Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis

Alcohol abuse, endoplasmic reticulum stress and pancreatitis

Alcohol abuse is a common cause of both acute and chronic pancreatitis. There is a wide spectrum of pancreatic manifestations in heavy drinkers from no apparent disease in most individuals to acute inflammatory and necrotizing pancreatitis in a minority of individuals with some progressing to chronic pancreatitis characterized by replacement of the gland by fibrosis and chronic inflammation. Both smoking and African-American ethnicity are associated with increased risk of alcoholic pancreatitis. In this review we describe how our recent studies demonstrate that ethanol feeding in rodents causes oxidative stress in the endoplasmic reticulum (ER) of the digestive enzyme synthesizing acinar cell of the exocrine pancreas. This ER stress is attenuated by a robust unfolded protein response (UPR) involving X-box binding protein-1 (XBP1) in the acinar cell. When the UPR activation is prevented by genetic reduction in XBP1, ethanol feeding causes significant pathological responses in the pancreas. These results suggest that the reason most individuals who drink alcohol heavily do not get significant pancreatic disease is because the pancreas mounts an adaptive UPR to attenuate the ER stress that ethanol causes. We hypothesize that disease in the pancreas results when the UPR is insufficiently robust to alleviate the ER stress caused by alcohol abuse.

Recent advances in the epidemiology of alcoholic pancreatitis

Clinical observation has defined the medical profile of alcoholic pancreatitis, but its low incidence and prevalence has limited characterizing the disease at a population level, the contribution of environmental exposures, and a clear picture of its natural history. Recent studies have defined the impact of alcohol use and smoking on disease risk, and a threshold for alcohol consumption has been identified. Recurrent attacks of acute pancreatitis have been linked with continued alcohol consumption, and aggressive alcohol intervention has been shown to decrease recurrence. Progression from alcoholic acute pancreatitis to chronic pancreatitis is now believed to occur infrequently, and factors associated with progression have been identified. Alcoholic pancreatitis reduces lifespan in these patients, and the economic impact of pancreatitis is substantial. Efforts are needed to increase awareness of the impact of alcohol consumption and smoking on risk for pancreatitis and the benefits of cessation for primary and secondary prevention.

Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis

BACKGROUND & AIMS

Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers.

METHODS

We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified).

RESULTS

The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP.

CONCLUSIONS

The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.

Smoking is underrecognized as a risk factor for chronic pancreatitis

BACKGROUND/AIMS

Smoking is an established risk factor for chronic pancreatitis (CP). We sought to identify how often and in which CP patients physicians consider smoking to be a risk factor.

METHODS

We analyzed data on CP patients and controls prospectively enrolled from 19 US centers in the North American Pancreatitis Study-2. We noted each subject's self-reported smoking status and quantified the amount and duration of smoking. We noted whether the enrolling physician (gastroenterologist with specific interest in pancreatology) classified alcohol as the etiology for CP and selected smoking as a risk factor.

RESULTS

Among 382/535 (71.4%) CP patients who were self-reported ever smokers, physicians cited smoking as a risk factor in only 173/382 (45.3%). Physicians cited smoking as a risk factor more often among current smokers, when classifying alcohol as CP etiology, and with higher amount and duration of smoking. We observed a wide variability in physician decision to cite smoking as a risk factor. Multivariable regression analysis however confirmed that the association of CP with smoking was independent of physician decision to cite smoking as a risk factor.

CONCLUSIONS

Physicians often underrecognize smoking as a CP risk factor. Efforts are needed to raise awareness of the association between smoking and CP. and IAP.

Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis

BACKGROUND & AIMS

Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers.

METHODS

We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified).

RESULTS

The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP.

CONCLUSIONS

The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.

Genetics and alcohol: a lethal combination in pancreatic disease?

