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Gómez Pérez A, Aparicio Serrano A, Serrano Ruiz FJ. Etiological diagnosis of recurrent acute pancreatitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38685884 DOI: 10.17235/reed.2024.10404/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Acute pancreatitis is the leading cause of inpatient care among gastrointestinal conditions. Despite early intervention, one-third of patients experience recurrent acute pancreatitis (RAP). A comprehensive diagnostic approach is warranted to identify and treat underlying factors in order to prevent recurrence. RAP is most frequent among men aged 30-40, smokers, and in those with excessive alcohol consumption. To identify the etiology is paramount to stratify patients according to their individual risk of RAP and for predicting an eventual evolution to chronic pancreatitis. Although the initial management of acute pancreatitis is widely homogeneous according to established guidelines, there are no defined protocols to investigate RAP. In the present editorial article we propose a structured algorithm with precise recommendations to investigate the etiology RAP as part of routine clinical practice. Although there are relevant knowledge gaps in this disease, we believe that our guidance would contribute for a more homogenous diagnostic approach of RAP in clinical practice.
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Affiliation(s)
- Alberto Gómez Pérez
- Clinical Management Unit of Digestive Diseases, Hospital Universitario Reina Sofía, España
| | - Ana Aparicio Serrano
- Clinical Management Unit of Digestive Diseases, Hospital Universitario Reina Sofía, España
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2
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Abstract
AbstractInterventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.
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Affiliation(s)
- Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S. Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Tepox-Padrón A, Bernal-Mendez RA, Duarte-Medrano G, Romano-Munive AF, Mairena-Valle M, Ramírez-Luna MÁ, Marroquin-Reyes JD, Uscanga L, Chan C, Domínguez-Rosado I, Hernandez-Calleros J, Pelaez-Luna M, Tellez-Avila F. Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000538. [PMID: 33402380 PMCID: PMC7786795 DOI: 10.1136/bmjgast-2020-000538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/19/2022] Open
Abstract
Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP.
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Affiliation(s)
- Alejandra Tepox-Padrón
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Rafael Ambrosio Bernal-Mendez
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Gilberto Duarte-Medrano
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Adriana Fabiola Romano-Munive
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Milton Mairena-Valle
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Miguel Ángel Ramírez-Luna
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Jose Daniel Marroquin-Reyes
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Luis Uscanga
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Carlos Chan
- Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Ismael Domínguez-Rosado
- Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
| | - Jorge Hernandez-Calleros
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Mario Pelaez-Luna
- Gastroenterology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Tlalpan, Mexico
| | - Felix Tellez-Avila
- Gastrointestinal Endoscopy Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
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Valverde-López F, Ortega-Suazo EJ, Wilcox CM, Fernandez-Cano MC, Martínez-Cara JG, Redondo-Cerezo E. Endoscopic ultrasound as a diagnostic and predictive tool in idiopathic acute pancreatitis. Ann Gastroenterol 2020; 33:305-312. [PMID: 32382235 PMCID: PMC7196619 DOI: 10.20524/aog.2020.0464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/01/2020] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic ultrasound (EUS) is useful in the diagnostic workup of idiopathic acute pancreatitis but its role as a predictor of recurrence has not been thoroughly assessed. Our aim was to study the performance of EUS in idiopathic acute pancreatitis, its impact on the natural history of the disease, and the factors related to recurrence. Methods Patients with idiopathic acute pancreatitis referred to our endoscopy unit were enrolled and followed, with assessment of the performance of endoscopic retrograde cholangiopancreatography (ERCP), cholecystectomy, and the incidence of recurrence. EUS findings and recurrence rates were compared between patients with a first episode or recurrent attacks and in patients with previous cholecystectomy versus those with gallbladder in situ. Results One hundred six patients were included (mean follow up: 53.59±27.79 months). Biliary disease related to stones was the most common finding on EUS (49.1%), and patients referred for recurrent attacks showed the highest recurrence rate during follow up (57.1%). ERCP or cholecystectomy reduced recurrences to 14.3% in patients with biliary disease. Age under 65 (odds ratio [OR] 3.56, 95% confidence interval [CI] 1.21-10.44; P=0.02), previous cholecystectomy (OR 3.19, 95%CI 1.11-9.17; P=0.03), and no lithiasis on EUS (OR 2.87, 95%CI 1.04-7.87; P=0.04) were independent risks factors for recurrence. Conclusions EUS-directed ERCP/cholecystectomy was associated with lower relapse rates in idiopathic acute pancreatitis. Along with age and gallbladder status, it provides predictive information about recurrence likelihood.
