The epidemiology and impact of pancreatic diseases in the United States

Advances in MRI of Chronic Pancreatitis

MRI and MRCP play an essential role in diagnosing CP by imaging pancreatic parenchyma and ducts. Quantitative and semi-quantitative MR imaging offers potential advantages over conventional MR imaging, including simplicity of analysis, quantitative and population-based comparisons, and more direct interpretation of disease progression or response to drug therapy. Using parenchymal imaging techniques may provide quantitative metrics for determining the presence and severity of acinar cell loss and aid in diagnosing CP. Given that the parenchymal changes of CP precede the ductal involvement, there would be a significant benefit from developing a new MRI/MRCP based, more robust diagnostic criteria combining ductal and parenchymal findings.

Correlation between Pancreatic Duct Variation and Related Diseases: An Effective Method Observing the Dual-Energy CT with Low-keV Monoenergetic Images

PURPOSE

Pancreatic duct variation can affect the secretory function of the pancreas. We aimed to explore the pancreatic duct variation, observed using low-keV monoenergetic images [MEI (+)] of dual-energy CT (DECT), and its relationship with related diseases. We further sought to compare pancreatic duct imaging using low-keV MEI (+) of DECT and magnetic resonance cholangiopancreatography (MRCP).

MATERIALS AND METHODS

The DECT and MRCP images of 854 patients were evaluated retrospectively. The 808 patients' pancreatic duct types were classified according to the anatomy and the opening of the pancreatic ducts, and the correlation with related diseases was analyzed. The DECT and MRCP images of 852 patients were graded according to the sharpness of the pancreatic ducts for evaluation.

RESULTS

A higher prevalence of acute pancreatitis (AP), chronic pancreatitis (CP), and duodenal papillary carcinoma (DPC) was observed in the variant group. Of the 27 AP cases in the variant group, 9 patients (33.3%) were Type 3c. Additionally, Type 4a was significantly correlated with AP and CP (p < 0.05). Low-keV MEI (+) of DECT outperformed the MRCP images in the sharpness of the pancreatic ducts in 852 patients.

CONCLUSIONS

Pancreatic duct variation is associated with AP, CP, and DPC. Low-keV MEI (+) DECT is an effective method to observe the pancreatic duct system.

Epidemiology and Characteristics of Chronic Pancreatitis-Do the East and West Meet?

Background and Aims

Previous large studies on the epidemiology and clinical profile of chronic pancreatitis have suggested significant differences in presentation and management in the eastern and western hemispheres. The aim of this systematic review was to compare large multicenter studies across different geographic regions of the world to detect meaningful differences in the presentation and management of this poorly understood disease.

Methods

We identified 237 manuscripts through a comprehensive literature review aiming to identify multicenter studies enrolling more than 200 patients to limit reporting biases. After rigorous screening, 12 studies were included for the final analysis. The Asian studies were included in the eastern cohort, and the European and American studies were included in the western cohort. Reported demographics, risk factors, etiologies, clinical presentation, complications, and management strategies were then compared.

Results

We found similar demographics across both cohorts including age, prevalence among gender, and predominant etiology. Clinical manifestations including pain, pancreatic calcifications, and diabetes were similar between both cohorts although pseudocysts, pancreatic cancer, and strictures were more common in the west. Notably opioids and surgical/endotherapy management were more common in the west as well.

Conclusion

Chronic pancreatitis is a protracted disease affecting predominantly middle-aged people, leading to a decreased quality of life. Chronic pancreatitis now appears to have a fairly similar clinical profile and natural history in the east and west. There is notable variability in management. We hope that international collaboration may identify common targets for research which could lead to significant advances in the understanding and management of chronic pancreatitis.

Temporal Trends and Predictors of Pancreatitis Patients Who Leave Against Medical Advice: A Nationwide Analysis

Background

Acute pancreatitis is the leading gastrointestinal cause of hospital admissions. Our study aims to determine the trends and predictors of discharge against medical advice (AMA).

Methods

We utilized the Nationwide Inpatient Sample (2003 - 2016) to identify patients admitted with pancreatitis. We compared in-hospital complications and determined predictors of discharge AMA using a multivariate logistic regression.

Results

A total of 7,158,894 patients were admitted with pancreatitis. Of those, 199,351 left AMA. Discharge AMA increased over time from 2.3% to 3.2%. Patients who left AMA were more likely to be younger, male, black, and a lower socioeconomic status (SES). They had a greater prevalence of depression, cirrhosis, smoking, drug abuse, and human immunodeficiency virus (HIV) infection. Alcohol use was the most likely etiology of pancreatitis among those leaving AMA. In a multivariate regression, patients more likely to leave AMA included: age 18 - 44, male, and black. Patients with a history of depression, drug abuse, and HIV infection were also more likely to be discharged AMA.

Conclusions

Discharges AMA increased over time. Predictors of AMA include patients who are younger, male, black, lower socioeconomic status, and have a history of depression, HIV infection, alcohol and drug use. Future studies are necessary to examine the reasons for discharge AMA among this population.

30-Day outcomes and predictors of complications after Puestow procedure

BACKGROUND

A lateral pancreaticojejunostomy, or a Puestow procedure, is used in chronic pancreatitis with ductal dilation and pain. The current literature on the Puestow is sparse. This study examines outcomes of Puestow procedures nationwide.

METHODS

Using ACS-NSQIP database, patients who underwent a Puestow procedure from 2010 to 2016 were identified. Univariate analysis and multivariable regression models were used to identify predictors of mortality and morbidities. Covariates included in the regression models were chosen based on clinical significance.

RESULTS

The cohort included 524 patients. The 30-day mortality rate was 1.2%(n = 6). At least one major complication occurred in 19.1% of patients including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical site infections (13.0%). Diabetes, COPD, and transfusions were the strongest predictors of complications.

CONCLUSIONS

The Puestow procedure is an acceptable treatment modality with low rates of morbidity and mortality. Minimizing transfusions and optimizing pulmonary status may improve 30-day outcomes.

Quality of Care Indicators in Patients with Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP.

AIMS

To define quality of care in patients with AP by developing explicit QIs using standardized techniques.

METHODS

We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP.

RESULTS

We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management.

CONCLUSIONS

We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study

Background Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S. Methods We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated. Results There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive. Conclusions Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.

Dietary pomegranate supplement alleviates murine pancreatitis by modulating Nrf2-p21 interaction and controlling apoptosis to survival switch

Dietary supplementation of polyphenol-rich pomegranate extract (POMx) has been shown to have anti-oxidant and anti-inflammatory activities. Here, we evaluate the efficacy of POMx in mitigating pancreatitis in mice and provide a mechanistic outline of the process. Age-matched male Swiss albino mice were injected with Lipopolysaccharide (LPS) and given POMx supplement alone or in combination with LPS. After 4 weeks of treatment histological scoring for pancreatic edema and vacuolization was performed. Serum insulin levels were estimated and the glucose tolerance test (IPGTT) data revealed that POMx reduced inflammation induced hyperglycemia in mice. Analysis of TLR4, IκB expression, and NF-κB nuclear translocation, and concentrations of IL-6 and TNFα showed that POMx is able to modulate the molecular instigators of inflammatory responses. Annexin V assay indicated that POMx protects against inflammation-mediated apoptosis in the pancreas. Expression profile of SAPK/JNK pathway, p53, Bax, Bcl-2 and Caspase-3 validate an apoptotic to survival shift in POMx treatment group. Co-immunoprecipitation studies show that POMx stabilizes p21 and Nrf2 interaction and increases its nuclear translocation. The study also proves that the nuclear fraction of Nrf2 is able to bind to the Bcl-2 promoter and activate an anti-apoptotic program. The findings of our study underline an anti-inflammatory, anti-oxidative and anti-apoptotic role of POMx and provide a mechanistic idea of how POMx confers protection during pancreatitis.

