Complications of Chronic Pancreatitis

Risk factors and nomogram for diabetes mellitus in idiopathic chronic pancreatitis

BACKGROUND AND AIM

Diabetes mellitus (DM) is a common complication of idiopathic chronic pancreatitis (ICP), which impairs the quality of life for patients. This study aimed to identify risk factors and develop nomogram for DM in ICP to help early diagnosis.

METHODS

Idiopathic chronic pancreatitis patients admitted to our center from January 2000 to December 2013 were included. Cumulative rates of DM were calculated by Kaplan-Meier method. Patients were randomly assigned, in a 2:1 ratio, to the training and validation cohort. Based on training cohort, risk factors for DM were identified through Cox proportional hazards regression model, and nomogram was developed. Internal and external validations were performed based on the training and validation cohort, respectively.

RESULTS

Totally, 1633 patients with ICP were finally enrolled. The median follow-up duration was 9.8 years. DM was found in 26.3% (430/1633) of patients after the onset of CP. Adult at onset of ICP, biliary stricture at/before diagnosis of CP, steatorrhea at/before diagnosis of CP, and complex pathologic changes in main pancreatic duct were identified risk factors for DM development. The nomogram achieved good concordance indexes in the training and validation cohorts, respectively, with well-fitted calibration curves.

CONCLUSIONS

Risk factors were identified, and nomogram was developed to determine the risk of DM in ICP patients. Patients with one or more of the risk factors including adult at onset of ICP, biliary stricture at/before diagnosis of CP, steatorrhea at/before diagnosis of CP, and complex pathologic changes in main pancreatic duct have higher incidence of DM.

Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous drainage: Meta-analysis

BACKGROUND

Pancreatic pseudocyst (PP) and walled-off necrosis can be managed endoscopically, percutaneously or surgically, but with diverse efficacy.

AIMS & METHODS

A comprehensive literature search was carried out from inception to December 2018, to identify articles which compared at least two of the three kinds of treatment modalities, regarding the mortality, clinical success, recurrence, complications, cost and length of hospitalisation (LOH).

RESULTS

The outcomes of endoscopic (ED) and percutaneous drainage (PD) were comparable in six articles. The clinical success of endoscopic intervention was better considering any types of fluid collections (OR = 3.36; 95% confidence interval (CI) 1.48, 7.63; p = 0.004). ED was preferable regarding recurrence of PP (OR = 0.23; 95% CI 0.08, 0.66; p = 0.006). Fifteen articles compared surgical intervention with ED. Significant difference was found in postoperative LOH (WMD (days) = -4.61; 95%CI -7.89, -1.33; p = 0.006) and total LOH (WMD (days) = -3.67; 95%CI -5.00, -2.34; p < 0.001) which favored endoscopy, but ED had lower rate of clinical success (OR = 0.54; 95% CI 0.35, 0.85; p = 0.007) and higher rate of recurrence (OR = 1.80; 95% CI 1.16, 2.79; p = 0.009) in the treatment of PP. Eleven studies compared surgical and percutaneous intervention. PD resulted in higher rate of recurrence (OR = 4.91; 95% CI 1.82, 13.22; p = 0.002) and lower rate of clinical success (OR = 0.13; 95% CI 0.07, 0.22, p < 0.001).

CONCLUSION

Both endoscopy and surgery are preferable over percutaneous intervention, furthermore endoscopic treatment is associated with shorter hospitalisation than surgery.

Chronic Pancreatitis: Managing a Difficult Disease

Chronic pancreatitis is characterized by progressive, irreversible morphologic and functional changes that are most commonly attributed to environmental insults, particularly when there is a genetic or anatomic predisposition. Heavy alcohol use and cigarette smoking are the most common environmental risk factors, but both may be absent. Antecedent episodes of acute pancreatitis occur in about half of patients. Abdominal pain is the most common symptom and requires a tailored approach depending on the anatomic changes in the pancreas. Other clinical manifestations include diabetes mellitus, exocrine pancreatic insufficiency, metabolic bone disease, pancreatic cancer, and anatomic complications. Current disease management is centered on risk factor reduction and screening for and treating disease complications. There are no current therapies to delay or retard disease progression, but there are ongoing efforts to more fully understand the natural history of chronic pancreatitis and underlying mechanisms of disease. These studies are expected to provide insights that will transform our approach to disease management and provide increased hope to patients.

