Current Gastroenterology Reports (2020) 22: 34

https://doi.org/10.1007/s11894-020-00772-4

PANCREAS AND BILIARY TRACT (O HALUSZKA AND H GAVINI, SECTION EDITORS)

Endoscopic Ultrasound-Guided Management of Chronic Pancreatitis

Raj Dalsania 1 & Rushikesh Shah 1 & Surinder Rana 2 & Saurabh Chawla 1

Published online: 4 June 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review The purpose of this review is to discuss the role of endoscopic ultrasound (EUS) in the diagnosis and
treatment of chronic pancreatitis (CP).
Recent Findings EUS has evolved and become invaluable in diagnosing early CP with the use of elastography and contrast
enhancement. Lumen-apposing metal stents have allowed for easier transmural drainage and necrosectomy for pancreatic
pseudocyst and walled of necrosis. EUS-guided pancreatic duct drainage is being utilized for pancreatic duct complications
including stenosis, stones, and duct disruptions that are not amendable to endoscopic retrograde cholangiopancreatography.
Summary EUS is an effective tool that assists with the diagnosis and treatment of CP. The technology continues to evolve
allowing for diagnosis of CP in earlier stages, which enables more effective therapy. The development of new EUS-guided tools
and techniques has improved the treatment of complications from CP.

Keywords Endoscopic ultrasound . Chronic pancreatitis . Early chronic pancreatitis

Introduction and radiographic findings [2]. Diagnosis of CP can be evident

Chronic pancreatitis (CP) is an inflammatory disease associ-
ated with a progressive loss of pancreatic parenchymal tissue.
It is accompanied by recurrent attacks of abdominal pain that
are often debilitating. Later in the disease state, exocrine and
endocrine insufficiency can develop [1]. The gold standard for
diagnosis is pancreatic tissue sampling; however, this is rarely
performed given the low sensitivity and potential complica-
tions associated with biopsy of the pancreas. As a result, di-
agnosis often relies on a combination of clinical, laboratory,
This article is part of the Topical Collection on Pancreas and Biliary Tract
* Raj Dalsania
rmdalsa@emory.edu
* Saurabh Chawla
saurabh.chawla@emory.edu
Rushikesh Shah
rushikesh.shah@emoryhealthcare.org
in advanced disease; however, it is much more difficult in
earlier stages. Additionally, due to the complex pathophysio-
logical changes associated with CP, management of the dis-
ease remains challenging. Usually, the sequence of disease
progression is initiated by a single offending agent (i.e., gall-
stones, alcohol, drugs). However, oftentimes even after elim-
ination of the offending agent, the progression of this disease
continues with worsening symptoms despite medical therapy.
When CP is diagnosed early, frequent monitoring allows for
detections of complications, so more effective therapy can be
delivered [3]. However, it remains unclear if early therapy
affects disease progression.
Over the past several years, endoscopic ultrasound (EUS)
has emerged as an essential tool in diagnostic and therapeutic
management of CP. In this review, we will focus on the role of
EUS in the diagnosis of CP with a focus on early diagnosis
and also highlight the important role this technology plays in
endoscopic therapy CP [4].