Pancreas regeneration

The pancreas is made from two distinct components: the exocrine pancreas, a reservoir of digestive enzymes, and the endocrine islets, the source of the vital metabolic hormone insulin. Human islets possess limited regenerative ability; loss of islet β-cells in diseases such as type 1 diabetes requires therapeutic intervention. The leading strategy for restoration of β-cell mass is through the generation and transplantation of new β-cells derived from human pluripotent stem cells. Other approaches include stimulating endogenous β-cell proliferation, reprogramming non-β-cells to β-like cells, and harvesting islets from genetically engineered animals. Together these approaches form a rich pipeline of therapeutic development for pancreatic regeneration.

The immune imbalance in the second hit of pancreatitis is independent of IL-17A

BACKGROUND

Severe acute pancreatitis (SAP) is characterised by two distinct clinical phases. Organ dysfunction and death is initially as a result of a systemic inflammatory response syndrome (SIRS). Systemic sepsis from infected pancreatic necrosis characterises the second phase, the so called 'second hit' of acute pancreatitis (AP). An immune imbalance during the second hit is postulated to contribute to the formation of the septic complications that occur in these patients. The pro-inflammatory T-helper (Th) 17 pathway has been shown to be an initiator of early SIRS in AP, however to date its role has not been established in the second hit in AP.

METHODS

Thirty-six patients with mild (n = 16), moderate (n = 10) and severe (n = 10) acute pancreatitis were enrolled. Peripheral blood samples were drawn on days 7, 9, 11 and 13 of illness for analysis of routine clinical markers as well as cytokine analysis. Flow cytometry and a IL-17A ELISA was performed to determine cytokine concentrations.

RESULTS

There were no significant differences between days 7, 9, 11 and 13 for either the mild/moderate or SAP groups for IL-17A (CBA assay or ELISA), IFN-γ, TNF-α, IL-2 or IL-4. For each of the study days, the mean IL-6 and IL-10 concentrations were significantly higher in the SAP group compared to the mild/moderate group. WCC, CRP and PCT were all significantly higher in severe acute pancreatitis over the study days.

CONCLUSIONS

An immune imbalance exists in patients with SAP, however secreted IL-17A is not responsible for the second hit in AP.

The Changing Epidemiology of Acute Pancreatitis Hospitalizations: A Decade of Trends and the Impact of Chronic Pancreatitis

OBJECTIVES

The epidemiological trends contributing to increasing acute pancreatitis (AP) hospitalizations remain unknown. We sought to analyze etiological factors and outcomes of increasing AP hospitalizations.

METHODS

Utilizing the Nationwide Inpatient Sample, retrospective analyses of adult (≥18 years) inpatient admissions with a primary diagnosis of AP (N = 2,016,045) were performed. Patient hospitalizations from 2009 to 2012 were compared with those from 2002 to 2005.

RESULTS

Compared with 2002-2005, there was a 13.2% (P < 0.001) increase in AP admissions in 2009-2012. Multivariate analysis adjusted for "period," patient and hospital demographics, AP etiologies, and disease associations demonstrated an increase in the odds of associated chronic pancreatitis (CP) [2002-2005: odds ratio, (OR), 32.04; 95% confidence interval (CI), 30.51-33.64; 2009-2012: OR, 35.02; 95% CI, 33.94-36.14], whereas associated odds of gallstones (2002-2005: OR, 36.37; 95% CI, 35.32-37.46; 2009-2012: OR, 29.85; 95% CI, 29.09-30.64) decreased. Compared with 2002-2005, the AP-related mortality decreased in 2009-2012 (1.62%-0.79%, P < 0.001) and was lower in AP with associated CP (0.65%-0.26%; P < 0.001) compared with AP without CP.

CONCLUSION

In the preceding decade, AP hospitalizations increased, but associated mortality declined. Associated CP has emerged as a leading contributor for AP-related hospitalizations. Further research is needed to identify novel interventions to prevent disease progression of AP.

Detection of exocrine dysfunction by MRI in patients with early chronic pancreatitis

PURPOSE

To determine if T1-weighted MR signal of the pancreas can be used to detect early CP.

METHODS

A retrospective analysis was performed on 51 suspected CP patients, who had both secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) and an intraductal secretin stimulation test (IDST). There were 29 patients in normal and 22 patients in the low bicarbonate group. Bicarbonate level, total pancreatic juice volume, and excretory flow rate were recorded during IDST. Signal intensity ratio of pancreas (SIR), fat signal fraction, pancreatograms findings, and grade of duodenal filling were recorded on S-MRCP by two blinded radiologists.

RESULTS

There was a significant difference in the signal intensity ratio of the pancreas to spleen (SIR_p/s) between the normal and low bicarbonate groups (p < 0.0001). A significant positive correlation was found between pancreatic fluid bicarbonate level and SIR_p/s (p < 0.0001). SIR_p/s of 1.2 yielded sensitivity of 77% and specificity of 83% for detection of pancreatic exocrine dysfunction (AUC: 0.89).

CONCLUSION

T1-weighted MR signal of the pancreas has a high sensitivity and specificity for the detection of parenchymal abnormalities related to exocrine dysfunction and can therefore be helpful in evaluation of suspected early CP.

Combining in Vitro Diagnostics with in Vivo Imaging for Earlier Detection of Pancreatic Ductal Adenocarcinoma: Challenges and Solutions

Pancreatic ductal adenocarcinoma (PDAC) is the fourth-leading cause of cancer-related death in the United States and is associated with a dismal prognosis, particularly when diagnosed at an advanced stage. Overall survival is significantly improved if PDAC is detected at an early stage prior to the onset of symptoms. At present, there is no suitable screening strategy for the general population. Available diagnostic serum markers are not sensitive or specific enough, and clinically available imaging modalities are inadequate for visualizing early-stage lesions. In this article, the role of currently available blood biomarkers and imaging tests for the early detection of PDAC will be reviewed. Also, the emerging biomarkers and molecularly targeted imaging agents being developed to improve the specificity of current imaging modalities for PDAC will be discussed. A strategy incorporating blood biomarkers and molecularly targeted imaging agents could lead to improved screening and earlier detection of PDAC in the future. (©) RSNA, 2015.