Risk and Outcomes of Clostridium difficile Infection With Chronic Pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is associated with high rates of recurrent hospitalizations, which predisposes to Clostridium difficile infection (CDI). We investigate the burden of CDI in CP.

METHODS

We identified records of patients with CP from the Nationwide Inpatient Sample (NIS) 2012-2014 and estimated the impact of CDI on their outcomes. We calculated the adjusted odds ratio (AOR) of CP on having CDI (NIS 2014). From NIS 2007-2014, we plotted the trends of CDI and its interaction with CP.

RESULTS

From 2012 to 2014, 886 (2.72%) of the 32,614 CP patients had concomitant CDI, which was associated with poorer outcomes: acute kidney injury (AOR, 2.57 [95% confidence interval {CI}, 2.11-3.13]), length of stay (13.3 vs 7.4 days), and charges (US $127,496 vs US $72,767), but not mortality (AOR, 0.93 [95% CI, 0.28-3.05]). In 2014, CP was associated with an increased risk of CDI (crude odds ratio, 2.10 [95% CI, 1.95-2.26]), which persisted after multivariate adjustment (AOR, 2.03 [95% CI, 1.87-2.19]). From 2007 to 2014, the annual prevalence of CDI was 106.4 cases per 10,000 hospitalizations, increasing from 2007 (95.5/10,000) to 2014 (118.4/10,000), with a 3.7 times higher annual rate of increase among CP versus no-CP patients (13.4/10,000 vs 3.7/10,000 population/year).

CONCLUSIONS

Chronic pancreatitis patients have high burden of CDI and may benefit from CDI prophylaxis.

Endoplasmic reticulum stress and NLRP3 inflammasome: Crosstalk in cardiovascular and metabolic disorders

When endoplasmic reticulum (ER) homeostasis is disrupted, known as ER stress (ERS), the ER generates an adaptive signaling pathway called the unfolded protein response to maintain the homeostasis of this organelle. However, if homeostasis is not restored, the ER initiates death signaling pathways, which contribute to the pathogenesis of various disorders. The activation of inflammatory mechanisms is also emerging as a crucial component of cardiovascular and metabolic disorders. Furthermore, the nucleotide-binding oligomerization domain-like receptor family, pyrin domain containing 3 (NLRP3) inflammasome has attracted more attention than others and is the best-characterized member of the NLR family of inflammasomes to date. ERS intersects with many different inflammatory pathways, particularly the NLRP3 inflammasome. In this review, we focus on the interactions between ERS and the NLRP3 inflammasome. The pharmacologic and nonpharmaceutical manipulation of these two processes may offer novel opportunities for the treatment of cardiovascular and metabolic disorders.

A phase 1/2 trial to evaluate the pharmacokinetics, safety, and efficacy of NI-03 in patients with chronic pancreatitis: study protocol for a randomized controlled trial on the assessment of camostat treatment in chronic pancreatitis (TACTIC)

Background

Chronic pancreatitis (CP) is a progressive, fibro-inflammatory disease characterized by enzymatic autoactivation and subsequent fibrotic replacement of acinar cells. A significant proportion of patients develop pain, which may be due to many causes, including perineural inflammation, altered central processing of pain signals, parenchymal structural changes, and ductal obstruction. Currently there are no approved medical treatment options for CP-associated pain. NI-03 (camostat mesilate) is an orally administered serine protease inhibitor that reduces pancreatic enzyme activity and has been widely used for the treatment of CP-associated pain in Japan. The current study will assess the safety and efficacy of NI-03 for reduction of CP-associated pain in the USA.

Methods

The current study consists of two phases. First, a phase I study will be performed to establish the pharmacokinetics and safety profile over a 1-week period following a single dose (100, 200, or 300 mg). Subsequently, a phase II study will be performed consisting of a double-blind, randomized, controlled trial (RCT). This RCT will evaluate the efficacy of each of the three doses of NI-03 given three times daily compared to placebo over 28 days. A 7-day, single-blind, run-in period will precede the double-blind phase to assess baseline pain characteristics. The primary efficacy outcome is the average of worst daily pain scores (numeric rating scale of 0–10) over the terminal 7 days of the study period compared to baseline. Secondary efficacy outcomes include change in opioid dose and quality of life measures, and time to first rescue intravenous analgesic. Adverse events will be recorded.