Surinder Rana
drsurinderrana@gmail.com
Diagnosis of Chronic Pancreatitis with EUS
1
Department of Digestive Diseases, Emory University School of
Medicine, Atlanta, GA, USA The pathophysiology of CP is not completely understood.
2
Postgraduate Institute of Medical Education and Research, Although the mechanism likely varies on the underlying eti-
Chandigarh, India ology, all causes of CP ultimately share a similar pathway. An
34 Page 2 of 10
insult leads to injury to the exocrine tissue which releases
activated pancreatic enzymes resulting in inflammation.
Repeated insults lead to activation of pancreatic stellate cells
which initiate fibrogenesis causing changes to the parenchyma
and ducts. Endoscopic ultrasound has assisted with identify-
ing these findings during early stages [5].
With the use of a high frequency (5 Mz to 30 MHz) probe
in close proximity to the pancreas, EUS provides high resolu-
tion images (within 1 mm) of pancreatic tissue and duct struc-
tures [2]. In a systematic review with meta-analysis of 43
studies evaluating 3460 patients, EUS was found to have a
higher sensitivity of 81% (95% CI 70–89%) for diagnosing
CP when compared with magnetic resonance imaging (MRI)
of 78% (95% CI 69–85%) and computed tomography (CT) of
75% (95% CI 66–83%). Additionally, in head to head com-
parison of EUS to other imaging modalities, EUS was found
to be an outperformer [6•]. EUS has been proven invaluable in
early chronic pancreatitis or minimal change chronic pancre-
atitis, where classical functional and radiographic findings are
not present. It has the ability to identify morphologic features
consistent with CP earlier than endoscopic retrograde
pancreatography. This was demonstrated in a prospective
study in which out of 38 patients with normal retrograde
pancreatography, 32 (84.2%) had morphological features con-
sistent with CP by EUS. At a mean follow-up of 18 months,
CP was confirmed by repeat endoscopic retrograde
pancreatography in 22 of 32 (68.8%) patients [7].
The use of EUS for the diagnosis of CP dates back to 1986.
As EUS became more utilized to evaluate CP, many publica-
tions encompassed different terminologies, features, and
criteria for CP. The lack of standardization and subjectivity
made it difficult to reproduce findings and apply them clini-
cally. In 2009, an international consensus was held with 32
endosonographers to develop the Rosemont criteria to address
the ambiguity. They identified several parenchymal and ductal
features on EUS (Table 1) in patients with CP and labeled
them as either major or minor criteria. Various combinations
of these major and minor criteria were developed to assist with
determining if the findings are consistent, suggestive,
indeterminant, or normal for CP (Table 2) [8].
Contrast-Enhanced EUS and Elastography
Newer endoscopic ultrasound techniques and adjuncts have
shown to assist in determining the severity of CP and identi-
fying benign vs. malignant changes. EUS with elastography
(EUS-E) is a technique that assesses the “stiffness” of the
pancreas, which can help with identifying duration and sever-
ity of CP. The principle of elastography is based on the as-
sumption that compression of a target tissue by a probe creates
displacement of one tissue structure by another called strain
that differs based on hardness or softness. This allows for the
calculation of the elasticity of the tissue to differentiate benign
Curr Gastroenterol Rep (2020) 22: 34
(soft) vs. malignant (hard) tissue. Elastography is visualized in
real time with color images superimposed over conventional
gray-scale b-mode EUS image. Strain is shown via different
colors (blue = hard tissue, green = soft tissue) providing a
qualitative assessment (Fig. 1) [9]. Newer software allows
for a calculation of a strain ratio in order to provide a quanti-
tative result.
Some studies suggest that CP may increase the risk of
developing pancreatic cancer. In the setting of distorted paren-
chymal tissue, it is often difficult to discriminate between CP
and pancreatic adenocarcinoma. EUS-E has proven to be use-
ful in characterizing solid pancreatic lesions (SPLs) (Fig. 2).
In a study of 86 consecutive patients with or without CP who
underwent EUS for solid pancreatic mass, EUS-E was per-
formed and a strain ratio was calculated. Final diagnosis was
based on histology from sampling of the lesions. The sensi-
tivity and specificity of strain ratio for detecting pancreatic
malignancies were 100% and 92.9% respectively [10]. In an-
other prospective study, 100 patients with or without CP and a
total of 102 SPLs (69 malignant, 33 benign), elastography
showed that that the pancreatic strain ratio (pSR) and wall
strain ratio (wSR) were higher in malignant vs. benign lesions
[pSR, 24.5 vs. 6.4 (P < 0.001); wSR, 56.6 vs. 15.3 (P <
0.001)] with a sensitivity of 88.4% and specificity of 78.8%
[11••].
Shear wave EUS-E has developed into a promising tool for
staging disease severity of CP. This technique assesses tissue
“stiffness” with the use of a focused acoustic impulse that
gives rise to shear waves in tissues. Velocities are obtained
and provide a direct measure of elasticity (Fig. 3). In a study
where 42 healthy subjects were compared with 52 consecutive
patients with CP, elastography revealed that patients with CP
had higher pancreatic stiffness (4.3 ± SD 2.4 vs. 2.8 ± SD
1.1 kPa, respectively, P = 0.001) and higher values were seen
in patients with longer disease (> 10 vs. ≤ 10 years) (5.8 ± SD
4 vs. 3.9 ± SD 1.5 kPa, respectively, P = 0.01) [12•]. Shear
wave elastography has additionally positively correlated with
histological fibrosis stages which can assist with determining
disease severity in CP through noninvasive measures [13].
Contrast-enhanced EUS (CE-EUS) has also become a reli-
able tool to help differentiate subtle pancreatic findings. Air
microbubble contrast agents are utilized to transiently enhance
ultrasound echoes that allow analysis of blood flow and vas-
cular structures (Fig. 4) [14, 15]. In a retrospective study of
215 patients, the sensitivity and specificity for identifying
pancreatic cancer in contrast-enhanced EUS were superior to
CT at 96% vs. 89% and 91% vs. 70%, respectively, and com-
parable to endoscopic ultrasound with fine needle aspiration
(EUS-FNA) at 96% and 100% [16]. In cases where EUS-FNA
of a lesion has negative pathology, a combination of
elastography and contrast-enhanced EUS can be used to in-
crease diagnostic certainty which can reduce the need for re-
peat FNA and/or surgery [17].
Curr Gastroenterol Rep (2020) 22: 34 Page 3 of 10 34

