Forsmark C E, Toskes P P
Department of Diagnostic and Therapeutic Endoscopy, University of Florida College of Medicine, Gainesville, USA.
Gastrointest Endosc Clin N Am. 1995 Jan;5(1):105-23.
The foregoing discussion emphasized the fact that pancreatography can document changes that are relatively specific for chronic pancreatitis but that similar changes can be seen in other clinical conditions and even as normal variants. In addition, the exact clinical implication of minor or equivocal changes is unclear and care should be taken not to overinterpret ERP findings. It also must be realized that ERP may miss a substantial number of patients with earlier or less advanced chronic pancreatitis. ERP also may document pancreas divisum, but is not helpful in explaining the patient's clinical condition in the absence of dorsal duct abnormalities. Finally, tests of pancreatic function--in particular, hormonal stimulation tests--are complementary to tests of pancreatic morphology and allow the diagnosis of less advanced or earlier chronic pancreatitis, as well as patients with divisum and normal dorsal ducts who nonetheless have obstruction to flow at the minor papilla. The evaluation of a patient with presumed chronic pancreatitis therefore should begin with simple, noninvasive tests that are able to detect advanced forms of chronic pancreatitis. These include plain abdominal radiograph and serum trypsin. If either of these is markedly abnormal, no further diagnostic testing is generally required. In patients in whom diagnostic uncertainty still exists, reasonable second-echelon tests include abdominal CT, bentiromide testing, or secretin stimulation testing. Of these, hormonal stimulation testing offers the most sensitivity but is not universally available. More invasive evaluations--in particular, ERP--should be reserved for patients in whom the diagnosis is still unclear or in whom therapeutic rather than diagnostic information is required (e.g., a patient classified a medical failure being considered for Peustow procedure).
上述讨论强调了这样一个事实，即胰管造影可以记录对慢性胰腺炎具有相对特异性的改变，但类似的改变也可见于其他临床情况，甚至作为正常变异。此外，轻微或不明确改变的确切临床意义尚不清楚，应注意避免对胰管逆行造影（ERP）结果过度解读。还必须认识到，ERP可能会遗漏大量早期或病情不太严重的慢性胰腺炎患者。ERP也可能显示胰腺分裂，但在没有背侧胰管异常的情况下，对解释患者的临床情况并无帮助。最后，胰腺功能测试——尤其是激素刺激试验——是对胰腺形态学检查的补充，有助于诊断病情不太严重或早期的慢性胰腺炎，以及胰腺分裂且背侧胰管正常但在小乳头处存在引流障碍的患者。因此，对疑似慢性胰腺炎患者的评估应从能够检测晚期慢性胰腺炎的简单、非侵入性检查开始。这些检查包括腹部平片和血清胰蛋白酶。如果其中任何一项明显异常，一般无需进一步的诊断检查。对于诊断仍不明确的患者，合理的二线检查包括腹部CT、苯替酪胺试验或促胰液素刺激试验。其中，激素刺激试验的敏感性最高，但并非普遍可用。更具侵入性的评估——尤其是ERP——应保留给诊断仍不明确或需要治疗而非诊断信息的患者（例如，被归类为内科治疗失败且考虑进行Peustow手术的患者）。