Discussion

NI-03 has been used successfully and safely in Japan to treat CP-associated pain. The aim of the current study is to assess the safety and efficacy of NI-03 using a rigorous RCT in a population in the USA. This study may fill an important clinical gap to provide an effective medical treatment option for CP-associated pain.

Trial registration

ClinicalTrials.gov, NCT02693093. Registered through the National Institutes of Health on 26 February 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3606-y) contains supplementary material, which is available to authorized users.

Does the Healthy Eating Index and Mediterranean Diet Score Identify the Nutritional Adequacy of Dietary Patterns in Chronic Pancreatitis?

BACKGROUND

Chronic pancreatitis (CP) is a progressive, irreversible disease characterized by maldigestion and frequently accompanied by epigastric pain, exocrine insufficiency, and/or endocrine insufficiency. There is limited information about the dietary patterns in CP from which to guide medical nutrition therapy recommendations.

METHODS

Study design was a cross-sectional, case-control study comparing subjects with CP (n = 52) to healthy controls (n = 48). Vioscreen™ food frequency questionnaire was used to assess the dietary pattern and nutrient intake in both groups. Dietary quality scores (the Healthy Eating Index, Mediterranean Diet score), and daily energy, macronutrient, and micronutrient intake levels were compared between groups.

ANALYSIS

Two sample t tests and Wilcoxon rank sum tests were used to evaluate differences in continuous variables, and Chi-squared tests were used for categorical variables.

RESULTS

CP was associated with a lower body mass index (BMI) (24 vs. 31 mg/kg²; p < 0.001), lower HEI (57 vs. 65; p = 0.002), and aMED scores (29 vs. 32; p = 0.043) compared to healthy controls. Subjects with CP in the highest BMI quartile had the highest median aMED score compared to those in the lowest BMI quartile. There were no differences in kilocalories, macronutrients, or fat-soluble vitamin intake between groups, with the exception that vitamin K intake was lower in the CP group.

CONCLUSIONS

The overall quality of dietary intake is lower in subjects with CP compared to controls when assessed by two independent nutritional measurement tools. Further research is needed to examine contributing factors, such as food insecurity and coexisting endocrine or exocrine insufficiency, to dietary patterns in patients with CP from which to guide evidence-based recommendations for medical nutritional therapy.

Practical guide to the management of chronic pancreatitis

Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.

A case of pancreatic pseudocysts accompanied by infection, pseudoaneurysm ruptures, and pseudocystocolonic fistulae

Pancreatic pseudocysts (PPs) can be accompanied by infection, pseudoaneurysm ruptures, and fistulae to other organs, which can be fatal without appropriate treatment. Herein, we present the case of an 82-year-old man with PPs accompanied by infection, pseudoaneurysm rupture, and pseudocystocolonic fistula that were managed via multidisciplinary treatment. Computed tomography (CT) revealed two inflamed PPs, one each in the pancreatic head and tail. He was, therefore, diagnosed with infectious PPs. The pancreatic head PP shrunk on endoscopic nasopancreatic drainage (ENPD), but the pancreatic tail PP did not. Endoscopic ultrasound (EUS)-guided transluminal drainage was performed to treat the pancreatic tail PP; his symptoms improved. However, he vomited blood at 14 day post-drainage. Angiography revealed pseudoaneurysm rupture in a left gastric artery branch. After successful angioembolization, he developed hematochezia 2 days later. We suspected re-bleeding of the pseudoaneurysm. The bleeding stopped spontaneously, but CT and radiography revealed the presence of a pseudocystocolonic fistula. Careful follow-up was performed, and he has not had any symptoms at 9 month post-discharge. We managed PP-related complications via ENPD, EUS-guided transluminal drainage, angioembolization, and careful follow-up. Infection, pseudoaneurysm rupture, and pseudocystocolonic fistula are rare, but can occur simultaneously. Therefore, clinicians should consider these complications when treating patients with PPs.