CXCR4 positive cell-derived Pdx1-high/Shh-low cells originated from embryonic stem cells improve the repair of pancreatic injury in mice

Treatments for pancreatic injuries have been significantly improved recently, but full recovery of pancreatic function remains difficult. Embryonic stem cells have great potentialities for self-renewal and multiple differentiations. In this study, we explored an approach to induce the differentiation of pancreatic progenitor cells from embryonic stem cells in vitro. Male mouse embryonic stem cells were cultured by the hanging-drop method to form embryoid bodies. The definitive endoderm marked by CXCR4 in embryoid bodies was sorted by magnetic activated cell sorting and subsequently administrated with b-FGF, exendin-4, and cyclopamine to induce the differentiation of putative pancreatic progenitor cells, which was monitored by Pdx1, and Shh expressions. The putative pancreatic progenitor cells were transplanted into female BALB/c mice with pancreatitis induced by L-Arginine. Male donor cells were located by detecting sex-determining region of Y-chromosome DNA. Definitive endoderm cells (CXCR4(+) cells) were sorted from 5-day embryoid bodies. After 3-day administration with b-FGF, exendin-4, and cyclopamine, Pdx1-high/Shh-low cells were differentiated from CXCR4(+) cells. These cells developed into more amylase-secreted cells in vitro and could specifically reside in the damaged pancreas acinar area in mice with acute pancreatitis to enhance the regeneration. The putative pancreatic progenitor cells (Pdx1-high/Shh-low cells) derived from mouse embryonic stem cells through the administration of b-FGF, exendin-4, and cyclopamine on the CXCR4(+) cells in vitro could improve the regeneration of injured pancreatic acini in vivo.

Effect of the Duration of Chronic Pancreatitis on Pancreas Islet Yield and Metabolic Outcome Following Islet Autotransplantation

BACKGROUND

Total pancreatectomy (TP) with islet autotransplantation (IAT) is a highly selected treatment for severe pain associated with chronic pancreatitis (CP) after exhausting medical and endoscopic therapies. The effect of duration of CP on TP-IAT has not been clarified.

METHODS

Retrospective review of a consecutive cohort undergoing TP-IAT was performed. Patients were classified according to islet dose of <2500 IEQ/kg, 2500 to 5000 IEQ/kg, and >5000 IEQ/kg. Islet yield and metabolic outcomes were compared to disease duration of CP.

RESULTS

A total of 76 CP patients underwent TP-IAT. Longer disease duration was associated with lower islet yield transplanted (Spearman's correlation = -0.24; p = 0.04) for total cohort. Highest absolute value of the coefficient was found in patients with hereditary CP when study subjects were classified by the etiology of CP (correlation = -0.72; p = 0.02). Higher islet yields were significantly associated with better metabolic outcomes (7.6 ± 1.1 vs 6.6 ± 1.1% of HbA1c post-TPIAT in patients with <2500 and >5000 IEQ/kg transplanted, respectively; p = 0.04).

CONCLUSIONS

The duration of CP could affect islet yield and metabolic outcomes. The time since the diagnosis of CP should be considered when selecting patients for islet autotransplantation.

[Chronic pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage of the pancreas. In most cases pain, maldigestion and weight loss are the leading symptoms, which significantly worsen the quality of life. Correct diagnosis and differential diagnosis of chronic pancreatitis and treatment of these patients requires up-to-date and evidence based treatment guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidence. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 123 relevant clinical questions in 11 topics were defined. Evidence was classified according to the UpToDate® grading system. The draft of the guidelines were presented and discussed at the consensus meeting in September 12, 2014. All clinical questions were accepted with total or strong agreement. The present guideline is the first evidence based guideline for chronic pancreatitis in Hungary. This guideline provides very important and helpful data for tuition, everyday practice and proper financing of chronic pancreatitis. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.

SATB1 Promotes Pancreatic Cancer Growth and Invasion Depending on MYC Activation

BACKGROUND

SATB1 plays an important role in human malignant progression, inducing cancer cell proliferation and metastasis by regulating downstream gene expressions. However, little is known about the underlying mechanisms in which SATB1 promotes pancreatic cancer tumorigenesis.

AIMS

To investigate SATB1 expression levels and its biological functions in promoting pancreatic cancer growth and invasion.

METHODS

SATB1 expression levels were detected in seven human pancreatic cancer cell lines and 16 pairs of normal pancreatic/pancreatic cancer tissues using RT-PCR and western blot. SW1990 or Capan-1 cells stably knockdown (shRNA) or transiently knockdown (siRNA) SATB1 cells, and PANC-1 stably overexpressing SATB1 cells were investigated with MTT, EdU assay, flow cytometry, and transwell invasion assay for cell proliferation and invasion activity. The binding of SATB1 to MYC promoter region was examined using reporter assay. Expression of SATB1 in 68 pancreatic cancer samples was studied by immunohistochemical staining and scoring.

RESULTS

SATB1 was overexpressed in pancreatic cancer tissues samples, showing strong correlation with pancreatic cancer invasion depth and tumor staging. SATB1 induced MYC mRNA and protein expression; promoted pancreatic cancer cell growth; increased cell population in S phase; and enhanced pancreatic cancer cell invasion in vitro. On the other hand, SATB1 knockdown showed opposite effects. Furthermore, MYC blocking in SATB1-overexpressing cells attenuated the promotion of pancreatic cancer cell growth and invasion. Our data also indicated that SATB1 bound to specific promoter region of MYC.

CONCLUSIONS

SATB1 is overexpressed in pancreatic cancer, promoting cancer cell proliferation and invasion through the activation of MYC.

Understanding and treatment of chronic pancreatitis

Chronic pancreatitis is characterized by an inflammatory process of the pancreas, which is replaced by fibrosis and progressive destruction. The three major clinical features of chronic pancreatitis are pain, maldigestion, and diabetes. Chronic pancreatitis has a profound impact on social life and employment patterns. In the current issue, different topics highlight experimental models of chronic pancreatitis and bridge findings from recent research to bedside. Although the disease is still difficult to treat the current papers represent useful guidelines on how to approach chronic pancreatitis in the clinical settings with the major aim to improve the patient’s suffering and quality of life.

[New guidelines on chronic pancreatitis : interdisciplinary treatment strategies]

Chronic pancreatitis is a common disorder associated with significant morbidity and mortality. Interdisciplinary consensus guidelines have recently updated the definitions and diagnostic criteria for chronic pancreatitis and provide a critical assessment of therapeutic procedures. Diagnostic imaging relies on endoscopic ultrasound (EUS) as the most sensitive technique, whereas computed tomography (CT) and magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) remain a frequent preoperative requirement. Endoscopic retrograde cholangiopancreatography (ERCP) is now used mostly as a therapeutic procedure except for the differential diagnosis of autoimmune pancreatitis. Complications of chronic pancreatitis, such as pseudocysts, duct stricture and intractable pain can be treated with endoscopic interventions as well as open surgery. In the treatment of pseudocysts endoscopic drainage procedures now prevail while pain treatment has greater long-term effectiveness following surgical procedures. Currently, endocopic as well as surgical treatment of chronic pancreatitis require an ever increasing degree of technical and medical expertise and are provided increasingly more often by interdisciplinary centres. Surgical treatment is superior to interventional therapy regarding the outcome of pain control and duodenum-preserving pancreatic head resection is presently the surgical procedure of choice.