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Affiliation(s)
- Francisco Valverde-López
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain (Francisco Valverde-López, Eva Julissa Ortega-Suazo, Maria Carmen Fernandez-Cano, Juan Gabriel Martínez-Cara, Eduardo Redondo-Cerezo)
| | - Eva Julissa Ortega-Suazo
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain (Francisco Valverde-López, Eva Julissa Ortega-Suazo, Maria Carmen Fernandez-Cano, Juan Gabriel Martínez-Cara, Eduardo Redondo-Cerezo)
| | - Charles Mel Wilcox
- Division of Gastroenterology and Hepatology and Pancreaticobiliary Center, University of Alabama at Birmingham, USA (Charles Mel Wilcox)
| | - Maria Carmen Fernandez-Cano
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain (Francisco Valverde-López, Eva Julissa Ortega-Suazo, Maria Carmen Fernandez-Cano, Juan Gabriel Martínez-Cara, Eduardo Redondo-Cerezo)
| | - Juan Gabriel Martínez-Cara
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain (Francisco Valverde-López, Eva Julissa Ortega-Suazo, Maria Carmen Fernandez-Cano, Juan Gabriel Martínez-Cara, Eduardo Redondo-Cerezo)
| | - Eduardo Redondo-Cerezo
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain (Francisco Valverde-López, Eva Julissa Ortega-Suazo, Maria Carmen Fernandez-Cano, Juan Gabriel Martínez-Cara, Eduardo Redondo-Cerezo)
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Kim YS, Chang JH, Kim TH, Kim CW, Kim JK, Han SW. Prolonged hyperamylasemia in patients with acute pancreatitis is associated with recurrence of acute pancreatitis. Medicine (Baltimore) 2020; 99:e18861. [PMID: 32011507 PMCID: PMC7220070 DOI: 10.1097/md.0000000000018861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Serum amylase levels in patients with acute pancreatitis often remain or fluctuate above the upper normal limit for over a week. This study investigated the clinical characteristics of patients with prolonged hyperamylasemia and their prognoses, including recurrence.We retrospectively analyzed patients with first attacks of acute pancreatitis in a single center between March 2010 and December 2016. Patients were divided into 2 groups according to normalization of the serum amylase levels within a week.A total of 313 patients were enrolled after exclusion. The serum amylase levels were normalized within a week in 205 patients (65.5%, group 1) and elevated over a week in 108 patients (34.5%, group 2). Group 2 was more related to alcohol, higher computed tomography (CT) severity index, local pancreatic complication, and moderately severe pancreatitis than group 1 (P < .05). Recurrent pancreatitis developed significantly more in group 2 (39.8%) than in group 1 (19.5%) (P < .001). The factors related to recurrent pancreatitis were amylase group, sex, alcohol, CT severity index, necrosis, and severity of pancreatitis (P < .05). Multivariate analysis showed that recurrent pancreatitis was independently associated with amylase group (odds ratio [OR] 2.123, 95% confidence interval [CI]= 1.227-3.673, P = .007) and alcohol (OR 2.023, 95% CI 1.134-3.611, P = .017).In conclusion, prolonged hyperamylasemia over a week is associated with recurrence of acute pancreatitis.
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Affiliation(s)
- Young Sun Kim
- Department of Internal Medicine, College of Medicine, the Catholic University of Korea, Seoul, Korea
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6
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Zakko L, Gardner TB. Endoscopic Management of Recurrent Acute Pancreatitis. Clin Gastroenterol Hepatol 2019; 17:2167-2170. [PMID: 31077835 DOI: 10.1016/j.cgh.2019.04.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Liam Zakko
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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7
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Guda NM, Trikudanathan G, Freeman ML. Idiopathic recurrent acute pancreatitis. Lancet Gastroenterol Hepatol 2019; 3:720-728. [PMID: 30215363 DOI: 10.1016/s2468-1253(18)30211-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 12/19/2022]
Abstract
Idiopathic recurrent acute pancreatitis is clinically challenging and has substantial socioeconomic consequences. Investigations are expensive and often reveal little about the cause of the disease. Little is known about the interaction between genetic, environmental, anatomical, and other factors that contribute to the disease. Data on the efficacy, safety, and long-term outcomes of endoscopic therapies are scarce. The effect of idiopathic recurrent pancreatitis on quality of life is often underestimated. A more thorough examination of the causes of the disease and the roles of other associated risk factors is needed, as are well designed clinical studies with robust and objectively measurable outcomes. Ideally, evaluation of the causes of disease and therapy should be done only in specialised centres, should follow a protocol, and all outcomes should be formally assessed.
