# Cambridge — Cambridge classification of chronic pancreatitis morphology

> Grades chronic-pancreatitis morphology from normal through marked using a ductal ERCP/MRCP branch and an APA CT/MRI/US adaptation; modality must be retained because cross-sectional imaging alone cannot reliably separate every intermediate grade.

**Situação:** vigente · **Órgão:** Pâncreas · **Órgão emissor:** Cambridge consensus / American Pancreatic Association · **Versão:** 1984; APA multimodality adaptation 2014 · **Ano:** 1984

> ⚠️ Uma versão mais nova pode existir (em revisão).

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: ERCP, MRCP, MRI, CT, US
- Fonte primária: Sarner M, Cotton PB. Classification of pancreatitis (1984) — https://pmc.ncbi.nlm.nih.gov/articles/PMC1432589/
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Always retain modality. Use the ductal branch when side branches and main duct are adequately shown; on CT, MRI or ultrasound alone preserve the APA II-versus-III limitation instead of inventing precision.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| normal | Grade 0, normal | Cambridge 0, normal: no abnormal signs on an adequately visualized ERCP/MRCP ductal examination and no chronic-pancreatitis morphology features on the applicable CT, MRI or ultrasound branch. | Report a normal morphology grade only with modality and technical adequacy. Normal morphology does not exclude early chronic pancreatitis; if clinical suspicion remains high, the APA recommends a stepwise clinical, cross-sectional, specialist endoscopic and functional evaluation rather than treatment based on Grade 0. | Grade 0 supplies no estimate of future pancreatitis, pain, exocrine or endocrine insufficiency, cancer or intervention. Early chronic pancreatitis can have normal ductal and cross-sectional morphology. | Conwell et al. 2014 APA guideline, Tables 5-6: normal morphology and insufficient-evidence framework; Evidence-Based Report and STEP-wise algorithm. Tirkes et al. 2018, Table 3 Grade 0 and imaging-limitations discussion. | ✓ |
| equivocal | Grade I, equivocal | Cambridge I, equivocal: one or two abnormal side branches on adequately visualized ERCP/MRCP, or exactly one APA cross-sectional base feature such as a 2-4 mm main duct, slight enlargement, heterogeneous parenchyma, a cavity under 10 mm, irregular ducts, focal pancreatitis, echogenic duct wall or irregular contour. | Equivocal morphology alone is insufficient evidence for a chronic-pancreatitis diagnosis in the APA framework. Preserve the exact feature and pursue a higher-specificity stepwise evaluation only when the history and clinical suspicion justify it; do not label or treat irreversible disease from Grade I alone. | Grade I is diagnostic uncertainty, not a low numeric risk tier. It does not quantify progression, pain, pancreatic insufficiency, malignancy or treatment need, and the isolated feature may have another cause. | Conwell et al. 2014 APA guideline, Table 5 insufficient evidence and Table 6 Grade I: fewer than three abnormal side branches or one CT/MRI/US feature; diagnostic algorithm text. Tirkes et al. 2018, Table 3 Grade I. | ✓ |
| mild | Grade II, mild | Cambridge II, mild on the ductal branch: three or more abnormal side branches without the full Grade III pattern of more than three abnormal branches plus an abnormal main pancreatic duct, and without a Grade IV marked feature. On CT/MRI/US alone, use the operational II-versus-III state when the intermediate grade cannot be separated. | In the APA evidence framework, mild morphology contributes to probable chronic pancreatitis when paired with a suggestive history or abnormal imaging context and abnormal pancreatic physiology. It is not a treatment category; characterize etiology and exocrine/endocrine function separately. | Grade II denotes mild morphologic burden but provides no per-grade probability of pain, functional failure, cancer, hospitalization or intervention. Symptoms and physiology may be discordant with morphology. | Conwell et al. 2014 APA guideline, Tables 5-6: mild imaging morphology, three or more abnormal side branches, probable-evidence requirements and CT/MRI intermediate-grade limitation. Tirkes et al. 2018, Table 3 Grade II. | ✓ |
| moderate | Grade III, moderate | Cambridge III, moderate on the ductal branch: more than three abnormal side branches together with an abnormal main pancreatic duct, without a Grade IV marked feature. The APA table states that CT/MRI morphology cannot reliably distinguish this grade from mild morphology by the base feature set alone. | Moderate ductal and parenchymal morphology is listed as definitive imaging evidence in the APA framework, but the report must still exclude a credible mimicker and describe physiology, etiology and complications. Grade III alone does not prescribe endoscopic, surgical or medical treatment. | Grade III indicates more advanced morphology than Grade II but is not a validated complication or cancer-risk percentage. Prognosis and care depend on function, pain, obstruction, stones, collections, nutrition, etiology and patient context. | Conwell et al. 2014 APA guideline, Table 5 definitive moderate/marked imaging evidence and Table 6 Grade III: abnormal main duct with more than three abnormal side branches; CT/MRI cannot distinguish from mild. Tirkes et al. 2018, Table 3 Grade III. | ✓ |
| marked | Grade IV, marked (severe) | Cambridge IV, marked or severe: the preceding moderate morphology plus at least one advanced feature, including a cavity over 10 mm, intraductal filling defect or calculus, duct obstruction or stricture, severe or gross duct irregularity/dilatation, or substantial gland enlargement in the cross-sectional adaptation. | Marked morphology is definitive imaging evidence in the APA framework and should trigger complete reporting of obstruction, stones, collections, vascular or biliary complications and cancer concern. It still does not dictate a procedure; management depends on symptoms, function, complications, anatomy and multidisciplinary assessment. | Grade IV is the greatest morphologic burden in this framework, but it supplies no individual probability of pain, insufficiency, malignancy, hospitalization or intervention. Advanced chronic change also does not exclude a superimposed pancreatic neoplasm. | Conwell et al. 2014 APA guideline, Tables 5-6 Grade IV: moderate changes plus large cavity, filling defect/calculus, obstruction, stricture, gross irregularity or enlargement; definitive-evidence context. Tirkes et al. 2018, Table 3 Grade IV and complications discussion. | ✓ |
| mild-or-moderate | Operational state: Grade II versus III unresolved on CT/MRI/US alone | Operational uncertainty state, not an additional official grade: CT, conventional MRI or ultrasound demonstrates at least two APA base morphology features without a marked feature, but no adequate ductal side-branch and main-duct assessment is available to distinguish Cambridge II from III. | Return the demonstrated feature list and the II-versus-III limitation. If the distinction would change diagnostic certainty or care, integrate history and physiology and consider specialist MRCP, secretin-enhanced MRCP or EUS as appropriate; never convert the ambiguity into a false Grade II or III. | Because the official intermediate grade is unresolved, no grade-specific risk inference is valid. Even after resolution, Cambridge morphology does not provide calibrated probabilities for symptoms, pancreatic failure, cancer or intervention. | Conwell et al. 2014 APA guideline, Table 6: CT/MRI Grade II uses at least two base features and the Grade III cell states that moderate cannot be distinguished from mild; Tables 5 and 8 show why morphology grade affects evidence nomenclature. Tirkes et al. 2018, Table 3 parallel modality branches. | ✓ |