Pancreatic acinar cell nuclear factor κB activation because of bile acid exposure is dependent on calcineurin

Biliary pancreatitis is the most common etiology of acute pancreatitis, accounting for 30-60% of cases. A dominant theory for the development of biliary pancreatitis is the reflux of bile into the pancreatic duct and subsequent exposure to pancreatic acinar cells. Bile acids are known to induce aberrant Ca(2+) signals in acinar cells as well as nuclear translocation of NF-κB. In this study, we examined the role of the downstream Ca(2+) target calcineurin on NF-κB translocation. Freshly isolated mouse acinar cells were infected for 24 h with an adenovirus expressing an NF-κB luciferase reporter. The bile acid taurolithocholic acid-3-sulfate caused NF-κB activation at concentrations (500 μm) that were associated with cell injury. We show that the NF-κB inhibitor Bay 11-7082 (1 μm) blocked translocation and injury. Pretreatment with the Ca(2+) chelator 1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid, the calcineurin inhibitors FK506 and cyclosporine A, or use of acinar cells from calcineurin Aβ-deficient mice each led to reduced NF-κB activation with taurolithocholic acid-3-sulfate. Importantly, these manipulations did not affect LPS-induced NF-κB activation. A critical upstream regulator of NF-κB activation is protein kinase C, which translocates to the membranes of various organelles in the active state. We demonstrate that pharmacologic and genetic inhibition of calcineurin blocks translocation of the PKC-δ isoform. In summary, bile-induced NF-κB activation and acinar cell injury are mediated by calcineurin, and a mechanism for this important early inflammatory response appears to be upstream at the level of PKC translocation.

Chronic pancreatitis--definition, etiology, investigation and treatment

BACKGROUND

Chronic pancreatitis has an annual incidence of 23 per 100 000 population in Germany, where it accounts for about 10 000 hospital admissions per year. The disease shortens the life expectancy of its sufferers by an average of 23%. It most commonly affects men aged 20 to 40.

METHODS

A systematic search for pertinent literature retrieved 19 569 publications, 485 of which were considered in the creation of this guideline, including 67 randomized controlled trials (RCTs). A consensus conference reached agreement on a total of 156 definitions and recommendations.

RESULTS

The identification of genetic risk factors for pancreatitis is now well established. The diagnosis is made mainly with ultrasonography of the pancreas; if the findings are uncertain, further studies can be performed, including endosonography and endosonographically assisted fine-needle puncture for the examination of small foci of disease. Computed tomography and MRI/magnetic resonance cholangiopancreatography are supplementary diagnostic methods. Endoscopic retrograde cholangiopancreatography is now used almost exclusively for treatment, rather than for diagnosis. 30% to 60% of patients develop complications of chronic pancreatitis, including pseudocysts, bile-duct stenosis, or medically intractable pain, which can be treated with an endoscopic or surgical intervention. Patients with steatorrhea, a pathological pancreatic function test, or clinical evidence of malabsorption should be given pancreatin supplementation. The head of the pancreas should be resected if it contains an inflammatory pseudotumor.

CONCLUSION

The management of patients with chronic pancreatitis requires close interdisciplinary collaboration, as it can be treated medically and endoscopically as well as surgically.

Construction of network for protein kinases that play a role in acute pancreatitis

OBJECTIVES

This study aimed to search for protein kinases that play a role in acute pancreatitis and analyze their potential connection with each other.

METHODS

Information of human protein kinases were collected in protein kinase database, and then a systematic search was performed using PubMed for studies addressing the association between these kinases and acute pancreatitis. Gene Ontology Annotations were used to build interactions network for acute pancreatitis-associated protein kinases.

RESULTS

A total of 570 human protein kinases were found, in which 28 kinases play a role in acute pancreatitis. Among the 28 kinases, RIPK1, JAK2, SRC, EGFR, FYN, MET, JAK1, TYK2, and MTOR were annotated in Gene Ontology database. A gene ontology interactions network was built to visualize the common biological process these kinases participated in.

CONCLUSIONS

This study provides observations that protein kinases participate in all the sequential events in the exocrine pancreas in acute pancreatitis and that protein kinases are potential therapeutical target for acute pancreatitis.

Bile acids induce pancreatic acinar cell injury and pancreatitis by activating calcineurin

Biliary pancreatitis is the leading cause of acute pancreatitis in both children and adults. A proposed mechanism is the reflux of bile into the pancreatic duct. Bile acid exposure causes pancreatic acinar cell injury through a sustained rise in cytosolic Ca(2+). Thus, it would be clinically relevant to know the targets of this aberrant Ca(2+) signal. We hypothesized that the Ca(2+)-activated phosphatase calcineurin is such a Ca(2+) target. To examine calcineurin activation, we infected primary acinar cells from mice with an adenovirus expressing the promoter for a downstream calcineurin effector, nuclear factor of activated T-cells (NFAT). The bile acid taurolithocholic acid-3-sulfate (TLCS) was primarily used to examine bile acid responses. TLCS caused calcineurin activation only at concentrations that cause acinar cell injury. The activation of calcineurin by TLCS was abolished by chelating intracellular Ca(2+). Pretreatment with 1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (acetoxymethyl ester) (BAPTA-AM) or the three specific calcineurin inhibitors FK506, cyclosporine A, or calcineurin inhibitory peptide prevented bile acid-induced acinar cell injury as measured by lactate dehydrogenase leakage and propidium iodide uptake. The calcineurin inhibitors reduced the intra-acinar activation of chymotrypsinogen within 30 min of TLCS administration, and they also prevented NF-κB activation. In vivo, mice that received FK506 or were deficient in the calcineurin isoform Aβ (CnAβ) subunit had reduced pancreatitis severity after infusion of TLCS or taurocholic acid into the pancreatic duct. In summary, we demonstrate that acinar cell calcineurin is activated in response to Ca(2+) generated by bile acid exposure, bile acid-induced pancreatic injury is dependent on calcineurin activation, and calcineurin inhibitors may provide an adjunctive therapy for biliary pancreatitis.

Diarrhoea due to pancreatic diseases

The exocrine pancreas provides essential digestive enzymes necessary for the proper breakdown and absorption of ingested food in humans. Any disruption of this process can lead to malabsorption and resultant diarrhoea. Typically, disruption of over 90 percent of the pancreatic parenchyma is needed to result in diarrhoea. This disruption can result from widespread pancreatic necrosis in acute pancreatitis, fibrotic replacement of the parenchyma as seen in chronic pancreatitis and in patients with pancreatic cancer where normal tissue is replaced by tumour and/or the pancreatic duct becomes obstructed. Several uncommon tumours of the pancreas can also cause diarrhoea through the secretion of hormones. This article will explore each of these diseases, including the pathogenesis and treatment.

Ryanodine receptors contribute to bile acid-induced pathological calcium signaling and pancreatitis in mice

Biliary pancreatitis is the most common etiology for acute pancreatitis, yet its pathophysiological mechanism remains unclear. Ca(2+) signals generated within the pancreatic acinar cell initiate the early phase of pancreatitis, and bile acids can elicit anomalous acinar cell intracellular Ca(2+) release. We previously demonstrated that Ca(2+) released via the intracellular Ca(2+) channel, the ryanodine receptor (RyR), contributes to the aberrant Ca(2+) signal. In this study, we examined whether RyR inhibition protects against pathological Ca(2+) signals, acinar cell injury, and pancreatitis from bile acid exposure. The bile acid tauro-lithocholic acid-3-sulfate (TLCS) induced intracellular Ca(2+) oscillations at 50 μM and a peak-plateau signal at 500 μM, and only the latter induced acinar cell injury, as determined by lactate dehydrogenase (LDH) leakage. Pretreatment with the RyR inhibitors dantrolene or ryanodine converted the peak-plateau signal to a mostly oscillatory pattern (P < 0.05). They also reduced acinar cell LDH leakage, basolateral blebbing, and propidium iodide uptake (P < 0.05). In vivo, a single dose of dantrolene (5 mg/kg), given either 1 h before or 2 h after intraductal TLCS infusion, reduced the severity of pancreatitis down to the level of the control (P < 0.05). These results suggest that the severity of biliary pancreatitis may be ameliorated by the clinical use of RyR inhibitors.

