Criteria

The Cambridge classification for chronic pancreatitis[5]

The Cambridge classification of endoscopic retrograde cholangiopancreatography (ERCP) (and ultrasound [US] or computed tomography [CT] imaging) grades the severity of pancreatic structural changes based on abnormalities of the main duct and side branches.

Score 1 (Cambridge class 0)

  • Severity: normal

  • Good quality ERCP/US or CT visualising whole gland without abnormal signs.

Score 2 (Cambridge class 0)

  • Severity: equivocal

  • ERCP: <3 abnormal branches

  • US/CT: abnormal sign: main pancreatic duct 2-4 mm diameter, gland 1 to 2 x normal.

Score 3 (Cambridge class I)

  • Severity: mild

  • ERCP: 3 or more abnormal branches

  • US/CT: 2+ abnormal signs: cavities <10 mm, duct irregularity, focal acute necrosis, parenchymal heterogeneity, increased echogenicity of duct wall, contour irregularity of head/body.

Score 4 (Cambridge class II)

  • Severity: moderate

  • ERCP: >3 side branches plus abnormal main duct

  • US/CT: as score 3.

Score 5 (Cambridge class III)

  • Severity: severe

  • ERCP: all of above, plus one or more of: large cavity >10 mm, intraductal filling defects, duct obstruction (stricture), duct dilation or irregularity

  • US/CT: all of above, plus one or more of: large cavity >10 mm, intraductal filling defects, duct obstruction (stricture), duct dilation or irregularity, calculi/pancreatic calcification, contiguous organ invasion.

Ammann's criteria (Zurich workshop) for diagnosing chronic pancreatitis[10][121]

Recurrent pancreatitis plus 1 of the following:

  • Calcifications

  • Moderate or severe ductal lesions as defined by the Cambridge criteria

  • Typical pancreatic histology

  • Persistent exocrine insufficiency (2 years or longer).

M-ANNHEIM criteria for definite chronic pancreatitis[6]

The M-ANNHEIM criteria are similar to Ammann’s but differ by grading the probability as definite, probable, or possible/borderline. Moreover, the M-ANNHEIM criteria define clinical symptoms more broadly. Diagnostic criteria require at least 1 clinical symptom (recurrent acute pancreatitis and typical abdominal pain except for primary painless pancreatitis) plus 1 of the following:

  • Calcifications

  • Moderate or severe ductal lesions as defined by the Cambridge criteria

  • Typical pancreatic histology

  • Persistent exocrine insufficiency (pancreatic steatorrhoea 2 years or longer).

Of note, a separate M-ANNHEIM scoring system grades the clinical severity of chronic pancreatitis using criteria similar to the Mayo Clinic.[11][122]

Japanese Pancreas Society (JPS) for definite chronic pancreatitis[123]

The JPS proposed criteria to evaluate patients with symptoms and findings suggestive of chronic pancreatitis. JPS criteria for definite chronic pancreatitis are similar to Ammann’s but differ by grading the probability as definite, probable, or possible, and by having different definitions for clinical criteria and exocrine pancreatic insufficiency. These criteria require at least 1 clinical symptom (chronic abdominal pain, recurrent acute pancreatitis, weight loss, or oily stools) and 1 of the following:

  • Calcifications

  • Moderate or severe ductal lesions as defined by the Cambridge criteria

  • Typical pancreatic histology

  • Persistent exocrine insufficiency (abnormal direct pancreatic function testing).

Of note, JPS criteria do not grade the severity of the pancreatitis and exclude several types of chronic pancreatitis from the definitions: obstructive, autoimmune, and tumour-forming pancreatitis.

Mayo Clinic diagnostic scoring system for chronic pancreatitis[11][122]

For the purpose of epidemiological study, a multi-component scoring system was validated and used.

Diagnosis is based on a total score of 4 or more derived from morphological and functional criteria (scores are in brackets):

  • Pancreatic calcification: definite (4) or probable (2)

  • Histology: definite (4) or probable (2)

  • Steatorrhoea or lipase output less than 2 standard deviations below mean normal value: determined for each laboratory (2)

  • Pancreatic duct abnormalities at ERCP, CT, magnetic resonance cholangiopancreatography (MRCP) Cambridge classification I to III (3)

  • Major clinical criteria: upper abdominal pain or weight loss over 10 kg in 12 months (2)

  • Diabetes (fasting glucose >140 mg/dL) (1).

Japanese Pancreas Society (JPS) diagnostic criteria for autoimmune pancreatitis[8]

Mandatory diagnostic imaging criteria detected by ultrasound, CT, and/or magnetic resonance imaging:

  • Narrowing of main pancreatic duct with irregular wall AND

  • Diffuse or localised enlargement of the pancreas.

PLUS 1 of the following:

  • Antibodies: high serum gamma-globulin, IgG, or IgG4, OR positive auto-antibodies (e.g., antinuclear antibody and rheumatoid factor)

  • Histology: marked interlobular fibrosis AND lymphocyte and plasma cell infiltration of peri-ductal areas and occasionally with lymphoid follicles in the pancreas.

Exclude pancreatic or biliary malignancy.

Mayo Clinic criteria for autoimmune pancreatitis[137]

The Mayo Clinic proposed diagnostic criteria for autoimmune pancreatitis based on the acronym HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy). Diagnosis requires at least one of the following sets of findings:

  • Diagnostic histology

  • Characteristic imaging on computed tomography and pancreatography (see JPS criteria) with elevated serum IgG4 level

  • Response to corticosteroid therapy of pancreatic/extrapancreatic manifestations of autoimmune pancreatitis (AIP).

The 2010 international consensus conference for autoimmune pancreatitis[138]

This international meeting of experts agreed on two histopathological types of AIP and a set of 5 diagnostic criteria for AIP similar to those proposed by the Mayo Clinic, and pertinent updates have since been reported.[137][141][142][143]​ Type I is an IgG4-related multi-organ disease with pancreatic histology showing periductal lymphoplasmacytic infiltrate, inflamed cellular stroma with storiform fibrosis, and obliterative phlebitis. Type II is a non-IgG4-related pancreas-specific disorder with histology showing granulocytic epithelial lesions. Type II AIP tends to present with pancreatitis (in contrast with painless jaundice in type I AIP), occurs at a younger age, and is associated with inflammatory bowel disease more commonly than type I; both types respond to corticosteroid treatment, but relapse occurs commonly only in type I disease.[144][145]

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