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Affiliation(s)
- Nalini M Guda
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; Aurora Saint Luke's Medical Center, Milwaukee, WI, USA.
| | - Guru Trikudanathan
- Department of Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology, and Nutrition, Advanced Endoscopy Fellowship, and Islet Autotransplantation, University of Minnesota, Minneapolis, MN, USA
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8
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Abstract
Patients with recurrent acute pancreatitis (RAP) have few treatment options available to them to manage their symptoms or prevent progression to chronic pancreatitis. At present, endotherapy is typically pursued as a means to achieve symptom remission and reduce rates of recurrence, hospitalization, abdominal pain, narcotic use, and surgical intervention. However, evidence that endotherapy effectively alters the natural history of disease remains limited. This article reviews the recent literature on the efficacy of endoscopic intervention in the treatment RAP with a focus on high-quality prospective randomized controlled studies. Additional studies are needed to corroborate these findings.
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Affiliation(s)
- Averill Guo
- Columbia University Medical Center, 161 Fort Washington Avenue, Suite 852, New York, NY 10032, USA
| | - John M Poneros
- Columbia University Medical Center, 161 Fort Washington Avenue, Suite 852, New York, NY 10032, USA.
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9
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Stigliano S, Belisario F, Piciucchi M, Signoretti M, Delle Fave G, Capurso G. Recurrent biliary acute pancreatitis is frequent in a real-world setting. Dig Liver Dis 2018; 50:277-282. [PMID: 29311029 DOI: 10.1016/j.dld.2017.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/28/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data about recurrent acute pancreatitis (RAP) are limited. AIMS To evaluate the rate of RAP and associated factors. METHODS Single-centre prospective study of consecutive patients at first episode of acute pancreatitis (AP) being followed-up. RESULTS Of 266 consecutive AP patients, (47% biliary, 15.4% alcoholic, 14.3% idiopathic) 66 (24.8%) had RAP in a mean follow-up of 42 months; 17.9% of recurrences occurred within 30 days from discharge. Age, gender, smoking and severity of first AP were not associated with RAP risk. The rate of biliary RAP was 31.3% in patients who did not receive any treatment, 18% in those treated with ERCP only, 16% in those who received cholecystectomy only, and 0% in those treated both with surgery and ERCP. Patients with biliary AP who received cholecystectomy had a significantly longer time of recurrence-free survival and reduced recurrence risk (HR = 0.45). In patients with alcoholic AP, the rate of recurrence was lower in those who quit drinking (5.8% vs 33%; p = 0.05). The alcoholic aetiology was associated with a higher risk of having >2 RAP episodes. CONCLUSION RAP occurs in about 25% of cases, and failure to treat biliary aetiology or quitting drinking is associated with increased recurrence risk.
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Affiliation(s)
- Serena Stigliano
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy
| | - Flaminia Belisario
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy
| | - Matteo Piciucchi
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy
| | - Marianna Signoretti
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy
| | - Gianfranco Delle Fave
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy
| | - Gabriele Capurso
- Digestive & Liver Disease Unit, S. Andrea Hospital, University "La Sapienza", Rome, Italy.
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10
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Kamath MG, Pai CG, Kamath A, Kurien A. Comparing acid steatocrit and faecal elastase estimations for use in M-ANNHEIM staging for pancreatitis. World J Gastroenterol 2017. [PMID: 28405150 DOI: 10.3748/wjg.v23.i12.2217.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
AIM To compare two tests for exocrine pancreatic function (EPF) for use in M-ANNHEIM staging for pancreatitis. METHODS One hundred and ninety four consecutive patients with acute pancreatitis (AP; n = 13), recurrent acute pancreatitis (RAP; n = 65) and chronic pancreatitis (CP; n = 116) were enrolled. EPF was assessed by faecal elastase-1 (FE-1) estimation and stool fat excretion by the acid steatocrit method. Patients were classified as per M-ANNHEIM stages separately based on the results of the two tests for comparison. Independent Student's t-test, χ2 test, Kruskal-Wallis test, Mann-Whitney U test and McNemar's test were used as appropriate. RESULTS Sixty-one (52.5%) patients with CP had steatorrhoea when assessed by the acid steatocrit method; 79 (68.1%) with CP had exocrine insufficiency by the FE-1 test (χ2 test, P < 0.001). The results of acid steatocrit and FE-1 showed a significant negative correlation (Spearman's rho = -0.376, P < 0.001). A statistically significant difference was seen between the M-ANNHEIM stages as classified separately by acid steatocrit and the FE-1. Thirteen (6.7%), 87 (44.8%), 89 (45.8%) and 5 (2.5%) patients were placed in M-ANNHEIM stages 0, I, II, and III respectively, with the use of acid steatocrit as against 13 (6.7%), 85 (43.8%), 75 (38.6%), and 21 (10.8%) respectively by FE-1 in stages 0, I, II, and III thereby altering the stage in 28 (14.4%) patients (P < 0.001, McNemar's test). CONCLUSION FE-1 estimation performed better than the acid steatocrit test for use in the staging of pancreatitis by the M-ANNHEIM classification since it diagnosed a higher proportion of patients with exocrine insufficiency.
