Cross-sectional imaging-based severity scoring of chronic pancreatitis: why it is necessary and how it can be done

  • Anil K. DasyamEmail author
  • Zarine K. Shah
  • Temel Tirkes
  • Navya Dasyam
  • Amir A. Borhani


Chronic pancreatitis (CP) remains a diagnostic challenge as clinical symptoms are non-specific, histopathological appearances are varied and pathogenesis remains incompletely understood. Multiple classifications and grading systems have been proposed for CP, but none leverage the full capabilities of cross-sectional imaging modalities and are not widely accepted or validated. CT and MRI/MRCP are useful in identifying a wide spectrum of histopathological changes in CP and can also assess exocrine reserve of pancreas. Advanced MRI techniques such as T1 mapping and extracellular volume fraction can potentially identify early CP. Cross-sectional imaging-based severity scoring can quantify CP disease burden and may have positive implications for clinicians and researchers. In this review, we discuss the need for cross-sectional imaging-based severity scoring for CP, role of CT, and MRI/MRCP in assessment of CP and how these modalities can be used to obtain severity scoring for CP. We summarize relevant information from recently published CT and MRI/MRCP reporting standards for CP, and from international guidelines for cross-sectional imaging and severity scoring for CP.


Chronic pancreatitis Multidetector computed tomography Magnetic resonance imaging Classification 