Table 1 Rosemont classification:

consensus-based parenchymal Feature Definition Major Minor
and ductal features of CP (adapted criteria criteria
from reference 5)
Hyperechoic foci with Echogenic structures ≥ 2 mm in length and width that shadow Major
shadowing A
Lobularity Well-circumscribed, ≥ 5 mm structures with enhancing rim
and relatively echo-poor center
A. With Contiguous ≥ 3 lobules Major
honeycombing B
B. Without Noncontiguous lobules Yes
honeycombing
Hyperechoic foci Echogenic structures ≥ 2 mm in both length and width with no Yes
without shadowing shadowing
Cysts Anechoic, rounded/elliptical structures with or without Yes
septations
Stranding Hyperechoic lines of ≥ 3 mm in length in at least 2 different Yes
directions with respect to the imaged plane
MPD calculi Echogenic structure(s) within MPD with acoustic shadowing Major
A
Irregular MPD Uneven or irregular outline and ectatic course Yes
contour
Dilated side branches 3 or more tubular anechoic structures each measuring ≥ 1 mm Yes
in width, budding form the MPD
MPD dilation ≥ 3.5-mm body or ≥ 1.50 mm tail Yes
Hyperechoic MPD Echogenic distinct structure greater than 50% of entire MPD in Yes
margin the body and tail

EUS and Pancreatic Cysts
Pancreatic cysts are common in patients with CP, and proper
differentiation of these lesions is imperative as some have
malignant potential (serous cystadenoma, mucinous
cystadenoma, intraductal papillary mucinous neoplasms, and
solid pseudopapillary neoplasm). Efforts to differentiate cystic
lesions from imaging tests are met with mixed success with up
to 40% of neoplastic cysts being diagnosed as pseudocysts
[18]. In a recent study, the use of EUS with FNA (CEA,
amylase, cytology) in addition to CT and MRI increased the
overall accuracy for diagnosing a cystic neoplasm by 36% and
54%, respectively [19]. Cyst wall sampling has shown to in-
crease diagnostic accuracy, specifically for mucinous cysts;
however, sample yields are low with traditional FNA needles.
A through-the-needle forceps device (Moray Micro Forceps,
US Endoscopy) has demonstrated to obtain biopsies that in-
creases diagnostic yield. In a multicenter study of 47 patients
who underwent through-the-needle biopsies (TTNB) and
FNA for cysts, the cumulative incremental diagnostic yield
of a mucinous cyst was significantly higher with TTNB vs.
FNA (52.6% vs. 18.4%; P = 0.004) [20•].
EUS-guided needle-based confocal laser endomicroscopy
(EUS-nCLE) has also allowed for greater accuracy in identi-
fying mucinous cysts when compared with CEA and cytology
analysis. EUS-nCLE is a technique that offers real-time mi-
croscopic imaging of cyst epithelium providing “virtual biop-
sies” with high resolution. In a recent single center study of 65
patients who underwent EUS with FNA of pancreatic cysts
and subsequent surgical resection allowing for analyzed his-
tology, the sensitivity and specificity for diagnosing a mucin-
ous cyst were 74% and 61%, respectively, for CEA and