An association between alcohol consumption and pancreatic diseases has been recognized for decades, but the absolute risk for pancreatic disease for individuals who drink alcohol is low. Other than smoking, few additional environmental factors have been identified, which suggests that genetic risk factors may be important. Studies in our laboratory using the Lieber-DeCarli feeding technique demonstrate that alcohol causes oxidative stress and mitochondrial damage and alters neruohormonal regulation of the pancreas after a threshold dose is exceeded, which makes the pancreas susceptible to withdrawal hypersensitivity and acute pancreatitis. Alcohol also shifts cell death from apoptosis to necrosis and promotes fibrosis through anti-inflammatory immune mechanisms. Others have demonstrated that alcohol lowers the threshold for trypsin activation in acinar cells, which increases sensitivity to triggering pancreatitis. In addition, we used the Lieber-DeCarli diet plus recurrent acute pancreatitis insults to develop the first animal model of chronic pancreatitis that mimics human disease. Finally, our North American Pancreatitis Study 2 (NAPS2), which was built on insights from animal studies, confirmed the threshold effect predicted by Charles Lieber (>5 drinks per day and >35 drinks/week). These studies and others also defined distinctive roles of alcohol and genetics in the etiology and progression of chronic pancreatitis.

Investigating the pathobiology of alcoholic pancreatitis

Alcohol abuse is one of the most common causes of pancreatitis. The risk of developing alcohol-induced pancreatitis is related to the amount and duration of drinking. However, only a small portion of heavy drinkers develop disease, indicating that other factors (genetic, environmental, or dietary) contribute to disease initiation. Epidemiologic studies suggest roles for cigarette smoking and dietary factors in the development of alcoholic pancreatitis. The mechanisms underlying alcoholic pancreatitis are starting to be understood. Studies from animal models reveal that alcohol sensitizes the pancreas to key pathobiologic processes that are involved in pancreatitis. Current studies are focussed on the mechanisms responsible for the sensitizing effect of alcohol; recent findings reveal disordering of key cellular organelles including endoplasmic reticulum, mitochondria, and lysosomes. As our understanding of alcohol's effects continue to advance to the level of molecular mechanisms, insights into potential therapeutic strategies will emerge providing opportunities for clinical benefit.

Treatment with oxymatrine down-regulates TGFβRII expression in chronic pancreatitis in rats

AIM: To investigate the effect of treatment with oxymatrine on the expression of transforming growth factor β1 type II receptor (TGFβRII) in chronic pancreatitis (CP) in rats and to explore the potential anti-fibrotic mechanism of oxymatrine.

METHODS: Forty male Wistar rats were randomly and equally assigned to four groups: negative control group (NC), CP group, oxymatrine treatment group (OT), and oxymatrine prevention group (OP). Each group was further divided into two subgroups for detection at different time points. Except the NC group, pancreatic fibrosis was induced in rats of the other groups by intraperitoneal injections of diethyldithiocarbamate (DDC 700 mg/kg). Preventive and therapeutic oxymatrine (100 mg/kg) was given to rats of the OT and OP group, respectively. Pancreatic tissue samples were taken for HE and Masson staining to evaluate histological alterations. The expression of TGFβRII in pancreatic tissue was detected by Western blot.

RESULTS: The contents of collagen fibers in the CP group were significantly higher than those in the other groups (day 20: 22.54% ± 4.45% vs 13.16% ± 1.84%, 19.58% ± 2.78%, 2.45% ± 0.24%; day 40: 35.14% ± 3.27% vs 25.14% ± 3.67%, 28.68% ± 2.55%, 3.0% ± 0.32%; all P < 0.05), and the percentages of collagen area in the OP and OT groups on day 40 were significantly higher than those on day 20 (25.14% ± 3.67% vs 13.16% ± 1.84%; 28.68% ± 2.55% vs 19.58% ± 2.78%; all P < 0.05) The expression level of TGFβRII in the CP group was significantly higher than those in the other groups (day 20: 0.74 ± 0.05 vs 0.47 ± 0.03, 0.61 ± 0.03, 0.21 ± 0.02; day 40: 1.01 ± 0.14 vs 0.64 ± 0.08, 0.75 ± 0.04, 0.23 ± 0.03; all P < 0.05). The expression levels of TGFβRII in the OP and OT groups on day 40 were significantly higher than those on day 20 (0.64 ± 0.08 vs 0.47 ± 0.03; 0.75 ± 0.04 vs 0.61 ± 0.03; all P < 0.05).

