 1 versus grades 2 and 3. Probably because of better coefficients of variation, only the maximal bicarbonate concentration in PPJ was independently associated with all grades of duodenal filling.

We performed MR pancreatography after secretin stimulation in some patients by placing a nasopancreatic catheter in the main pancreatic duct. In these patients, we observed that a fraction of the pancreatic secretion flowed into the duodenum without being collected through the catheter. This could explain why only the maximal bicarbonate concentration, and not the secretory volume, was independently associated with duodenal filling (ie, the volume of pancreatic secretions filling the duodenum).

A previously determined weighted linear combination of maximal bicarbonate concentration and maximal bicarbonate output after secretin stimulation was used to express pancreatic secretory capability as a percentage of normal function (7). Decreased duodenal filling was observed on MR pancreatograms in only 13% of patients with a calculated pancreatic function of greater than 50%, but duodenal filling was assigned a grade of 2 in all these patients. In the two groups of patients who underwent both PPJ analysis and MR pancreatography after secretin stimulation, the odds ratio for reduced duodenal filling was 17.6 for patients with a calculated function of 50% or less, relative to patients with a calculated function of greater than 50%. This result indicates a strong association between reduced duodenal filling and impaired pancreatic exocrine function. It also suggests that patients with reduced duodenal filling observed at MR pancreatography are 17.6 times more likely to have deficient pancreatic function (ie, <=50% of normal function) than are patients with normal duodenal filling. By considering duodenal filling alone in patients with reduced pancreatic function, reduced duodenal filling is specific (87%) but less sensitive (72%) for detection of impaired pancreatic exocrine function; therefore, normal duodenal filling seen at MR pancreatography after secretin stimulation does not exclude reduced pancreatic exocrine function.

Of interest, no clear relationship was observed in the present study between the duodenal filling grade determined with MR pancreatograms and severe morphologic changes due to chronic pancreatitis as determined at ERP (Fig 2). The correlation between pancreatic function and morphologic changes has been investigated in a number of studies. Although some investigators (2–4) have shown a correlation between secretin stimulation test and ERP results in patients with chronic pancreatitis, others (5), including us, have shown that exocrine pancreatic function as assessed with PPJ analysis (and with findings of duodenal filling, in our study) may be normal in patients with abnormal ERP findings and vice versa, with discordant results in 12%–29% of cases (3–5) and in 27% of patients in our study (Figs 4, 5).



View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 4. Coronal single-shot turbo spin-echo MR pancreatograms ({infty}/1,050, echo train length of 296) obtained before (top left) and at 3 (top right), 4 (bottom left), and 9 (bottom right) minutes after secretin injection illustrate normal duodenal filling (arrowheads) in a patient with severe chronic pancreatitis with marked dilatation and irregularity of the main pancreatic duct and its side branches (small arrows) up to a stricture (large arrow). Main pancreatic ductal diameter was 7.2 mm at baseline, 7.8 mm at maximal dilatation, and 7.3 mm at 10 minutes after secretin stimulation.

 


View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5. Coronal single-shot turbo spin-echo MR pancreatograms ({infty}/1,050, echo train length of 296) obtained before (top left) and at 4 (top right), 6 (bottom left), and 9 (bottom right) minutes after secretin injection illustrate reduced duodenal filling (arrowhead) in a patient with mild chronic pancreatitis and no obstruction of the main pancreatic duct (arrows). No side branch is depicted. Main pancreatic ductal diameter was 1.8 mm at baseline, 2.0 mm at maximal dilatation, and 1.7 mm at 10 minutes after secretin stimulation.

 
A major diagnostic problem concerns the patient with abdominal pain who is suspected of having chronic pancreatitis but in whom the results of imaging (US, CT, or both) reveal minimal or no morphologic changes. In such patients, additional pancreatic function tests usually are necessary to establish the diagnosis (10). In this context, MR pancreatography after secretin stimulation is potentially useful because it allows evaluation of both morphologic and functional changes during a single noninvasive procedure. In two studies (25,26), follow-up results in patients with abnormal function test results but normal ERP findings show evolution to overt chronic pancreatitis. These findings suggest that the secretin test, and possibly MR pancreatography after secretin stimulation, may help determine which patients have chronic pancreatitis earlier than would ERP.