Table 2 EUS diagnosis of CP

based on consensus criteria
I. Consistent with CP A. 1 major A feature (+) ≥ 3 minor features
B. 1 major A feature (+) major B feature
C. 2 major A features
II. Suggestive of CP A. 1 major A feature (+) < 3 minor features
B. 1 major B feature (+) ≥ 3 minor features
C. ≥ 5 minor features (any)
III. Indeterminate for CP A. 3 to 4 minor features, no major features
B. major B feature alone or with < 3 minor features
IV. Normal C. ≤ 2 minor features, no major features
34 Page 4 of 10
Fig. 1 EUS elastography in
chronic pancreatitis: focal
inflammatory mass with
calcifications in the body of the
pancreas showing a heterogenous
blue color (arrows)
cytology analysis compared with 98% and 97% for EUS with
nCLE, respectively [21].
EUS in the Management of Chronic
Pancreatitis
EUS-Guided Endoscopic Drainage of Pancreatic
Pseudocysts and Walled of Necrosis
In CP patients with persistent recurrent episodes of acute pan-
creatitis or progressive disease, pancreatic duct (PD) disrup-
tions or leaks can occur leading to pancreatic fluids collections
(PFCs). Most collections resolve spontaneously; however,
those with severe attacks or necrosis have an increased risk
of developing persistent collections. The revised Atlanta con-
sensus classifications divide PFCs based on their maturity and
content. A collection that contains only fluid is categorized as
an acute peri-PFC and after 4 weeks as pseudocyst if it does
not resolve. Collections that contain necrotic debris are clas-
sified as acute necrotic collections early on and walled off
necrosis (WON) after 4 weeks where the cyst wall has ma-
tured [22]. These complications can be self-limiting; however,
Fig. 2 EUS elastography in
pancreatic adenocarcinoma: The
color pattern of the lesion shows a
predominant blue color
suggestive of a hard lesion
(arrows)
Curr Gastroenterol Rep (2020) 22: 34
often times they become symptomatic (infection, obstruction,
fistula, bleeding) and require drainage.
EUS-guided intervention has become the preferred choice
modality of drainage of pseudocysts and WON given the min-
imally invasive nature, decreased length of hospital stay, and
decreased cost when compared with percutaneous and surgi-
cal approaches. In a large systematic review and meta-analysis
comparing EUS-guided transmural drainage with percutane-
ous approach of PFCs, endoscopic intervention had a higher
rate of clinical success (OR = 3.36; 95% confidence internal
(CI) 1.48, 7.63; P = 0.004) and was preferable regarding re-
currence of collections (OR = 0.23; 95% CI 0.08, 0.66; P =
0.0006) [23•]. Percutaneous drainage is currently reserved for
immature pseudocysts, infected collections, and those with
co\morbidities that would not allow endoscopy or surgery
[24]. In the same meta-analysis above, when EUS drainage
of 842 patients was compared with surgical drainage of 896
patients for both pseudocysts and WON, clinical success was
lower in endoscopic drainage (0.59 95% CI 0.37, 0.93; P =
0.022), but mortality, recurrence, and complication rates were
similar. Additionally, the total length of hospital stay was
3.67 days shorter (95% CI 5.00, − 2.34; P < 0.001) for endo-
scopic therapy when compared with surgery.
Curr Gastroenterol Rep (2020) 22: 34
Fig. 3 EUS elastography in
chronic pancreatitis: The pancreas
shows echogenic foci and strands.
The main pancreatic duct is not
dilated. The strain ratio on
quantitative elastography is 9.45
suggestive of a stiff pancreas
When a mature collection is abutting the gastric or duo-
denal wall, a transmural approach can be taken to create a
tract to gain access to the collection (Fig. 5). EUS allows
identification of an ideal point to create a puncture avoiding
neighboring vasculature. A guidewire can then be ad-
vanced into the cyst cavity, and the tract is then dilated so
that stents can be placed [25]. EUS-guided transmural
drainage may be achieved with plastic stents (PS), larger
caliber fully covered self-expandable metal stents
(FCSEMS), and lumen-apposing metal stents (LAMS).
For pseudocysts, clinical success rates approach > 90%
when a 7 French to 10 French plastic stents are used and
metal stents and LAMS have not shown to provide any
additional benefit [26]. WON require the drainage of thick