CONCLUSION: Treatment with oxymatrine exerts beneficial effects against CP possibly by inhibiting TGFβRII signaling.

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

BACKGROUND

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients.

AIM

To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres.

METHODS

Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians.

RESULTS

Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%.

CONCLUSIONS

Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

CREON (Pancrelipase Delayed-Release Capsules) for the treatment of exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is associated with conditions including cystic fibrosis (CF), chronic pancreatitis (CP), and pancreatic surgery (PS). The symptoms include maldigestion, malnutrition, weight loss, flatulence, and steatorrhea. Pancreatic enzyme replacement therapy (PERT) is the standard treatment for EPI; it is regulated in many countries and most recently in the USA following a US FDA mandate for all PERT manufacturers to submit new drug applications. Pancrelipase delayed-release capsules (CREON®, Abbott, Marietta, GA, USA) have been available in Europe since 1984 and in the USA since 1987; a new formulation was the first PERT to gain approval in the USA in 2009. The efficacy and safety of CREON have been demonstrated in double-blind, randomized, placebo-controlled trials in patients with CF aged ≥7 years and in patients with CP or post-PS. The data consistently demonstrate significantly better fat and nitrogen absorption with CREON versus placebo, and improvements in clinical symptoms, stool frequency, and body weight. Additionally, efficacy and safety of CREON have been shown in open-label studies in young children with CF (aged 1 month to 6 years), with control of fat malabsorption and control of clinical symptoms. The most commonly reported adverse events (AEs) with PERT are gastrointestinal disorders and allergic skin reactions. In clinical studies, CREON was well tolerated with very few withdrawals due to AEs and a low frequency of AEs judged treatment related, regardless of patient age. To further support the known safety profile of PERT, all manufacturers are required to investigate risk factors for fibrosing colonopathy, a rare gastrointestinal complication of CF, and the theoretical risk of viral transmission from porcine-derived PERT products. Together, the clinical study data and wealth of clinical experience suggest that CREON is effective and safe in patients with EPI regardless of etiology, with a very favorable risk-benefit profile.

Can by-products in country-made alcohols induce acute pancreatitis?

OBJECTIVES

We previously reported a high incidence of alcohol-related acute pancreatitis (AP) in Goa, India, where country-made alcoholic products are consumed in addition to the commercially available alcoholic products. We aimed to analyze the composition of these country-made alcoholic products consumed by a population with a high incidence of alcohol-related AP.

METHODS

Three locally distilled alcoholic products (ethanol content, >20%) regularly consumed by patients developing AP, as determined by responses in a patient questionnaire, were selected. Three commercially available products with comparable ethanol content (rum, whiskey, and brandy) were used for comparison. Representative samples were analyzed using gas chromatography/mass spectrometry. Compound assignments used mass spectral searches of the NIST library (2008).

RESULTS

Commercially available rum, whiskey, and brandy used for comparison contained the 2 major constituents, ethanol and water. In addition, the country-made alcoholic products contained a higher level of by-products including long-chain alcohols (eg, butanol, propanol), aldehydes (eg, acetaldehyde), acids (eg, acetic acid), and even traces of methanol.

CONCLUSIONS

Country-made alcoholic products contain many compounds in addition to ethanol. Given the high incidence of alcohol-related AP in the population where these products are consumed, further evaluation of their constituents in relation to the induction of pancreatic damage is warranted.

Early readmission in acute pancreatitis: incidence and risk factors

OBJECTIVES

Early unplanned readmission is a potential target for quality improvement and cost reduction. The aims of this study were to (i) determine the frequency of early readmission following hospitalization for acute pancreatitis (AP) and (ii) identify risk factors for early readmission in patients hospitalized for AP.

METHODS

A retrospective, observational cohort study was performed including all inpatients with AP at a tertiary-care hospital between June 2005 and December 2007. Early readmission was defined as admission to the hospital or reevaluation in the emergency department within 30 days of discharge. We analyzed demographics, etiology, markers of severity (according to Atlanta symposium), comorbidities, complications, therapeutic interventions, and discharge symptoms as potential risk factors for readmission.

