Diabetes and the Pancreatobiliary Diseases

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis

Background  Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management.

Methods  This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies.

Results  Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound–guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay.

Conclusion  The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

Underexpression of miR-126-3p in Patients with Cholangiocarcinoma

Objectives:

To evaluate the expression of miR-126-3p and its potential as a biomarker for cholangiocarcinoma (CCA) and to better understand the prognosis, comorbidities, and lifestyle habits associated with the disease.

Methods:

Fifty-nine individuals were distributed into either the study group (38 CCA patients) or the control group (21 individuals without liver diseases). Total RNA was extracted, cDNA synthesis was performed, and miR-126-3p expression was assessed using real-time PCR. For statistical analysis, alpha error was set at 5%.

Results:

MiR-126-3p was found to be underexpressed in the study group relative to the controls (0.42; P=0.001). Additionally, marked underexpression was found in the study group in when associated with smoking (0.28; P=0.0001), alcoholism (0.19; P=0.0001), hypertension (0.29; P=000.1), and diabetes (0.12; P=0.0003) relative to the controls. No association was found between miR-126-3p expression and tumor subtypes (iCCA=0.42; pCCA=0.45; dCCA=0.72; P=0.9155). A total of 67% of dCCA patients were event-free at 16 months of follow up, while both pCCA and iCCA exhibited event-free survival rates of 25%, though there was no significant difference between these subgroups (P=0.273).

Conclusion:

The underexpression of mir-126-3p is associated with cholangiocarcinoma and can be potentiated by alcoholism, hypertension, diabetes, and smoking, the latter of which is an independent risk factor for this cancer. Furthermore, dCCA patients exhibit higher survival rates relative to patients with pCCA and iCCA.

Erectile Dysfunction in Men With Gallbladder Stone Disease: A Nationwide Population-Based Study

We assessed the risk of erectile dysfunction after the diagnosis of gallbladder stone disease. We identified 9,362 men aged ≥20 years diagnosed with gallbladder stone disease between 2000 and 2011 from Taiwan’s National Health Insurance Research Database as the study cohort, and we randomly selected 9,362 men from the nongallbladder stone disease population by 1:1 frequency-matching with the case cohort based on age, the index date for the diagnosis of gallbladder stone disease, and comorbidities as the control cohort. All subjects were followed until December 31, 2011, for measuring the erectile dysfunction incidence. The risk of organic erectile dysfunction was higher in the gallbladder stone disease cohort than the nongallbladder stone disease cohort (4.01 vs. 2.69 per 1,000 person-years, adjusted hazard ratio = 1.41, 97.5% confidence interval [1.12, 1.78]), but the risk of psychogenic erectile dysfunction was comparable between the gallbladder stone disease cohort and the nongallbladder stone disease cohort (0.40 vs. 0.28 per 1,000 person-years, adjusted hazard ratio = 1.37, 97.5% confidence interval [0.67, 2.79]). Moreover, gallbladder stone disease men with cholecystectomy exhibited a lower risk of developing organic erectile dysfunction than gallbladder stone disease men without cholecystectomy (adjusted hazard ratio = 0.58, 97.5% confidence interval [0.41, 0.80]). The risk of organic erectile dysfunction contributed by gallbladder stone disease was only significantly higher in men aged ≥65 years (adjusted hazard ratio = 2.21, 97.5% confidence interval [1.34, 3.63]) and in men with comorbidities (adjusted hazard ratio = 1.42, 97.5% confidence interval [1.09, 1.85]). The risk of psychogenic erectile dysfunction contributed by gallbladder stone disease was nonsignificant in each age group and in men with or without comorbidities. Gallbladder stone disease is associated with an increased risk of organic erectile dysfunction, but it has no association with psychogenic erectile dysfunction. History of cholecystectomy for gallbladder stone disease may ameliorate the risk of organic erectile dysfunction; it requires more studies to ascertain the protective mechanism and to clarify whether the existence of gallbladder stone disease is an epiphenomenon or independent risk factor of erectile dysfunction.