necrotic material, so it was postulated that larger conduit
stents would allow for better drainage of the necrotic ma-
terial and the ability to perform necrosectomy. In a retro-
spective study of 313 patents comparing PS, FCSEMS, and
LAMS placement for WON, there was no difference in
technical success; however, the mean number of proce-
dures was significantly lower in the LAMS group
Fig. 4 Contrast EUS in
pancreatic adenocarcinoma: The
lesion is hypo-enhancing (arrows)
Page 5 of 10 34
compared with the FCESEMS and PS (2.2 vs. 3 vs. 3.6,
respectively, P = 0.04) [27]. These findings contrast a re-
cent randomized clinical trial comparing 60 patients who
underwent LAMS (n = 31) versus plastic stent (n = 29)
placement for WON, where there was no overall significant
difference in total number of procedures for treatment suc-
cess (median 2 for LAMS vs. 3 for plastic; P = 0.192).
Procedure duration was shorter (15 vs. 40 min < 0.001)
for patients who had LAMS placed. There was significant
stent-related adverse events with LAMS when compared
with plastics (32% vs. 6.9%, P = 0.01) which included bur-
ied stents, bleeding, and stent-related biliary strictures.
Most of these events were observed > 3-week postinterven-
tion with LAMS. The study protocol was revised where a
CT scan was obtained at 3-week postintervention followed
by LAMS removal if the WON has resolved and this result-
ed in no significant difference in adverse events between
the cohorts [28••]. Many endoscopists have developed a
preference for LAMS as they are less cumbersome to place
and allow the ability to perform necrosectomy without re-
moving the stent and recannulating the cavity [29].
34 Page 6 of 10
Fig. 5 EUS-guided cystgastrostomy. a A walled off necrosis cavity. b
Using coaxial stent deployment system, cyst wall is penetrated from
gastric lumen under EUS guidance. c Under EUS guidance, the distal
EUS-Guided Celiac Plexus/Ganglion Blocks and
Neurolysis
Pain is a predominant symptom in most CP patients and often
times becomes extremely challenging to manage. Dependence
and abuse of oral pain medications is a growing concern, and
thus, EUS-guided celiac plexus neurolysis (EUS-CPN) and
celiac plexus blocks (EUS-CPB) are being utilized in those
with refractory pain. CPB is a treatment that uses a local an-
esthetic in combination with a corticosteroid that causes a
temporary effect, whereas CPN uses alcohol or phenol with
the intent of a more permanent effect [30]. Traditionally, CPN
and CPB are performed with fluoroscopic guidance using rec-
ognized bony landmarks. A needle is then placed in an ap-
proximate region for the celiac plexus. This technique is lim-
ited as there is no direct visualization and there is risk for
vascular puncture or neurological damage if a posterior ap-
proach is used [31]. EUS allows for real-time visualization
and color Doppler imaging for an improved and safer delivery
of medication. There are currently no comparison studies to
demonstrate the superiority of percutaneous fluoroscopy vs.
EUS-guided neurolysis/blocks in CP patients.
In a single center prospective study including 90 patients
who underwent EUS-CPB for chronic pancreatitis-related
pain, there was a significant improvement in overall pain
scores in 55% of the patients from a mean of 8 to 2 at 4 and
8 week follow-up appointments (P < 0.05). Persistent benefit
Curr Gastroenterol Rep (2020) 22: 34
flange is deployed into WON cavity. d Coaxial stent is deployed using
linear echoendoscope confirmed under fluoroscopy. e Endoscopic
appearance of WON cavity through the coaxial stent lumen
beyond 12 and 24 weeks was only seen in 26% and 10%,
respectively [32]. There are currently two techniques that are
used for EUS-CPN. In the central technique, a neurolytic
agent is injected at the base of the celiac axis, whereas in the
bilateral technique, the agent is injected on both sides of the
celiac axis [33]. In a meta-analysis with 9 studies and 376
patients, EUS-CPN provided pain relief in 59.45% of patients
[34].
Direct injection into the celiac ganglion, EUS-guided celiac
ganglion neurolysis (EUS-CGN), has been recently per-
formed for chronic pancreatitis and pancreatic adenocarcino-
ma. Early studies showed relief in pain; however, the sample