RESULTS

There were a total of 248 patients discharged with AP during the study period, of whom 19% (47/248) had an early readmission. Median time to readmission was 9 days (interquartile range, 5-15). Median rehospitalization length of stay was 4 days (2.5-8). In multivariate analysis, the strongest risk factors for early readmission included (i) gastrointestinal symptoms (nausea, vomiting, or diarrhea) at discharge (odds ratio (OR) 44.2; 95% confidence interval (CI) 4.1-472.1); (ii) discharge on less than a solid diet (OR 23.8; 95% CI 4.8-118.2); and (iii) moderate to heavy alcohol use (OR 10.1; 95% CI 1.2-82.6).

CONCLUSIONS

(i) Early readmission is a common occurrence in AP. (ii) Risk factors for early readmission included moderate to heavy alcohol use, persistent symptoms, and diet at the time of discharge.

Smoking as a cofactor for causation of chronic pancreatitis: a meta-analysis

OBJECTIVES

To assess the evidence for tobacco smoking as a risk factor for the causation of chronic pancreatitis.

METHODS

We performed a meta-analysis with random-effects models to estimate pooled relative risks (RRs) of chronic pancreatitis for current, former, and ever smokers, in comparison to never smokers. We also performed dose-response, heterogeneity, publication bias, and sensitivity analyses.

RESULTS

Ten case-control studies and 2 cohort studies that evaluated, overall, 1705 patients with chronic pancreatitis satisfied the inclusion criteria. When contrasted to never smokers, the pooled risk estimates for current smokers was 2.8 (95% confidence interval [CI], 1.8-4.2) overall and 2.5 (95% CI, 1.3-4.6) when data were adjusted for alcohol consumption. A dose-response effect of tobacco use on the risk was ascertained: the RR for subjects smoking less than 1 pack per day was 2.4 (95% CI, 0.9-6.6) and increased to 3.3 (95% CI, 1.4-7.9) in those smoking 1 or more packs per day. The risk diminished significantly after smoking cessation, as the RR estimate for former smokers dropped to a value of 1.4 (95% CI, 1.1-1.9).

CONCLUSIONS

Tobacco smoking may enhance the risk of developing chronic pancreatitis. Recommendation for smoking cessation, besides alcohol abstinence, should be incorporated in the management of patients with chronic pancreatitis.

Are genetic variants in the platelet-derived growth factor [beta] gene associated with chronic pancreatitis?

OBJECTIVES

Platelet-derived growth factor [beta] (PDGF-[beta]) is a major signal in proliferation and matrix synthesis through activated pancreatic stellate cells, leading to fibrosis of the pancreas. Recurrent acute pancreatitis (RAP) seems to predispose to chronic pancreatitis (CP) in some patients but not others. We tested the hypothesis that 2 known PDGF-[beta] polymorphisms are associated with progression from RAP to CP. We also tested the hypothesis that PDGF-[beta] polymorphisms in combination with environmental risk factors such as alcohol and smoking are associated with CP.

METHODS

Three hundred eighty-two patients with CP (n = 176) and RAP (n = 206) and 251 controls were evaluated. Platelet-derived growth factor [beta] polymorphisms +286 A/G (rs#1800818) seen in 5'-UTR and +1135 A/C (rs#1800817) in first intron were genotyped using single-nucleotide polymorphism polymerase chain reaction approach and confirmed by DNA sequencing.

RESULTS

The genotypic frequencies for PDGF-[beta] polymorphisms in positions +286 and +1135 were found to be similar in controls and patients with RAP and CP. There was no difference in genotypic frequencies among RAP, CP, and controls in subjects in the alcohol and smoking subgroups.

CONCLUSIONS

Known variations in the PDGF-[beta] gene do not have a significant effect on promoting or preventing fibrogenesis in pancreatitis. Further evaluation of this important pathway is warranted.

Update in acute pancreatitis

Acute pancreatitis is a common cause for hospitalization that carries a substantial burden of disease in the United States and worldwide. Recent reports have encompassed a wide array of topics including new insights into the acinar cell pH microenvironment, signal pathways for acinar cell fate, and the innate immune response. Clinical researchers have reported new methods to assess disease severity, innovative techniques for management of local complications, the importance of early recognition of pancreatic or extrapancreatic infection, and prevention of disease recurrence. Recent data also suggest that specialized centers may be of benefit for the management of severe acute pancreatitis. This review summarizes a number of recent advances in basic and clinical science with an emphasis on findings that are relevant to clinicians who manage patients with acute pancreatitis.

