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Tirkes T, Yadav D, Conwell DL, Territo PR, Zhao X, Persohn SA, Dasyam AK, Shah ZK, Venkatesh SK, Takahashi N, Wachsman A, Li L, Li Y, Pandol SJ, Park WG, Vege SS, Hart PA, Topazian M, Andersen DK, Fogel EL. Diagnosis of chronic pancreatitis using semi-quantitative MRI features of the pancreatic parenchyma: results from the multi-institutional MINIMAP study. Abdom Radiol (NY) 2023; 48:3162-3173. [PMID: 37436452 PMCID: PMC10650972 DOI: 10.1007/s00261-023-04000-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE To determine the diagnostic performance of parenchymal MRI features differentiating CP from controls. METHODS This prospective study performed abdominal MRI scans at seven institutions, using 1.5 T Siemens and GE scanners, in 50 control and 51 definite CP participants, from February 2019 to May 2021. MRI parameters included the T1-weighted signal intensity ratio of the pancreas (T1 score), arterial-to-venous enhancement ratio (AVR) during venous and delayed phases, pancreas volume, and diameter. We evaluated the diagnostic performance of these parameters individually and two semi-quantitative MRI scores derived using logistic regression: SQ-MRI Model A (T1 score, AVR venous, and tail diameter) and Model B (T1 score, AVR venous, and volume). RESULTS When compared to controls, CP participants showed a significantly lower mean T1 score (1.11 vs. 1.29), AVR venous (0.86 vs. 1.45), AVR delayed (1.07 vs. 1.57), volume (54.97 vs. 80.00 ml), and diameter of the head (2.05 vs. 2.39 cm), body (2.25 vs. 2.58 cm), and tail (1.98 vs. 2.51 cm) (p < 0.05 for all). AUCs for these individual MR parameters ranged from 0.66 to 0.79, while AUCs for the SQ-MRI scores were 0.82 and 0.81 for Model A (T1 score, AVR venous, and tail diameter) and Model B (T1 score, AVR venous, and volume), respectively. After propensity-matching adjustments for covariates, AUCs for Models A and B of the SQ-MRI scores increased to 0.92 and 0.93, respectively. CONCLUSION Semi-quantitative parameters of the pancreatic parenchyma, including T1 score, enhancement ratio, pancreas volume, diameter and multi-parametric models combining these parameters are helpful in diagnosis of CP. Longitudinal analyses including more extensive population are warranted to develop new diagnostic criteria for CP.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd. Suite 0663, Indianapolis, IN, 46202, USA.
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Paul R Territo
- Division of Clinical Pharmacology, Stark Neurosciences Research Institute, Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Xuandong Zhao
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Scott A Persohn
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zarine K Shah
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Ashley Wachsman
- Department of Imaging, University of California in Los Angeles, Los Angeles, CA, USA
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yan Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Walter G Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | | | - Phil A Hart
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Evan L Fogel
- Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy, Indiana University School of Medicine, Indianapolis, IN, USA
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Zafar HB, Adler JR. Surgical Management of Chronic Pancreatitis: A Systemic Review. Cureus 2023; 15:e35806. [PMID: 36891174 PMCID: PMC9986717 DOI: 10.7759/cureus.35806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Chronic pancreatitis is a debilitating disease. It is caused by the progressive destruction of normal pancreatic parenchyma, which is replaced by fibrous tissue causing pain in addition to pancreatic insufficiency. There is no single mechanism of pain in chronic pancreatitis. Several medical, endoscopic, and surgical treatment strategies are available to control this disease. Surgical techniques are divided into resection, drainage, and hybrid procedures. The review aimed to compare various surgical procedures used in the management of chronic pancreatitis. The ideal operation is the one that effectively and persistently relieves the pain and has the least morbidity with favorable pancreatic reserve. All the randomized control trials from inception to January 2023, which fulfilled the inclusion criteria, were extensively searched on PubMed and a systemic review was conducted comparing the surgical outcomes of the variety of operations used in chronic pancreatitis. Duodenum-preserving pancreatic head resection is the common procedure done with favorable outcomes.
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Affiliation(s)
- Hafiz Bilal Zafar
- Department of Hepatobiliary and Liver Transplant Surgery, Hamad Medical Corporation, Doha, QAT
| | - John R Adler
- Department of Hepatobiliary and Liver Transplant Surgery, Hamad Medical Corporation, Doha, QAT
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3
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OUP accepted manuscript. Br J Surg 2022; 109:363-371. [DOI: 10.1093/bjs/znab473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/16/2021] [Accepted: 12/22/2021] [Indexed: 11/14/2022]
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Krafft MR, Nasr JY. Anterograde Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A Technical Review. Dig Dis Sci 2019; 64:1770-1781. [PMID: 30734236 DOI: 10.1007/s10620-019-05495-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/24/2019] [Indexed: 12/27/2022]
Abstract
The advancement of pancreatic endotherapy has increased the availability of minimally invasive endoscopic pancreatic ductal drainage techniques. In this regard, familiarity with endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is critical for treatment of obstructed pancreatic ductal systems, especially in nonsurgical candidates and in patients desiring a minimally invasive approach. Two distinct forms of EUS-PDD exist, viz. rendezvous-assisted endoscopic retrograde pancreatography (rendezvous-assisted ERP) and anterograde EUS-PDD. Anterograde EUS-PDD refers to transmural anterograde passage of a pancreatic drainage catheter or stent directly into the main pancreatic duct, through either the gastric or enteral wall. Rendezvous-assisted ERP should be attempted after failed conventional ERP, and anterograde EUS-PDD should be considered if rendezvous-assisted ERP fails or is not technically feasible. Common clinical scenarios that fulfil these conditions are chronic pancreatitis with high-grade main pancreatic duct obstruction, surgically altered anatomy with ductal/anastomotic obstruction, pancreas divisum, and disconnected pancreatic duct syndrome. The focus of this review article is anterograde EUS-PDD and its indications, technique, and outcomes. It also provides a summary of our own experience with this procedure, and a video demonstration of the technique.
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Affiliation(s)
- Matthew R Krafft
- Section of Digestive Diseases, West Virginia University Medicine, PO Box 9161, One Medical Center Drive, Morgantown, WV, 26506-9161, USA
| | - John Y Nasr
- Section of Digestive Diseases, West Virginia University Medicine, PO Box 9161, One Medical Center Drive, Morgantown, WV, 26506-9161, USA.
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Jansson L, Carlsson PO. Pancreatic Blood Flow with Special Emphasis on Blood Perfusion of the Islets of Langerhans. Compr Physiol 2019; 9:799-837. [PMID: 30892693 DOI: 10.1002/cphy.c160050] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The pancreatic islets are more richly vascularized than the exocrine pancreas, and possess a 5- to 10-fold higher basal and stimulated blood flow, which is separately regulated. This is reflected in the vascular anatomy of the pancreas where islets have separate arterioles. There is also an insulo-acinar portal system, where numerous venules connect each islet to the acinar capillaries. Both islets and acini possess strong metabolic regulation of their blood perfusion. Of particular importance, especially in the islets, is adenosine and ATP/ADP. Basal and stimulated blood flow is modified by local endothelial mediators, the nervous system as well as gastrointestinal hormones. Normally the responses to the nervous system, especially the parasympathetic and sympathetic nerves, are fairly similar in endocrine and exocrine parts. The islets seem to be more sensitive to the effects of endothelial mediators, especially nitric oxide, which is a permissive factor to maintain the high basal islet blood flow. The gastrointestinal hormones with pancreatic effects mainly influence the exocrine pancreatic blood flow, whereas islets are less affected. A notable exception is incretin hormones and adipokines, which preferentially affect islet vasculature. Islet hormones can influence both exocrine and endocrine blood vessels, and these complex effects are discussed. Secondary changes in pancreatic and islet blood flow occur during several conditions. To what extent changes in blood perfusion may affect the pathogenesis of pancreatic diseases is discussed. Both type 2 diabetes mellitus and acute pancreatitis are conditions where we think there is evidence that blood flow may contribute to disease manifestations. © 2019 American Physiological Society. Compr Physiol 9:799-837, 2019.
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Affiliation(s)
- Leif Jansson
- Uppsala University, Department of Medical Cell Biology, Uppsala, Sweden
| | - Per-Ola Carlsson
- Uppsala University, Department of Medical Cell Biology, Uppsala, Sweden.,Uppsala University, Department of Medical Sciences, Uppsala, Sweden
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Ashley SW. Profiles: Stanley W. Ashley. Dig Dis Sci 2018; 63:1685-1689. [PMID: 29736831 DOI: 10.1007/s10620-018-5104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Stanley W Ashley
- Frank Sawyer Professor of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Liu Q, Wang Y, Zeng H, Hu B. Successful endoscopic removal of a rare, large impacted pancreatic duct stone using grasping forceps: A case report with video. Medicine (Baltimore) 2018; 97:e0304. [PMID: 29620654 PMCID: PMC5902254 DOI: 10.1097/md.0000000000010304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE As a main complication of chronic pancreatitis (CP), pancreatic duct stones (PDSs) are often associated with ductal obstruction resulting in increasing intraductal and parenchymal pressure and long-lasting pain. There are many methods for removing PDSs. However, for large stones, it is technically difficult to remove them entirely by endoscopic retrograde cholangiopancreatography (ERCP). PATIENT CONCERNS A 57-year-old man presented with a chief complaint of severe epigastric pain radiating to his back 3 or 4 times annually for 2 years. DIAGNOSIS The abdominal computed tomography scan revealed dilation of the proximal pancreatic duct with an irregular high-density calcification shadow located at the head of the pancreas. INTERVENTIONS A pancreatic stent was placed initially by ERCP to relieve epigastric pain and alleviate symptom. Repeated ERCP was subsequently performed 2 months later to extract the impacted large pancreatic stone. OUTCOME By using grasping forceps, the huge coralloid stone (272 × 0 mm) was successfully extracted in an en bloc manner. Then, a 7-French × 5 cm plastic pancreatic stent was placed for 2 weeks. The patient was free of any pancreatic pain during the 2-year follow-up. LESSONS Generally, for large or impacted pancreatic stones, endoscopic removal is technically difficult to achieve. Pancreatic stenting can be an effective method of alleviating abdominal pain and facilitating subsequent endoscopic lithoextraction. Extraction of large stones with grasping forceps can be an alternative approach instead of extracorporeal shock wave lithotripsy or surgery when stones are impacted at the papilla's orifice and partially protruding into the duodenal lumen.
