North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the Society for Pediatric Radiology Joint Position Paper on Noninvasive Imaging of Pediatric Pancreatitis

Acute Pancreatitis

The diagnosis of AP in children has been defined as the presence of at least 2 of the following: abdominal symptoms consistent with AP; serum amylase or lipase values ≥3 times the upper normal level; and imaging findings consistent with AP (11.). Biliary causes, anatomic causes, and genetic pancreatitis represent the most common etiologies of AP in children, but up to 20% of cases remain idiopathic (Table 1) (12.-14.). Severity staging of AP has only recently been defined for pediatrics (Table 2), and is structured to classify which children are most at risk of complicated courses (15., 16.). Mild AP is defined as AP without organ failure or local or systemic complication, and usually resolves within 1 week. Moderately severe AP is defined as either the presence of transient (≤48 hours) organ failure, the presence of local complications, or the exacerbation of comorbid disease. Severe AP (SAP) is defined by organ failure lasting longer than 48 hours. Moderately severe or SAP have been reported to occur in approximately 13% to 30% of children with AP (15., 17.). To date, pediatric-specific risk factors for SAP remain unclear.

TABLE 1. Categorical etiologies of pediatric pancreatitis

TABLE 2. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition acute pancreatitis working group classification of pediatric acute pancreatitis severity

In general terms, the roles of imaging in AP are to: identify findings of AP at diagnosis; assess for local complications; identify potential etiologies of AP; monitor the evolution of local complications, and plan and guide interventions. Largely on the basis of the lack of ionizing radiation, transabdominal ultrasound is favored as the initial imaging modality for the diagnosis of AP in children, whereas computed tomography (CT) and/or magnetic resonance imaging (MRI) are reserved for more complicated cases or to answer specific clinical questions (4.).

Acute Recurrent Pancreatitis

Acute recurrent pancreatitis (ARP) has been defined as 2 distinct attacks of AP with more than 1 month pain-free interval between attacks, or with normalization of pancreatic enzymes and complete resolution of pain regardless of interval between episodes (11.). ARP is believed to develop in 15% to 35% of pediatric patients who suffer from an initial event of AP (3., 17., 18.). In 1 study, the majority of patients who developed ARP had a second attack within 5 months after their initial episode (19.). Genetic mutations represent the most common risk factor for the development of ARP with almost 50% of patients carrying a mutation in CFTR, PRSS1, CTRC or SPINK1 in 1 series. Additionally, approximately 1/3 had a pancreatic duct obstructive risk factor, such as pancreas divisum (3., 18.). It should be noted, however, that pancreas divisum alone does not necessarily cause pancreatitis.

In general terms, the roles of imaging in ARP are to: confirm attacks of AP; assess for local complications; identify potential etiologies of ARP; monitor the evolution of complications; plan and guide interventions; and assess for imaging findings suggestive of progression to CP. There are no robust data to define an optimal imaging modality or strategy for ARP though most favor MRI because of its ability to optimally assess both parenchyma and duct (11.).

Chronic Pancreatitis

CP results from progressive inflammation that results in fibrotic replacement of pancreatic parenchyma, and eventually, exocrine and endocrine dysfunction. CP in children has been defined as imaging findings of CP combined with at least 1 of the following: abdominal pain consistent with pancreatic origin; exocrine pancreatic insufficiency (EPI); or pancreatic endocrine insufficiency (11.). Less frequently, surgical or biopsy specimens consistent with CP are obtained. In children, genetic factors (seen in up to 73% of patients) are the most prevalent etiology of CP followed by obstructive causes, similar to those seen in ARP (3., 18.).

In general terms, the roles of imaging in CP are to: contribute to/establish the initial diagnosis of CP; stage and monitor disease, including complications; assess for superimposed AP; identify potential etiologies of CP; identify findings that might herald endocrine or exocrine dysfunction; characterize secretory (exocrine) function; and plan for intervention. Although findings of CP may be identified on ultrasound or CT, MRI/magnetic resonance cholangiopancreatography (MRI/MRCP) is favored for the diagnosis and characterization of CP given its superiority in visualizing parenchymal and duct changes (20.).