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Affiliation(s)
- M Ganesh Kamath
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - C Ganesh Pai
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - Asha Kamath
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - Annamma Kurien
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
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Lin SY, Hsu WH, Lin CC, Lin CL, Tsai CH, Kao CH. Effect of acute pancreatitis on the risk of developing osteoporosis: A nationwide cohort study. PLoS One 2017; 12:e0179358. [PMID: 28604838 PMCID: PMC5467899 DOI: 10.1371/journal.pone.0179358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/27/2017] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Chronic exocrine pancreatic insufficiency can lead to osteoporosis. However, the incidence and risk of osteoporosis after acute inflammation of pancreas remained known. Thus, we conducted a population-based cohort study to clarify the association between acute pancreatitis (AP) and osteoporosis. METHODS Patients newly diagnosed with AP with index date between 2000 and 2011 were identified from the National Health Insurance Research Database. Osteoporosis were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied age-, sex-, and comorbidities-adjusted variable Cox proportional hazard models for assessing the association between AP and osteoporosis. Moreover, these models were used to adjust for the influences of patient characteristics and comorbidities. RESULTS In this study, 4,016 patients were included in the AP cohort (males, 67.9%; mean age, 51.8 years) and 4,016 matched controls in the non-AP cohort. After a mean follow-up period of 4.97 and 5.21 years in the AP and non-AP cohorts, respectively, the incidence of osteoporosis was 8.22 per 1000 person-years in the AP cohort. The AP cohort had a higher risk [adjusted hazard ratio (aHR) = 1.27, 95% confidence interval (CI) = 1.02-1.58] of osteoporosis than did the non-AP cohort. The risk of osteoporosis was highest in the female patients of the AP cohort (aHR = 2.26, 95% CI = 1.85-2.76) and patients aged 50-64 years (aHR = 4.14, 95% CI = 3.13-5.47). CONCLUSION AP patients are at a risk of osteoporosis, especially female gender and age 50-64 years. Those with > 3 episodes of AP had highest significant risk of developing osteoporosis.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chung-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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12
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Pai CG, Kamath MG, Shetty MV, Kurien A. Continuing episodes of pain in recurrent acute pancreatitis: Prospective follow up on a standardised protocol with drugs and pancreatic endotherapy. World J Gastroenterol 2017; 23:3538-3545. [PMID: 28596690 PMCID: PMC5442090 DOI: 10.3748/wjg.v23.i19.3538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the outcomes of drug therapy (DT) followed by pancreatic endotherapy for continuing painful episodes in recurrent acute pancreatitis.
METHODS DT comprised of pancreatic enzymes and anti-oxidants failing which, endotherapy (ET; pancreatic sphincterotomy and stent placement) was done. The frequency of pain, its visual analogue score (VAS), quality of life (QoL), serum C peptide and faecal elastase were compared between baseline and after 1 year of follow up in all patients and in the two subgroups on DT and ET. Response was defined as at least 50% reduction in the severity of pain to below a score of 5.
RESULTS Of the thirty nine patients analysed, 21 (53.9%) responded to DT and 18 (46.1%) underwent ET. The VAS for pain (7.0 ± 2.0 vs 1.3 ± 2.5, P < 0.001) and the number of days with pain per month decreased [1.0 (1.0, 2.0) vs 1.0 (0.0, 1.0), P < 0.001], and the QoL scores [55.0 (44.0, 66.0) vs 38.0 (32.00, 51.00), P < 0.01] improved significantly during follow up. Similar significant improvements were seen in patients in the subgroups of DT and ET except for QoL in ET. The serum C-peptide (P = 0.001) and FE (P < 0.001) levels improved significantly in the entire group and in the two subgroups of patients except for the C peptide levels in patients on DT.