Optimal timing of oral refeeding in mild acute pancreatitis: results of an open randomized multicenter trial

OBJECTIVES

The aim of this study was to compare 2 protocols regarding the initiation of oral nutrition in patients with mild acute pancreatitis.

METHODS

We randomized 143 patients to the Lipase directed (LIP) (n = 74) and the self selected PAT (n = 69) group. In the (PAT) group, the patients restarted eating through self-selection. In the LIP group, serum lipase had to normalize before eating.

RESULTS

The mean time between admission and oral nutrition was 2 days (interquartile range [IQR], 1-3) in the PAT group and 3 days (IQR, 2-4) in the LIP group (P < 0.005). Before and after the first meal, the mean Δ visual analogue scale (VAS) was +3.14 mm (±11.5 mm) in the PAT group and +2.85 mm (±16.4) in the LIP group (P = 0.597). The length of hospital stay was 7 days (median; IQR, 5-10.5) in the PAT group and 8 days (median; IQR, 5.75-12) in the LIP group (P = 0.315).

CONCLUSIONS

We were not able to demonstrate a difference in postprandial abdominal pain or in the length of hospital stay. Patients with self-selected eating, however, were able to restart eating 1 day earlier, and this difference was found to be significant. Our data suggest that normalization of serum lipase is not obligatory for enteral nutrition in mild acute pancreatitis.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the past year.

RECENT FINDINGS

Cigarette smoking is a dose-dependent risk factor for acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. A minority of chronic alcohol consumers develop recurrent acute pancreatitis but very heavy drinking associates with chronic pancreatitis. More patients with alcohol-induced chronic pancreatitis have cirrhosis than patients with cirrhosis have chronic pancreatitis (39 vs. 18%). Most patients with asymptomatic hyperenzymemia have no pancreatic lesions. Pancreatic calcifications are most frequently due to chronic pancreatitis, followed by cystic neoplasms and other disorders. The new Rosemont consensus classification of endoscopic ultrasonography criteria for chronic pancreatitis is unvalidated. Zinc deficiency correlates only with severe chronic pancreatitis and the fecal elastase test is an inaccurate marker of pancreatic steatorrhea. Patients commonly receive insufficient lipase to abolish pancreatic steatorrhea. Ultrastructural neuropathies are common to chronic pancreatitis and pancreatic cancer and correlate with pain severity.

SUMMARY

Results of this year's investigations further elucidated risk factors for pancreatic disease, the natural history of alcoholic pancreatitis, the differential diagnosis of pancreatic calcifications, the diagnosis of chronic pancreatitis with the Rosemont criteria, the limited diagnostic utility of fecal elastate test and zinc measurements, the proper dosing of pancreatic enzyme supplements, and treatment of pancreatic pain.

Pain management in chronic pancreatitis: A treatment algorithm

Abdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.

Oxymatrine enhances the expression of collagen I and α-SMA in rat chronic pancreatitis

AIM: To investigate the treatment effects of oxymatrine (OM) against chronic pancreatitis in rats and to explore the potential mechanisms involved.

METHODS: Forty healthy Wistar rats were randomly and equally divided into four groups: negative control group (NC group), CP model group (CP group), OM treatment group (OT group), and OM pretreatment group (OP group), which received saline qod, diethyldithiocarbamate (DDC) at 700 mg/kg qod, diethyldithiocarbamate (DDC) at 700 mg/kg qod and OM at 100 mg/kg a week later, and diethyldithiocarbamate (DDC) at 700 mg/kg qod and OM at 100 mg/kg simultaneously, respectively. Thirty days later, DDC injection was discontinued, while OM treatment continued. Rats were executed on days 20 and 40 (n = 5 at each time point). Collagen fibers were stained by Masson's trichrome. The localization and expression of collagen I and α-SMA in chronic pancreatitis were examined by immunohistochemistry.