Transabdominal Ultrasound

Current consensus recommendations favor transabdominal ultrasound as the initial imaging examination to evaluate suspected AP as it is widely available, the examination can be performed with minimal patient preparation, and the examination does not use sedation, contrast material, or ionizing radiation (4., 21.-23.). The major advantages of ultrasound over other imaging modalities are availability and portability. The latter allows bedside imaging of critically ill and difficult-to-transport patients. Ultrasound can, however, be limited in patients with large body habitus, or with excessive bowel gas. In addition, ultrasound may underestimate or poorly delineate the extent of extrapancreatic sequelae of AP (24.).

A right upper quadrant ultrasound examination typically does not provide full imaging of the pancreas and will not evaluate other areas of the abdomen for potential pancreatitis complications. A complete abdominal ultrasound allows evaluation of both upper quadrants and the pancreas, and may include assessment of the lower quadrants for fluid.

Ultrasound examinations are ideally performed fasting (≥4 hours) to reduce bowel gas that can obscure the pancreas and to distend the gallbladder. When the patient is able, drinking water immediately prior to the examination to distend the stomach with fluid and displace gastric air may provide an improved acoustic window for imaging the pancreas. A complete ultrasound examination should assess pancreatic size, contour, echogenicity, pancreatic duct diameter (and for duct filling defects), and should assess for peripancreatic edema and pancreatic or peripancreatic fluid collections (25.). In addition, the gallbladder should be assessed for calculi (an etiology of pancreatitis), and the biliary tree should be assessed for dilation and calculi (4., 22., 26.). Color Doppler along with gray-scale imaging can evaluate the peripancreatic vascular structures for complications, such as splenic vein or portal vein thrombosis and can assess vascularity of the pancreas.

Contrast-enhanced ultrasound (CEUS), which involves the intravenous administration of contrast material consisting of microbubbles, has been explored for assessment of both AP and CP but is not yet accepted as standard of care, so its role in pediatric pancreatitis remains to be defined (27., 28.).

Computed Tomography

The major advantage of CT versus other noninvasive imaging modalities is that the examinations are short and can generally be achieved without sedation or anesthesia. For this reason, CT is the modality of choice for acute assessment of traumatic injury of the pancreas. Body habitus and air-filled bowel loops are not limiting factors for CT (compared with ultrasound).

CT for pediatric pancreatitis should utilize intravenous (IV) contrast material, which optimizes assessment of the solid organs and vasculature. CT with IV contrast material can be performed as a single (arterial or portal venous phase) or multiphase examination. When performed as a single-phase examination for pancreatic indications, portal venous phase imaging is most common. Intravenous iodinated contrast material carries a very low risk of allergic-like reactions. Risk of exacerbation of renal dysfunction in children with estimated glomerular filtration rate less than 60 mL /min/1.73 m² should be balanced with the potential benefit of the examination (29.).

Use of oral contrast material for CT in pancreatitis is inconsistent; specific recommendations do not exist for children. In adults, oral water is recommended for imaging of pancreatitis (20.). A potential benefit of positive oral contrast, which is high in attenuation, is distinguishing fluid collections from bowel loops but oral contrast material can be difficult for pediatric or acutely ill patients to consume and prolongs the preparatory phase of the CT examination.

Limiting CT to the abdomen only is discouraged. CT limited to the abdomen allows assessment of the pancreas, adjacent vessels, and surrounding structures but does not allow assessment for extension of complications (eg, fluid collections) into the lower abdomen and pelvis. CT of the abdomen and pelvis allows assessment of the pancreas and the full extent of associated complications.

Magnetic Resonance Imaging and Magnetic Resonance Cholangiopancreatography

MRI has the best soft tissue contrast of available cross-sectional imaging modalities. This soft tissue contrast optimizes parenchymal characterization and visualization and characterization of ducts and fluid collections. MRCP, which is sometimes arbitrarily distinguished from other MRI examinations, simply reflects a type of MRI sequence that utilizes heavy T2-weighting to accentuate fluid-filled structures including the pancreatic and biliary ducts. Like CT, body habitus and air-filled bowel loops are not limitations for MRI. Potential need for sedation or general anesthesia in the pediatric population to accomplish relatively long examinations is the primary disadvantage of MRI.

Given its superior soft tissue contrast, MRI is the preferred imaging modality for ARP, CP, and autoimmune pancreatitis where characterization of both the pancreatic parenchyma and duct is important (30.). Protocol guidelines exist for adults but have not been formalized for children (20.). An MRCP sequence should be included in most pancreatic MRI examinations. IV gadolinium-based contrast material can be useful for characterization of the vasculature and for diagnosis of autoimmune pancreatitis but is not required for routine assessment of CP. IV contrast material is not required to acquire an MRCP sequence and hepatobiliary contrast material can compromise MRCP sequences.

Use of intravenous secretin as an adjunctive medication may improve visualization of the pancreatic duct and allows assessment of exocrine function (31.-39.). According to adult studies, secretin improves visualization of the pancreatic duct by MRCP with a higher diagnostic accuracy of detecting pancreas divisum (34.-37.). The reported sensitivity and specificity of diagnosing pancreas divisum with secretin-MRCP falls in the range of 73% to 100% and 97% to 100%, respectively (40.).

Timing of Imaging

Optimal timing of imaging, particularly relative to an attack of AP, depends on the unique patient situation. Few studies have published pediatric data specific to this question, but adult data suggest that imaging within the first 48 hours of an attack of AP infrequently alters management and poorly predicts the severity of organ failure (41.). However, if imaging is necessary to make a diagnosis or to manage a patient, it should not be deferred. In patients with suspected or known CP where imaging confirmation of findings of CP is needed, imaging when the patient does not have superimposed AP is preferred to prevent obscuration of findings by acute inflammation.

General Imaging Technique Summary Statements and Recommendations

TABLE 3. Summary statements and recommendations

Purpose/ Indication/Rationale for Imaging in Acute Pancreatitis

Imaging in the context of suspected or known AP serves the multiple purposes previously described. At diagnosis, it is particularly important to identify gallstones or biliary obstruction (usually because of choledocholithiasis) as etiologies of AP. These entities can be urgently addressed with endoscopic and/or surgical intervention (4., 42.-44.). Identification of local complications of AP including necrosis, acute fluid collections, venous stenosis/thrombosis or arterial aneurysms, and hemorrhage has relevance for clinical staging of attack severity (15., 45.). In adults, severity scoring can help prognosticate and triage appropriate management but there is currently no consensus imaging severity staging/scoring system in children. In a clinical report, the Pancreas Committee of NASPGHAN has proposed stratifying AP in children as mild, moderately severe, or severe utilizing a combination of clinical and imaging criteria (Table 2) (15.).

The most common complication of AP is the development of acute peripancreatic fluid collections and pseudocysts (13%–15%) (46., 47.). The frequency of these fluid collections secondary to AP has been reported in pediatric studies to be between 8% and 41% (48.). Pancreatic and peripancreatic necrosis (sterile or infected) occur less commonly (47., 49.). As an attack of AP progresses, imaging serves to assess the evolution and maturity of fluid collections (necrotic or simple) to help define the timing of interventions. Fluid collections generally need to have a well-defined wall to be amenable to intervention, particularly endoscopic intervention.

Imaging Findings of Acute Pancreatitis

Two forms of AP are distinguishable by imaging: interstitial edematous and necrotizing pancreatitis, with the former more common (Fig. 1). The imaging features of acute interstitial pancreatitis are similar on ultrasound, CT, and MRI (Table 4). In the very early stages of AP, ultrasound and CT may show no abnormal findings, as laboratory abnormalities often precede imaging findings of AP (22.). This does not, however, seem to apply to MRI, which has higher soft tissue contrast resolution (50.).

TABLE 4. Imaging findings of acute pancreatitis

Findings of necrotizing pancreatitis depend on the stage of necrosis. Early in the course of necrotizing pancreatitis, there is decreased or absent vascularity/perfusion of the gland with hypoenhancement following contrast administration. As necrosis evolves, the gland and peripancreatic tissues may be replaced by necrotic collections. By ultrasound and MRI, these collections will contain debris. By CT, the collections may deceptively appear simpler. Superinfection of these collections may occur, with air in the collection(s) being a specific, but not sensitive, finding (50.).

Fluid collections associated with AP have specific definitions, which were updated in the 2012 Revised Atlanta Classification (Table 5) (41.). The definitions apply to adults but have been extrapolated to children. One important nuance of the Revised Atlanta Criteria is that if acute necrotic collections organize, these are by definition walled off necrosis (not pseudocysts) regardless of how simple they appear. Pseudocysts occur only in the context of acute interstitial edematous pancreatitis, or, rarely, in the case of disconnected duct, due to prior necrosis or intervention.

TABLE 5. Definitions of pancreatic and peripancreatic collections based on the Revised Atlanta Classification

Diagnostic Performance of Imaging Modalities in Acute Pancreatitis

Little data are available on the diagnostic performance of ultrasound, CT, and MRI for the assessment of AP in children.

Computed Tomography

On the basis of adult literature, CT with IV contrast material is considered the imaging reference standard for AP (26., 57., 58.). IV contrast material allows evaluation for necrosis, based on absent parenchymal enhancement, and optimizes identification and assessment of intra- or extra-pancreatic fluid collections. IV contrast material also allows evaluation of the peripancreatic vasculature to ensure patency and assess for pseudoaneurysm formation (22.). Other than for specific assessment of the arteries, adult data suggest that a single-phase portal venous phase examination is sufficient for assessment of AP (59.).

Adult data suggest CT is more sensitive than ultrasound for AP, particularly for severe pancreatitis and acute necrosis (22.). Diagnostic performance has not been specifically defined for children; however, Coffey et al (54.) reported CT to show findings of AP in 62% of 42 patients with AP based on positive enzymes (vs 23% for ultrasound).

Compared with ultrasound, CT with intravenous contrast material provides improved characterization of the location and extent of fluid collections and abscesses, integrity of the splenic vein and portal system, and presence of parenchymal necrosis (43., 52., 60., 61.). A small surgical series (n = 13) in adult patients showed CT to have 100% per patient sensitivity for necrosis (62.). Of note, however, on a per-segment basis, CT was only approximately 64% sensitive, missing additional sites of necrosis in several patients (62.). When infected necrosis is present, gas pockets are more readily visible on CT (Fig. 2) than on ultrasound. CT may, however, underestimate the complexity of fluid collections relative to ultrasound or MRI (Fig. 3) (63., 64.). For serial imaging of children with AP, the ionizing radiation associated with CT should be considered when selecting an imaging modality for follow-up.

CT severity scoring indices (eg, CT severity index [CTSI], Balthazar score) were established in adult populations, but more recently have been applied to children (15., 65.). Similar to adult studies, the CTSI has been shown to be a better predictor of the severity of AP compared with clinical scores in children (65.-67.). A recent pediatric study applying the CTSI scores in 211 children with AP found the sensitivity and specificity of the CTSI in predicting a severe course of AP to be 81% and 76%, respectively, with positive-predictive and negative-predictive values of 62% and 90%, respectively (68.). In this same pediatric cohort, the presence of necrosis in AP was associated with higher rate of major complications (68.).

Magnetic Resonance Imaging/Magnetic Resonance Cholangiopancreatography

Studies are lacking regarding the diagnostic performance of MRI in diagnosing AP in children, particularly compared with other imaging modalities. MRI can be used for assessment of AP, but because of the need for long periods of holding still may not be suitable for children, especially if critically ill. MRI may contribute to confirmation of an attack of AP or to identification/confirmation of acute duct obstruction (see below) but pancreatic edema because of an acute episode of pancreatitis can obscure pancreatic duct anomalies that may be relevant to the cause of pancreatitis.

The greater soft tissue contrast of MRI (vs CT) is advantageous when assessing the pancreatic parenchyma and biliary and pancreatic ducts and when characterizing fluid collections (22.). Adult data suggest that MRI is more sensitive than CT for findings of AP including edema and hemorrhage with up to 15% to 30% of patients with a normal CT showing findings of AP on MRI (69.-71.). Adult data have also shown the diagnostic performance of MRI to be as good as CT for pancreatic necrosis (72.).

MRI, particularly MRCP, has also been shown to be more sensitive than CT for biliary etiologies of pancreatitis (20.). Specifically, in adults, MRCP has up to 100% sensitivity for pancreatic and biliary duct stones greater than 3 mm in size (73.). MRCP can be particularly useful in the evaluation of choledocholithiasis when biliary duct dilatation is found on ultrasound without stone(s) visible in the duct(s) (74.-78.). Structural abnormalities of the pancreatic duct and parenchyma, such as pancreas divisum and an abnormal union of the pancreaticobiliary junction with a long common channel have also been associated with acute pancreatitis (79.), and MRCP is the optimal noninvasive imaging modality for these entities.

MRI can help distinguish acute necrotic collections from acute peripancreatic fluid collections by identifying and characterizing the internal content of these collections (50.). MRI is also superior to CT in detecting hemorrhage, which can be a complication of necrosis (80.) (Fig. 4). In clinical practice, MRI is often used for assessment and monitoring of late complications of AP, such as fluid collections, to time and guide therapeutic interventions (22., 81.). This, in part, not only capitalizes on the high soft tissue contrast but also on the fact that MRI does not involve exposure to ionizing radiation, and is thus, more acceptable for serial examinations.

Acute Pancreatitis Summary Statements and Recommendations

Acute Recurrent Pancreatitis Summary Statements and Recommendations

The recommendations for AP above also apply to assessment of repeated episodes of AP in the child with ARP.

Purpose/Indication/Rationale for Imaging in Chronic Pancreatitis

Imaging in CP serves multiple purposes. The dominant role of imaging at the time of diagnosis is to identify findings of CP that can be leveraged in combination with other criteria (clinical and histologic whenever available) to make the diagnosis of CP (11.). Accurate diagnosis of CP will lead to altered management as it is now understood that children diagnosed with CP require specific clinical and laboratory follow-up as well as nutritional management (10.).

In addition to diagnosing CP (11.), there are specific imaging features that are of interest to the clinician in the child with known or suspected CP. Signs of acute inflammation or complications that may require therapeutic intervention/drainage, and, certainly, suspected pancreatic masses are relevant to diagnosis and management. One relatively rare but increasingly recognized and important differential diagnosis of a pancreatic “mass” is autoimmune pancreatitis (AIP) (82., 83.). AIP is highly responsive to steroid therapy, and hence its diagnosis will lead to a medical therapeutic intervention. Focal, segmental, or global enlargement of the pancreas with loss of the normal contour can be evidence of AIP, especially with delayed enhancement and the presence of a capsule-like rim, which is uncommon but very specific (Fig. 5) (84., 85.). Focal pancreatic enlargement should be differentiated from tumors as management is completely different (82.).

The presence of pancreatic atrophy is helpful in interpretation of biochemical markers of CP and estimating the clinical risk for pancreatic exocrine and endocrine dysfunction. Studies correlating imaging findings and function are, however, lacking (86.). The presence of parenchymal calcifications is a major feature of most criteria (generally adult-focused) for CP, though anecdotally, calcification appears to be less common in pediatrics.

Characterization of biliary and pancreatic duct anatomy is also important, particularly with regard to diagnostic and therapeutic decisions. Congenital anomalies, such as pancreaticobiliary maljunction and pancreas divisum can contribute to the underlying pancreatitis (87., 88.). Duct filling defects/calcifications can be both diagnostic criteria and therapeutic targets. An irregular narrow main pancreatic duct without marked upstream dilation and with smooth tapering of the common bile duct can be suggestive of AIP in the appropriate clinical context (89., 90.).

Imaging plays a critical role in surgical planning for patients with CP. Decompressing surgeries, such as lateral pancreaticojejunostomies, can be utilized in cases of very dilated pancreatic ducts, with or without the presence of intraductal stones (91.). Pancreaticoduodenectomy-type procedures are considered particularly with pancreatic head pathologies (92.). Total pancreatectomy-islet cell autotransplantation (TP-IAT) surgery is considered not only based on symptoms and the underlying etiology of CP but also based on the overall imaging appearance of pancreas, including perceived capacity to retrieve a critical mass of islet cells (93.). As such, characterization of duct abnormalities and the extent of parenchymal change are important.

Imaging Findings of Chronic Pancreatitis

Imaging features of advanced CP have been well characterized and described in the adult literature (Table 6) (21.). Imaging findings of advanced CP specific to pediatrics have not yet been defined, and findings of early or probable CP, when intervention might be attempted to slow disease progression, have not been well-defined for any population (94.). Features that may herald “early” CP include a few ectatic duct side branches, parenchymal volume loss, or mild T1 signal changes but these remain to be validated (95.).

TABLE 6. -a Glossary of imaging terms/findings for chronic pancreatitis in adults. Applicability to pediatrics has yet to be defined

Currently, no standard imaging classification system exists for CP in children. The Cambridge classification, based on pancreatic duct findings on ERCP in adult patients (Table 7), has been adapted to MRCP in adults but this classification does not incorporate parenchymal changes of CP, and this classification has not been validated in children (96., 97.). The Cambridge classification defines CP based on the number of abnormal side branches, cavities, filling defects, or obstruction visualized (20.). The M-ANNHEIM Classification for adult CP published in 2007 relied partially on the Cambridge classification as well as other imaging findings at transabdominal ultrasound, CT, EUS, and/or MRI but has not been validated in children (Table 8) (98.). Recently, the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer (CPDPC) proposed new reporting standards for CT and MRCP in adults with CP (20.). These remain to be validated in adults, and their applicability to pediatrics is unknown.

TABLE 7. Cambridge classification of chronic pancreatitis in adults by endoscopic retrograde cholangiopancreatography

TABLE 8. M-ANNHEIM diagnostic criteria for chronic pancreatitis

Given the expected growth and maturation of the pancreas during childhood, knowledge of normal anatomy and gland and duct size based on age is critical to define abnormalities (eg, atrophy and duct dilation) suggestive of CP. Normative values for gland thickness exist for ultrasound and CT (56., 99.). Based on no significant difference between CT measurements and measurements previously reported at ultrasound, Trout et al (99.) suggested that thickness values could likely be extrapolated to MRI, though this remains to be confirmed. Normative values for pancreatic duct diameter also exist for ultrasound and MRI (Table 9) (56., 99.). Although normal values exist, cut-off values for diagnosis of CP have not been defined.

TABLE 9. -a Reference values for normal pancreatic duct diameter at ultrasound and magnetic resonance imaging in children

Diagnostic Performance of Imaging Modalities in Chronic Pancreatitis

Data specific to the diagnostic performance of specific imaging modalities for pediatric CP are not available. A meta-analysis of adult literature concluded ultrasound, MRI, and CT all have high diagnostic sensitivity and specificity for CP without significant differences (100.). Reference standards varied across the included studies. Specifically, in 3460 adults, estimated sensitivities were 67% (95% CI: 53%--78%) for ultrasound, 78% (95% CI: 69%--85%) for MRI, and 75% (95% CI: 66%--83%) for CT. Estimates of specificity were 98% (95% CI: 89%--100%) for ultrasound, 96% (95% CI: 90%--98%) for MRI, and 91% (95% CI: 81%--96%) for CT.

Chronic Pancreatitis Summary Statements and Recommendations

Basic Imaging Strategies

A paucity of rigorous research exists on the diagnostic performance of transabdominal ultrasound (including CEUS), CT, and MRI for pediatric pancreatitis. These basic studies are needed to define the optimal imaging modality(ies) for AP, ARP, and CP in children and to inform future diagnostic guidelines. Such research should include exploration of the optimal timing, relative to attack(s) of AP, of imaging aimed at identifying a pancreatic duct cause of pancreatitis. Further, research is needed to define the optimal imaging strategies for pancreatitis that balance diagnostic performance with cost, and the risks of sedation, intravenous contrast material and radiation exposure.

Prognostication and Prediction

Research into imaging (and other diagnostic) methods is needed to prognosticate and predict disease severity in the context of AP and disease progression in the context of AP and ARP. Currently, it is not possible to predict which patients will progress from AP to ARP and from ARP to CP. However, preliminary data are emerging. A recent study in adults showed a decrease in pancreas volume after 3 episodes of AP, with volume loss possibly reflecting an early finding in the transition to CP (112.). Understanding and predicting the progression through various stages of pancreatitis would allow for more effective counseling and optimization of the timing of interventions. Further, research is also needed into the role of imaging in prognostication based on genetic etiologies of pancreatitis.

Identification of Minimal Change Chronic Pancreatitis

Currently the identification of CP is often delayed, with imaging findings only apparent when disease is well established. CP, and attendant pancreatic dysfunction, are sources of significant morbidity, particularly in children, and thus early identification and intervention are critical. As such, research is needed to facilitate identification of minimal change or early CP. Early studies in adult populations suggest quantitative MRI methods, such as T1 mapping and MR elastography may be able to identify early CP (109., 113.).

Noninvasive Pancreatic Function Assessment

Diagnosis of exocrine and, to some degree, endocrine insufficiency remains invasive. Research is needed to identify noninvasive, or minimally invasive techniques to diagnose insufficiency, and more importantly to predict development of insufficiency to allow early intervention. Some data suggest that imaging can noninvasively assess exocrine and endocrine pancreatic function, but these techniques require further study (114., 115.).