Sivelestat mitigates severe acute pancreatitis in rats

AIM: To evaluate the therapeutic effect of sivelestat on severe acute pancreatitis (SAP) in a rat model by measuring the levels of serum neutrophil elastase (NE) and interleukin-6 (IL-6) and examining pancreatic pathological changes.

METHODS: SAP was induced in rats by retrograde injection of 5% sodium taurocholate into the biliopancreatic duct. Sivelestat was instilled continuously with an infusion pump in rats in the treatment group. Pancreatic pathological changes were evaluated by HE staining. The levels of serum NE and IL-6 were measured by ELISA. The level of serum amylase was measured using a biochemical analyzer.

RESULTS: The level of serum amylase was higher and pancreatic pathological changes were obvious in SAP rats compared to control rats. The levels of serum amylase, NE and IL-6 at various time points were significantly lower in treated rats than in SAP rats (3 h: 5636.22 ± 713.57 vs 5835.75 ± 681.52, 16.99 ± 3.28 vs 22.93 ± 4.74, 181.86 ± 36.56 vs 281.82 ± 30.79; 6 h: 5743.44 ± 624.93 vs 6253.66 ± 533.99, 23.63 ± 4.47 vs 31.81 ± 4.69, 184.15 ± 28.56 vs 319.39 ± 21.73; 12 h: 7098.93 ± 698.42 vs 8420.74 ± 779.72, 24.46 ± 5.02 vs 39.21 ± 6.23, 192.52 ± 37.65 vs 354.21 ± 23.72, all P < 0.05). The score of pancreatic pathological changes was significantly lower in treated rats than in SAP rats (P < 0.05). Serum levels of NE and IL-6 had a positive correlation with the score of pancreatic pathology.

CONCLUSION: Sivelestat could reduce serum levels of IL-6 and NE, mitigate pancreatic injury, and inhibit inflammatory reaction in rats with SAP.

Metformin inhibits cell proliferation, migration and invasion by attenuating CSC function mediated by deregulating miRNAs in pancreatic cancer cells

Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States, which is, in part, due to intrinsic (de novo) and extrinsic (acquired) resistance to conventional therapeutics, suggesting that innovative treatment strategies are required for overcoming therapeutic resistance to improve overall survival of patients. Oral administration of metformin in patients with diabetes mellitus has been reported to be associated with reduced risk of pancreatic cancer and that metformin has been reported to kill cancer stem cells (CSC); however, the exact molecular mechanism(s) has not been fully elucidated. In the current study, we examined the effect of metformin on cell proliferation, cell migration and invasion, and self-renewal capacity of CSCs and further assessed the expression of CSC marker genes and microRNAs (miRNA) in human pancreatic cancer cells. We found that metformin significantly decreased cell survival, clonogenicity, wound-healing capacity, sphere-forming capacity (pancreatospheres), and increased disintegration of pancreatospheres in both gemcitabine-sensitive and gemcitabine-resistant pancreatic cancer cells. Metformin also decreased the expression of CSC markers,CD44, EpCAM,EZH2, Notch-1, Nanog and Oct4, and caused reexpression of miRNAs (let-7a,let-7b, miR-26a, miR-101, miR-200b, and miR-200c) that are typically lost in pancreatic cancer and especially in pancreatospheres. We also found that reexpression of miR-26a by transfection led to decreased expression of EZH2 and EpCAM in pancreatic cancer cells. These results clearly suggest that the biologic effects of metformin are mediated through reexpression of miRNAs and decreased expression of CSC-specific genes, suggesting that metformin could be useful for overcoming therapeutic resistance of pancreatic cancer cells.

Current treatment options for chronic pancreatitis

Chronic pancreatitis (CP) is characterized by progressive and ultimately irreversible pancreatic injury. Alcohol abuse is the most common cause of CP in the Western world. As the pathophysiology of this disorder is better understood, it is probable that the treatment will be more successful. Therapeutic efforts for CP are focused on the treatment of maldigestion, pain, and diabetes. Dosage and timing of enteric-coated pancreatic enzymes are important issues in the treatment of malabsorption due to CP. Non-enteric-coated enzyme preparations along with acid suppression (histamine-2 blockers or proton-pump inhibitors) are of limited to modest effectiveness in treating pain caused by CP but are worth a trial in patients with less advanced disease. Extracorporeal shock wave lithotripsy (ESWL) of calcified stones is sometimes needed to achieve stone fragmentation before endoscopic removal. The role of ESWL alone in relieving calcified CP pain needs further study. Endoscopic therapy is aimed at decompressing the obstructed pancreatic duct and removal of pancreatic stone and is associated with pain relief in many patients. The role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with CP whose pain has not responded to other modalities. Radiation therapy to the whole pancreas for CP pain relief is a revived treatment option that needs further study to confirm the safety and efficacy. Total pancreatectomy followed by autologous islet cell autotransplantation appears to be a potential therapeutic approach but should be considered as the last option in patients with refractory pain who have failed conventional medical, endoscopic, and surgical options.

Liver metastases of pancreatic cancer: role of repetitive transarterial chemoembolization (TACE) on tumor response and survival

OBJECTIVE

To evaluate the effect of chemoembolization on pancreatic cancer liver metastases.

METHOD

Thirty-two patients with pancreatic cancer liver metastases retrospectively underwent chemoembolization (4- to 8-week intervals). Size-based evaluation (response evaluation criteria in solid tumors [RECIST]) and survival indexes were assessed overall and for sex and number of lesions.

RESULTS

Of the patients, 71.87% showed stable disease, 9.37% partial response (PR) and 18.75% progressive disease (PD). Survival rate for 1, 3, and 5 years from first TACE was 60%, 25%, and 11%, respectively. Median survival time was 16 months and for stable disease group was 20 months. Progression-free survival for 6 months and 1, 3, and 5 years was 84%, 57.3%, 20%, and 10%, respectively. There was significant difference between men and women in response. Survival rates for 1 and 5 years for the men were 80% and 14% and for the women were 47% and 0%. There was no significant difference between oligonodular liver lesion (n < 5) and multinodular (n > 5) groups. Survival rates for 1 and 5 years for oligonodular were 84% and 14%, and for multinodular was 50% and 0%.

CONCLUSION

Repetitive TACE resulted in a relevant response for the control of liver metastases of pancreatic cancer with respectable median survival time. Interestingly, the number of lesions, statistically, was not an effective factor.