In this study, we compared an invasive nonphysiologic reference method for assessment of pancreatic exocrine function invasively (the intraductal secretin test) and a noninvasive imaging technique (MR pancreatography after secretin stimulation) to help evaluate the pancreatic ducts and the pancreatic response to hormonal stimulation in a physiologic state. Our data show that by grading duodenal filling at MR pancreatography, a specific estimate of pancreatic exocrine function can be determined. The potential clinical effect of imaging combined with functional testing is the enhancement of diagnostic accuracy in the absence of marked ductal alteration. In advanced stages of chronic pancreatitis, functional testing is a valid complement to enable characterization of the clinical stage of disease and may influence therapeutic decisions.


   Footnotes
 
Abbreviations: ERP = endoscopic retrograde pancreatography PPJ = pure pancreatic juice

Author contributions: Guarantors of integrity of entire study, C.M., M.D.; study concepts and design, C.M., M.D.; definition of intellectual content, O.C., M.D., C.M., J.D.; literature research, O.C., M.D.; clinical studies, M.D.; data acquisition, C.M., N.N., M.D., J.D., M.C., O.L.M.; data analysis, O.C., M.D.; statistical analysis, O.L.M., T.M., O.C.; manuscript preparation and editing, O.C.; manuscript review, M.D., C.M., J.D., J.S.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Axon ATR, Classen M, Cotton PB, Cremer M, Freeny PC, Lees WR. Pancreatography in chronic pancreatitis: international definitions. Gut 1984; 25:1107-1112.[Abstract/Free Full Text]
  2. Bozkurt T, Braun U, Leferink S, Gilly G, Lux G. Comparison of pancreatic morphology and exocrine functional impairment in patients with chronic pancreatitis. Gut 1994; 35:1132-1136.[Abstract/Free Full Text]
  3. Malfertheiner P, Büchler M, Stanescu A, Ditschuneit H. Exocrine pancreatic function in correlation to ductal and parenchymal morphology in chronic pancreatitis. Hepatogastroenterology 1986; 33:110-114.[Medline]
  4. Braganza JM, Hunt LP, Warwick F. Relationship between pancreatic exocrine function and ductal morphology in chronic pancreatitis. Gastroenterology 1982; 82:1341-1347.[Medline]
  5. Otte M. Pankreasfunktionsdiagnostik. Internist 1979; 20:331-340.[Medline]
  6. Lankish PG. Function tests in the diagnosis of CP. Int J Pancreatol 1993; 14:9-20.[Medline]
  7. Devière J, Gulbis B, Delhaye M, Quenon M, Cremer M. A study of the relationship between the canalar morphology and the exocrine function of the pancreas: a new method of linear estimation of the pancreatic function. Acta Endosc 1985; 15:403-414.
  8. Ochi K, Harada H, Mizushima T, Tanaka J, Matsumoto S. Intraductal secretin test is as useful as duodenal secretin test in assessing exocrine pancreatic function. Dig Dis Sci 1997; 42:492-496.[Medline]
  9. Wada K, Yamadera K, Yokoyama K, Goto M, Makino I. Application of pure pancreatic juice collection to the pancreatic exocrine function test. Pancreas 1998; 16:124-128.[Medline]
  10. Malfertheiner P, Büchler M. Correlation of imaging and function in chronic pancreatitis. Radiol Clin North Am 1989; 27:51-64.[Medline]