Gastrointestinal complications in acute and chronic pancreatitis

Pancreatitis is one of the important medical conditions. Gastrointestinal (GI) complications of pancreatitis are important and lead to significant morbidity and mortality. Diagnosis of these complications is difficult and may require a strong clinical suspicion coupled with various imaging features. This review provides an extensive update of the whole spectrum of GI complication of pancreatitis, both acute and chronic, from inflammation, ischemia, and necrosis to obstruction, perforation, and GI fistulae. The focus is on the clinical and imaging features of this less commonly described aspect of pancreatitis.

Chronic Pancreatitis: What the Clinician Wants to Know from MR Imaging

Diagnosis of chronic pancreatitis requires a complete medical history and clinical investigations, including imaging technologies and function tests. MR imaging/magnetic resonance cholangiopancreatography is the preferred diagnostic tool for detection of ductal and parenchymal changes in patients with chronic pancreatitis. Ductal changes may not be present in the initial phase of chronic pancreatitis. Therefore, early diagnosis remains challenging.

Guidelines for the Diagnostic Cross Sectional Imaging and Severity Scoring of Chronic Pancreatitis

The paper presents the international guidelines for imaging evaluation of chronic pancreatitis. The following consensus was obtained: Computed tomography (CT) is often the most appropriate initial imaging modality for evaluation of patients with suspected chronic pancreatitis (CP) depicting most changes in pancreatic morphology. CT is also indicated to exclude other potential intraabdominal pathologies presenting with symptoms similar to CP. However, CT cannot exclude a diagnosis of CP nor can it be used to exclusively diagnose early or mild disease. Here magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) is superior and is indicated especially in patients where no specific pathological changes are seen on CT. Secretin-stimulated MRCP is more accurate than standard MRCP in the depiction of subtle ductal changes. It should be performed after a negative MRCP, when there is still clinical suspicion of CP. Endoscopic ultrasound (EUS) can also be used to diagnose parenchymal and ductal changes mainly during the early stage of the disease. No validated radiological severity scoring systems for CP are available, although a modified Cambridge Classification has been used for MRCP. There is an unmet need for development of a new and validated radiological CP severity scoring system based on imaging criteria including glandular volume loss, ductal changes, parenchymal calcifications and parenchymal fibrosis based on CT and/or MRI. Secretin-stimulated MRCP in addition, can provide assessment of exocrine function and ductal compliance. An algorithm is presented, where these imaging parameters can be incorporated together with clinical findings in the classification and severity grading of CP.

Identification of risk factors for pancreatic pseudocysts formation, intervention and recurrence: a 15-year retrospective analysis in a tertiary hospital in China

BACKGROUND

Pancreatic pseudocyst (PPC) is a common complication of acute and chronic pancreatitis. To our knowledge no study has systematically reported the risk factors for the formation, intervention and recurrence of PPC. Therefore, the present study aimed to investigate the potential risk factors for PPC, with regards to its formation, intervention and recurrence.

METHODS

A database containing 5106 pancreatitis patients was retrospectively analyzed. As a result, a total of 4379 eligible patients were identified and divided into 2 groups: PPC group (group A, n = 759) and non-PPC group (group B, n = 3620). The PPC group was subdivided into 2 groups: intervention PPC (group C, n = 347) and resolution PPC (group D, n = 412). The differences in surgical complication and recurrence rates were compared among 347 PPC patients receiving different interventions, including surgical, endoscopic and percutaneous drainages. Furthermore, group C was subdivided into 2 groups: recurrent PPC (group E, n = 34) and non-recurrent PPC (group F, n = 313). All possible risk factors for PPC formation, intervention and recurrence were determined by multivariate regression analysis.

RESULTS

In this study, PPC was developed in 17.3% (759/4379) of pancreatitis patients. The significant risk factors for PPC formation included alcoholic pancreatitis (OR, 6.332; 95% CI, 2.164-11.628; p = 0.031), chronic pancreatitis (CP) (OR, 5.822; 95% CI, 1.921-10.723; p = 0.006) and infected pancreatic necrosis (OR, 4.253; 95% CI, 3.574-7.339; p = 0.021). Meanwhile, the significant risk factors of PPC patients who received intervention were alcoholic pancreatitis (OR, 7.634; 95% CI, 2.125-13.558; p = 0.016), size over 6 cm (OR, 8.834; 95% CI, 2.017-16.649; p = 0.002) and CP (OR, 4.782; 95% CI, 1.897-10.173; p = 0.038). In addition, the recurrence rate in PPC patients treated with percutaneous drainage was found to be the highest (16.3%) among the three intervention groups. Furthermore, percutaneous drainage was the only risk factor of PPC recurrence (OR, 7.812; 95% CI, 3.109-23.072; p = 0.013) identified from this retrospective cohort study.