CONCLUSION A standardised protocol of DT, followed by ET decreased the intensity and frequency of pain in recurrent acute pancreatitis, enhanced QoL and improved pancreatic function.
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13
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Reply to: Yang et al, Clinical Features of Recurrent Acute Pancreatitis: Experience From a Single Center. Pancreas 2017; 46:e37-e38. [PMID: 28426494 DOI: 10.1097/mpa.0000000000000630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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14
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Kamath MG, Pai CG, Kamath A, Kurien A. Comparing acid steatocrit and faecal elastase estimations for use in M-ANNHEIM staging for pancreatitis. World J Gastroenterol 2017; 23:2217-2222. [PMID: 28405150 PMCID: PMC5374134 DOI: 10.3748/wjg.v23.i12.2217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare two tests for exocrine pancreatic function (EPF) for use in M-ANNHEIM staging for pancreatitis.
METHODS One hundred and ninety four consecutive patients with acute pancreatitis (AP; n = 13), recurrent acute pancreatitis (RAP; n = 65) and chronic pancreatitis (CP; n = 116) were enrolled. EPF was assessed by faecal elastase-1 (FE-1) estimation and stool fat excretion by the acid steatocrit method. Patients were classified as per M-ANNHEIM stages separately based on the results of the two tests for comparison. Independent Student’s t-test, χ2 test, Kruskal-Wallis test, Mann-Whitney U test and McNemar’s test were used as appropriate.
RESULTS Sixty-one (52.5%) patients with CP had steatorrhoea when assessed by the acid steatocrit method; 79 (68.1%) with CP had exocrine insufficiency by the FE-1 test (χ2 test, P < 0.001). The results of acid steatocrit and FE-1 showed a significant negative correlation (Spearman’s rho = -0.376, P < 0.001). A statistically significant difference was seen between the M-ANNHEIM stages as classified separately by acid steatocrit and the FE-1. Thirteen (6.7%), 87 (44.8%), 89 (45.8%) and 5 (2.5%) patients were placed in M-ANNHEIM stages 0, I, II, and III respectively, with the use of acid steatocrit as against 13 (6.7%), 85 (43.8%), 75 (38.6%), and 21 (10.8%) respectively by FE-1 in stages 0, I, II, and III thereby altering the stage in 28 (14.4%) patients (P < 0.001, McNemar’s test).
CONCLUSION FE-1 estimation performed better than the acid steatocrit test for use in the staging of pancreatitis by the M-ANNHEIM classification since it diagnosed a higher proportion of patients with exocrine insufficiency.
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Kamath MG, Pai CG, Kamath A. Progression of recurrent acute and chronic pancreatitis: A short-term follow up study from a southern Indian centre. Indian J Gastroenterol 2016; 35:425-431. [PMID: 27783351 DOI: 10.1007/s12664-016-0700-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little data exist on the progression of recurrent acute (RAP) and chronic pancreatitis (CP) from regions from where the entity of tropical chronic pancreatitis was originally described. The study aimed to follow up patients with RAP and CP seen at a southern Indian centre for progression of disease over time. METHODS Prospectively enrolled patients with RAP and CP were followed up, and the alcoholic and idiopathic subgroups were assessed for progression of structural and functional changes in the organ. RESULTS One hundred and forty patients (RAP = 44; 31.4 %, CP = 96; 68.5 %) were followed up over a median 12.2 (interquartile range 12.0-16.8) months. The cause was alcohol in 31 (22.1 %) and not evident in 109 (77.8 %). The disease progressed from RAP to CP in 7 (15.9 %), 6 (16.2 %) out of 37 in the idiopathic and 1 (14.2 %; p = 1.00) out of 7 in the alcoholic subgroups. Three (42.8 %) and 1 (14.2 %) developed steatorrhea and diabetes mellitus (DM), respectively, and 2 (4.5 %) developed calcification. Established CP progressed in 19 (19.7 %), 1 (1.0 %), 5 (5.2 %), 2 (2.0 %) and 11 (11.4 %) newly developed DM, steatorrhea, calcification and duct dilation during follow up. Among the idiopathic and alcoholic CP, disease progression was seen in 15 (20.8 %) out of 72 and 4 (16.6 %) out of 24 respectively. CONCLUSIONS Idiopathic RAP and CP progressed during the short-term follow up. This is similar to other etiological forms of pancreatitis, as described from elsewhere in the world.