The authors would like to thank Dr. Dhiraj Yadav, Professor of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh School of Medicine, for reviewing the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, et al. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines. Pancreas. 2014;43(8):1143CrossRefGoogle Scholar
  2. 2.
    Duggan SN, Chonchubhair HMN, Lawal O, O’Connor DB, Conlon KCJWjog. Chronic pancreatitis: A diagnostic dilemma. 2016;22(7):2304Google Scholar
  3. 3.
    Perrier C. Symposium of the etiology and pathological anatomi of chronic pancreatics. Marseilles, 1963. Am J Dig Dis. 1964;9:371-6CrossRefGoogle Scholar
  4. 4.
    Steer ML, Waxman I, Freedman S. Chronic pancreatitis. New England Journal of Medicine. 1995;332(22):1482-90CrossRefGoogle Scholar
  5. 5.
    Whitcomb DC. Peering Into the “black box” of the complex chronic pancreatitis syndrome. Pancreas. 2016;45(10):1361CrossRefGoogle Scholar
  6. 6.
    Whitcomb DC, Shimosegawa T, Chari ST, Forsmark CE, Frulloni L, Garg P, et al. International consensus statements on early chronic Pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with The International Association of Pancreatology, American Pancreatic Association, Japan Pancreas Society, PancreasFest Working Group and European Pancreatic Club. Pancreatology. 2018.Google Scholar
  7. 7.
    Sarner M, Cotton P. Classification of pancreatitis. Gut. 1984;25(7):756-9CrossRefGoogle Scholar
  8. 8.
    Shimosegawa T, Kataoka K, Kamisawa T, Miyakawa H, Ohara H, Ito T, et al. The revised Japanese clinical diagnostic criteria for chronic pancreatitis. Journal of gastroenterology. 2010;45(6):584-91CrossRefGoogle Scholar
  9. 9.
    Ammann RW. A clinically based classification system for alcoholic chronic pancreatitis: summary of an international workshop on chronic pancreatitis. Pancreas. 1997;14(3):215-21CrossRefGoogle Scholar
  10. 10.
    Schneider A, Löhr JM, Singer MV. The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease. Journal of Gastroenterology. 2007;42(2):101-19CrossRefGoogle Scholar
  11. 11.
    Frøkjær JB, Akisik F, Farooq A, Akpinar B, Dasyam A, Drewes AM, et al. Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis. Pancreatology. 2018;18(7):764-73CrossRefGoogle Scholar
  12. 12.
    Catalano MF, Sahai A, Levy M, Romagnuolo J, Wiersema M, Brugge W, et al. EUS-based criteria for the diagnosis of chronic pancreatitis: the Rosemont classification. Gastrointestinal endoscopy. 2009;69(7):1251-61CrossRefGoogle Scholar
  13. 13.
    Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. The American journal of gastroenterology. 2007;102(8):1781CrossRefGoogle Scholar
  14. 14.
    Wallace MB, Hawes RH, Durkalski V, Chak A, Mallery S, Catalano MF, et al. The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers. Gastrointestinal endoscopy. 2001;53(3):294-9CrossRefGoogle Scholar
  15. 15.
    Tirkes T, Shah ZK, Takahashi N, Grajo JR, Chang ST, Venkatesh SK, 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):207-15CrossRefGoogle Scholar
  16. 16.
    Tirkes T, Lin C, Cui E, Deng Y, Territo PR, Sandrasegaran K, et al. Quantitative MR evaluation of chronic pancreatitis: extracellular volume fraction and MR relaxometry. American Journal of Roentgenology. 2018;210(3):533-42CrossRefGoogle Scholar
  17. 17.
    Bieliuniene E, Frøkjær JB, Pockevicius A, Kemesiene J, Lukosevicius S, Basevicius A, et al. Magnetic Resonance Imaging as a Valid Noninvasive Tool for the Assessment of Pancreatic Fibrosis. Pancreas. 2019;48(1):85-93CrossRefGoogle Scholar
  18. 18.
    Tirkes T, Lin C, Fogel EL, Sherman SS, Wang Q, Sandrasegaran K. T1 mapping for diagnosis of mild chronic pancreatitis. J Magn Reson Imaging. 2017;45(4):1171-6CrossRefGoogle Scholar
  19. 19.
    Tirkes T, Yadav D, Conwell DL, Territo PR, Zhao X, Venkatesh SK, et al. Magnetic resonance imaging as a non-invasive method for the assessment of pancreatic fibrosis (MINIMAP): a comprehensive study design from the consortium for the study of chronic pancreatitis, diabetes, and pancreatic cancer. Abdom Radiol (NY). 2019;44(8):2809-21CrossRefGoogle Scholar
  20. 20.
    Klöppel G, Detlefsen S, Feyerabend B. Fibrosis of the pancreas: the initial tissue damage and the resulting pattern. Virchows Archiv. 2004;445(1):1-8CrossRefGoogle Scholar
  21. 21.
    Kleeff J, Whitcomb DC, Shimosegawa T, Esposito I, Lerch MM, Gress T, et al. Chronic pancreatitis. Nature Reviews Disease Primers. 2017;3:nrdp201760.Google Scholar
  22. 22.
    Ulzheimer S, Bongers M, Flohr T. Multi-slice CT: Current Technology and Future Developments. 2018.Google Scholar
  23. 23.
    Siddiqui N, Vendrami CL, Chatterjee A, Miller FH. Advanced MR imaging techniques for pancreas imaging. Magnetic Resonance Imaging Clinics. 2018;26(3):323-44CrossRefGoogle Scholar
  24. 24.
    Sinha A, Singh VK, Cruise M, Afghani E, Matsukuma K, Ali S, et al. Abdominal CT predictors of fibrosis in patients with chronic pancreatitis undergoing surgery. European radiology. 2015;25(5):1339-46CrossRefGoogle Scholar
  25. 25.
    Lesniak RJ, Hohenwalter MD, Taylor AJ. Spectrum of causes of pancreatic calcifications. American Journal of Roentgenology. 2002;178(1):79-86CrossRefGoogle Scholar
  26. 26.
    Zhang XM, Shi H, Parker L, Dohke M, Holland GA, Mitchell DG. Suspected early or mild chronic pancreatitis: enhancement patterns on gadolinium chelate dynamic MRI. Journal of Magnetic Resonance Imaging: An Official Journal of the International Society for Magnetic Resonance in Medicine. 2003;17(1):86-94CrossRefGoogle Scholar
  27. 27.