### Citações por categoria
- **normal**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6: normal morphology and insufficient-evidence framework; Evidence-Based Report and STEP-wise algorithm. Tirkes et al. 2018, Table 3 Grade 0 and imaging-limitations discussion.
- **equivocal**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 5 insufficient evidence and Table 6 Grade I: fewer than three abnormal side branches or one CT/MRI/US feature; diagnostic algorithm text. Tirkes et al. 2018, Table 3 Grade I.
- **mild**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6: mild imaging morphology, three or more abnormal side branches, probable-evidence requirements and CT/MRI intermediate-grade limitation. Tirkes et al. 2018, Table 3 Grade II.
- **moderate**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 5 definitive moderate/marked imaging evidence and Table 6 Grade III: abnormal main duct with more than three abnormal side branches; CT/MRI cannot distinguish from mild. Tirkes et al. 2018, Table 3 Grade III.
- **marked**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Tables 5-6 Grade IV: moderate changes plus large cavity, filling defect/calculus, obstruction, stricture, gross irregularity or enlargement; definitive-evidence context. Tirkes et al. 2018, Table 3 Grade IV and complications discussion.
- **mild-or-moderate**: Conwell DL, Lee LS, Yadav D, et al.. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: Evidence-Based Report on Diagnostic Guidelines (2014) — https://pmc.ncbi.nlm.nih.gov/articles/PMC5434978/ · Conwell et al. 2014 APA guideline, Table 6: CT/MRI Grade II uses at least two base features and the Grade III cell states that moderate cannot be distinguished from mild; Tables 5 and 8 show why morphology grade affects evidence nomenclature. Tirkes et al. 2018, Table 3 parallel modality branches.

## Referências cruzadas
- _fronteira compartilhada_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — Cambridge grades chronic pancreatitis ductal severity; the revised Atlanta classification grades acute pancreatitis.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2014-11-01 | revised | The American Pancreatic Association diagnostic guideline adapted Cambridge morphology to CT, MRI, ultrasound and MRCP, and placed the grade inside a stepwise evidence framework. | confirmed |
| 1984-07-01 | published | The Cambridge consensus defined the pancreatitis terminology and the ductographic chronic-pancreatitis morphology framework. | confirmed |


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