The epidemiology and socioeconomic impact of chronic pancreatitis

Effect of Neurostimulation on Chronic Pancreatic Pain: A Systematic Review

BACKGROUND

Chronic pancreatic pain is one of the most severe causes of visceral pain, and treatment response is often limited. Neurostimulation techniques have been investigated for chronic pain syndromes once there are pathophysiological reasons to believe that these methods activate descending pain inhibitory systems. Considering this, we designed this systematic literature review to investigate the evidence on neuromodulation techniques as a treatment for chronic pancreatic pain.

MATERIALS AND METHODS

We performed a literature search using the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase until April 2024. The included studies used neurostimulation techniques in participants with chronic pancreatic pain and reported pain-related outcomes, with a focus on pain scales and opioid intake. Two reviewers screened and extracted data, and a third reviewer resolved discrepancies. We assessed the risk of bias using the Jadad scale. The authors then grouped the findings by the target of the neurostimulation, cortex, spinal cord, or peripheral nerves; described the findings qualitatively in the results section, including qualitative data reported by the articles; and calculated effect sizes of pain-related outcomes.

RESULTS

A total of 22 studies were included (7 randomized clinical trials [RCTs], 14 case series, and 1 survey), including a total of 257 clinical trial participants. The two outcomes most commonly reported were pain, measured by the visual analogue scale (VAS), numeric rating scale (NRS), and pressure pain threshold scores, and opioid intake. Two RCTs investigated repetitive transcranial magnetic stimulation (rTMS), showing a reduction of 36% (±16) (d = 2.25; 95% CI, 0.66-3.83) and 27.2% (±24.5%) (d = 2.594; 95% CI, 1.303-3.885) in VAS pain scale. In another clinical trial, transcranial direct-current stimulation (tDCS) and transcranial pulsed current stimulation were not observed to effect a significant reduction in VAS pain (χ2 = 5.87; p = 0.12). However, a complete remission was reported in one tDCS case. Spinal cord stimulation (SCS) and dorsal root ganglion stimulation were performed in a survey and 11 case series, showing major pain decrease and diminished opioid use in 90% of participants after successful implantation; most studies had follow-up periods of months to years. Two noninvasive vagal nerve stimulation (VNS) RCTs showed no significant pain reduction in pain thresholds or VAS (d = 0.916; 95% CI, -0.005 to 1.838; and d = 0.17; -0.86 to 1.20; p = 0.72; respectively). Splanchnic nerve stimulation in one case report showed complete pain reduction accompanied by discontinuation of oral morphine and fentanyl lozenges and a 95% decrease in fentanyl patch use. Two RCTs investigated transcutaneous electrical nerve stimulation (TENS). One found a significant pain reduction effect with the NRS (d = 1.481; 95% CI, 1.82-1.143), and decreased opioid use, while the other RCT did not show significant benefit. Additionally, one case report with TENS showed pain improvement that was not quantitatively measured.

DISCUSSION

The neuromodulation techniques of rTMS and SCS showed the most consistent potential as a treatment method for chronic pancreatic pain. However, the studies have notable limitations, and SCS has had no clinical trials. For VNS, we have two RCTs that showed a non-statistically significant improvement; we believe that both studies had a lack of power issue and suggest a gap in the literature for new RCTs exploring this modality. Additionally, tDCS and TENS showed mixed results. Another important insight was that opioid intake decrease is a common trend among most studies included and that adverse effects were rarely reported. To further elucidate the potential of these neurostimulation techniques, we suggest the development of new clinical trials with larger samples and adequate sham controls.

Financial Toxicity in Patients With Chronic Pancreatitis

OBJECTIVES

Patients with chronic illnesses are susceptible to the financial burden of disease-related treatment costs. Financial toxicity is well researched in cancer and several chronic diseases. This review explores the financial challenges faced by patients with chronic pancreatitis and the impact of financial hardship on their well-being.

MATERIALS AND METHODS

We performed a review of the published literature to summarize the body of existing research and to identify knowledge gaps related to the financial burden experienced by patients with chronic pancreatitis.

RESULTS

Research on financial burden, cost-coping behaviors, cost-related nonadherence to prescribed medications, and social vulnerabilities in people with chronic pancreatitis is sparse. No studies have assessed the suitability and validity of instruments measuring subjective financial toxicity in a patient population with chronic pancreatitis.

CONCLUSIONS

There is a critical need for further studies of financial toxicity in the patient population with chronic pancreatitis, considering that if the sources of financial burden can be identified, opportunities emerge to dampen or mitigate their impact on patients with chronic pancreatitis.

Chronic Pancreatitis in a Large Developing Country: Temporal Trends of Over 64,000 Hospitalizations from 2009 to 2019

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a progressive inflammatory disorder associated with marked morbidity and mortality and frequently requires hospitalization. This study aimed to investigate the time trends and geographical distribution of hospital admissions, the lethality rate of CP across Brazil, and the potential relationship with social indicators and associated risk factors.

METHODS

Data were retrospectively obtained from the Brazilian Public Health System Registry between January 2009 and December 2019. The prevalence and lethality rates of CP per 100,000 inhabitants in each municipality were estimated from hospitalizations to in-hospital deaths and classified by age, sex, and demographic features.

RESULTS

During the study period, 64,609 admissions were retrieved, and most of the patients were males (63.54%). Hospitalization decreased by nearly half (-54.68%) in both sexes. CP rates in males were higher in all age groups. The greatest reduction in admissions (- 64%) was also noted in patients ≥ 70y. CP In-hospital lethality remained stable (5-6%) and similar for males and females. Patients ≥ 70y showed the highest lethality. The greatest increase in CP lethality rates (+ 10%) was observed in municipalities integrated into metropolises, which was mainly driven by small-sized municipalities (+ 124%).