CONCLUSIONS

Alcoholic pancreatitis and CP are the main risk factors for PPC formation and intervention, but not PPC recurrence. A higher recurrence rate is found in PPC patients treated with percutaneous drainage, as compared to endoscopic and surgical interventions.

Total Pancreatectomy and Islet Autotransplantation Following Treated Hepatitis C Infection

Hepatic parenchymal disease, including chronic viral hepatitis, has traditionally been considered a relative contraindication to islet transplantation as the islets are infused into the recipient’s liver. We present a case study of a patient with treated chronic hepatitis C infection (HCV) who safely received an autologous islet transplant following total pancreatectomy with excellent clinical outcomes. The patient was a 60-year-old woman diagnosed with debilitating abdominal pain secondary to chronic pancreatitis and with preserved islet function. She had previously been treated >10 years prior to surgical evaluation with interferon monotherapy for 1 year that led to sustained virologic response, including at the time of surgical evaluation for total pancreatectomy and islet autotransplantation (TPIAT). She underwent comprehensive preoperative evaluation of the liver, including liver biopsy, which showed no significant portal inflammation or fibrosis. Following a multidisciplinary meeting and discussion of the potential risks for the patient, the decision was made to proceed with TPIAT. The patient underwent a standard total pancreatectomy, and an autologous islet dose of 6638 islet equivalents/kg body weight was infused into the liver via the portal vein. Portal vein pressure was monitored throughout the infusion with a transient peak pressure of 27 cm H₂O (basal pressure of 14 cm H₂O) and final pressure of 23 cm H₂0 at 10 min post-infusion. Aside from a transient transaminitis, liver enzymes were normal at the time of hospital discharge. At greater than 1 year of follow-up, the patient has improved quality of life, with reduction in narcotic analgesia, remains insulin independent (with normal islet function), and has normal liver function. This case illustrates that islet autotransplant into the liver can be safely performed and suggests that carefully selected patients with liver disease may be eligible for TPIAT.

Fecal fat and energy loss in pancreas exocrine insufficiency: the role of pancreas enzyme replacement therapy

BACKGROUND

Chronic pancreatitis (CP) can lead to severe pancreatic exocrine insufficiency (PEI). Pancreatic enzyme replacement therapy (PERT) is well established, but knowledge of the physiological response to increasing doses on fecal fat- and energy loss is scarce.

METHODS

We included 10 patients with CP and established PEI and 12 healthy controls for a prospective interventional study. Subjects received no PERT in the first week followed by four weeks PERT incrementally increasing doses every week. For each week, three-day stool collection followed three days registration of nutritional intake. We measured the fecal output of fat and energy by van de Kamer titration and decomposition vessel calorimetry, respectively. We calculated fecal fat- and energy loss per day, the coefficient of fat absorption (CFA) and coefficient of energy absorption (CEA).

RESULTS

Without PERT treatment, CP patients with PEI had significantly higher daily fecal fat and energy loss (p = .022; p = .035) compared to HC. In CP patients, there was a significant reduction of fecal fat and energy loss (p = .045; p = .037) when PERT doses reached maximum intake of 75,000 units per meal. In CP patients, there was a strong positive correlation between fecal loss of energy and fat (r = 0.99), and between fecal loss of energy and daily stool weight (r = 0.97). CFA and CEA correlated negatively with daily fecal fat loss (r = -0.72) and fecal energy loss (r = -0.65).

CONCLUSIONS

PERT reduces fecal energy and fat loss in patients with CP and PEI. Fecal energy loss in CP patients is strongly dependent on fecal fat loss, and on fecal weight.