Exploring and validating the clinical risk factors for pancreatic cancer in chronic pancreatitis patients using electronic medical records datasets: three cohorts comprising 2,960 patients

Background

Patients with chronic pancreatitis (CP) have an increased risk of developing pancreatic cancer (PC). The purpose of this study was to identify predictors of PC in CP patients.

Methods

Electronic medical records (EMRs) of CP patients from two cohorts were collected, and a logistic regression analysis was performed to investigate the risk factors for PC. Subsequently, we validated the value of the risk prediction model with the EMRs of a third cohort.

Results

The derivation cohort consisted of 2,545 CP patients, and among them, 14 patients developed PC 7 years after CP diagnosis. Cyst of the pancreas [COP; odds ratio (OR): 4.37, 95% confidence interval (CI): 1.11 to 18.40, P=0.033], loss of weight (LW; OR: 3.21, 95% CI: 0.76 to 12.91, P=0.096) and high platelet (PLT) count (OR: 1.01 per 1 increment, 95% CI: 1.00 to 1.01, P=0.042) were independent risk factors for PC among CP patients. A risk prediction equation was constructed as follows: ln[p/(1–p)] = –6.68 + 1.55COP + 1.23LW + 0.0046PLT. The areas under the receiver operating characteristic (ROC) curve of our risk score were 0.83 and 0.72 in the derivation and validation cohorts, respectively. A score >0.0128 and >0.0122 had the best balance between sensitivity and specificity in the derivation and validation cohorts, respectively.

Conclusions

In CP patients, LW, COP and high PLT count were identified as novel predictors of PC. A risk prediction model based on these factors exhibited moderate predictive value for CP patients.

Incidence and causes of mildly to moderately elevated aminotransferase in Japanese patients with type 2 diabetes

Objectives

To identify the association of type 2 diabetes (T2DM) and liver disease with elevated ALT and factors associated with increased ALT in patients with and without T2DM.

Design and setting

We performed a retrospective study in adults with ≥ 2 claims for blood tests recorded in the Medical Data Vision claims database between 2010 and 2016.

Participants

Patients were entered into T2DM and non-DM groups based on diagnosis and medication claim codes.

Primary outcome measure

The primary endpoint was the first follow-up ALT elevation over three times the normal value, and etiologies were categorized by subsequent diagnoses. We estimated the ALT elevation incidence and association with T2DM using Poisson regression and Cox proportional hazard models.

Results

We identified 3161 cases of elevated ALT in 104,903 patients (follow-up, 280,659 patient-years). The age- and sex-adjusted incidence of elevated ALT in the T2DM group (13.47 per 1000 patient-years; 95% confidence interval (CI) 12.53-14.48) was significantly higher than that in the non-DM group (8.43 per 1000 patient-years; 95% CI 7.72-9.20, p < 0.0001). Compared to the non-DM group, the T2DM group had an approximately 3.5 times higher risk of fatty liver-related ALT elevation (adjusted hazard ratio (HR), 3.54; 95% CI 1.90-6.58). T2DM was not associated with an increased incidence of jointly elevated ALT and total bilirubin (adjusted HR, 0.94; 95% CI 0.77-1.15).

Conclusion

T2DM is strongly associated with increased liver enzymes secondary to fatty liver. The causes of liver enzyme abnormalities were not fully characterized due to a high proportion of unexplained ALT elevation.

Management of severe acute pancreatitis

The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.