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Affiliation(s)
- M Ganesh Kamath
- Department of Physiology, Melaka Manipal Medical College, Manipal University, Madhav Nagar, Manipal, 576 104, India
| | - C Ganesh Pai
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Madhav Nagar, Manipal, 576 104, India.
| | - Asha Kamath
- Department of Community Medicine, Kasturba Medical College, Manipal University, Madhav Nagar, Manipal, 576 104, India
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Bellin MD, Kerdsirichairat T, Beilman GJ, Dunn TB, Chinnakotla S, Pruett TL, Radosevich DR, Schwarzenberg SJ, Sutherland DER, Arain MA, Freeman ML. Total Pancreatectomy With Islet Autotransplantation Improves Quality of Life in Patients With Refractory Recurrent Acute Pancreatitis. Clin Gastroenterol Hepatol 2016; 14:1317-23. [PMID: 26965843 PMCID: PMC5538725 DOI: 10.1016/j.cgh.2016.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Therapeutic options are limited for patients with recurrent acute pancreatitis who have intractable symptoms despite maximal endoscopic and medical treatment, but equivocal or no morphologic or functional evidence of chronic pancreatitis. We performed a prospective observational cohort study to determine the efficacy of total pancreatectomy with islet autotransplantation (TPIAT) for these patients. METHODS We collected data from all patients undergoing TPIAT at the University of Minnesota from 2007 through 2013; 49 patients (42 female; mean age, 32.8 ± 7.8 years) had a diagnosis of recurrent acute pancreatitis not provoked by intervention, with negative or equivocal findings from nondiagnostic imaging or pancreatic function tests for chronic pancreatitis, and intractable pain between episodes. Data on insulin use, narcotic requirements, pain scores, and health-related quality of life were collected before TPIAT; 3 months, 6 months, and 1 year afterward; and then yearly. RESULTS All 49 patients studied required narcotics before TPIAT (45 daily users and 4 intermittent users); 2 had insulin-treated diabetes. At 1 year after TPIAT, 22 out of 48 patients (46%) reported no use of narcotic pain medications (P < .001 vs baseline). Health-related quality of life score, measured by the physical and mental component summary score, increased by approximately 1 standard deviation from the population mean (P < .001 for the physical component summary; P = .019 for the mental component summary). At 1 year after TPIAT, 21 out of 48 patients (45%) were insulin independent; their mean percent glycosylated hemoglobin A1c at 1 year after TPIAT was 6.0% ± 0.9% (5.2% ± 0.6% pre-TPIAT). CONCLUSIONS Patients with recurrent acute pancreatitis but lacking clear chronic pancreatitis benefit from TPIAT, with outcomes similar to those previously described for patients with chronic pancreatitis (improved quality of life and reduced narcotic use). For these patients who have otherwise limited surgical treatment options, TPIAT can be considered when medical and endoscopic therapies have failed.
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Wu JS, Li WM, Chen YN, Zhao Q, Chen QF. Endoplasmic reticulum stress is activated in acute pancreatitis. J Dig Dis 2016; 17:295-303. [PMID: 27059531 DOI: 10.1111/1751-2980.12347] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 12/11/2022]
Abstract
Endoplasmic reticulum (ER) is one of the most important cell organelles in the body, regulating protein synthesis, folding and aggregation. Endoplasmic reticulum stress (ERS) is a particular subcellular pathological process involving an imbalance of homeostasis and ER disorder. In the early stage of ERS, cells show a protective unfolded protein response that changes the cellular transcriptional and translational programs to alleviate the process. Therefore, a certain degree of ERS can activate the protective adaptation of cells, whereas sustained severe ERS triggers an apoptotic signal and leads to apoptosis. Acute pancreatitis is a disease caused by trypsin digestion of the pancreas, although the pathogenesis is not completely understood. However, a close association has been suggested between pancreatitis and ERS. This article reviewed relevant research advances and discussed the effect of ERS on the development and progression of acute pancreatitis.