  11. Takehara Y, Ichijo K, Tooyama N, et al. Breath-hold MR cholangiopancreatography with a long-echo-train fast spin-echo sequence and a surface coil in chronic pancreatitis. Radiology 1994; 192:73-78.[Abstract/Free Full Text]
  12. Soto JA, Barish MA, Yucel EK, et al. Pancreatic duct: MR cholangiopancreatography with a three-dimensional fast spin-echo technique. Radiology 1995; 196:459-464.[Abstract/Free Full Text]
  13. Bret PM, Reinhold C, Taourel P, Guibaud L, Atri M, Barkun AN. Pancreas divisum: evaluation with MR cholangiopancreatography. Radiology 1996; 199:99-103.[Abstract/Free Full Text]
  14. Sica GT, Braver J, Cooney MJ, Miller FH, Chai JL, Adams DF. Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis. Radiology 1999; 210:605-610.[Abstract/Free Full Text]
  15. Matos C, Metens T, Devière J, et al. Pancreatic duct: morphologic and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology 1997; 203:435-441.[Abstract/Free Full Text]
  16. Nicaise N, Pellet O, Metens T, et al. Magnetic resonance cholangiopancreatography: interest of IV secretin administration in the evaluation of pancreatic ducts. Eur Radiol 1998; 8:16-22.[Medline]
  17. Bolondi L, Gaiani S, Gullo L, Labo G. Secretin administration induces a dilatation of the main pancreatic duct. Dig Dis Sci 1984; 29:802-808.[Medline]
  18. Glazer J, Högemann B, Krummenerl T, et al. Sonographic imaging of the pancreatic duct: new diagnostic possibilities using secretin stimulation. Dig Dis Sci 1987; 32:1075-1081.[Medline]
  19. Lindström E, Ihse I. Dynamic CT scanning of pancreatic duct after secretin provocation in pancreas divisum. Dig Dis Sci 1990; 35:1371-1376.[Medline]
  20. Geenen JE, Hogan WJ, Dodds WJ, Stewart ET, Arndorfer RC. Intraluminal pressure recording from the human sphincter of Oddi. Gastroenterology 1980; 78:317-324.[Medline]
  21. Bolondi L, Li Bassi S, Gaiani S, Santi V, Gullo L, Barbara L. Impaired response of main pancreatic duct to secretin stimulation in early chronic pancreatitis. Dig Dis Sci 1989; 34:834-840.[Medline]
  22. Gullo L, Costa PL, Fontana G, et al. Investigation of exocrine pancreatic function by continuous infusion of caerulein and secretin in normal subjects and in chronic pancreatitis. Digestion 1976; 14:97-107.[Medline]
  23. Gyr H, Agraval NM, Felsenfeld O, et al. Comparative study of secretin and Lundh tests. Am J Dig Dis 1975; 20:506-512.[Medline]
  24. Hayakawa T, Kondo T, Shibata T, Noda A, Suzuki T, Nakano S. Relationship between pancreatic exocrine function and histological changes in chronic pancreatitis. Am J Gastroenterol 1992; 87:1170-1174.[Medline]
  25. Lankisch PG, Seidensticker F, Otto J, et al. Secretin-pancreozymin test and endoscopic retrograde cholangiopancreatography: both are necessary for diagnosing or excluding chronic pancreatitis. Pancreas 1996; 12:149-152.[Medline]
  26. Lambiase L, Forsmark CE, Albert C, Toskes PP. Secretin test diagnoses chronic pancreatitis earlier than ERCP (abstr). Gastroenterology 1993; 104(4 pt 2):A315.



This article has been cited by other articles:


Home page
 GutHome page
J.-M. Dumonceau, G. Costamagna, A. Tringali, K. Vahedi, M. Delhaye, A. Hittelet, G. Spera, E. Giostra, M. Mutignani, V. De Maertelaer, et al.
Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial
Gut, April 1, 2007; 56(4): 545 - 552.
[Abstract] [Full Text] [PDF]