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Affiliation(s)
- Qin Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu
| | - Yiping Wang
- Department of Gastroenterology, Affiliated Cixi People's Hospital, Wenzhou Medical University, Ningbo, Zhejiang, China
| | - Hongze Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu
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8
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Duct Diameter and Size of Stones Predict Successful Extracorporeal Shock Wave Lithotripsy and Endoscopic Clearance in Patients With Chronic Pancreatitis and Pancreaticolithiasis. Pancreas 2016; 45:1208-11. [PMID: 26967455 DOI: 10.1097/mpa.0000000000000622] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The need for endoscopic therapy before extracorporeal shock wave lithotripsy (SWL) to facilitate pancreatic duct stone removal is unclear. Predictive factors associated with successful fragmentation and subsequent complete duct clearance are variable. We hypothesize pancreatic duct strictures and large stones, but not pre-SWL endotherapy, correlate with successful fragmentation and complete duct clearance. METHODS A retrospective cohort study of patients with pancreaticolithiasis who underwent SWL and endoscopic retrograde cholangiopancreatography between January 2009 and June 2014 was evaluated. RESULTS Thirty-seven patients were treated. Technical success (TS) of fragmentation was achieved in 22 patients (60%). Technical success was associated with fewer stones and SWL sessions and smaller stone and duct size. By multivariate logistic regression, only duct dilation was associated with TS. Endoscopic success of complete duct clearance was achieved in 29 patients (80%). Endoscopic success was more frequent with stones 12 mm or less and with successful TS. By multivariate logistic regression, stones greater than 12 mm were associated with endoscopic failure. CONCLUSIONS Pre-SWL endotherapy does not affect stone fragmentation. Patients with a dilated duct (>8 mm) and pancreatic stones 12 mm or greater were associated with unsuccessful TS and endoscopic success, respectively, and may benefit from early referral for surgical decompression.
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9
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Hobbs PM, Johnson WG, Graham DY. Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World J Gastrointest Pharmacol Ther 2016; 7:370-386. [PMID: 27602238 PMCID: PMC4986390 DOI: 10.4292/wjgpt.v7.i3.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.
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10
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Abstract
The early phase of both acute and chronic pancreatitis can be characterized by disrupt level and function of the cystic fibrosis transmembrane conductance regulator (CFTR) Cl(-) channel, decreased bicarbonate secretion, intraductal acidosis, decrease of fluid secretion and elevation of mucoprotein levels. It is almost needless to say that these intrapancreatic changes are very similar to the pathophysiological changes observed in cystic fibrosis. The aim of this mini review is to describe the development of the above mentioned pathological observations in details, moreover highlight some future therapeutic opportunities in pancreatitis.
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Affiliation(s)
- Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- First Department of Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Momentum Translational Gastroenterology Research Group, Szeged, Hungary.
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11
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Reed AM, Kolodecik T, Husain SZ, Gorelick FS. Low pH enhances connexin32 degradation in the pancreatic acinar cell. Am J Physiol Gastrointest Liver Physiol 2014; 307:G24-32. [PMID: 24812055 PMCID: PMC4080162 DOI: 10.1152/ajpgi.00010.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/22/2014] [Indexed: 01/31/2023]
Abstract
Decreased extracellular pH is observed in a number of clinical conditions and can sensitize to the development and worsen the severity of acute pancreatitis. Because intercellular communication through gap junctions is pH-sensitive and modulates pancreatitis responses, we evaluated the effects of low pH on gap junctions in the rat pancreatic acinar cell. Decreasing extracellular pH from 7.4 to 7.0 significantly inhibited gap junctional intracellular communication. Acidic pH also significantly reduced levels of connexin32, the predominant gap junction protein in acinar cells, and altered its localization. Increased degradation through the proteasomal, lysosomal, and autophagic pathways mediated the decrease in connexin32 under low-pH conditions. These findings provide the first evidence that low extracellular pH can regulate gap junctional intercellular communication by enhancing connexin degradation.
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Affiliation(s)
- Anamika M Reed
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut;
| | - Thomas Kolodecik
- Veterans Affairs Healthcare System, West Haven, Connecticut; and
| | - Sohail Z Husain
- Division of Pediatric Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Fred S Gorelick
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut; Veterans Affairs Healthcare System, West Haven, Connecticut; and
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Abstract
PRACTICAL RELEVANCE Pancreatitis is a frequent finding in cats, the chronic form being more common than the acute form. Despite the large number of diseases or conditions that may be associated with feline pancreatitis, in most cases no cause is diagnosed and the pancreatitis is said to be idiopathic. The chronic form can be mild and asymptomatic, and has a high prevalence in apparently healthy cats. This has generated debate concerning the clinical significance of chronic feline pancreatitis. However, several reports have demonstrated the severity of clinical signs in certain forms of acute feline pancreatitis, while other studies have reported a strong association between chronic pancreatitis and the development of comorbidities such as hepatic lipidosis, diabetes mellitus, inflammatory bowel disease or exocrine pancreatic insufficiency. This suggests that feline pancreatitis should not be overlooked. CLINICAL CHALLENGES Diagnosis of feline pancreatitis is complicated by the non-specific clinical signs and poor diagnostic value of basic biochemistry and haematology or imaging techniques. Development of a feline-specific pancreatic lipase immunoassay has improved our diagnostic ability in the past decade, but may have more limited application for mild and chronic forms of pancreatitis. Moreover, histopathology (the 'gold standard' diagnostic test) can be associated with false-negative results due to multifocal distribution of lesions or mild forms of the disease. With respect to treatment, it is important to take into account the idiosyncrasies of the feline species when considering medical therapies. EVIDENCE BASE This article reviews the literature on feline pancreatitis, focusing on the different forms and their relative clinical significance, while explaining difficulties inherent in the diagnosis of this disease. An overview of current recommendations for the management of cats with pancreatitis is also provided.
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Affiliation(s)
- Julien Bazelle
- Willows Veterinary Centre and Referral Service, Shirley, Solihull, West Midlands, B90 4NH, UK
| | - Penny Watson
- Queen’s Veterinary School Hospital, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK
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Abstract
Pancreatic stenting for patients with obstructive pain secondary to a malignant pancreatic duct stricture is safe and effective, and should be considered a therapeutic option. Although pancreatic stenting does not seem to be effective for patients with chronic pain, it may be beneficial in those with obstructive type pains, pancreatic duct disruption, or smoldering pancreatitis. Fully covered metal stents may be an option, but data on their use are limited. Further studies, including prospective randomized studies comparing plastic and metal stents in these indications, are needed to further validate and confirm these results.
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Dhyani AH, Fan X, Leoni L, Haque M, Roman BB. Empirical mathematical model for dynamic manganese-enhanced MRI of the murine pancreas for assessment of β-cell function. Magn Reson Imaging 2012; 31:508-14. [PMID: 23102946 DOI: 10.1016/j.mri.2012.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/11/2012] [Accepted: 09/12/2012] [Indexed: 12/25/2022]
Abstract
Autoimmune ablation of pancreatic β-cells and alteration of its microvasculature may be a predictor of Type I diabetes development. A dynamic manganese-enhanced MRI (MEMRI) approach and an empirical mathematical model were developed to monitor whole pancreatic β-cell function and vasculature modifications in mice. Normal and streptozotocin-induced diabetic FVB/N mice were imaged on a 9.4T MRI system using a 3D magnetization prepared rapid acquisition gradient echo pulse sequence to characterize low dose manganese kinetics in the pancreas head, body and tail. Average signal enhancement in the pancreas (head, body, and tail) as a function of time was fit by a novel empirical mathematical model characterizing contrast uptake/washout rates and yielding parameters describing peak signal, initial slope, and initial area under the curve. Signal enhancement from glucose-induced manganese uptake was fit by a linear function. The results demonstrated that the diabetic pancreatic tail had a significantly lower contrast uptake rate, smaller initial slope/initial area under the curve, and a smaller rate of Mn uptake following glucose activation (p<0.05) compared to the normal pancreatic tail. These observations parallel known patterns of β-cell loss and alteration in supportive vasculature associated with diabetes. Dynamic MEMRI is a promising technique for assessing β-cell functionality and vascular perfusion with potential applications for monitoring diabetes progression and/or therapy.