size for chronic pancreatitis patients has been very small [35].
Randomized clinical trials for EUS-CGN have been primarily
performed in those with upper abdominal cancer pain. Doi
et al. performed a randomized multicenter trial comparing
EUS-CGN with EUS-CPN in patients with upper abdominal
cancer pain. Each arm had 34 patients, and at day 7, evaluation
was performed with a pain scale of 0 to 10. Patients for whom
pain decreased to ≤ 3 were considered to have a positive re-
sponse, and those experiencing a decrease in pain to ≤ 1 dem-
onstrated complete response. The positive response rate in the
EUS -CGN group compared with the EUS-CPN group was
73.5% vs. 45.5%, respectively, whereas the complete re-
sponse rate was 50% vs. 18.2%, respectively.
A recent randomized clinical trial demonstrated poor long-
term outcomes for EUS-CGN. Levy et al. compared the effect
Curr Gastroenterol Rep (2020) 22: 34
of EUS-CGN vs. the effects of EUS-CPN on pain, quality of
life (QOL), and survival. Rates of pain response at 12 weeks
were 46.2% for CGN and 40.4% for CPN (P = 0.84). There
was no significant difference in improvement of QOL be-
tween the techniques either. The median survival time was
significantly shorter for patients receiving CGN (5.59 months)
compared with CPN (10.46 months), and rates of survival at
12 months were 26% for patients who underwent CGN vs.
42% for patients who underwent CPN. Overall, they demon-
strated that EUS-CGN reduced median survival time without
improving pain, QOL, or adverse events, compared with CPN
in patients with pancreatic adenocarcinoma [36••]. These find-
ings are difficult to generalize to CP patients, and given the
lack of clinical trials, EUS-CGN is not readily being applied to
CP patients. Additionally, EUS-guided celiac ganglion radio
frequency ablation for pain control is being investigated for
pancreatic cancer-related pain; however, it has yet to be ap-
plied to patients with CP [37, 38].
Currently, most centers do not routinely perform EUS-
guided celiac plexus/ganglion blocks and neurolysis given
the limited efficacy and short-lived responses. Many practi-
tioners do not actually see a decrease in oral pain medications
Fig. 6 EUS-guided pancreaticogastrostomy. a EUS-guided puncture of
the pancreatic duct in the upstream body is performed. b Contrast is
injected revealing a dilated pancreatic duct with a tight stricture in the
Page 7 of 10 34
after a block or neurolysis. Additionally, there is a lack of
chronic pancreatitis-specific controlled studies with much of
the theories being extrapolated from pancreatic cancer pain.
EUS-Guided Pancreatic Duct Therapy
The mechanism for pain in CP is multifactorial; however, one of
the proposed mechanisms is intraductal hypertension. When sig-
nificant stenosis, stones, or duct disruption occurs, ductal pressure
increases causing dilation which subsequently increases the pan-
creatic parenchymal pressure. Management typically involves de-
compression with surgical or endoscopic techniques. Surgical
techniques are effective, however have significant morbidity and
mortality, and often require repeat operations. Endoscopic decom-
pression has also demonstrated to be quite effective with lower
rates of complications when compared with surgery [39].
Endoscopic intervention is, however, limited when the major
pancreatic duct (MPD) and duct of Santorini cannot be cannu-
lated via endoscopic retrograde cholangiopancreatography
(ERCP). In these situations, EUS-guided interventions have been
shown to be effective. Endoscopic ultrasound-guided pancreatic
duct drainage (EUS-PDD) can be performed in CP patients who
head of the pancreas. c A guidewire is negotiated into the pancreatic duct.
d The transmural tract is dilated with a 6 Fr cystotome. e A plastic stent is
placed in situ of the pancreaticogastrostomy
34 Page 8 of 10
develop significant MPD stenosis, duct disruptions, and large
stones. Drainage attempts are generally performed in dilated
ducts where proper visualization and duct manipulation are fea-
sible. Typically, a 19-gauge FNA needle is placed into the prox-
imal pancreatic duct, contrast is injected to confirm proper place-
ment, and a guidewire is then inserted through the duct. At this
point, there are generally two approaches for drainage. If the
guidewire can be advanced across the stenosis and papilla into
the duodenum, a rendezvous technique is performed where the
EUS scope is exchanged with a duodenoscope for traditional
endotherapy to be performed. If the initial guidewire does not
traverse the stenosis, the tract must be created between the stom-
ach and MPD must be dilated with the use of a hydrostatic
balloon, tapered catheter, cannulas, and/or diathermic catheters
such as needle knives [40]. In this anterograde approach, a plastic
stent can be placed in the MPD with termination into the stomach
(Fig. 6). Rendezvous-assisted ERCP should be considered prior
to anterograde EUS-PDD as in the former; there is no need for
fistula formation which leads to a decreased risk of pancreatic
injury, bleeding, or leak [41, 42].
The current literature on EUS-PPD is limited to retrospec-
tive and case studies. A recent review summarized 33 studies
with a total of 517 procedures. Technical success rates for the
rendezvous technique were 55.6% and anterograde was
93.8% (P < 0.01). The lower rates for success for rendezvous
technique are attributed to failure of guidewire passage across
the papilla. Therefore, an anterograde approach should be per-
formed if initial rendezvous attempt fails. The adverse events
rate of EUS-PPD is around 20% and include pancreatitis, ab-
dominal pain, duct leakage, fluid collections, peritonitis, stent
dislocation, bleeding, and perforation [41, 43].
In CP patients with symptomatic pancreaticolithiasis, endo-
scopic retrograde cholangiopancreatography (ERCP) is an effec-
tive therapy. Pancreatoscopy can be utilized to deliver intraductal
electrohydraulic lithotripsy (IEHL) to assist with fragmenting
stones. CP patients can develop small caliber pancreatic ducts
which can make retrograde pancreatoscopy technically difficult.
In a recent study by James et al., 5 patients who failed ERCP for
treatment of pancreaticolithiasis underwent endoscopic
ultrasound-guided pancreaticogastrostomy (EUS-PG) where a
pancreatic duct stent was passed anterograde through the pancre-
atic duct across the ampulla into the duodenum or left upstream to
the obstructing stone. The tracts matured for a mean of 56 days,
and ERCP was subsequently performed with stent removal.
Pancreaticogastrostomy dilation was performed and anterograde
pancreatoscopy was conducted with administration of IEHL.
Clinical success was 100% with no reported adverse events [44].
Conclusion
EUS has become an essential tool in the diagnosis and man-
agement of CP. Early diagnosis in early stages of the disease
Curr Gastroenterol Rep (2020) 22: 34
allows for targeted therapy and surveillance of complications.
The development of the Rosemont criteria has allowed EUS to
become a highly sensitive, specific, and reproducible diagnos-
tic study for CP. Elastography and contrast-enhanced EUS
have assisted with better differentiation of fibrotic pancreatic
tissue from malignancies with the future of the technology
moving towards defining specific stages of CP. Pancreatic
pseudocysts and walled off necrosis are common complica-
tions of CP with EUS-guided transmural drainage and stent
placement being first-line therapy given the minimal invasive
nature, cost-effectiveness, and decreased hospital stay.
Abdominal pain is one of the most debilitating symptoms of
CP which often leads to oral pain medication dependence and
abuse. EUS-guided celiac plexus/ganglion blocks and
neurolysis have been utilized in attempt to improve pain con-
trol; however, the effects are short lived and have not demon-
strated reduction in oral pain medications. This technique is
not readily being performed and will require more dedicated
controlled studies to CP. Lastly, endoscopic ultrasound-
guided pancreatic duct drainage (EUS-PDD) can be per-
formed in CP patients who develop significant MPD stenosis,
duct disruptions, and large stones that cannot be treated con-
ventionally with ERCP.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interest.
Human and Animal Rights This article does not contain any studies
with human or animal subjects performed by any of the authors.
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