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• W1987266975 abstract "Chronic pancreatitis is not a common disease in children, and its diagnosis can be difficult. The clinical diagnostic criteria for chronic pancreatitis include abnormal radiologic findings in abdominal plain radiographs, ultrasonography, computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) (1). Although irregular dilatation and stenosis of the main pancreatic duct (MPD) observed during ERCP are the best diagnostic indicators of chronic pancreatitis (2), ERCP is invasive and therefore unsuitable for repeated use, as is necessary to observe the MPD. This is especially true in the case of children. Several previous studies have shown that magnetic resonance cholangiopancreatography (MRCP) is useful for the evaluation of structural abnormalities of the pancreaticobiliary tract, including chronic pancreatitis, and that MRCP can at least partially replace ERCP as a diagnostic tool in the adult population (3,4). However, no previous study has shown the usefulness of MRCP for the diagnosis or observation of chronic pancreatitis in children, although some have reported that MRCP can be used to diagnose certain kinds of pancreaticobiliary tract abnormalities (5–8). We report the use of MRCP to observe the progressive dilatation of the MPD in chronic pancreatitis and discuss the usefulness of MRCP for observing MPD abnormalities in children with chronic pancreatitis. CASE REPORT A 12-year-2-month-old boy had a 2-year history of epigastric abdominal pain and vomiting. He had a history of normal growth and development with no abdominal or systemic diseases and no family history of pancreatic diseases. At the age of 10 years 1 month, he first had epigastric abdominal pain and vomiting with elevated serum amylase (9144 IU/l; normal, 130–360 IU/l) and lipase (3220 IU/l; normal, 0–200 IU/l), and he was admitted to one of our branch hospitals with a diagnosis of acute pancreatitis. Abdominal ultrasonography and CT revealed an enlarged pancreas with decreased density but without dilated pancreatic or biliary ducts. His clinical symptoms and elevated enzyme levels disappeared within 3 weeks after conservative treatment, including restricted enteral feeding. After another episode, which occurred 6 months after the first, an ERCP was performed and revealed an irregular dilatation (5 mm) of the peripheral aspect of the MPD (Fig. 1). Results of an N-benzoyl-l-tyrosyl-p-aminobenzoic acid (BT-PABA) test of pancreatic exocrine function showed 58.7% (normal, 60.6–86.2%). These results, together with the patient's clinical history led to a diagnosis of chronic pancreatitis.FIG. 1.: At the age of 10 years 7 months, endoscopic retrograde cholangiopancreatography showed an irregular dilatation (5 mm) of the peripheral aspect of the main pancreatic duct (arrows).At the age of 12 years 2 months, he was referred to our hospital for evaluation of relapsing pancreatitis, having had four subsequent episodes within 18 months. To evaluate the dilatation of the MPD, we performed non-breath-hold MRCP using a half-Fourier, single-shot, fast spin-echo imaging method. To lessen the high signal intensity of intestinal fluid, ferric ammonium citrate (FerriSeltz; Ohtsuka Co., Tokyo, Japan), a T2 negative-contrast agent, was mixed with water and administered orally (5). The MRCP revealed an irregular dilatation (5 mm) of the peripheral aspect of the MPD, which agreed with an ERCP analysis performed 18 months earlier (Fig. 2).FIG. 2.: At the age of 12 years 2 months, magnetic resonance cholangiopancreatography revealed an irregular dilatation (5 mm) of the peripheral aspect of the main pancreatic duct (arrows).Three months after the first MRCP, he had the most severe episode of epigastric abdominal pain and vomiting with elevated serum amylase and lipase. Re-evaluation using MRCP showed marked dilatation (10 mm) of the MPD from 15 mm of Vater's papilla to the pancreatic tail, with several filling defects (Fig. 3). Results of another BT-PABA test showed a reduction to 45.8%. To relieve recurrent abdominal pain and to prevent degradation of pancreatic exocrine function we performed a pancreaticojejunostomy. Protein plaques were detected in the proximal aspect of the dilated MPD and were thoroughly washed out at the time of the operation.FIG. 3.: At the age of 12 years 5 months, re-evaluation, by magnetic resonance cholangiopancreatography showed marked dilatation (10 mm) of the main pancreatic duct from 15 mm upstream of Vater's papilla to the pancreatic tail, with several filling defects (arrows).The patient has been symptom free since surgery with 12 months' follow-up. DISCUSSION Recent reductions in imaging time and improvements in spatial resolution have facilitated the diagnosis of structural abnormalities of the pancreaticobiliary tract in children, such as choledochal cysts, congenital biliary atresia, and abnormal union of the pancreaticobiliary junction (5–8). However, this is the first case report of the usefulness of MRCP in assessing abnormalities of the pancreatic duct, such as irregular dilatation and stenosis of the MPD, in a child with chronic pancreatitis. Abnormalities of the MPD are among the most important indicators of chronic pancreatitis. Studies have demonstrated the value of MRCP in diagnosing chronic pancreatitis in adults. Takehara et al. (4) first reported that MRCP could provide excellent visualization of the pancreatic duct in patients with chronic pancreatitis and allowed detection of narrowing, dilatation, and filling defects with moderate to high accuracy. Ueno et al. (3) recently reported the advantage of MRCP over ERCP in visualizing the upstream pancreatic duct in cases of obstruction or stenosis of the MPD. Our findings suggest that progressive dilatation of the MPD was due to obstruction by protein plugs, which appeared to be filling defects when observed by MRCP. Our findings further suggest that any abnormalities of the MPD should be observed throughout the course of chronic pancreatitis to identify the obstruction, as in the case of our patient. Although abdominal ultrasonography is a convenient noninvasive method for repeated observations, it does not permit visualization of the entire duct. Similarly, although ERCP allows complete visualization of the MPD, it is relatively invasive and is not appropriate during the acute phase of pancreatitis. Thus, given the present alternatives, MRCP is a noninvasive and useful method that can be used repeatedly to detect MPD abnormalities at any phase of chronic pancreatitis, even in children. It is expected, therefore, that ERCP will be used less frequently in the future and may be reserved for preoperative cases in which exceptional detail is required before surgery." @default.
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• W1987266975 title "Progressive Dilatation of the Main Pancreatic Duct Using Magnetic Resonance Cholangiopancreatography in a Boy with Chronic Pancreatitis" @default.
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