Home page
 RadioGraphicsHome page
M. F. Akisik, K. Sandrasegaran, A. A. Aisen, D. D. T. Maglinte, S. Sherman, and G. A. Lehman
Dynamic secretin-enhanced MR cholangiopancreatography.
RadioGraphics, May 1, 2006; 26(3): 665 - 677.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
R. Tamura, T. Ishibashi, and S. Takahashi
Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation
Radiology, March 1, 2006; 238(3): 920 - 928.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
J. Monill, J. Pernas, J. Clavero, A. Farre, A. Morales, M. Gonzalez, V. Artigas, and A. Martinez-Noguera
Pancreatic Duct After Pancreatoduodenectomy: Morphologic and Functional Evaluation with Secretin-Stimulated MR Pancreatography
Am. J. Roentgenol., November 1, 2004; 183(5): 1267 - 1274.
[Abstract] [Full Text] [PDF]

Home page
 ANN INTERN MEDHome page
J. Romagnuolo, M. Bardou, E. Rahme, L. Joseph, C. Reinhold, and A. N. Barkun
Magnetic Resonance Cholangiopancreatography: A Meta-Analysis of Test Performance in Suspected Biliary Disease
Ann Intern Med, October 7, 2003; 139(7): 547 - 557.
[Abstract] [Full Text] [PDF]

Home page
 GutHome page
P D Thomas, A Forbes, J Green, P Howdle, R Long, R Playford, M Sheridan, R Stevens, R Valori, J Walters, et al.
Guidelines for the investigation of chronic diarrhoea, 2nd edition
Gut, July 1, 2003; 52(90005): v1 - 15.
[Full Text]

Home page
 GutHome page
W Schwizer, M Fox, and A Steingotter
Non-invasive investigation of gastrointestinal functions with magnetic resonance imaging: towards an "ideal" investigation of gastrointestinal function
Gut, June 1, 2003; 52(90004): iv34 - 39.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
R. Manfredi, V. Lucidi, B. Gui, M. G. Brizi, A. Vecchioli, G. Maresca, L. Dall'Oglio, G. Costamagna, and P. Marano
Idiopathic Chronic Pancreatitis in Children: MR Cholangiopancreatography after Secretin Administration
Radiology, September 1, 2002; 224(3): 675 - 682.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
K. J. Hellerhoff, H. Helmberger III, T. Rosch, M. R. Settles, T. M. Link, and E. J. Rummeny
Dynamic MR Pancreatography After Secretin Administration: Image Quality and Diagnostic Accuracy
Am. J. Roentgenol., July 1, 2002; 179(1): 121 - 129.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
J. H. Kim, M.-J. Kim, S. I. Park, J.-J. Chung, S. Y. Song, H. S. Yoo, and J. T. Lee
Using Kinematic MR Cholangiopancreatography to Evaluate Biliary Dilatation
Am. J. Roentgenol., April 1, 2002; 178(4): 909 - 914.
[Abstract] [Full Text] [PDF]

Home page
 Cancer Res.Home page
C. Rosty, L. Christa, S. Kuzdzal, W. M. Baldwin, M. L. Zahurak, F. Carnot, D. W. Chan, M. Canto, K. D. Lillemoe, J. L. Cameron, et al.
Identification of Hepatocarcinoma-Intestine-Pancreas/Pancreatitis-associated Protein I as a Biomarker for Pancreatic Ductal Adenocarcinoma by Protein Biochip Technology
Cancer Res., March 1, 2002; 62(6): 1868 - 1875.
[Abstract] [Full Text] [PDF]

Home page
 RadioGraphicsHome page
C. Matos, O. Cappeliez, C. Winant, E. Coppens, J. Deviere, and T. Metens
MR Imaging of the Pancreas: A Pictorial Tour
RadioGraphics, January 1, 2002; 22(1): e2 - e2.
[Abstract] [Full Text]

Home page
 RadiologyHome page
Y. Fukukura, F. Fujiyoshi, M. Sasaki, and M. Nakajo
Pancreatic Duct: Morphologic Evaluation with MR Cholangiopancreatography after Secretin Stimulation
Radiology, March 1, 2002; 222(3): 674 - 680.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cappeliez, O.
Right arrow Articles by Matos, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cappeliez, O.
Right arrow Articles by Matos, C.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE