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Endoscopic retrograde pancreatography criteria to diagnose autoimmune pancreatitis: an international multicentre study
  1. Aravind Sugumar1,
  2. Michael J Levy1,
  3. Terumi Kamisawa5,
  4. George J M Webster6,
  5. Myung-Hwan Kim3,
  6. Felicity Enders1,
  7. Zahir Amin7,
  8. Todd H Baron1,
  9. Mike H Chapman6,
  10. Nicholas I Church6,
  11. Jonathan E Clain1,
  12. Naoto Egawa5,
  13. Gavin J Johnson6,
  14. Kazuichi Okazaki4,
  15. Randall K Pearson1,
  16. Stephen P Pereira6,
  17. Bret T Petersen1,
  18. Samantha Read7,
  19. Raghuwansh P Sah1,
  20. Neomal S Sandanayake6,
  21. Naoki Takahashi2,
  22. Mark D Topazian1,
  23. Kazushige Uchida4,
  24. Santhi Swaroop Vege1,
  25. Suresh T Chari1
  1. 1Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
  2. 2Division of Radiology, Mayo Clinic College of Medicine, Rochester, MN, USA
  3. 3University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
  4. 4Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata Hospital, Osaka, Japan
  5. 5Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
  6. 6Department of Gastroenterology, University College Hospital, London, UK
  7. 7Department of Radiology, University College Hospital, London, UK
  1. Correspondence to Suresh T Chari, Mayo Clinic College of Medicine, Division of Gastroenterology and Hepatology, 200 First St. SW, Rochester, MN 55905, USA; chari.suresh{at}


Background Characteristic pancreatic duct changes on endoscopic retrograde pancreatography (ERP) have been described in autoimmune pancreatitis (AIP). The performance characteristics of ERP to diagnose AIP were determined.

Methods The study was done in two phases. In phase I, 21 physicians from four centres in Asia, Europe and the USA, unaware of the clinical data or diagnoses, reviewed 40 preselected ERPs of patients with AIP (n=20), chronic pancreatitis (n=10) and pancreatic cancer (n=10). Physicians noted the presence or absence of key pancreatographic features and ranked the diagnostic possibilities. For phase II, a teaching module was created based on features found most useful in the diagnosis of AIP by the four best performing physicians in phase I. After a washout period of 3 months, all physicians reviewed the teaching module and reanalysed the same set of ERPs, unaware of their performance in phase I.

Results In phase I the sensitivity, specificity and interobserver agreement of ERP alone to diagnose AIP were 44, 92 and 0.23, respectively. The four key features of AIP identified in phase I were (i) long (>1/3 the length of the pancreatic duct) stricture; (ii) lack of upstream dilatation from the stricture (<5 mm); (iii) multiple strictures; and (iv) side branches arising from a strictured segment. In phase II the sensitivity (71%) of ERP significantly improved (p<0.05) without a significant decline in specificity (83%) (p>0.05); the interobserver agreement was fair (0.40).

Conclusions The ability to diagnose AIP based on ERP features alone is limited but can be improved with knowledge of some key features.

  • Autoimmune pancreatitis
  • lymphoplasmacytic sclerosing pancreatitis
  • idiopathic duct centric pancreatitis
  • immunoglobulin G4
  • endoscopic retrograde pancreatogram
  • autoimmune disease
  • endoscopic retrograde pancreatography
  • pancreatic cancer
  • pancreatic disease
  • pancreatitis

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  • See Commentary, p 565

  • Linked articles 232157.

  • Competing interests None.

  • Ethics approval The study was approved by the Mayo Clinic's institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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