    Balci NC, Alkaade S, Magas L, Momtahen AJ, Burton FR. Suspected chronic pancreatitis with normal MRCP: findings on MRI in correlation with secretin MRCP. Journal of Magnetic Resonance Imaging: An Official Journal of the International Society for Magnetic Resonance in Medicine. 2008;27(1):125-31CrossRefGoogle Scholar
  28. 28.
    Szczepaniak EW, Malliaras K, Nelson MD, Szczepaniak LS. Measurement of pancreatic volume by abdominal MRI: a validation study. PloS one. 2013;8(2):e55991CrossRefGoogle Scholar
  29. 29.
    Burute N, Nisenbaum R, Jenkins DJ, Mirrahimi A, Anthwal S, Colak E, et al. Pancreas volume measurement in patients with Type 2 diabetes using magnetic resonance imaging-based planimetry. Pancreatology. 2014;14(4):268-74CrossRefGoogle Scholar
  30. 30.
    Sandrasegaran K, Lin C, Akisik FM, Tann M. State-of-the-art pancreatic MRI. American Journal of Roentgenology. 2010;195(1):42-53CrossRefGoogle Scholar
  31. 31.
    Balci NC, Smith A, Momtahen AJ, Alkaade S, Fattahi R, Tariq S, 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):601-6CrossRefGoogle Scholar
  32. 32.
    Gillams A, Punwani S, Smart S, Lees W, editors. Quantification of Pancreatic Exocrine Function Using Secretln Stimulated MRCP.Google Scholar
  33. 33.
    Hafezi-Nejad N, Singh VK, Faghih M, Kamel IR, Zaheer A. Jejunal response to secretin is independent of the pancreatic response in secretin-enhanced magnetic resonance cholangiopancreatography. European journal of radiology. 2019;112:7-13CrossRefGoogle Scholar
  34. 34.
    Semelka RC, Patrick Shoenut J, Kroeker MA, Micflikier AB. Chronic pancreatitis: MR imaging features before and after administration of gadopentetate dimeglumine. Journal of Magnetic Resonance Imaging. 1993;3(1):79-82CrossRefGoogle Scholar
  35. 35.
    Winston CB, Mitchell DG, Cutwater EK, Ehrlich SM. Pancreatic signal intensity on Tl‐weighted fat saturation MR images: Clinical correlation. Journal of Magnetic Resonance Imaging. 1995;5(3):267-71CrossRefGoogle Scholar
  36. 36.
    Manikkavasakar S, AlObaidy M, Busireddy KK, Ramalho M, Nilmini V, Alagiyawanna M, et al. Magnetic resonance imaging of pancreatitis: an update. World Journal of Gastroenterology: WJG. 2014;20(40):14760CrossRefGoogle Scholar
  37. 37.
    Tirkes T, Lin C, Cui E, Deng Y, Territo PR, Sandrasegaran K, et al. Quantitative MR Evaluation of Chronic Pancreatitis: Extracellular Volume Fraction and MR Relaxometry. AJR Am J Roentgenol. 2018;210(3):533-42CrossRefGoogle Scholar
  38. 38.
    Tirkes T, Mitchell JR, Li L, Zhao X, Lin C. Normal T1 relaxometry and extracellular volume of the pancreas in subjects with no pancreas disease: correlation with age and gender. Abdom Radiol (NY). 2019.Google Scholar
  39. 39.
    Akisik MF, Sandrasegaran K, Jennings SG, Aisen AM, Lin C, Sherman S, et al. Diagnosis of chronic pancreatitis by using apparent diffusion coefficient measurements at 3.0-T MR following secretin stimulation. Radiology. 2009;252(2):418-25.Google Scholar
  40. 40.
    Cho SG, Lee DH, Lee KY, Ji H, Lee KH, Ros PR, et al. Differentiation of chronic focal pancreatitis from pancreatic carcinoma by in vivo proton magnetic resonance spectroscopy. 2005;29(2):163-9Google Scholar
  41. 41.
    Heuck A, Maubach PA, Reiser M, Feuerbach S, Allgayer B, Lukas P, et al. Age-related morphology of the normal pancreas on computed tomography. Gastrointestinal radiology. 1987;12(1):18-22CrossRefGoogle Scholar
  42. 42.
    Sato T, Ito K, Tamada T, Sone T, Noda Y, Higaki A, et al. Age-related changes in normal adult pancreas: MR imaging evaluation. European journal of radiology. 2012;81(9):2093-8CrossRefGoogle Scholar
  43. 43.
    Hastier P, Buckley MJ, Dumas R, Kuhdorf H, Staccini P, Demarquay J-F, et al. A study of the effect of age on pancreatic duct morphology. Gastrointestinal endoscopy. 1998;48(1):53-7CrossRefGoogle Scholar
  44. 44.
    Edge MD, Hoteit M, Patel AP, Wang X, Baumgarten DA, Cai Q. Clinical significance of main pancreatic duct dilation on computed tomography: single and double duct dilation. World Journal of Gastroenterology: WJG. 2007;13(11):1701CrossRefGoogle Scholar
  45. 45.
    Sai JK, Suyama M, Kubokawa Y, Watanabe S. Diagnosis of mild chronic pancreatitis (Cambridge classification): comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography. World journal of gastroenterology: WJG. 2008;14(8):1218CrossRefGoogle Scholar
  46. 46.
    Tamura R, Ishibashi T, Takahashi S. Chronic pancreatitis: MRCP versus ERCP for quantitative caliber measurement and qualitative evaluation. Radiology. 2006;238(3):920-8CrossRefGoogle Scholar
  47. 47.
    Cappeliez O, Delhaye M, Deviere J, Le Moine O, Metens T, Nicaise N, et al. Chronic pancreatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation. Radiology. 2000;215(2):358-64CrossRefGoogle Scholar
  48. 48.
    Wu C, Li F, Niu G, Chen X. PET imaging of inflammation biomarkers. Theranostics. 2013;3(7):448Google Scholar
  49. 49.
    Foss CA, Liu L, Mease RC, Wang H, Pasricha P, Pomper MG. Imaging macrophage accumulation in a murine model of chronic pancreatitis with 125I-Iodo-DPA-713 SPECT/CT. Journal of Nuclear Medicine. 2017;58(10):1685-90CrossRefGoogle Scholar
  50. 50.
    Yasaka K, Abe O. Deep learning and artificial intelligence in radiology: Current applications and future directions. PLoS medicine. 2018;15(11):e1002707CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of RadiologyUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.Department of RadiologyOhio State University Wexner Medical CenterColumbusUSA
  3. 3.Department of RadiologyIndiana University School of MedicineIndianapolisUSA
  4. 4.Department of RadiologyUniversity of Pittsburgh Medical CenterPittsburghUSA

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