Classically this was done at the time of ERCP; however, this diagnostic modality carries a risk of causing or worsening pancreatitis. The

development of high-quality cross-sectional imaging in the form of abdominal Angiogenesis inhibitor ultrasound, pancreatic protocol computed tomography (CT), secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP), and endoscopic ultrasound have gradually left ERCP with primarily a therapeutic role in this setting. Unfortunately, there has recently been a worldwide shortage of secretin, making this adjunct to MRCP often unavailable. In some situations, aspiration of fluid via endoscopic learn more ultrasound (EUS) or percutaneous methods may be necessary to help solidify the diagnosis. A pancreatic duct leak can often be diagnosed in a straightforward manner when a patient presents with a typical clinical picture of pancreatitis followed by persistent or recurrent

symptoms. A far more challenging situation occurs when a patient without a known history of pancreatitis is found to have a pancreatic or peripancreatic cyst. In this situation, parenchymal or ductal calcifications can suggest the diagnosis of chronic pancreatitis and therefore suggest a leak. Also, a pseudocyst is suggested in the presence of a uniform cyst with a thick rind without mural calcifications. Endoscopic ultrasound facilitates fine-needle aspiration to sample cyst fluid for amylase, CEA, and cytology which can help differentiate pseudocysts from cystic neoplasms.[12] Pseudocysts will typically have high amylase levels, low CEA levels, and fluid which demonstrates inflammatory cells or is acellular on cytologic evaluation.

As external pancreatic fistulas are most commonly iatrogenic, the most important step in making the diagnosis is considering the diagnosis. A patient with persistent output from a JP drain after pancreatic surgery or variable output of clear pancreatic see more juice following percutaneous drainage of a pseudocyst or percutaneous output of clear fluids after a penetrating injury are all patients with likely leaks. These patients should have the fluid checked for amylase levels which will be elevated in the setting of a pancreatic leak.[13] Also, one can consider contrast injection through the drain or fistula to assess for a pancreatogram which confirms the diagnosis. A pancreatic protocol CT is typically the best initial diagnostic test for patients with smoldering or severe pancreatitis who may have a pancreatic duct leak.[14] With this clinical picture, a fluid collection implies an active leak.