The complexities of obesity and diabetes with the development and progression of pancreatic cancer

Pancreatic cancer (PC) is one of the most lethal malignant diseases with the worst prognosis. It is ranked as the fourth leading cause of cancer-related deaths in the United States. Many risk factors have been associated with PC. Interestingly, large numbers of epidemiological studies suggest that obesity and diabetes, especially type-2 diabetes, are positively associated with increased risk of PC. Similarly, these chronic diseases (obesity, diabetes, and cancer) are also a major public health concern. In the U.S. population, 50 percent are overweight, 30 percent are medically obese, and 10 percent have diabetes mellitus (DM). Therefore, obesity and DM have been considered as potential risk factors for cancers; however, the focus of this article is restricted to PC. Although the mechanisms responsible for the development of these chronic diseases leading to the development of PC are not fully understood, the biological importance of the activation of insulin, insulin like growth factor-1 (IGF-1) and its receptor (IGF-1R) signaling pathways in insulin resistance mechanism and subsequent induction of compensatory hyperinsulinemia has been proposed. Therefore, targeting insulin/IGF-1 signaling with anti-diabetic drugs for lowering blood insulin levels and reversal of insulin resistance could be useful strategy for the prevention and/or treatment of PC. A large number of studies have demonstrated that the administration of anti-diabetic drugs such as metformin and thiazolidinediones (TZD) class of PPAR-γ agonists decreases the risk of cancers, suggesting that these agents might be useful anti-tumor agents for the treatment of PC. In this review article, we will discuss the potential roles of metformin and TZD anti-diabetic drugs as anti-tumor agents in the context of PC and will further discuss the complexities and the possible roles of microRNAs (miRNAs) in the pathogenesis of obesity, diabetes, and PC.

Ethanol enhances carbachol-induced protease activation and accelerates Ca2+ waves in isolated rat pancreatic acini

Alcohol abuse is a leading cause of pancreatitis, accounting for 30% of acute cases and 70-90% of chronic cases, yet the mechanisms leading to alcohol-associated pancreatic injury are unclear. An early and critical feature of pancreatitis is the aberrant signaling of Ca(2+) within the pancreatic acinar cell. An important conductor of this Ca(2+) is the basolaterally localized, intracellular Ca(2+) channel ryanodine receptor (RYR). In this study, we examined the effect of ethanol on mediating both pathologic intra-acinar protease activation, a precursor to pancreatitis, as well as RYR Ca(2+) signals. We hypothesized that ethanol sensitizes the acinar cell to protease activation by modulating RYR Ca(2+). Acinar cells were freshly isolated from rat, pretreated with ethanol, and stimulated with the muscarinic agonist carbachol (1 μM). Ethanol caused a doubling in the carbachol-induced activation of the proteases trypsin and chymotrypsin (p < 0.02). The RYR inhibitor dantrolene abrogated the enhancement of trypsin and chymotrypsin activity by ethanol (p < 0.005 for both proteases). Further, ethanol accelerated the speed of the apical to basolateral Ca(2+) wave from 9 to 18 μm/s (p < 0.0005; n = 18-22 cells/group); an increase in Ca(2+) wave speed was also observed with a change from physiologic concentrations of carbachol (1 μM) to a supraphysiologic concentration (1 mM) that leads to protease activation. Dantrolene abrogated the ethanol-induced acceleration of wave speed (p < 0.05; n = 10-16 cells/group). Our results suggest that the enhancement of pathologic protease activation by ethanol is dependent on the RYR and that a novel mechanism for this enhancement may involve RYR-mediated acceleration of Ca(2+) waves.

Incidence, prevalence, etiology, and prognosis of first-time chronic pancreatitis in young patients: a nationwide cohort study

BACKGROUND/AIMS

Publications on etiology of chronic pancreatitis (CP) are infrequent. Etiologies today encompass genetic disorders. We wanted to describe etiologies of today and identify patients with genetic disorders like hereditary pancreatitis (HP), mutations in Serine Protease Inhibitor Kazal type1 (SPINK1), and the Cystic Fibrosis Transmembrane Conductance Regulator gene (CFTR) among patients formerly considered to have idiopathic CP.

METHODS

Data on patients diagnosed with first-time CP < 30 years of age in Denmark identified in the Danish National Registry of Patients were retrieved. Patients previously considered to have idiopathic pancreatitis were offered genetic counseling and evaluation for HP, SPINK1, and CFTR mutations.

RESULTS

In the period 1980-2004, 580 patients < 30 years of age presented with CP, the standardized prevalence ratio of CP increased from 11.7 per 100,000 person years in 1980-1984 to 17.0 per 100,000 in 2000-2004 (p < 0.001). The odds ratio (OR) having gallstone-related CP increased in the latter time period, especially in women, that of alcohol-induced CP decreased over time. OR having idiopathic CP increased in the latter period; 50% of patients with idiopathic pancreatitis accepted genetic reevaluation; 28 patients had a genetic mutation that totally or partly could explain their pancreatitis, nine of these had two, and 11 patients had HP.

CONCLUSION

The prevalence of CP, especially in women, increased over time. Genetic causes that partly or totally could explain the CP were found in 54.90% (95% CI (40.45-68.62)) of those with idiopathic CP, as a minimum estimation 1.9% (95% CI (1.00-3.47)) of the total cohort had HP.

Molecular and cellular mechanisms of pancreatic injury

PURPOSE OF REVIEW

This review focuses on studies from the past year that highlight molecular and cellular mechanisms of pancreatic injury arising from acute and chronic pancreatitis.

RECENT FINDINGS

Factors that induce or ameliorate injury as well as cellular pathways involved have been examined. Causative or sensitizing factors include refluxed bile acids, hypercalcemia, ethanol, hypertriglyceridemia, and acidosis. In addition, the diabetes drug exendin-4 has been associated with pancreatitis, whereas other drugs may reduce pancreatic injury. The intracellular events that influence disease severity are better understood. Cathepsin-L promotes injury through an antiapoptotic effect, rather than by trypsinogen activation. In addition, specific trypsinogen mutations lead to trypsinogen misfolding, endoplasmic reticulum stress, and injury. Endogenous trypsin inhibitors and upregulation of proteins including Bcl-2, fibroblast growth factor 21, and activated protein C can reduce injury. Immune cells, however, have been shown to increase injury via an antiapoptotic effect.

SUMMARY

The current findings are critical to understanding how causative factors initiate downstream cellular events resulting in pancreatic injury. Such knowledge will aid in the development of targeted treatments for pancreatitis. This review will first discuss factors influencing pancreatic injury, and then conclude with studies detailing the cellular mechanisms involved.

A comparison of presentation and management trends in acute pancreatitis between infants/toddlers and older children

OBJECTIVES

Acute pancreatitis is a necroinflammatory disease that leads to 210,000 hospitalizations in the United States annually. Recent reports suggest that there may be important differences in clinical features between infants/toddlers and older children. Thus, in this study we make a direct comparison between the pediatric age groups in presentation and management trends of acute pancreatitis.

PATIENTS AND METHODS

We examined all children (ages 0 to 20 years) admitted to Yale-New Haven Children's Hospital with pancreatitis between 1994 and 2007.

RESULTS

Two hundred seventy-one cases met inclusion criteria for acute pancreatitis. Infants and toddlers manifested fewer signs and symptoms of abdominal pain, epigastric tenderness, and nausea compared with older children (43% vs 93%; 57% vs 90%; and 29% vs 76%, respectively; P < 0.05 for all comparisons). They were more likely to be diagnosed by serum lipase than by amylase and to undergo radiographic evaluation (P < 0.05). They had a longer hospital stay (19.5 vs 4 days; P < 0.05) and were less likely to be directly transitioned to oral nutrition (14% vs 71%; P < 0.05).