Arterial Pseudoaneurysm within a Pancreatic Pseudocyst

The formation of pancreatic pseudocysts and (pseudo-)aneurysms of intestinal vessels are rare but life-threatening complications in acute and chronic pancreatitis. Here we report the rare case of a patient suffering from chronic pancreatitis with an arterial pseudoaneurysm within a pancreatic pseudocyst and present its successful therapeutic management by angioembolization to prevent critical bleeding. A 67-year-old male with a history of chronic pancreatitis presented with severe acute abdominal pain and vomiting to the emergency department. Seven weeks prior to the present admission, a CT scan had displayed a pancreatic pseudocyst with a maximum diameter of 53 mm. A laboratory examination revealed an elevated white blood cell count (15.40 × 103/μL), as well as elevated serum lipase (191 U/L), bilirubin (1.48 mg/dL), and blood glucose (353 mg/dL) levels. Sonographically, the previously described pancreatic pseudocyst revealed a slightly increased maximum diameter of 65 mm and an inhomogeneous echo of the cystic content. A contrast-enhanced CT scan showed a further increase in maximum diameter to 70 mm of the known pseudocyst. Inside the pseudocyst, a pseudoaneurysm originating from the splenic artery with a maximum diameter of 41 mm was visualized. After interdisciplinary consultation, prophylactic coil embolization of the splenic artery was immediately performed. The pseudoaneurysm was shut off from blood supply by back-door/front-door occlusion employing 27 coils, resulting in complete exclusion of the pseudoaneurysm from the circulation. Pseudoaneurysms are a rare complication of acute and chronic pancreatitis which has been shown to be efficiently treated by coil embolization.

Prevalence and outcomes of cystic lesions of the transplant pancreas: The University of Wisconsin Experience

Literature on the behavior of cystic lesions in pancreas transplants is scarce, and hence a better understanding is warranted. Data on recipients and their respective donors that underwent simultaneous kidney and pancreas, pancreas transplant alone, and pancreas after kidney between 1994 and 2015 were reviewed (n = 1185). Cystic lesions of the transplant pancreas developed in 22 patients (1.8%): 12 pseudocysts, 2 cysts/remnants, 4 intraductal papillary mucinous neoplasms (IPMN), 2 adenocarcinomas, 1 low-grade intraepithelial pancreatic neoplasia, and 1 case of polycystic kidney disease. The median size was 3.6 cm (1.6-5.5 cm), and occurred at a median time of 65.5 months (2-183 months) posttransplant. The median age of the graft at time of diagnosis was 42 years (25.7-54.5), with 17 of 22 grafts (77%) functioning at time of diagnosis. Triggers for investigation were elevations in pancreatic enzymes, re-admissions for abdominal pain, and incidentalomas. High-resolution imaging and diagnostic biopsy/aspiration with ancillary tests were the main diagnostic tests. Most pseudocysts were managed by percutaneous drainage, and although no firm inference can be made from such a small series, we have observed that the behavior and management of IPMN and adenocarcinoma in the pancreas graft appears congruent to that of the native pancreas.

Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel

BACKGROUND

Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release.

PURPOSE

To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI.

METHODS

For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors?

FINDINGS

The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist.

CONCLUSIONS

In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

Association between alcohol consumption pattern and the incidence risk of type 2 diabetes in Korean men: A 12-years follow-up study

Moderate alcohol consumption is generally associated with reduced risk of type 2 diabetes. However, this beneficial effects of alcohol intake remains controversial due to inconsistent results across studies. The analysis was performed using data from the Ansung-Ansan cohort study. We categorized the participants into four groups-based on the baseline (one-point measure; non-drinking, <5 g/day, ≥5, <30 g/day, and ≥30 g/day) and follow-up (consumption pattern; never-drinking, light, moderate, and heavy drinking) measurement. At baseline, ≥30 g/day alcohol consumption increased the risk of incident diabetes (HR: 1.42; 95% CI, 1.10-1.85), but ≥5, <30 g/day alcohol consumption had no effects on the incident diabetes. Meanwhile, when using the alcohol consumption pattern, a heavy-drinking pattern increased the risk of incident diabetes (HR = 1.32, 1.01-1.73), but the light and moderate consumption pattern was associated with a reduced risk of type 2 diabetes (HR: 0.66; 0.50-0.87 and HR: 0.74; 0.57-0.95, respectively). At the end point of follow-up, the insulinogenic index (IGI), but not the insulin sensitivity index (ISI), differed among the groups. Alcohol consumption pattern had a J-shaped association with the incident type 2 diabetes in Korean men. The IGI showed an inverted J-shaped association according to alcohol drinking pattern, but the ISI was not a J-shape.