The main reason for this research study is to find out more about acute recurrent pancreatitis and chronic pancreatitis in children. There are few studies on childhood pancreatitis, so diagnosis and treatment are based on adult studies. This limits our understanding and treatment of these disorders in children. Endoscopic ultrasound (EUS) is a tool used to assess and diagnose pancreatic disease. We can use ultrasound with shear wave elastography (SWE) to measure fibrosis (scarring) of the pancreas. We can use SWE on both EUS and transabdominal ultrasound (TUS) systems. Both TUS and EUS SWE have been studied for diagnosis of chronic pancreatitis in adult patients, however they have not been studied in children. We plan to use EUS SWE and TUS SWE information in this study to help us understand pancreatitis in children. Children with pancreatitis and children without pancreatitis (controls) will be invited to participate in this study.
The aims of the proposed study are as follows: Aim 1: Characterize endoscopic ultrasound (EUS) findings of pediatric acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP). Adult criteria for EUS diagnosis of CP exist, but no such criteria exist for children. As such, the applicability of current diagnostic criteria to pediatric patients is unknown. 1.1: Catalogue grayscale EUS findings of ARP and CP in a pediatric cohort and compare to healthy controls. Hypothesis: EUS findings of ARP and CP in pediatric patients will differ from those of adult ARP and CP and will be characteristically different from healthy controls. Exp1: We will catalogue grayscale EUS findings in 40 pediatric patients with known history of ARP or CP undergoing clinically indicated EUS and will compare those with findings in 20 patients without a history of pancreatitis who are undergoing EUS for other indications. 1.2: Benchmark grayscale EUS against other imaging modalities for diagnosis of CP, particularly early CP, in children. Hypothesis: Grayscale EUS findings will be more sensitive than other imaging modalities in all stages of CP. Exp2: We will test associations, in blinded fashion, of grayscale EUS findings catalogued under S.A1.1 in enrolled children with findings on alternative pancreas imaging modalities performed for clinical indications. Specifically, we will correlate to endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) performed for clinical indications within +/- 3 months of the EUS. Aim 2: Define the diagnostic performance of ultrasound elastography for CP and pancreatic stiffness as a measure of fibrosis in pediatric patients. 2.1: Define the diagnostic performance of EUS and TUS elastography for pediatric CP. Hypothesis: EUS and TUS elastography will have high specificity for CP with increased stiffness in patients compared to controls. Exp 1: Patients enrolled under Aim 1 will undergo shear wave elastography (SWE) measurement of the pancreas during EUS. These same patients will undergo research TUS with SWE of the pancreas. SWE results by both EUS and TUS will be evaluated for diagnostic performance for CP. 2.2: Define agreement between EUS and TUS measurement of pancreatic parenchymal stiffness in pediatric patients. Hypothesis: EUS and TUS measures of pancreatic parenchymal stiffness will agree with minimal bias. Exp2: EUS and TUS SWE data obtained under S.A2.1 will be evaluated for agreement and divergent cases will be investigated to define causes. 2.3: Define the diagnostic performance of elastography for pancreatic fibrosis. Hypothesis: SWE is a sensitive indicator of pancreatic fibrosis as identified by histology. Exp3: Patients undergoing clinically indicated total pancreatectomy and islet auto transplant (TPIAT) or other pancreatic surgical resection at our institution (approximately 20 per year) will be approached to undergo pre-operative TUS SWE. These SWE measurements, along with EUS SWE measurements obtained preoperatively, will be compared to binary and semi-quantitative assessments of pancreatic parenchymal fibrosis by histology.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
DIAGNOSTIC
Masking
NONE
Enrollment
66
TUS SWE will be performed using a Canon Aplio i800 ultrasound system and a curved 1-6 MHz transducer. 2D SWE will be performed with measurement of shear wave speed in the head, body and tail of the pancreas.
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States
EUS Pancreatic Findings- Rosemont Criteria
Rosemont Criteria Features * Hyperechoic foci with shadowing (Major A) * Lobularity with honeycombing (Major B) * Lobularity without honeycombing (Minor) * Hyperechoic foci without shadowing (Minor) * Cysts (Minor) * Stranding (Minor) * Main pancreatic duct calculi (Major A) * Irregular main pancreatic duct contour (Minor) * Dilated side branches (Minor) * Main pancreatic duct dilation (Minor) * Hyperechoic main pancreatic duct margin (Minor)
Time frame: At time of EUS procedure
Calculated BMI
Capturing weight(kg) and height(cm) to calculate
Time frame: 6 months (3 months prior to endoscopic ultrasound through 3 months post-endoscopic ultrasound)
Acute Recurrent Pancreatitis
The presence or absence of recurrence of pancreatitis.
Time frame: 6 months (3 months prior to endoscopic ultrasound through 3 months post-endoscopic ultrasound)
Chronic Pancreatitis
The presence or absence of Chronic pancreatitis diagnosis
Time frame: 6 months (3 months prior to endoscopic ultrasound through 3 months post-endoscopic ultrasound)
Exocrine Pancreatic Insufficiency
The presence or absence of exocrine pancreatic insufficiency diagnosis.
Time frame: 6 months (3 months prior to endoscopic ultrasound through 3 months post-endoscopic ultrasound)
Diabetes Mellitus
The presence or absence of a diagnosis of diabetes.
Time frame: 6 months (3 months prior to endoscopic ultrasound through 3 months post-endoscopic ultrasound)
EUS Rosemont Classification - Normal
The Rosemont classification has been established to standardize an approach to EUS diagnosis of CP. The following criteria are used to determine the classification. Hyperechoic foci with shadowing Lobularity with honeycombing Lobularity without honeycombing Hyperechoic foci without shadowing Cysts Stranding Main pancreatic duct calculi Irregular main pancreatic duct contour Dilated side branches Main pancreatic duct dilation Hyperechoic main pancreatic duct margin
Time frame: At time of EUS
EUS Rosemont Classification - Indeterminate for CP
The Rosemont classification has been established to standardize an approach to EUS diagnosis of CP. The following criteria are used to determine the classification. Hyperechoic foci with shadowing Lobularity with honeycombing Lobularity without honeycombing Hyperechoic foci without shadowing Cysts Stranding Main pancreatic duct calculi Irregular main pancreatic duct contour Dilated side branches Main pancreatic duct dilation Hyperechoic main pancreatic duct margin
Time frame: At time of EUS
EUS Rosemont Classification - Suggestive of CP
The Rosemont classification has been established to standardize an approach to EUS diagnosis of CP. The following criteria are used to determine the classification. Hyperechoic foci with shadowing Lobularity with honeycombing Lobularity without honeycombing Hyperechoic foci without shadowing Cysts Stranding Main pancreatic duct calculi Irregular main pancreatic duct contour Dilated side branches Main pancreatic duct dilation Hyperechoic main pancreatic duct margin
Time frame: At time of EUS
EUS Rosemont Classification - Consistent With CP
The Rosemont classification has been established to standardize an approach to EUS diagnosis of CP. The following criteria are used to determine the classification. Hyperechoic foci with shadowing Lobularity with honeycombing Lobularity without honeycombing Hyperechoic foci without shadowing Cysts Stranding Main pancreatic duct calculi Irregular main pancreatic duct contour Dilated side branches Main pancreatic duct dilation Hyperechoic main pancreatic duct margin
Time frame: At time of EUS
MRI Cambridge Grade: Normal
Cambridge Grade: 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Severe)
Time frame: At time of MRI
MRI Cambridge Grade: Equivocal
Cambridge Grade: 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Severe)
Time frame: At time of MRI
MRI Cambridge Grade: Mild
Cambridge Grade: 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Severe)
Time frame: At time of MRI
MRI Cambridge Grade: Moderate
Cambridge Grade: 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Severe)
Time frame: At time of MRI
MRI Cambridge Grade: Severe
Cambridge Grade: 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of MRI
ERCP Cambridge Criteria: Normal
Cambridge Criteria 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of ERCP
ERCP Cambridge Criteria: Equivocal
Cambridge Criteria 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of ERCP
ERCP Cambridge Criteria: Mild
Cambridge Criteria 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of ERCP
ERCP Cambridge Criteria: Moderate
Cambridge Criteria 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of ERCP
ERCP Cambridge Criteria: Marked
Cambridge Criteria 1. (Normal) 2. (Equivocal) 3. (Mild) 4. (Moderate) 5. (Marked)
Time frame: At time of ERCP
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