RESULTS: Collage I was localized in the periphery of the pancreas in the NC group. In the CP group, collagen I could also be seen in periacinar and perilobular areas. The immunoreactivity of α-SMA was detected in the blood vessel wall in the NC group, and in the blood vessel wall and periacinar area in the CP group. The expression of collagen I and α-SMA in periacinar area was significantly lower in the OP and OT groups than in the CP group. The percentages of collagen area on days 20 and 40 were significantly lower in the NC group (3.0% ± 0.32% and 2.45% ± 0.24%) than in the other groups (all P < 0.05), but significantly higher in the CP group (22.54% ± 4.45% and 35.14% ± 3.27%) than in the OP group (13.16% ± 1.84% and 25.14% ± 3.67%) and the OT group (19.58% ± 2.78% and 28.68% ± 2.55%). The percentages of collagen areas on day 40 in the CP and OT groups were significantly higher than those on day 20 (both P < 0.05). The relative expression levels of α-SMA on days 20 and 40 were significantly higher in the CP group (1.06 ± 0.04 and 1.16 ± 0.03) than in other groups (all P < 0.05). The NC group had the lowest relative expression level of α-SMA (0.73 ± 0.06 and 0.78 ± 0.06). No significant difference was noted in the relative expression level of α-SMA between the OT and OP groups.

CONCLUSION: The expression of collagen I and α-SMA is enhanced in rat CP, predominantly localized in perivascular, periacinar and perilobular areas. OM can decrease collagen production and pancreatic stellate cell activation and thereby inhibit the development of pancreatic fibrosis.

Pancreatitis: understanding the disease and implications for care

Pancreatitis, or inflammation of the pancreas, has a variety of etiologies. Severity of the disease can range from its mildest form, which resolves quickly with few complications, to its most severe form, necrotizing pancreatitis, which is associated with an increased risk for developing multiple system organ failure and mortality. Treatment of pancreatitis aims to eliminate the etiologic factors for the disease while managing its complications and preventing further disease progression. Patients with mild forms of pancreatitis may improve with symptom management, whereas those with more severe disease will need significant supportive interventions. Most patients are managed medically. Surgery may be indicated for severe pancreatitis. It is important to understand the disease process and its impact on other organ systems when caring for these patients. Accurate assessment of changes in the patient's condition can lead to interventions that can limit complications and reduce the risk of mortality. This article reviews the pathophysiology of pancreatitis, its diagnosis and treatment, associated complications and their management, and essential nursing assessment and interventions.

Polymorphisms in tumour necrosis factor alpha (TNFalpha) gene in patients with acute pancreatitis

Proinflammatory cytokines, such as tumour necrosis factor α (TNFα), play fundamental roles in the pathogenesis of acute pancreatitis (AP). The aim of this study was to determine if polymorphisms in the TNFα gene are associated with AP. Two polymorphisms located in the promoter region (positions −308 and −238) in TNFα gene were determined using polymerase chain reaction- (PCR-) restriction fragment length polymorphism (RFLP) methods in 103 patients with AP and 92 healthy controls. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression analysis adjusted for age, sex, BMI and smoking. The frequencies of TNFα polymorphisms were both similar in patients with mild or severe pancreatitis, so were in pancreatitis patients and in controls. We suggest that both SNPs of TNFα are not genetic risk factor for AP susceptibility (OR = 1.63; 95% CI: 1.13−4.01 for TNFα⁻³⁰⁸ and OR = 0.86; 95% CI: 0.75−1.77 for TNFα⁻²³⁸).

The role of alcohol and smoking in pancreatitis

Chronic alcohol use has been linked to chronic pancreatitis for over a century, but it has not been until the last decade that the role of alcohol in chronic pancreatitis has been elucidated in animals and, only in recent years, in human populations. Although a dose-dependent association between alcohol consumption and chronic pancreatitis may exist, a staistical association has been shown only with the consumption of >or=5 alcoholic drinks per day. Smoking also confers a strong, independent and dose-dependent risk of pancreatitis that may be additive or multiplicative when combined with alcohol. Alcohol increases the risk of acute pancreatitis in several ways and, most importantly, changes the immune response to injury. Genetic factors are also important and further studies are needed to clarify the role of gene-environment interactions in pancreatitis. In humans, aggressive interventional counseling against alcohol use may reduce the frequency of recurrent attacks of disease and smoking cessation may help to slow the progression of acute to chronic pancreatitis.