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Affiliation(s)
- Anita H Dhyani
- Department of Radiology, MC2026, University of Chicago, Chicago, IL 60637, USA
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Bramis K, Gordon-Weeks AN, Friend PJ, Bastin E, Burls A, Silva MA, Dennison AR. Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Br J Surg 2012; 99:761-6. [PMID: 22434330 DOI: 10.1002/bjs.8713] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Total pancreatectomy and islet autotransplantation (TP/IAT) is a treatment option in a subset of patients with chronic pancreatitis. A systematic review of the literature was performed to evaluate the outcome of this procedure, with an attempt to ascertain when it is indicated. METHODS MEDLINE (1950 to present), Embase (1980 to present) and the Cochrane Library were searched to identify studies of outcomes in patients undergoing TP/IAT. Cohort studies that reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review. RESULTS Five studies met the inclusion criteria. The techniques reported for pancreatectomy and islet cell isolation varied between studies. TP/IAT was successful in reducing pain in patients with chronic pancreatitis. Comparing morphine requirements before and after the procedure, two studies recorded significant reductions. Concurrent IAT reduced the insulin requirement after TP; the rate of insulin independence ranged from 46 per cent of patients at 5 years' mean follow-up to 10 per cent at 8 years. The impact on quality of life was poorly reported. The studies reviewed did not provide evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis. CONCLUSION This systematic review showed that TP/IAT had favourable outcomes with regard to pain reduction. Concurrent IAT enabled a significant proportion of patients to remain independent of insulin supplementation.
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Affiliation(s)
- K Bramis
- Department of Hepatobiliary and Transplant Surgery, Churchill Hospital, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
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Shu J, Zhang XM, Zhao JN, Yang L, Zeng NL, Zhai ZH. DCE-MRI in experimental chronic pancreatitis. CONTRAST MEDIA & MOLECULAR IMAGING 2009; 4:127-34. [PMID: 19330791 DOI: 10.1002/cmmi.273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To assess pancreatic perfusion in experimental chronic pancreatitis (CP) by dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). DCE MRI on a 1.5 T MR scanner was performed on 21 piglets with the ligation of pancreatic duct. They were divided into four groups based on pathology, including seven normal pigs and seven, three and four piglets with grade I, II and III CP, respectively. The signal intensity measured in the pancreatic body on DCE MRI was plotted against time to create a signal intensity-time (SI-T) curve for each piglet. The steepest slope (SS), time-to-peak (TTP) and peak enhancement ratio (PER) of the SI-T curve were noted. In the four groups, on the SI-T curve derived from DCE MRI, the SS was, respectively, 10.88 +/- 1.20, 10.59 +/- 1.02, 6.67 +/- 1.31 and 5.48 +/- 1.97%/s (F = 20.509, p = 0.000) from normal piglets to piglets with grade III CP. The TTP was 13.82 +/- 3.09, 12.31 +/- 5.52, 20.55 +/- 3.79 and 37.26 +/- 14.56 s (F = 10.681, p = 0.000) and the PER was 62.95 +/- 20.20, 60.44 +/- 20.00, 46.33 +/- 22.70 and 67.65 +/- 32.66% (F = 0.529, p = 0.668), respectively. The SS (r = -0.719, p = 0.000) and TTP (r = 0.538, p = 0.012) of the SI-T curve was correlated to the severity of CP, respectively. DCE MRI has a potential to diagnose moderate to advanced CP. The SS and TTP of the SI-T curve were correlated to the severity of CP.
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Affiliation(s)
- Jian Shu
- Department of Radiology, the Second Affiliated Hospital Of Chongqing Medical University, Chongqing, People's Republic of China
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Bhoomagoud M, Jung T, Atladottir J, Kolodecik TR, Shugrue C, Chaudhuri A, Thrower EC, Gorelick FS. Reducing extracellular pH sensitizes the acinar cell to secretagogue-induced pancreatitis responses in rats. Gastroenterology 2009; 137:1083-92. [PMID: 19454288 PMCID: PMC2736307 DOI: 10.1053/j.gastro.2009.05.041] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 04/23/2009] [Accepted: 05/14/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Protease activation within the pancreatic acinar cell is a key early event in acute pancreatitis and may require low pH intracellular compartments. Clinical studies suggest that acidosis may affect the risk for developing pancreatitis. We hypothesized that exposure to an acid load might sensitize the acinar cell to secretagogue-induced pancreatitis. METHODS Secretagogues (cerulein, carbachol, and bombesin) can induce protease activation in acinar cells at high (100 nmol/L, 1 mmol/L, and 10 micromol/L, respectively) but not at physiologically relevant concentrations. The effects of decreasing extracellular pH (pHe) in early secretagogue-induced pancreatitis (zymogen activation and injury) were examined in rats (1) in vitro with isolated acini and (2) in vivo with an acid challenge. RESULTS In acini, lowering pHe from 7.6 to 6.8 enhanced secretagogue-induced zymogen activation and injury, but did not affect secretion. For cerulein, this sensitization was seen over a range of concentrations (0.01-100.00 nmol/L). However, reduced pHe alone had no effect on zymogen activation, amylase secretion, or cell injury. We have reported that zymogen activation is mediated by the vacuolar ATPase (vATPase), a proton transporter. vATPase inhibition, using concanamycin (100 nmol/L), blocked the low pHe effects on zymogen activation. An acute acid load given in vivo enhanced cerulein-induced (50 microg/kg) trypsinogen activation and pancreatic edema. CONCLUSION These studies suggest that acid challenge sensitizes the pancreatic acinar cell to secretagogue-induced zymogen activation and injury and may increase the risk for the development and severity of acute pancreatitis.
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Affiliation(s)
- Madhavi Bhoomagoud
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas Jung
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jorunn Atladottir
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas R Kolodecik
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christine Shugrue
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Anamika Chaudhuri
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edwin C Thrower
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Fred S Gorelick
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut,Department of Veterans Affairs Connecticut Healthcare, West Haven, Connecticut,Department of Cell Biology, Yale University School of Medicine, New Haven, Connecticut
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Kotzampassi K, Grosomanidis B, Dadoukis D, Eleftheriadis E. Retroperitoneal compartment pressure elevation impairs pancreatic tissue blood flow. Pancreas 2007; 35:169-72. [PMID: 17632324 DOI: 10.1097/01.mpa.0000281355.67633.8e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To investigate whether the increase of the retroperitoneal compartment pressure, as in the case of peripancreatic fluid accumulation in severe acute pancreatitis, simulated by infusing a colloid fluid into the retroperitoneum, has any effect on pancreatic tissue blood flow. METHODS Six male anesthetized swine were subjected to a transcutaneous placement of catheters into the retroperitoneal space. Through these catheters, a colloid solution was infused, under continuous retroperitoneal pressure monitoring, to achieve a pressure up to 20 mm Hg. Pancreatic tissue blood flow was assessed by colored microsphere injection technique, and pancreatic interstitial pressure was measured by means of a commercially available pressure monitor system before and after the distension of the retroperitoneal space, allowing the appropriate time for the animals to be stabilized from any intervention. RESULTS The increase in the retroperitoneal compartment pressure was found to significantly increase pancreatic interstitial pressure (from 8 +/- 1 to 20 +/- 2.4 mm Hg, P = 0.001) as well as reduce pancreatic tissue blood flow (from 1.75 +/- 0.4 to 0.56 +/- 0.12 mL . min . g, P = 0.002). CONCLUSIONS The increase of retroperitoneal pressure leads to an impairment of pancreatic tissue blood flow in the healthy pancreas. Although these findings support the hypothesis that peripancreatic fluid collection during the course of acute pancreatitis could contribute or augment pancreatic tissue ischemia, further assessment is necessary.
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Affiliation(s)
- Katerina Kotzampassi
- Department of Surgery, University of Thessaloniki Medical School, Thessaloniki, Greece
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Sakorafas GH, Tsiotou AG, Peros G. Mechanisms and natural history of pain in chronic pancreatitis: a surgical perspective. J Clin Gastroenterol 2007; 41:689-99. [PMID: 17667054 DOI: 10.1097/mcg.0b013e3180301baf] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pain is a major clinical manifestation of chronic pancreatitis (CP) and a common indication for surgery in these patients. Pathogenesis of pain in CP is multifactorial and the mechanisms of pain may differ from patient to patient. This can explain why one therapeutic method of treatment of pain does not work in all patients and in different stages of the disease. Two main complimentary pathogenetic theories have been proposed to explain the mechanisms of pain in CP, the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. According to the neurogenic theory, in CP there are alterations of pancreatic/peripancreatic nerves, exposing them to noxious substances and/or activated immune cells, thereby generating pain ("neuroimmune interaction"). The other theory of intraductal/intraparenchymal hypertension suggests that pain in CP is generated as a result of increased pressures within the pancreatic ductal system and/or pancreatic parenchyma, like the pain in the classic compartment syndrome. The theory of intraductal/intraparenchymal hypertension is strongly supported by the good results of drainage procedures in the surgical management of CP. Pancreatic ischemia, oxygen-free radicals, centrally sensitized pain state, acute exacerbations of CP, development of complications from the pancreas (most commonly, pseudocysts) or adjacent organs (usually, duodenal and/or common bile duct stenosis), etc. are other possible contributing factors. Different patterns of pain have been described in idiopathic (early vs. late onset) and in alcoholic CP. Interestingly, pain is automatically relieved during the natural course of the disease in some patients (the "burn-out" phenomenon), after a relatively long time (from a few years to up to 3 decades). However, this is an unpredictable evolution for the individual patient. Therefore, surgery should be offered when pain is intense and after failure of conservative treatment. Surgical management should be individualized, depending on the particular findings of each patient. The knowledge of the pathophysiologic basis and of natural course of pain in CP is of paramount importance for the surgeon to select appropriate therapy for the individual patient with CP.