Acute Pancreatitis: A Multifaceted Set of Organelle and Cellular Interactions

Acute pancreatitis is an inflammatory disorder of the exocrine pancreas associated with tissue injury and necrosis. The disease can be mild, involving only the pancreas, and resolve spontaneously within days or severe, with systemic inflammatory response syndrome-associated extrapancreatic organ failure and even death. Importantly, there are no therapeutic agents currently in use that can alter the course of the disease. This article emphasizes emerging findings that stressors (environmental and genetic) that cause acute pancreatitis initially cause injury to organelles of the acinar cell (endoplasmic reticulum, mitochondria, and endolysosomal-autophagy system), and that disorders in the functions of the organelles lead to inappropriate intracellular activation of trypsinogen and inflammatory pathways. We also review emerging work on the role of damage-associated molecular patterns in mediating the local and systemic inflammatory response in addition to known cytokines and chemokine pathways. In the review, we provide considerations for correction of organelle functions in acute pancreatitis to create a discussion for clinical trial treatment and design options.

Glycated serum proteins: High in pancreatic cancer and low in preeclampsia

Glycated serum protein (GSP, measured as serum fructosamine concentration in μmol/L) is a product of glycation reaction between glucose and serum proteins in the blood circulation. GSP is used along with blood glucose, glycated hemoglobin (HbA1c), and glycated albumin as indicators of glycemic control for diabetic patients. However, a systematic comparison of the GSP levels in different types of human diseases has not been reported. In this study, 62,698 clinical lab test results of GSP levels in patients with 61 clinically defined diseases over the past 5 years in our hospital were retrieved and compared to that of 1861 clinical lab test results in healthy individuals. Based on the mean (SD), median, and p (-Log₁₀p) values, we found that patients with type 2 diabetes, hepatic encephalopathy, pancreatic cancer, healthy individuals >65 years old, and cerebral arteriosclerosis had significantly (p<0.05, -Log₁₀p>1.30) increased whereas patients with 49/61 diseases including preeclampsia, nephrotic syndrome, sepsis, lupus erythematous, and leukemia had significantly decreased GSP levels compared to that of healthy controls. Among the 61 diseases, type 2 diabetes and leukemia had the highest -Log₁₀p values (>274) and lupus erythematous, nephrotic syndrome, and gastric cancer had -Log₁₀p values >140. Revealing the molecular mechanisms especially those underlying the decreased GSP levels in most of human diseases might make GSP levels serve more clinical purposes in future.

Endocrine and exocrine pancreas pathologies crosstalk: Insulin regulates the unfolded protein response in pancreatic exocrine acinar cells

Exocrine pancreas insufficiency is common in diabetic mellitus (DM) patients. Cellular stress is a prerequisite in the development of pancreatic pathologies such as acute pancreatitis (AP). The molecular mechanisms underlying exocrine pancreatic ER-stress in DM are largely unknown. We studied the effects of insulin and glucose (related to DM) alone and in combination with cerulein (CER)-induced stress (mimicking AP) on ER-stress unfolded protein response (UPR) in pancreatic acinar cells. Exocrine pancreas cells (AR42J) were exposed to high glucose (Glu, 25 mM) and insulin (Ins, 100 nM) levels with or without CER (10 nM). ER-stress UPR activation was analyzed at the transcript, protein, immunocytochemistry, western blotting, quantitative RT-PCR and XBP1 splicing, including; XBP1, sXBP1, ATF6, cleaved ATF6, IRE1-p, CHOP, Caspase-12 and Bax. Exocrine acinar cells exposed to high Ins or Ins+Glu concentrations (but not Glu alone) exhibited ER-stress UPR, demonstrated by significant increase of transcript and protein levels of downstream markers in the ATF6 and IRE1 transduction arms, including: sXBP1, cleaved ATF6, XBP1, CHOP, IRE1-p and caspase-12. UPR activation resulted in IRE1-p aggregation and nuclear trans-localization of cleaved activated ATF6 and sXBP1. Ins further aggravated UPR when cells were co-challenged with CER-induced stress, exacerbating the effects of CER alone. High Ins levels, typical to type-2-DM, activate the ER-stress UPR in pancreatic acinar cells, through the ATF6 and IRE1 pathways. This effect of Ins in naïve acinar cells further augments CER-induced UPR. Our data highlight molecular pathways through which DM enhances exocrine pancreas pathologies.