The management of acute and chronic pancreatitis

Pancreatitis, which is most generally described as any inflammation of the pancreas, is a serious condition that manifests in either acute or chronic forms. Chronic pancreatitis results from irreversible scarring of the pancreas, resulting from prolonged inflammation. Six major etiologies for chronic pancreatitis have been identified: toxic/ metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, and obstruction. The most common symptom associated with chronic pancreatitis is pain localized to the upper-to-middle abdomen, along with food malabsorption, and eventual development of diabetes. Treatment strategies for acute pancreatitis include fasting and short-term intravenous feeding, fluid therapy, and pain management with narcotics for severe pain or nonsteroidal anti-inflammatories for milder cases. Patients with chronic disease and symptoms require further care to address digestive issues and the possible development of diabetes. Dietary restrictions are recommended, along with enzyme replacement and vitamin supplementation. More definitive outcomes may be achieved with surgical or endoscopic methods, depending on the role of the pancreatic ducts in the manifestation of disease.

Systematic review: efficacy and safety of pancreatic enzyme supplements for exocrine pancreatic insufficiency

BACKGROUND

Pancreatic enzyme supplements are standard therapy for fat malabsorption in patients with exocrine pancreatic insufficiency. The FDA determined that published data are insufficient to support the efficacy and safety of these agents.

AIM

To determine if pancreatic enzyme supplements are: (i) superior to placebo for treating fat malabsorption and (ii) superior to other supplements based on randomized cross-over trials.

METHODS

A computer-assisted search of MEDLINE and EMBASE was performed to identify relevant studies. Data extraction on study design, improvement in coefficient of fat absorption, diarrhoea and adverse events using prespecified forms.

RESULTS

A total of 12 manuscripts met inclusion criteria. Most studies (10/12) compared pancreatic enzyme supplements that used different delivery systems, while using similar quantities of enzymes. These studies found no consistent difference in fat malabsorption or gastrointestinal symptoms between different active treatments. Two small placebo-controlled trials (n = 65 patients) demonstrate that pancreatic enzyme supplements are superior to placebo for fat absorption. Data are inadequate to determine if pancreatic enzyme supplements lead to weight gain or improvement in diarrhoea.

CONCLUSIONS

Based on data from randomized cross-over trials, pancreatic enzyme supplements appear to improve fat malabsorption. No specific branded product or specific delivery system is superior for treatment of fat malabsorption in patients with exocrine pancreatic insufficiency.

Etiology of chronic pancreatitis: Has it changed in the last decade?

The evidence from recent surveys on chronic pancreatitis carried out around the world shows that alcohol remains the main factor associated with chronic pancreatitis, even if at a frequency lower than that reported previously. It has further confirmed that heavy alcohol consumption and smoking are independent risk factors for chronic pancreatitis. Autoimmune pancreatitis accounts for 2%-4% of all forms of chronic pancreatitis, but this frequency will probably increase over the next few years. The rise in idiopathic chronic pancreatitis, especially in India, represents a black hole in recently published surveys. Despite the progress made so far regarding the possibility of establishing the hereditary forms of chronic pancreatitis and the recognition of autoimmune pancreatitis, it is possible that we are more inaccurate today than in the past in identifying the factors associated with chronic pancreatitis in our patients.

Inflammation and pancreatic cancer: an evidence-based review

There is a growing awareness that inflammation plays a contributory role in numerous pathologies, including pancreatic carcinogenesis. Inflammatory states are characterized by the creation of reactive oxygen species and the induction of cell cycling for tissue growth and repair. The initiation, promotion and expansion of tumors may be influenced by numerous components that function in the inflammatory response. Recognized risk factors for pancreatic cancer include cigarette smoking, chronic/hereditary pancreatitis, obesity and type II diabetes. Each risk factor is linked by the fact that the inflammatory state significantly drives its pathology. This article will outline how inflammatory mechanisms are etiologically linked to pancreatic adenocarcinoma.