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


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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9


  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):1143

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Duggan SN, Chonchubhair HMN, Lawal O, O’Connor DB, Conlon KCJWjog. Chronic pancreatitis: A diagnostic dilemma. 2016;22(7):2304

    CAS  Google Scholar 

  3. 3.

    Perrier C. Symposium of the etiology and pathological anatomi of chronic pancreatics. Marseilles, 1963. Am J Dig Dis. 1964;9:371-6

    Google Scholar 

  4. 4.

    Steer ML, Waxman I, Freedman S. Chronic pancreatitis. New England Journal of Medicine. 1995;332(22):1482-90

    CAS  PubMed  Google Scholar 

  5. 5.

    Whitcomb DC. Peering Into the “black box” of the complex chronic pancreatitis syndrome. Pancreas. 2016;45(10):1361

    PubMed  PubMed Central  Google 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.

  7. 7.

    Sarner M, Cotton P. Classification of pancreatitis. Gut. 1984;25(7):756-9

    CAS  PubMed  PubMed Central  Google 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):584-91

    PubMed  Google 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):215-21

    CAS  PubMed  Google 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):101-19

    PubMed  Google 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):764-73

    PubMed  Google 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):1251-61

    PubMed  Google 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):1781

    PubMed  Google 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):294-9

    CAS  PubMed  Google 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):207-15

    PubMed  Google 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):533-42

    PubMed  Google 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):85-93

    PubMed  Google 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):1171-6

    PubMed  Google 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):2809-21

    PubMed  Google 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):1-8

    PubMed  Google 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.

  22. 22.

    Ulzheimer S, Bongers M, Flohr T. Multi-slice CT: Current Technology and Future Developments. 2018.

  23. 23.

    Siddiqui N, Vendrami CL, Chatterjee A, Miller FH. Advanced MR imaging techniques for pancreas imaging. Magnetic Resonance Imaging Clinics. 2018;26(3):323-44

    Google 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):1339-46

    PubMed  Google Scholar 

  25. 25.

    Lesniak RJ, Hohenwalter MD, Taylor AJ. Spectrum of causes of pancreatic calcifications. American Journal of Roentgenology. 2002;178(1):79-86

    PubMed  Google 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):86-94

    CAS  Google 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):125-31

    Google 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):e55991

    CAS  PubMed  PubMed Central  Google 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):268-74

    PubMed  Google Scholar 

  30. 30.

    Sandrasegaran K, Lin C, Akisik FM, Tann M. State-of-the-art pancreatic MRI. American Journal of Roentgenology. 2010;195(1):42-53

    PubMed  Google 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):601-6

    PubMed  Google Scholar 

  32. 32.

    Gillams A, Punwani S, Smart S, Lees W, editors. Quantification of Pancreatic Exocrine Function Using Secretln Stimulated MRCP.

  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;112:7-13

    PubMed  Google 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):79-82

    CAS  PubMed  Google 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):267-71

    CAS  PubMed  Google 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):14760

    PubMed  Google 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):533-42

    PubMed  PubMed Central  Google 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.

  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.

  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):163-9

    Google 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):18-22

    CAS  PubMed  Google 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):2093-8

    PubMed  Google 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):53-7

    CAS  PubMed  Google 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):1701

    PubMed  Google 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):1218

    PubMed  Google 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):920-8

    PubMed  Google 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):358-64

    CAS  PubMed  Google Scholar 

  48. 48.

    Wu C, Li F, Niu G, Chen X. PET imaging of inflammation biomarkers. Theranostics. 2013;3(7):448

    PubMed  Google 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):1685-90

    CAS  PubMed  PubMed Central  Google Scholar 

  50. 50.

    Yasaka K, Abe O. Deep learning and artificial intelligence in radiology: Current applications and future directions. PLoS medicine. 2018;15(11):e1002707

    PubMed  PubMed Central  Google Scholar 

Download references


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.

Author information



Corresponding author

Correspondence to Anil K. Dasyam.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dasyam, A.K., Shah, Z.K., Tirkes, T. et al. Cross-sectional imaging-based severity scoring of chronic pancreatitis: why it is necessary and how it can be done. Abdom Radiol 45, 1447–1457 (2020).

Download citation


  • Chronic pancreatitis
  • Multidetector computed tomography
  • Magnetic resonance imaging
  • Classification