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Affiliation(s)
- Jian Sheng Wu
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Wei Min Li
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Yi Na Chen
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Qian Zhao
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Qin Fen Chen
- Department of Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
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Gurram KC, Czapla A, Thakkar S. Acute pancreatitis: pancreas divisum with ventral duct intraductal papillary mucinous neoplasms. BMJ Case Rep 2014; 2014:bcr-2014-205322. [PMID: 25293684 DOI: 10.1136/bcr-2014-205322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Acute recurrent pancreatitis occurs rarely in individuals with pancreas divisum. A 39-year-old woman with no significant history presented with pancreatitis. CT scan and MRI suggested acute on chronic pancreatitis with calcifications and pancreatic divisum. An endoscopic ultrasound demonstrated complete pancreas divisum. A large calcification measuring 12 mm × 6 mm was seen in the head of the pancreas with associated dilation of the ventral pancreatic duct. Fine-needle aspiration of the dilated ventral pancreatic duct showed an amylase level of 36,923 U/L and a carcinoembryonic antigen of 194. A ventral duct intraductal papillary mucinous neoplasm was suspected and a pancreaticoduodenectomy procedure was recommended. After the procedure, pathology demonstrated an intraductal papillary lesion in the main duct with moderate dysplasia. A pancreatic intraepithelial neoplasia, grade 2 was also present. Margins of resection were clear. This case represents the importance of assessing for secondary causes of pancreatitis in pancreas divisum.
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Affiliation(s)
- Krishna C Gurram
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Agata Czapla
- Departement of Pathology, Allegheny Health Network AGH, Pittsburgh, Pennsylvania, USA
| | - Shyam Thakkar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Sah RP, Garg SK, Dixit AK, Dudeja V, Dawra RK, Saluja AK. Endoplasmic reticulum stress is chronically activated in chronic pancreatitis. J Biol Chem 2014; 289:27551-61. [PMID: 25077966 DOI: 10.1074/jbc.m113.528174] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The pathogenesis of chronic pancreatitis (CP) is poorly understood. Endoplasmic reticulum (ER) stress has now been recognized as a pathogenic event in many chronic diseases. However, ER stress has not been studied in CP, although pancreatic acinar cells seem to be especially vulnerable to ER dysfunction because of their dependence on high ER volume and functionality. Here, we aim to investigate ER stress in CP, study its pathogenesis in relation to trypsinogen activation (widely regarded as the key event of pancreatitis), and explore its mechanism, time course, and downstream consequences during pancreatic injury. CP was induced in mice by repeated episodes of acute pancreatitis (AP) based on caerulein hyperstimulation. ER stress leads to activation of unfolded protein response components that were measured in CP and AP. We show sustained up-regulation of unfolded protein response components ATF4, CHOP, GRP78, and XBP1 in CP. Overexpression of GRP78 and ATF4 in human CP confirmed the experimental findings. We used novel trypsinogen-7 knock-out mice (T(-/-)), which lack intra-acinar trypsinogen activation, to clarify the relationship of ER stress to intra-acinar trypsinogen activation in pancreatic injury. Comparable activation of ER stress was seen in wild type and T(-/-) mice. Induction of ER stress occurred through pathologic calcium signaling very early in the course of pancreatic injury. Our results establish that ER stress is chronically activated in CP and is induced early in pancreatic injury through pathologic calcium signaling independent of trypsinogen activation. ER stress may be an important pathogenic mechanism in pancreatitis that needs to be explored in future studies.
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Affiliation(s)
- Raghuwansh P Sah
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
| | - Sushil K Garg
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
| | - Ajay K Dixit
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
| | - Vikas Dudeja
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
| | - Rajinder K Dawra
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
| | - Ashok K Saluja
- From the Division of Basic and Translational Research, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota 55455
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Abstract
OBJECTIVES The objectives of this study were to evaluate the severity of patients with acute pancreatitis (AP) on chronic pancreatitis (CP) and compare this to patients with AP without CP. METHODS The Maryland Health Services database was queried for all adult inpatient discharges with a primary diagnosis of AP from 1994 to 2010. Acute pancreatitis on CP and AP without CP were defined by the presence of the associated diagnosis code for CP. Severity was defined as organ failure, intensive care unit stay, or mortality. RESULTS Acute pancreatitis on CP accounted for 13.7% of all AP discharges (9747/70,944). The proportion of AP-on-CP discharges doubled during the study period (8.8% to 17.6%; P < 0.0001). When compared with patients with AP without CP, AP-on-CP patients were younger, were more likely to be male and black, had higher rates of alcohol and drug abuse, and had less severe disease with lower rates of mortality, organ failure, need for mechanical ventilation, and intensive care unit stay. Among AP-on-CP patients, significant predictors of severity included advanced age, weight loss, and 2 or more comorbidities. CONCLUSIONS Patients with AP on CP have less severe disease than do those with AP without CP. Weight loss, advanced age, and comorbidity increase the risk of severity in patients with AP on CP.