CONCLUSIONS

Infants and toddlers with acute pancreatitis present with fewer classical symptoms and are managed differently from older children. We believe these data will be helpful in evaluating and understanding treatment practices in this age group.

The difficulty in predicting outcome in acute pancreatitis

Current methods to predict the development of severe pancreatitis are complex, cumbersome, and inaccurate. Simpler scoring systems like the one studied in this issue of the Journal are an improvement in simplicity but not in accuracy. More sophisticated approaches are needed for more accurate prediction, which would allow improved triage and management of these patients.

Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients

BACKGROUND

No data on chronic pancreatitis in Italy are available yet.

AIM

To evaluate demographic, clinical, diagnostic and therapeutic aspects in patients suffering from chronic pancreatitis.

PATIENTS AND METHODS

Eligible patients were prospectively enrolled from 2000 to 2005. Information concerning demographic data, lifestyle risk factors, family and clinical history, associated factors (alcohol, autoimmunity, cystic dystrophy of the duodenal wall, obstruction, genetic mutations) concomitant diseases, diagnostic findings, and pharmacological, endoscopic and surgical therapy were gathered.

RESULTS

893 patients (74% males, mean age 53.7+/-15.2 years) were evaluated. 519/859 patients (60%) were drinkers and 555/840 (66%) were smokers. A strong positive correlation between drinking and cigarette consumption (R=0.53; p<0.0001) was found. Heavy alcohol consumption (>80g of alcohol/day for more than 5 years) was considered the most important risk factor in 300 patients (34%), obstruction in 238 (27%), alcohol and obstruction in 82 (9%), autoimmunity in 34 (4%), cystic dystrophy of the duodenal wall/groove pancreatitis in 55 (6%), gene mutations in 36 (4%), and none (idiopathic) in 148 (17%). Bile stones were diagnosed in 287 patients (33%) and cholecystectomy was performed in 329 patients (38%). Pancreatic calcifications were diagnosed in 547/879 patients (62%). Pancreatic surgery was performed in 273 patients (31%). Endoscopic sphincterotomy was performed in 371 patients (42%). Exocrine and endocrine insufficiency were found, respectively, in 373/834 (45%) and 275/885 patients (31%).

CONCLUSIONS

An unexpected low frequency of alcohol abuse and new emerging associated risk factors for chronic pancreatitis were observed in Italy.

Mechanisms of primary operative failure and results of remedial operation in patients with chronic pancreatitis

INTRODUCTION

Resection and drainage operations achieve long-term pain relief in approximately 85% of patients with chronic pancreatitis (CP). In patients who develop recurrent pain, a few data exist on the long-term results of remedial operations.

MATERIALS AND METHODS

Over an 18-year period (1988-2006), 316 patients with CP had primary resection or drainage operations at our institution. Thirty-nine developed recurrent pain and were treated by a remedial resection or drainage operation. Patient demographics, time to symptom recurrence, radiographic anatomic abnormalities, type of remedial operation, postoperative morbidity, and long-term outcomes were analyzed.

RESULTS

Thirty-nine patients, 56% female with a mean age of 41 years (range 16-61 years) had either remedial resection: total pancreatectomy (TP; N = 8), pancreaticoduodenectomy (PD; N = 6), distal pancreatectomy (DP; N = 5), or drainage operation: duodenal preserving pancreatic head resection (DPPHR; N = 8), revision of pancreaticojejunostomy (N = 12). TP achieved pain relief in 88% with postoperative complications greater than or equal to grade III in 38% and diabetes in 100%. Drainage operations achieved pain relief in 67% of patients with postoperative complications greater than or equal to grade III in only 8%. Partial parenchymal resections (DPPHR, PD, DP) as a remedial procedure achieved pain relief <50% of the time.

CONCLUSION

Drainage procedures, when anatomically feasible, are the preferred reoperation to treat patients with recurrent pain after failed primary operation for chronic pancreatitis.

Critical roles for macrophages in islet angiogenesis and maintenance during pancreatic degeneration

OBJECTIVE

Chronic pancreatitis, characterized by pancreatic exocrine tissue destruction with initial maintenance of islets, eventually leads to insulin-dependent diabetes in most patients. Mice deficient for the transcription factors E2F1 and E2F2 suffer from a chronic pancreatitis-like syndrome and become diabetic. Surprisingly, onset of diabetes can be prevented through bone marrow transplantation. The goal of the described studies was to determine the hematopoietic cell type responsible for maintaining islets and the associated mechanism of this protection.

RESEARCH DESIGN AND METHODS

Mouse models of acute and chronic pancreatitis, together with mice genetically deficient for macrophage production, were used to determine roles for macrophages in islet angiogenesis and maintenance.

RESULTS

We demonstrate that macrophages are essential for preventing endocrine cell loss and diabetes. Macrophages expressing matrix metalloproteinase-9 migrate to the deteriorating pancreas. E2f1/E2f2 mutant mice transplanted with wild-type, but not macrophage-deficient colony stimulating factor 1 receptor mutant (Csf1r(-/-)), bone marrow exhibit increased angiogenesis and proliferation within islets, coinciding with increased islet mass. A similar macrophage dependency for islet and islet vasculature maintenance is observed during caerulein-induced pancreatitis.

CONCLUSIONS

These findings demonstrate that macrophages promote islet angiogenesis and protect against islet loss during exocrine degeneration, could explain why most patients with chronic pancreatitis develop diabetes, and suggest an avenue for preventing pancreatitis-associated diabetes.

The pancreas misled: signals to pancreatitis

Acute pancreatitis is an increasingly common and sometimes severe disease for which there is little specific therapy. Chronic pancreatitis is a common and grossly debilitating sequel that is largely irreversible, whatever treatment is adopted. In the face of these burdens, the absence of specific treatments is a spur to research. The acinar cell is the primary target of injury from alcohol metabolites, bile, hyperlipidaemia, hyperstimulation and other causes. These induce abnormal, prolonged, global, cytosolic calcium signals, the prevention of which also prevents premature digestive enzyme activation, cytokine expression, vacuole formation and acinar cell necrosis. Such agents increase calcium entry through the plasma membrane and/or increase calcium release from intracellular stores, shown to result from effects on calcium channels and calcium pumps, or their energy supply. A multitude of signalling mechanisms are activated, diverted or disrupted, including secretory mechanisms, lysosomal regulators, inflammatory mediators, cell survival and cell death pathways, together with or separately from calcium. While recent discoveries have increased insight and suggest prophylaxis or treatment targets, more work is required to define the mechanisms and interactions of cell signalling pathways in the pathogenesis of pancreatitis.

Changing incidence of acute pancreatitis: 10-year experience at the Royal Children's Hospital, Melbourne

BACKGROUND AND AIM

The aim of this study was to assess the incidence and etiology of acute pancreatitis at a major pediatric referral center in Australia.

METHODS

A 10-year retrospective audit was conducted at The Royal Children's Hospital, Melbourne, Australia. All patients from 1993 and 2002 with a serum lipase level greater than three times the upper reference range and a history consistent with acute pancreatitis were included.