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Affiliation(s)
- George H Sakorafas
- Fourth Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Athens, Greece.
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Page JM, Vinson SL, Jones DP. Complex pancreatic duct stricture with stone versus partial pancreas divisum: a therapeutic dilemma. Dig Dis Sci 2007; 52:1621-6. [PMID: 17091390 DOI: 10.1007/s10620-005-9001-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Accepted: 08/15/2005] [Indexed: 12/09/2022]
Affiliation(s)
- John M Page
- Department of Gastroenterology, Brooke Army Medical Center, FT Sam Houston, TX 78234, USA.
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Balci NC, Alkaade S, Akduman IE, Bilgin M, Murdock CP, Burton FR. Serial contrast-enhanced MRI of the pancreas: correlation with secretin-stimulated endoscopic pancreatic function test. Acad Radiol 2006; 13:1367-72. [PMID: 17070454 DOI: 10.1016/j.acra.2006.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 08/14/2006] [Accepted: 08/15/2006] [Indexed: 12/15/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to determine the relationship between the pancreatic enhancement on serial contrast-enhanced MRI (CEMRI) and pancreatic exocrine function using the secretin-stimulated endoscopic pancreatic function test (ePFT). MATERIALS AND METHODS A total of 30 patients with clinical symptoms consistent with chronic pancreatitis underwent CEMRI of the abdomen and ePFT within a 1- to 4-week interval. CEMRI was performed in arterial, early venous, and late venous phases. Secretin ePFT was performed with the measurement of HCO(3) concentration from the duodenal aspirates after secretin stimulation. Contrast enhancement ratio of the arterial phase to early venous phase was measured on CEMRI (SIRa/SIRv). A three-point evaluation system was used for grading the HCO(3) concentration and the enhancement ratio on MRI. For the significance of correlation, kappa statistics was used. Sensitivity and specificity of CEMRI was determined for the diagnosis of early chronic pancreatitis accepting ePFT as a reference. RESULTS Twenty patients had identical scores on both secretin ePFT and CEMRI. Ten patients revealed discrepancy in scores. Kappa statistics revealed moderate agreement between MRI and ePFT (kappa = 0.44). Sensitivity and specificity values for the diagnosis of pancreatitis were 82% and 57%, respectively. Positive predictive value was 56%, and negative predictive value was 86%. CONCLUSION The results of our data indicate that serial CEMRI is an appropriate imaging technique to rule out early chronic pancreatitis. However, secretin-stimulated imaging or ePFT may still be needed for the definite diagnosis of pancreatic exocrine dysfunction.
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Affiliation(s)
- N Cem Balci
- Department of Radiology, Saint Louis University, St. Louis, MO; and Giessen-Marburg University Giessen, Germany.
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Coenegrachts K, Van Steenbergen W, De Keyzer F, Vanbeckevoort D, Bielen D, Chen F, Dockx S, Maes F, Bosmans H. Dynamic contrast-enhanced MRI of the pancreas: initial results in healthy volunteers and patients with chronic pancreatitis. J Magn Reson Imaging 2005; 20:990-7. [PMID: 15558558 DOI: 10.1002/jmri.20212] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To characterize pancreatic perfusion in volunteers and patients with chronic pancreatitis (CP) by dynamic contrast-enhanced (DCE) MRI. MATERIALS AND METHODS Pancreatic enhancement after bolus injection of Gd-DTPA with a three-dimensional ultrafast partial-Fourier radiofrequency (RF) spoiled gradient-echo (GE) acquisition was examined prospectively. An acquisition volume of the pancreatic parenchyma was obtained every 4.2 seconds during a single breath-hold in 31 volunteers and 19 patients with CP. We calculated the wash-in rate and a newly defined parameter, the "time-to-inflow deceleration" (TID). A statistical analysis of the differences between both groups was performed with the use of Student's t-test. RESULTS Significant differences in the TID and wash-in rate were found for the head and body of the pancreas: the TID was 22.4 sec +/- 4.4 sec and 23.5 sec +/- 6.1 sec in the pancreatic head and body of the healthy volunteers, and 29.8 sec +/- 8.6 sec and 29.4 sec +/- 3.8 sec in patients with CP. The wash-in rate was 96 +/- 37 sec(-1) and 101 +/- 27 sec(-1) in controls, and 62 +/- 17 sec(-1) and 75 +/- 27 sec(-1) in CP. CONCLUSION CP can be identified by semiquantitative changes on DCE-MRI. Whether DCE-MRI of the pancreas can be used to detect early CP remains to be validated.
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Affiliation(s)
- Kenneth Coenegrachts
- Department of Radiology, University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium.
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Chen YD, Zhou ZG, Wang Z, Gao HK, Yan WW, Wang C, Zhao GP, Peng XH. Pituitary adenylate cyclase activating-peptide and its receptor antagonists in development of acute pancreatitis in rats. World J Gastroenterol 2005; 11:538-44. [PMID: 15641142 PMCID: PMC4250807 DOI: 10.3748/wjg.v11.i4.538] [Citation(s) in RCA: 7] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: Pituitary adenylate cyclase activating-peptide (PACAP) is a late member of the secretin/glucagon/vasoactive intestinal peptide (VIP) family of brain-gut peptides. It is unknown whether PACAP takes part in the development of acute pancreatitis and whether PACAP or its antagonists can be used to suppress the progression of acute pancreatitis. We investigated the actions of PACAP and its receptor antagonists in acute pancreatitis on rats.
METHODS: Acute pancreatitis was induced in rats with caerulein or 3.5% sodium taurocholate. The rats were continuously infused with 5-30 μg/kg PACAP via jugular vein within the first 90 min, while 10-100 μg/kg PACAP6-27 and (4-Cl-D-Phe6, Leu17) VIP (PACAP receptor antagonists) were intravenously infused for 1 h. Biochemical and histopathological assessments were made at 4 h after infusion. Pancreatic and duodenal PACAP concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Chinese ink-perfused pancreas was fixed, sectioned and cleared for counting the functional capillary density.
RESULTS: PACAP augmented caerulein-induced pancreatitis and failed to ameliorate sodium taurocholate-induced pancreatitis. ELISA revealed that relative concentrations of PACAP in pancreas and duodenum were significantly increased in both sodium taurocholate- and caerulein-induced pancreatitis compared with those in normal controls. Unexpectedly, PACAP6-27 and (4-Cl-D-Phe6, Leu17) VIP could induce mild acute pancreatitis and aggravate caerulein-induced pancreatitis with characteristic manifestations of acute hemorrhagic/necrotizing pancreatitis. Functional capillary density of pancreas was interpreted in the context of pancreatic edema, and calibrated functional capillary density (calibrated FCD), which combined measurement of functional capillary density with dry weight/wet weight ratio, was introduced. Hyperemia or congestion, rather than ischemia, characterized pancreatic microcirculatory changes in acute pancreatitis.
CONCLUSION: PACAP may take part in the pathogenesis of acute pancreatitis in rats. The two PACAP receptor antagonsits might act as partial agonists. Calibrated functional capillary density can reflect pancreatic microcirculatory changes in acute pancreatitis.
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Affiliation(s)
- You-Dai Chen
- Instistute of Digestive Surgery/ Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Watanabe S, Nagashio Y, Asaumi H, Nomiyama Y, Taguchi M, Tashiro M, Kihara Y, Nakamura H, Otsuki M. Pressure activates rat pancreatic stellate cells. Am J Physiol Gastrointest Liver Physiol 2004; 287:G1175-81. [PMID: 15319186 DOI: 10.1152/ajpgi.00339.2004] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pancreatic stellate cells (PSCs) play a central role in development of pancreatic fibrosis. In chronic pancreatitis, pancreatic tissue pressure is higher than that of the normal pancreas. We here evaluate the effects of pressure on the activation of rat PSCs. PSCs were isolated from the pancreas of Wistar rat using collagenase digestion and centrifugation with Nycodenz gradient. Pressure was applied to cultured rat PSCs by adding compressed helium gas into the pressure-loading apparatus to raise the internal pressure. Cell proliferation rate was assessed by 5-bromo-2'-deoxyuridine (BrdU) incorporation. MAPK protein levels and alpha-smooth muscle actin (alpha-SMA) expression were evaluated by Western blot analysis. Concentration of activated transforming growth factor-beta1 (TGF-beta1) secreted from PSCs into culture medium was determined by ELISA. Collagen type I mRNA expression and collagen secretion were assessed by quantitative PCR and Sirius red dye binding assay, respectively. Application of pressure significantly increased BrdU incorporation and alpha-SMA expression. In addition, pressure rapidly increased the phosphorylation of p44/42 and p38 MAPK. Treatment of PSCs with an MEK inhibitor and p38 MAPK inhibitor suppressed pressure-induced cell proliferation and alpha-SMA expression, respectively. Moreover, pressure significantly promoted activated TGF-beta1 secretion, collagen type I mRNA expression, and collagen secretion. Our results demonstrate that pressure itself activates rat PSCs and suggest that increased pancreatic tissue pressure may accelerate the development of pancreatic fibrosis in chronic pancreatitis.