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Abstract
Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.
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Abstract
PURPOSE OF REVIEW In this article, we review important advances in our understanding of the mechanisms of pancreatitis. RECENT FINDINGS The relative contributions of intrapancreatic trypsinogen activation and nuclear factor kappa B (NFκB) activation, the two major early independent cellular events in pancreatitis, have been investigated using novel genetic models. Trypsinogen activation has traditionally held the spotlight for many decades as the central pathogenic event of pancreatitis. However, recent experimental evidence points to the role of trypsin activation in early acinar cell damage but not in the inflammatory response of acute pancreatitis, which was shown to be induced by NFκB activation. Further, chronic pancreatitis developed independently of trypsinogen activation in the caerulein model. Sustained NFκB activation, but not persistent intra-acinar expression of active trypsin, was shown to result in chronic pancreatitis. Calcineurin-NFAT (nuclear factor of activated T-cells) signaling was shown to mediate downstream effects of pathologic rise in intracellular calcium. Interleukin-6 was identified as a key cytokine mediating pancreatitis-associated lung injury. SUMMARY Recent advances challenge the long-believed trypsin-centered understanding of pancreatitis. It is becoming increasingly clear that activation of intense inflammatory signaling mechanisms in acinar cells is crucial to the pathogenesis of pancreatitis, which may explain the strong systemic inflammatory response in pancreatitis.
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Sah RP, Dudeja V, Dawra RK, Saluja AK. Cerulein-induced chronic pancreatitis does not require intra-acinar activation of trypsinogen in mice. Gastroenterology 2013; 144:1076-1085.e2. [PMID: 23354015 PMCID: PMC3928043 DOI: 10.1053/j.gastro.2013.01.041] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 01/02/2013] [Accepted: 01/07/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Premature activation of trypsinogen activation can cause pancreatic injury and has been associated with chronic pancreatitis (CP). Mice that lack intra-acinar activation of trypsinogen, such as trypsinogen-7-null (T(-/-)) and cathepsin B-null (CB(-/-)) mice, have been used to study trypsin-independent processes of CP development. We compared histologic features and inflammatory responses of pancreatic tissues from these mice with those from wild-type mice after the development of CP. METHODS CP was induced in wild-type, T(-/-), and CB(-/-) mice by twice-weekly induction of acute pancreatitis for 10 weeks; acute pancreatitis was induced by hourly intraperitoneal injections of cerulein (50 μg/kg × 6). Pancreatic samples were collected and evaluated by histologic and immunohistochemical analyses. Normal human pancreas samples, obtained from the islet transplant program at the University of Minnesota, were used as controls and CP samples were obtained from surgical resections. RESULTS Compared with pancreatic tissues from wild-type mice, those from T(-/-) and CB(-/-) mice had similar levels of atrophy, histomorphologic features of CP, and chronic inflammation. All samples had comparable intra-acinar activation of nuclear factor (NF)-κB, a transcription factor that regulates the inflammatory response, immediately after injection of cerulein. Pancreatic tissue samples from patients with CP had increased activation of NF-κB (based on nuclear translocation of p65 in acinar cells) compared with controls. CONCLUSIONS Induction of CP in mice by cerulein injection does not require intra-acinar activation of trypsinogen. Pancreatic acinar cells of patients with CP have increased levels of NF-κB activation compared with controls; regulation of the inflammatory response by this transcription factor might be involved in the pathogenesis of CP.
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Abstract
OBJECTIVES There are limited data on health-related quality of life (HRQOL) in pediatric patients with long-standing pancreatitis (including acute relapsing and chronic pancreatitis) using age-appropriate measurement instruments. METHODS We evaluated HRQOL in children with long-standing pancreatitis using the PedsQL 4.0 Generic Core Scales by patient self-report as well as parent proxy report. Additionally, patient self-reports and parent proxy reports were completed for the PedsQL Multidimensional Fatigue Scale. RESULTS Across all of the dimensions, significantly impaired HRQOL and higher fatigue were noted for both pediatric patient self-report and parent proxy report in comparison with the matched healthy children samples. Higher fatigue was associated with lower HRQOL. There was moderate to good agreement between patient self-reports and parent proxy reports. CONCLUSIONS Given the impaired HRQOL and fatigue documented in the present study, future studies are needed to determine whether specific factors can modify HRQOL and fatigue in this patient population.
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