RESULTS

During the 10-year period, 279 confirmed cases of acute pancreatitis were identified. The median age at presentation was 10 years (range, 0.2-15.9). In 209 (74.9%) patients, a likely cause of acute pancreatitis was found, including trauma (36.3%), systemic disease (22.2%), metabolic (5.8%), biliary (5.4%), drugs (3.2%), or viral illness (2.2%). In the remaining 70 (25.1%) cases, the pancreatitis was deemed idiopathic. Comparing data from 1993 to 1997 with data from 1998-2002, there was a significant increase in the annual incidence of pancreatitis (24.6 +/- 2.3 vs 31.2 +/- 6 cases per year; P = 0.04). A linear regression analysis showed a strong association between the incidence and the year of diagnosis (r(2) = 0.5775, P = 0.01). This increase was mainly due to a significant rise in idiopathic disease (r(2) = 0.83, P = 0.0002) and systemic disease (r(2) = 0.41, P = 0.048), whereas the incidence of other causes of acute pancreatitis remained unchanged.

CONCLUSION

The incidence of acute pancreatitis in children has increased significantly over the past decade. The increase was greatest in children with idiopathic pancreatitis. It remains unclear whether this reflects a true incidence increase or improved clinical awareness.

Target therapy using a small molecule inhibitor against angiogenic receptors in pancreatic cancer

PURPOSE

PD173074, a small molecule inhibitor of VEGF-RII and FGF-RI, targets neoangiogenesis and mitogenesis. This study aimed to analyze a single-compound-driven inhibition of FGF and VEGF receptors in pancreatic cancer.

EXPERIMENTAL DESIGN

RT-PCR and Western blots were performed to quantify protein expression and phosphorylation. Anchorage dependent and independent growth assays were used to study cell growth. With flow cytometry, cell cycle analysis and apoptosis were studied. In vivo HPAF-II and MIA PaCa-2 cells were xenografted. Animals were treated daily for 10 weeks. Immunohistochemistry was used to quantify microvessel density and apoptosis.

RESULTS

Highest levels of FGF-RI were detectable in MIA PaCa-2 cells, lowest in HPAF-II cells. PD173074 inhibited cell growth most prominently in cells expressing high levels of FGF-RI. Cell cycle progression was inhibited by blocking transition in the G(0)/G(1) phase, and consequently, apoptosis was increased. In vivo significant inhibition of orthotopic tumor growth was achieved by a combination effect of inhibition of mitogenesis, induction of apoptosis, and reduction of angiogenesis in PD173074-treated animals.

CONCLUSIONS

These data highlight VEGF-RII and FGF-RI as therapeutic targets and suggest a potential role for the combined use of tyrosine kinase inhibitors in the management of inoperable pancreatic cancer patients.

Peptide YY Reverses TNF-α Induced Transcription Factor Binding of Interferon Regulatory Factor-1 and p53 in Pancreatic Acinar Cells

BACKGROUND

Cytokine activation in the pancreatitis induces local and systemic cellular damage. Transcription factors interferon regulatory factor-1 (IRF-1) and the tumor suppressor gene p53 collaborate to enhance p21 related cell cycle regulation during pathological disease progression. However, little is known about their role in the pancreas after cytokine challenge. Our laboratory has previously shown that TNF-alpha induces the binding of many transcription factors, including NF-kappa B, and treatment with the gut hormone, Peptide YY (PYY), ameliorates the effects. We hypothesized that TNF-alpha would induce IRF-1 and p53 protein binding in pancreatic acinar cells and that PYY would attenuate the effect.

MATERIALS AND METHODS

Rat pancreatic acinar AR42J cells were treated with rat recombinant TNF-alpha (200 ng/ml). To verify that our model was inducing pancreatitis, alpha-amylase activity was measured in the cell culture supernatant by fluorescence spectroscopy. PYY [3-36] was added at 500 pM 30 min post-TNF treatment; cells were harvested at 2 h for extraction of nuclear protein. Transcription factor binding of IRF-1 and p53 were determined by protein/DNA array analysis using chemiluminescence detection, and relative spot densities were measured by densitometry. A two-fold increase or decrease in density was considered significant.

RESULTS

Amylase enzyme activity was significantly (P < 0.05) elevated in the TNF-alpha-treated cells by 2 h. Protein/DNA array analysis revealed significant up-regulation of both IRF-1 and p53 protein in nuclear extracts. Induction by TNF-alpha increased IRF-1 protein binding 3.5-fold, while binding levels of p53 protein increased six-fold. The addition of PYY to TNF-treated cells reduced IRF-1 and p53 binding to control levels.

CONCLUSIONS

We have shown for the first time that short-term exposure to TNF-alpha induces the binding activity of transcription factors IRF-1 and p53 in rat pancreatic acinar cells, and that addition of PYY reduces it. Regulation of transcription factor activity by PYY may have therapeutic potential in altering the progression of pancreatitis.

Association of childhood socioeconomic position with cause-specific mortality in a prospective record linkage study of 1,839,384 individuals

Previous studies have lacked sufficient power to assess associations between early-life socioeconomic position and adult cause-specific mortality. The authors examined associations of parental social class at age 0-16 years with mortality among 1,824,064 Swedes born in 1944-1960. Females and males from manual compared with nonmanual childhood social classes were more likely to die from smoking-related cancers, stomach cancer, respiratory disease, cardiovascular disease, and diabetes. Males from manual compared with nonmanual social classes were more likely to die from unintentional injury, homicide, and alcoholic cirrhosis. The association with stomach cancer was little affected by adjustment for parental later-life and own adult social class or education. For other outcomes, educational attainment resulted in greater attenuation of associations than did adjustment for adult social class. Early-life social class was not related to suicide or to melanoma, colon, breast, brain, or lymphatic cancers or to leukemia. With the exception of stomach cancer, caused by Helicobacter pylori infection acquired in childhood, poorer social class in early life was associated with diseases largely caused by behavioral risk factors such as smoking, physical inactivity, and an unhealthy diet. Educational attainment may be important in reducing the health inequalities associated with early-life disadvantage.

Chronic pancreatitis

PURPOSE OF REVIEW

As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. Topics recently reviewed were truncated to accommodate a surge in publications on clinical aspects of chronic pancreatitis, which contained new observations or insights into new or old concepts.

RECENT FINDINGS

Cystic fibrosis carriers have been found to be at increased risk of pancreatitis. Autoimmune pancreatitis may belong to a multiorgan immunoglobulin G4-related autoimmune disease, and the natural history of chronic pancreatitis differs among the etiologies. Diffusion-weighted magnetic resonance imaging improves upon previous methodologies for diagnosing reduced pancreatic exocrine secretion, and fecal elastase-1 has been found to be a poor test for diagnosing pancreatic malabsorption. Visceral hyperalgesia or heightened central pain perception may contribute to pain in chronic pancreatitis. Instruments are evolving to assess quality of life in chronic pancreatitis, and fibrolytic agents have been found to have therapeutic promise.

SUMMARY

Researchers this past year have further characterized genetic, molecular and clinical aspects of chronic pancreatitis. Advancing the understanding of fibrogenesis, mechanisms of exocrine insufficiency, calcification, and pain and continuing development/modification of diagnostic tests should lead to improved prevention, detection and treatment of the condition. More accurate quantification of outcomes is critical for translating potential therapies from bench to bedside.