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Affiliation(s)
- Shiro Watanabe
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
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Stevens T, Conwell DL, Zuccaro G. Pathogenesis of chronic pancreatitis: an evidence-based review of past theories and recent developments. Am J Gastroenterol 2004; 99:2256-70. [PMID: 15555009 DOI: 10.1111/j.1572-0241.2004.40694.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the past several decades, four prominent theories of chronic pancreatitis pathogenesis have emerged: the toxic-metabolic theory, the oxidative stress hypothesis, the stone and duct obstruction theory, and the necrosis-fibrosis hypothesis. Although these traditional theories are formulated based on compelling scientific observations, substantial contradictory data also exist for each. Furthermore, the basic premises of some of these theories are directly contradictory. Because of the recent scientific progress in the underlying genetic, cellular, and molecular pathophysiology, there have been substantial advances in the understanding of chronic pancreatitis pathogenesis. This paper will provide an evidence-based review and critique of the traditional pathogenic theories, followed by a discussion of the new advances in pancreatic fibrogenesis. Moreover, we will discuss plausible pathogenic sequences applied to each of the known etiologies.
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Affiliation(s)
- Tyler Stevens
- The Pancreas Clinic, Section of Endoscopy and Pancreaticobiliary Disease, Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio 44118, USA
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McKim SE, Uesugi T, Raleigh JA, McClain CJ, Arteel GE. Chronic intragastric alcohol exposure causes hypoxia and oxidative stress in the rat pancreas. Arch Biochem Biophys 2003; 417:34-43. [PMID: 12921777 DOI: 10.1016/s0003-9861(03)00349-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The effect of chronic enteral ethanol on pancreatic hypoxia was investigated using the hypoxia marker, pimonidazole. Male Wistar rats were fed an ethanol-containing diet for 3 weeks using an enteral model shown to cause pancreatic damage; pimonidazole (120 mg/kg i.v.) was injected 1h before sacrifice. Pimonidazole and 4-hydroxynonenal (an index of lipid peroxidation) adducts were detected immunochemically. Breathing air with low oxygen content (8% O(2)) for 1h increased pimonidazole adduct accumulation approximately 2-fold in pancreata of nai;ve rats, confirming that this technique will detect increases in hypoxia in pancreata. Pancreata of rats fed ethanol began to show signs of damage after 3 weeks. Ethanol feeding also significantly increased pimonidazole adducts in pancreas approximately 2-fold (1 or 3 weeks of ethanol produced similar values). Concomitant with increasing hypoxia in the pancreas, alcohol also caused a significant increase in 4-hydroxynonenal adducts, indicative of increased oxidative stress. These results indicate that chronic ethanol causes hypoxia at the cellular level in the pancreas in vivo; further, the data support the hypothesis that hypoxia is involved in mechanisms of chronic alcoholic pancreatitis.
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Affiliation(s)
- Stephen E McKim
- Laboratory of Hepatobiology and Toxicology, Department of Pharmacology, University of North Carolina, Chapel Hill, NC, USA
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Schmidt J, Ebeling D, Ryschich E, Werner J, Gebhard MM, Klar E. Pancreatic capillary blood flow in an improved model of necrotizing pancreatitis in the rat. J Surg Res 2002; 106:335-41. [PMID: 12175989 DOI: 10.1006/jsre.2002.6464] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The development of acute pancreatitis is characterized by profound changes in pancreatic microcirculation. Using in vivo microscopy with fluorescent-labeled erythrocytes as tracers we studied changes in pancreatic microcirculation in an improved rat model of necrotizing pancreatitis (NP) in comparison to edematous pancreatitis (EP) and healthy controls. METHODS Twenty-one male Wistar rats had their pancreatae exteriorized in a temperature-controlled immersion chamber followed by intravenous administration of fluorescent-labeled autologous erythrocytes. EP was induced by intraductal saline and intravenous caerulein (5 microg/kg/h) for 6 h (n = 7) and NP by controlled intraductal infusion of glycodeoxycholic acid (10 mmol/L) followed by intravenous caerulein (n = 7). Control animals received intraductal and intravenous saline (n = 7). The determination of pancreatic microcirculation was performed before as well as 1, 3, and 6 h after intraductal infusion by correlating the number of passing labeled erythrocytes/capillary/min with their concentration per microliter of arterial blood. RESULTS Pancreatic capillary flow in control animals remained constant over the 6-h observation period. Pancreatic capillary flow in the EP group rapidly increased to 188% of baseline after 3 h and remained significantly elevated throughout the experiments (P = 0.0001). In contrast, pancreatic capillary flow decreased significantly in the group suffering NP with values 46.7% of baseline after 6 h (P = 0.0001). Complete capillary stasis developed in 38% of investigated capillaries in the NP group compared to 0-1% in both other groups (P = 0.0001). CONCLUSION Pancreatic microcirculation in mild edematous pancreatitis is significantly increased while the evolution of necrotizing pancreatitis in the model studied herein is characterized by a dramatic reduction in pancreatic capillary flow in conjunction with areas of capillary stasis. These results underline the pathophysiologic relevance of the model and of therapeutic measures aimed at an improvement of pancreatic microcirculation in clinical necrotizing pancreatitis.
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Affiliation(s)
- Jan Schmidt
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
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Demols A, Van Laethem JL, Quertinmont E, Degraef C, Delhaye M, Geerts A, Deviere J. Endogenous interleukin-10 modulates fibrosis and regeneration in experimental chronic pancreatitis. Am J Physiol Gastrointest Liver Physiol 2002; 282:G1105-12. [PMID: 12016137 DOI: 10.1152/ajpgi.00431.2001] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Interleukin (IL)-10, a potent anti-inflammatory cytokine, limits the severity of acute pancreatitis and downregulates transforming growth factor (TGF)-beta release by inflammatory cells on stimulation. Proinflammatory mediators, reactive oxygen species, and TGF-beta can activate pancreatic stellate cells and their synthesis of collagen I and III. This study evaluates the role of endogenous IL-10 in the modulation of the regeneration phase following acute pancreatitis and in the development of pancreatic fibrosis. IL-10 knockout (KO) mice and their C57BL/6 controls were submitted to repeated courses (3/wk, during 6 wk, followed by 1 wk of recovery) of cerulein-induced acute pancreatitis. TGF-beta(1) release was measured on plasma, and its pancreatic expression was assessed by quantitative RT-PCR and immunohistochemistry. Intrapancreatic IL-10 gene expression was assessed by semiquantitative RT-PCR, and intrapancreatic collagen content was assessed by picrosirius staining. Activated stellate cells were detected by immunohistochemistry. S phase intrapancreatic cells were marked using tritiated thymidine labeling. After repeated acute pancreatitis, IL-10 KO mice had more severe histological lesions and fibrosis (intrapancreatic collagen content) than controls. TGF-beta(1) plasma levels, intrapancreatic transcription, and expression by ductal and interstitial cells, as well as the number of activated stellate cells, were significantly higher. IL-10 KO mice disclosed significantly fewer acinar cells in S phase, whereas the opposite was observed for pseudotubular cells. Endogenous IL-10 controls the regeneration phase and limits the severity of fibrosis and glandular atrophy induced by repeated episodes of acute pancreatitis in mice.
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Affiliation(s)
- Anne Demols
- Department of Gastroenterology, Hôpital Erasme and Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, B 1070 Brussels, Belgium.
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Affiliation(s)
- R J Washabau
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104-6010, USA
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Ulrich CD, Kopras E, Wu Y, Ward S. Hereditary pancreatitis: epidemiology, molecules, mutations, and models. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2000; 136:260-74. [PMID: 11039846 DOI: 10.1067/mlc.2000.109405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- C D Ulrich
- Department of Internal Medicine, University of Cincinnati, OH, USA
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Lewis MP, Lo SK, Reber PU, Patel A, Gloor B, Todd KE, Toyama MT, Sherman S, Ashley SW, Reber HA. Endoscopic measurement of pancreatic tissue perfusion in patients with chronic pancreatitis and control patients. Gastrointest Endosc 2000; 51:195-9. [PMID: 10650267 DOI: 10.1016/s0016-5107(00)70417-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic blood flow is diminished in experimental models of acute and chronic pancreatitis. We attempted to develop a safe and reliable technique for its measurement in patients and to examine blood flow in patients with chronic pancreatitis and in control subjects. METHOD Pancreatic blood flow was measured using the hydrogen gas clearance technique and an endoscopically placed platinum ductal electrode. Pancreatic blood flow was measured in 12 patients with chronic pancreatitis diagnosed clinically and radiographically, and in 11 control patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for non-pancreatic pathology. RESULTS Patients with chronic pancreatitis had a significantly lower pancreatic blood flow compared with control patients (51.5 versus 91.7 mL/min/100 gm, p < 0.01). With secretin stimulation pancreatic blood flow increased in two control patients, whereas this notable rise was not seen in three patients with chronic pancreatitis. CONCLUSIONS Measurement of pancreatic blood flow with an endoscopically placed electrode is relatively safe and simple to perform. The scarring and vascular fibrosis associated histologically with chronic pancreatitis is reflected in lower pancreatic blood flow.
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Affiliation(s)
- M P Lewis
- Department of Surgery, Addenbrookes Hospital, Cambridge, United Kingdom
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Patel AG, Reber PU, Toyama MT, Ashley SW, Reber HA. Effect of pancreaticojejunostomy on fibrosis, pancreatic blood flow, and interstitial pH in chronic pancreatitis: a feline model. Ann Surg 1999; 230:672-9. [PMID: 10561091 PMCID: PMC1420921 DOI: 10.1097/00000658-199911000-00009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study the relation between fibrosis, pancreatic blood flow (PMBF), interstitial pH (pHi), and the effects of pancreaticojejunostomy (PJ) in chronic pancreatitis. BACKGROUND Chronic pancreatitis is associated with low PMBF and pHi, suggesting the existence of underlying ischemia. METHODS In cats, the main pancreatic duct was partially obstructed and the animals were studied 2, 4, 6, and 8 weeks later. PJ was performed after 2 and 4 weeks of ductal obstruction and studied 4 weeks later. PMBF and pH were measured before and after stimulation with secretin and cholecystokinin. pHi was measured with microelectrodes, PMBF by hydrogen gas clearance. Histologic analysis of the pancreas with Sirius red (collagen stain) and fast green FCF (noncollagen protein) stains allowed semiquantitative analysis of the ratio between collagen and total protein (C/TP). RESULTS With the evolution of chronic pancreatitis, there is a progressive increase in the collagen content and C/TP ratio, a reduction in basal PMBF and pHi, and loss of the normal response to stimulation. Early PJ restores collagen content, C/TP ratio, and basal and stimulated PMBF and pHi to normal. PJ performed in established CP returns the C/TP ratio to normal, improves basal PMBF, and restores the normal hyperemic response to secretion. Basal pHi is improved and the "acid tide" associated with secretin returns, but there is still no response to cholecystokinin. CONCLUSIONS Pancreaticojejunostomy restores the elevated collagen and C/TP ratio to normal and reverses the ischemia present in CP. The authors speculate that restoration of PMBF and its normal response to stimulation allows "regeneration" and restoration of secretory function.
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Affiliation(s)
- A G Patel
- Department of Surgery, Sepulveda VA Medical Center, Los Angeles, California, USA
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Migita Y, Nakano I, Goto M, Ito T, Nawata H. Effect of pancreastatin on cerulein-stimulated pancreatic blood flow and exocrine secretion in anaesthetized rats. J Gastroenterol Hepatol 1999; 14:583-7. [PMID: 10385069 DOI: 10.1046/j.1440-1746.1999.01918.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Pancreastatin (PST) is an inhibitor of pancreatic exocrine secretion in vivo but not in vitro, which suggests that the inhibitory effect of PST is indirect, that is, not mediated by a specific receptor on pancreatic acinar cells. In this study, we investigated the effects of PST on pancreatic exocrine secretion and local pancreatic blood flow in anaesthetized rats to elucidate the participation of PST in indirect regulation of pancreatic exocrine function through blood supply. METHODS Pancreastatin (100, 200 or 500 pmol/kg per h) was administered intravenously under background infusion of cerulein (0.5 microg/kg per h), a cholecystokinin analogue. Pancreatic exocrine secretion was monitored by volume and protein output of the pancreatic juice and local pancreatic blood flow was measured by the hydrogen gas clearance method. RESULTS Pancreastatin significantly reduced cerulein-induced local pancreatic blood flow in a dose-dependent manner. Pancreatic exocrine secretion was also reduced significantly by PST dose-dependently. Pancreastatin did not change systemic blood pressure. These results suggested that the reduction of pancreatic blood flow is associated with the reduction of pancreatic exocrine secretion. CONCLUSIONS We conclude that the mechanism of PST-induced inhibition of pancreatic exocrine secretion is, at least, partly mediated by the reduction of local pancreatic blood flow through blockade, caused by the action of cerulein on pancreatic blood flow.
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Affiliation(s)
- Y Migita
- Third Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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Reber PU, Patel AG, Toyama MT, Ashley SW, Reber HA. Feline model of chronic obstructive pancreatitis: effects of acute pancreatic duct decompression on blood flow and interstitial pH. Scand J Gastroenterol 1999; 34:439-44. [PMID: 10365907 DOI: 10.1080/003655299750026489] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The mechanism by which duct decompression (DD) relieves pain in patients with chronic pancreatitis (CP) is unknown. CP is associated with increased tissue pressure (IP), low pancreatic microvascular blood flow (PMBF), and interstitial pH (pH(I)). The aims of this study were to examine the effects of acute DD on PMBF, increased IP, and pH(I) in cats with CP. METHODS The main pancreatic duct was partially obstructed. At 6 weeks PMBF (ml/min/100g H2 gas clearance), IP (mmHg needle electrode), and pH(I) (microelectrode) were measured before and after secretin stimulation. The duct was then opened, and the studies were repeated. RESULTS PMBF normally increased with secretin stimulation (118 +/- 20 versus 271 +/- 52, P < 0.05). IP was unaltered, and pH(I) decreased as hydrogen ions produced during bicarbonate secretion were dissipated (7.41 +/- 0.01 versus 7.38 +/- 0.01, P < 0.05). In CP, basal PMBF was lower than normal (51 +/- 6 versus 118 +/- 20, P < 0.05) and decreased with stimulation (51 +/- 3.5 versus 31 +/- 3.5, P < 0.05). Basal pancreatic IP was increased (3.47 +/- 0.7 versus 0.05 +/- 0.3, P < 0.05) and increased further with secretory stimulation (3.47 +/- 0.7 versus 4.41 +/- 0.7, P < 0.05) (a compartment syndrome). The low basal pancreatic pH(I) (7.23 +/- 0.02) did not change with secretin stimulation, since bicarbonate secretion was minimal. DD decreased IP (3.66 +/- 0.5 versus 2.81 +/- 0.5, P < 0.05) and increased PMBF (50 +/- 6 versus 79 +/- 6, P < 0.05) and pH(I) (7.24 +/- 0.02 versus 7.34 +/- 0.02, P < 0.05). The normal increase in PMBF after stimulation was restored (79 +/- 6 versus 218 +/- 54, P < 0.05). pH(I) now increased with stimulation (7.34 +/- 0.002 versus 7.37 +/- 0.002, P < 0.05), perhaps due to the marked hyperaemic response. CONCLUSIONS DD acutely restored basal and stimulated PMBF and IP towards normal. Basal pancreatic pH(I) also improved and reflects the underlying ischaemia.
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Affiliation(s)
- P U Reber
- Dept. of Surgery, Sepulveda VA Medical Center, UCLA School of Medicine, Los Angeles, California, USA
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Pap A, Topa L, Berger Z, Flautner L, Varró V. Pain relief and functional recovery after endoscopic interventions for chronic pancreatitis. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1998; 228:98-106. [PMID: 9867119 DOI: 10.1080/003655298750026624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pain and functional deterioration in chronic pancreatitis is multifactorial. Early surgery in non-alcoholic patients with mild to moderate chronic pancreatitis can relieve pain and prevent progression of pancreatic insufficiency for some time, but the good results are only short term. Endoscopic intervention can relieve pain and recover pancreatic function without surgery. METHODS AND RESULTS To achieve the burned out state of chronic pancreatitis, occlusion of the pancreatic duct was first attempted by our team with Ethibloc at ERCP. Temporary obstruction of the pancreatic duct did not result in a long-lasting symptom and relapse-free situation because of early recovery of pancreatic function. On the contrary, endoscopic simple and double papillotomy, pancreatic drainage with citrate lavage, biliary endoprosthesis with multiple stents and endoscopic decompression of pseudocysts with or without jejunal feeding resulted in pain-free patients for a considerable time and in several cases significant functional recovery occurred. In cases where pain remained, percutaneous celiac plexus block with long-lasting steroids can be applied and only if all of these treatments fail should surgery be recommended. CONCLUSION Endoscopic intervention can successfully substitute for surgery for chronic pancreatitis in individual cases.
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Affiliation(s)
- A Pap
- Second Dept. of Medicine, St. Imre Hospital, Budapest, Hungary
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Zhao P, Tu J, Martens A, Ponette E, Van Steenbergen W, Oord JV, Fevery J. Radiologic investigations and pathologic results of experimental chronic pancreatitis in cats. Acad Radiol 1998; 5:850-6. [PMID: 9862003 DOI: 10.1016/s1076-6332(98)80245-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study was to evaluate a variety of methods to induce chronic pancreatitis and its radiologic expression by experimentally inducing this condition in cats. MATERIALS AND METHODS Chronic inflammatory and fibrosing pancreatitis was produced in cats by intraductal injection of 1.5 mL of 94% ethanol in one group or by a combination of intraductal and intraparenchymal injection of ethanol together with partial obstruction of the main pancreatic duct to 70% of its original lumen by fixation of a small catheter in the papilla. For comparison, other cats underwent total obstruction of the main pancreatic duct. All groups, as well as untreated control cats (n = 3), underwent repeat laparotomy to obtain biopsy specimens. RESULTS Cats with total obstruction showed progressing fibrosis with dilatation of ductules occasionally infiltrated with granulocytes. From 26 weeks on, acini and islets of Lnagerhans became atrophic. Radiographs showed progressive but diffuse dilatation of ducts, ductules, and side branches. Cats from the other two groups had interlobular inflammation and fibrosis with flattened and irregular ductular epithelium. Later, ductular proliferation occurred, interstitial inflammation subsided, and fibrosis increased. Radiographs showed very irregular ducts and ductules with stenosis and dilatation. From 26 weeks on, no substantial differences were observed between the cats who received only intraductal injection of ethanol and the cats who underwent the combination of procedures. CONCLUSION The histopathologic and radiographic alterations that evolved from damage to the ductal epithelium in the cat resembled the features of chronic pancreatitis in humans and differed from those caused by total obstruction of the main pancreatic duct in cats.
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Affiliation(s)
- P Zhao
- Division of Liver and Pancreatic Diseases, Catholic University of Leuven, Belgium
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Reber PU, Patel AG, Lewis MP, Ashley SW, Reber HA. Stenting does not decompress the pancreatic duct as effectively as surgery in experimental chronic pancreatitis. Surgery 1998. [DOI: 10.1016/s0039-6060(98)70103-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Matos C, Devière J, Cremer M, Nicaise N, Struyven J, Metens T. Acinar filling during secretin-stimulated MR pancreatography. AJR Am J Roentgenol 1998; 171:165-9. [PMID: 9648781 DOI: 10.2214/ajr.171.1.9648781] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this study is to report a new sign, "acinar filling," observed on dynamic MR pancreatography after secretin stimulation in patients with suspected early chronic pancreatitis. CONCLUSION Acinar filling might reflect tissue hypertension or loss of pancreatic parenchyma compliance or both. This finding is probably an insensitive but specific sign of early chronic pancreatitis.
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Affiliation(s)
- C Matos
- Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Lewis MP, Reber HA, Ashley SW. Pancreatic blood flow and its role in the pathophysiology of pancreatitis. J Surg Res 1998; 75:81-9. [PMID: 9614861 DOI: 10.1006/jsre.1998.5268] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M P Lewis
- Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts 02115, USA
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Toyama MT, Patel AG, Nguyen T, Ashley SW, Reber HA. Effect of ethanol on pancreatic interstitial pH and blood flow in cats with chronic pancreatitis. Ann Surg 1997; 225:223-8. [PMID: 9065300 PMCID: PMC1190652 DOI: 10.1097/00000658-199702000-00011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the effects of ethanol on pancreatic blood flow and interstitial pH in chronic pancreatitis. BACKGROUND Ethanol is known to contribute to the development of both acute and chronic pancreatitis. However, it is unclear how ethanol precipitates episodes of acute pancreatic inflammation in the setting of chronic pancreatitis. In a model of chronic pancreatitis in cats, it is known that pancreatic blood flow is abnormally low and decreases further after ethanol ingestion. Because it is possible that this reduction in blood flow might be damaging to the pancreas, we investigated the effects of ethanol on pancreatic interstitial pH, an index of pancreatic ischemia. METHODS In normal cats and cats with obstructive chronic pancreatitis, pancreatic blood flow and interstitial pH were measured using the hydrogen gas clearance technique and pH microelectrode, respectively. RESULTS In normal cats, intragastric, but not intravenous, ethanol reduced both pancreatic blood flow by 62% (p < 0.05) and interstitial pH (7.38 +/- 0.03 to 7.20 +/- 0.03, p < 0.05). In cats with chronic pancreatitis in which basal pancreatic blood flow was already only 60% of normal flow, both intragastric and intravenous ethanol decreased both pancreatic blood flow (intragastric, 40% decrease, p < 0.05; intravenous, 34% decrease, p < 0.05) and interstitial pH (intragastric, 7.24 +/- 0.04 to 7.08 +/- 0.04, p < 0.05; intravenous 7.20 +/- 0.08 to 7.07 +/- 0.07, p < 0.05). CONCLUSIONS This profound decrease in pH, lasting up to 2 hours after ethanol exposure in the chronic pancreatitis animals, suggests the possibility of ischemic cellular damage to the pancreas. These findings may explain the pathogenesis of bouts of acute pancreatic inflammation after ethanol ingestion in the setting of chronic disease.
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Affiliation(s)
- M T Toyama
- Department of Surgery, Sepulveda VA Medical Center, Los Angeles, California, USA
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Toyama MT, Lewis MP, Kusske AM, Reber PU, Ashley SW, Reber HA. Ischaemia-reperfusion mechanisms in acute pancreatitis. Scand J Gastroenterol 1996. [PMID: 8865466 DOI: 10.3109/00365529609104994] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The role of ischaemia in the pathogenesis of acute pancreatitis is unknown. Some experimental studies have shown that ischaemia has little effect on the pancreas, while others have found an association with pancreatic injury. Ischaemia-reperfusion damage has been well documented in other sites such as the intestine, cardiac muscle, and skeletal muscle. However, in the pancreas, injury is usually seen only after complete ischaemia, which is uncommon clinically. Experimental chronic pancreatitis is characterized by low pancreatic blood flow, low interstitial pH, and impaired pancreatic tissue oxygenation, which are all findings consistent with the ischaemia-reperfusion mechanisms. Acute pancreatitis is also associated with a reduction in pancreatic blood flow and evidence of free radical generation, similarly suggesting the possibility of ischaemia-reperfusion injury. Ethanol ingestion, which is commonly associated clinically with both chronic and acute pancreatitis, may itself contribute to an ischaemic-reperfusion injury. We have shown that administration of ethanol to cats decreases pancreatic blood flow and may also directly activate neutrophils. Further investigation is needed to determine whether or not these findings are also associated with an ischaemia-reperfusion injury.
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Affiliation(s)
- M T Toyama
- Dept. of Surgery, Sepulveda VA Medical Center, Los Angeles, California, USA
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Kakugawa Y, Giaid A, Yanagisawa M, Baynash AG, Melnyk P, Rosenberg L, Duguid WP. Expression of endothelin-1 in pancreatic tissue of patients with chronic pancreatitis. J Pathol 1996; 178:78-83. [PMID: 8778321 DOI: 10.1002/(sici)1096-9896(199601)178:1<78::aid-path423>3.0.co;2-n] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Chronic pancreatitis is characterized by the presence of an inflammatory infiltrate, progressive destruction of acinar cells, and fibrosis. The finding that endothelin-1, an endothelium-derived peptide with vasoconstrictive and mitogenic properties, reduces pancreatic blood flow in normal rats suggested that the peptide may be associated with the reduced pancreatic flow seen in animal models of chronic pancreatitis and in the morphological abnormalities of the disease. The aim of this study was to investigate sites of endothelin-1 expression in the pancreas of normal subjects and patients with chronic pancreatitis. The techniques of immunohistochemistry, in situ hybridization, and Northern blotting were used. Endothelin-1-like immunoreactivity was localized predominantly to islet cells both in normal subjects and in patients with chronic pancreatitis. Semi-quantitative analyses of immunostaining showed that endothelin-1-like immunoreactivity in islet cells of patients with chronic pancreatitis was greater than in normal subjects. Co-localization studies with glucagon, insulin, somatostatin, and pancreatic polypeptide showed that endothelin-1-like immunoreactivity co-exists with glucagon and insulin. There was no apparent co-existence of endothelin-1-like immunoreactivity with somatostatin or pancreatic polypeptide. Endothelin-1 mRNA was expressed in sites similar to those of the immunostaining, as well as in vascular endothelial cells. Northern blot analysis showed an increase in the expression of endothelin-1 mRNA in the patient population. There was a significant correlation between intensity of endothelin-1 immunostaining and severity of fibrosis in the patients with chronic pancreatitis. These findings suggest that an elevation in local expression of endothelin-1 may be associated with the morphological and haemodynamic changes of chronic pancreatitis.
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Affiliation(s)
- Y Kakugawa
- Department of Pathology, Montreal General Hospital and McGill University, Quebec, Canada
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Patel AG, Toyama MT, Alvarez C, Nguyen TN, Reber PU, Ashley SW, Reber HA. Pancreatic interstitial pH in human and feline chronic pancreatitis. Gastroenterology 1995; 109:1639-45. [PMID: 7557149 DOI: 10.1016/0016-5085(95)90654-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS Advanced chronic pancreatitis is associated with a reduction in pancreatic blood flow. To determine the physiological significance of this decrease, pancreatic interstitial pH was measured in a model of obstructive chronic pancreatitis in cats and in patients with chronic pancreatitis. METHODS In cats, pancreatic interstitial pH and blood flow were measured serially under basal conditions and after secretory stimulation as chronic pancreatitis evolved. Basal pancreatic interstitial pH was also measured in patients undergoing an operation for chronic pancreatitis or periampullary cancer (controls). RESULTS In normal cats, pancreatic interstitial pH was 7.41 +/- 0.01 and blood flow was 124 mL.min-1.(100 g pancreas-1). With the evolution of chronic pancreatitis, interstitial pH and blood flow progressively decreased to 7.21 +/- 0.04 (P < 0.007) and 75 +/- 11 (P < 0.007), respectively. From 1 to 2 weeks, secretory stimulation reduced pancreatic interstitial pH and blood flow further, but as secretory function was lost, this effect disappeared. In patients with chronic pancreatitis, the interstitial pH was lower (7.02 +/- 0.06) than in controls (7.25 +/- 0.04; P < 0.05). CONCLUSIONS These observations are consistent with the hypothesis that, in chronic pancreatitis, acidic metabolites associated with pancreatic secretion accumulate within the pancreas, probably because of impaired blood flow.
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Affiliation(s)
- A G Patel
- Department of Surgery, Sepulveda Veterans Administration Medical Center, Los Angeles, California, USA
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Goto M, Nakano I, Kimura T, Miyahara T, Kinjo M, Nawata H. New chronic pancreatitis model with diabetes induced by cerulein plus stress in rats. Dig Dis Sci 1995; 40:2356-63. [PMID: 7587814 DOI: 10.1007/bf02063237] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To establish a new experimental model of chronic pancreatitis (CP) with diabetes, we investigated pancreatic endocrine function, blood flow, and histopathology in CP induced by repetition of cerulein injection plus water immersion stress in rats. CP rats were treated with water immersion stress for 5 hr and two intraperitoneal injections of 20 micrograms/kg body weight of cerulein once a week for 16 weeks. In the CP group, pancreatic contents of protein, amylase, elastase, and lipase significantly decreased to 64, 38, 23, and 68% of the control group, respectively. In oral glucose tolerance test (glucose 2 g/kg body wt), blood glucose level in the CP group was 212.1 +/- 97.8 mg/dl (mean +/- SD) at 30 min and was significantly higher than the control group (126.3 +/- 15.4 mg/dl)(P < 0.05). Two of seven rats in the CP group showed an obvious diabetic insulin in the CP group was 640.1 +/- 148.7 pM, significantly lower than in the control group (1133.4 +/- 242.0 pM)(P < 0.001). However, insulin content in the pancreas was 12.37 nmol/pancreas). In CP rats, winding and dilatation of surface blood vessels and gland atrophy were evident. Marked fibrosis, fatty changes, and destruction of lobular architecture were also demonstrated microscopically, although the structure of each pancreatic islet was preserved and each islet was fully stained with anti-insulin antibody. In the CP group, pancreatic blood flow by the hydrogen gas-clearance method was 197.6 +/- 33.0 ml/min/100 g, which was significantly less than the control group (276.2 +/- 19.1 ml/min/100 g) (P < 0.001). Thus, we conclude that the CP model induced by cerulein plus stress is a new CP model with diabetes in rats, in which the glucose tolerance was impaired without loss of insulin reserve.
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Affiliation(s)
- M Goto
- Third Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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Liu X, Nakano I, Yamaguchi H, Ito T, Goto M, Koyanagi S, Kinjoh M, Nawata H. Protective effect of nitric oxide on development of acute pancreatitis in rats. Dig Dis Sci 1995; 40:2162-9. [PMID: 7587783 DOI: 10.1007/bf02209000] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Nitric oxide (NO) has been implicated to regulate pancreatic circulation, promote capillary integrity, and inhibit leukocyte adhesion. We investigated the role of NO in the development of pancreatitis. Nitro-L-arginine, an inhibitor of NO synthase, in total dose of 35 mg/kg body wt was infused in the rats with edematous pancreatitis induced by two intraperitoneal injections of cerulein (20 micrograms/kg). L-Arginine (125 or 250 mg/kg), a NO donor was intravenously administered twice in the rats with hemorrhagic pancreatitis induced by water-immersion stress plus two intraperitoneal injections of cerulein (40 micrograms/kg). The degree of pancreas edema, serum amylase levels, and histologic alterations were investigated. Nitro-L-arginine exacerbated cerulein-induced pancreatitis and caused a decrease in pancreatic blood flow. L-Arginine ameliorated the severity of hemorrhagic pancreatitis dose dependently and improved the pancreatic blood flow. These findings suggest that NO could confer protection against the development of hemorrhagic pancreatitis, probably through improvement of the pancreatic microcirculation.
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Affiliation(s)
- X Liu
- Third Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka City, Japan
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Patel AG, Toyama MT, Nguyen TN, Cohen GA, Ignarro LJ, Reber HA, Ashley SW. Role of nitric oxide in the relationship of pancreatic blood flow and exocrine secretion in cats. Gastroenterology 1995; 108:1215-20. [PMID: 7535273 DOI: 10.1016/0016-5085(95)90222-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS Recent studies have suggested that, in the gastrointestinal tract, nitric oxide is an important mediator of alterations in blood flow and, in some organs, a second messenger involved in secretion. This study examined the role of NO in changes in pancreatic blood flow associated with basal and stimulated pancreatic exocrine secretion. METHODS In anesthetized cats, we determined the effects of the NO synthase inhibitor NG-monomethyl-L-arginine (10 mg/kg) and the NO donor sodium nitroprusside (10 micrograms.kg-1.min-1) on pancreatic secretion and blood flow (hydrogen gas clearance). RESULTS NG-monomethyl-L-arginine had no effect on the increase in blood flow associated with secretin stimulation (271 +/- 52 vs. 290 +/- 50 mL.min-1.100 g-1) but reduced that associated with cholecystokinin stimulation (189 +/- 17 vs. 53 +/- 15 mL.min-1.100 g-1; P < 0.001). In contrast, NG-monomethyl-L-arginine significantly reduced both secretin- and cholecystokinin-stimulated secretion. Sodium nitroprusside had no effect on basal blood flow but significantly increased secretion. CONCLUSIONS NO has a selective role in mediating changes in pancreatic perfusion and secretion. It seems to be important in stimulus-secretion coupling with both secretin and cholecystokinin but is only responsible for the accompanying increase in pancreatic blood flow with cholecystokinin.
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Affiliation(s)
- A G Patel
- Department of Surgery, Sepulveda Veterans Administration Medical Center, California
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Liu XH, Nakano I, Ito T, Yamaguchi H, Migita Y, Miyahara T, Koyanagi S, Ohgoshi K, Nawata H. Role of endothelin in the development of hemorrhagic pancreatitis in rats. J Gastroenterol 1995; 30:275-7. [PMID: 7773362 DOI: 10.1007/bf02348679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- X H Liu
- Third Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka City, Japan
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Abstract
In experimental obstructive chronic pancreatitis the normal hyperaemic response to secretory stimulation is lost, suggesting abnormal vascular regulation. Vascular regulatory mechanisms were investigated by observing the effect of increments in portal pressure on pancreatic blood flow in normal cats and cats with chronic pancreatitis. Normal cats maintained pancreatic blood flow until portal pressure was > 15 mm Hg, after which it decreased. Total vascular resistance decreased until the portal pressure was 15 mm Hg and increased thereafter. These observations suggested that metabolic regulatory mechanisms prevailed while portal pressure was in the physiological range but myogenic mechanisms became dominant during portal hypertension. In chronic pancreatitis the basal pancreatic blood flow was reduced and was inversely proportional to portal pressure. Total vascular resistance increased as portal pressure increased. In chronic pancreatitis myogenic regulatory responses prevailed at all levels of portal pressure. In conclusion, intrinsic regulation of pancreatic blood flow was abnormal in cats with chronic pancreatitis. The loss of the predominance of metabolic regulation over the normal range of portal pressure may partly explain the reduction of pancreatic blood flow in response to secretory stimulation.
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50
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Karanjia ND, Widdison AL, Leung F, Alvarez C, Lutrin FJ, Reber HA. Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct. Br J Surg 1994; 81:259-64. [PMID: 8156353 DOI: 10.1002/bjs.1800810236] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic pancreatitis is characterized by persistent and severe pain, which can be relieved by decompression of the main pancreatic duct (MPD). Both ductal and interstitial pressures have been shown to be increased in chronic pancreatitis in patients. A study was carried out of pancreatic interstitial pressure and pancreatic blood flow in normal cats and those in which chronic obstructive pancreatitis had been induced 5 weeks earlier to determine the effect of decompression of the MPD. In the normal pancreas, median(interquartile range (i.q.r.)) basal interstitial pressure was 0.05(1.2) mmHg and median(i.q.r.) basal pancreatic blood flow 58.3(24.3) ml per min per 100 g. Secretory stimulation did not change the interstitial pressure significantly, but was associated with a 40 per cent increase in median(i.q.r.) blood flow to 81.8(45.8) ml per min per 100 g. In contrast, in chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.5) mmHg, which was significantly higher than in the normal gland, and median(i.q.r.) pancreatic blood flow was 38.3(9.8) ml per min per 100 g, significantly lower than in the normal pancreas. Furthermore, secretory stimulation was associated with a significant increase in median(i.q.r.) interstitial pressure to 3.3(1.6) mmHg and a simultaneous decrease in median(i.q.r.) blood flow to 31.5(13.7) ml per min per 100 g. After decompression of the MPD in cats with chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.4) mmHg and on secretory stimulation 1.8(1.5) mmHg. Decompression thus prevented the increase in interstitial pressure seen in the animals with obstruction. In contrast, ductal decompression improved the median(i.q.r.) basal pancreatic blood flow to 45.9(38.4) ml per min per 100 g and, furthermore, this increased significantly on secretory stimulation to a median(i.q.r.) of 81.4(47.8) ml per min per 100 g. Decompression thus restored the normal pattern of secretory hyperaemia. Within the confines of this model, these observations demonstrate that chronic obstructive pancreatitis exhibits a compartment syndrome that is relieved by duct drainage.
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Affiliation(s)
- N D Karanjia
- Department of Surgery, Sepulveda Veterans' Affairs Medical Center, California
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