CONCLUSIONS

CP hospitalizations decrease in both urban and rural areas, particularly in the North, Northeast, and Central-West regions, and in those above 70 years of age, but are not correlated with lethality rates in the South. This suggests ongoing changes in the environmental and socioeconomic factors in Brazil.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Novel therapeutics to treat chronic pancreatitis: targeting pancreatic stellate cells and macrophages

INTRODUCTION

Chronic pancreatitis (CP) is a persistent, recurrent, and progressive disorder that is characterized by chronic inflammation and irreversible fibrosis of the pancreas. It is associated with severe morbidity, resulting in intense abdominal pain, diabetes, exocrine and endocrine dysfunction, and an increased risk of pancreatic cancer. The etiological factors are diverse and the major risk factors include smoking, chronic alcoholism, as well as other environmental and genetic factors. The treatment and management of CP is challenging, and no definitive curative therapy is currently available.

AREAS COVERED

This review paper aims to provide an overview of the different cell types in the pancreas that is known to mediate disease progression and outline potential novel therapeutic approaches and drug targets that may be effective in treating and managing CP. The information presented in this review was obtained by conducting a NCBI PubMed database search, using relevant keywords.

EXPERT OPINION

In recent years, there has been an increased interest in the development of novel therapeutics for CP. A collaborative multi-disciplinary approach coupled with a consistent funding for research can expedite progress of translating the findings from bench to bedside.

Pregnancy Outcomes in Patients with Early-Onset Idiopathic Chronic Pancreatitis

BACKGROUND

Early-onset idiopathic chronic pancreatitis (EOICP) is a disease that affects young individuals. Data on pregnancy outcomes in EOICP are limited.

AIM

To assess the pregnancy outcomes in patients with EOICP and the effect of pregnancy on the course of EOICP.

METHODS

Patients with EOICP with disease onset before their pregnancy were recruited. Data regarding demographic variables, disease duration, pregnancy outcomes, and course of illness were noted.

RESULTS

50 patients were included in the study contributing to a total of 86 pregnancies. The mean age of onset of symptoms and at the time of delivery was 17.95 (5.71) and 23.44 (4.28) years, respectively. Gestational diabetes (GD) and gestational hypertension (GH) noted in one (1.5%) each. 3 (4.5%) pregnancies were preterm. 19 (22.1%) pregnancies did not have successful outcomes (7 (8.1%) were induced abortions). 12 (15.2%) pregnancies had spontaneous pregnancy losses. 8 (10.1%) were spontaneous abortions and 4 (5.1%) were stillbirths. Of 67 successful pregnancies, 33 (49.3%) pregnancies were delivered by LSCS. Compared to average rates of LSCS in India, this was significantly higher (21.5% vs 49.3%-p ≤ 0.001). The average birth weight was 2.87 (0.48) kg. There was one (1.5%) neonatal death. Compared to the published Indian data, there was no significant difference in the incidence of spontaneous pregnancy losses, GD, GH, preterm labor, and birth weight. Pancreatic pain was reported by 21 (42%) women in total 27 (31.4%) pregnancies. There was no difference in maternal or fetal outcomes between pregnancies with or without pancreatic pain. There were no pancreatitis-related complications reported during the pregnancies.

CONCLUSION

The present study shows that mothers affected with EOICP have pregnancy outcomes similar to healthy women in India.

Anxiety, depression, and coping styles among patients with chronic pancreatitis in East China

BACKGROUND

Anxiety and depression are common psychological comorbidities in patients with chronic pancreatitis (CP). There is still a lack of epidemiological studies on anxiety and depression in Chinese CP patients. This study aimed to identify the incidence and related factor of anxiety and depression among East Chinese CP patients and explore the relationship between anxiety, depression, and coping styles.

METHODS

This prospective observational study was conducted from June 1, 2019 to March 31, 2021 in Shanghai, China. Patient diagnosed with CP were interviewed using the sociodemographic and clinical characteristics questionnaire, Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Coping Style Questionnaire (CSQ). Multivariate logistic regression analysis was conducted to identify the related factors of anxiety and depression. Correlation test was preformed to analyze the correlation between anxiety, depression, and coping styles.

RESULTS

The incidence of anxiety and depression in East Chinese CP patients was 22.64% and 38.61%, respectively. Patients' previous health status, level of disease coping, frequency of abdominal pain episodes, and pain severity were significantly associated with anxiety and depression. Mature coping styles (Problem solving, Seeking for help) had a positive impact on anxiety and depression, while immature coping styles (Self-blame, Fantasy, Repression, Rationalization) had negative effects on anxiety and depression.

CONCLUSION

Anxiety and depression were common in patients with CP in China. The factors identified in this study may provide references for the management of anxiety and depression in CP patients.

Role of contrast-enhanced ultrasound with time-intensity curve analysis for differentiating hypovascular solid pancreatic lesions

OBJECTIVES

To evaluate the clinical value of contrast-enhanced ultrasound (CEUS) with time-intensity curve (TIC) in distinguishing different types of hypovascular solid pancreatic lesions.

METHODS

A total of 89 patients with 90 pancreatic lesions (all confirmed by surgery or biopsy pathology) that manifested hypoenhancement on contrast-enhanced ultrasound (CEUS) were included in this study. Six peak enhancement patterns were proposed for differentiating hypovascular pancreatic lesions. CEUS qualitative and TIC-based quantitative parameters were analyzed, and each lesion was scored based on the statistically significant qualitative parameters to evaluate the diagnostic ability of CEUS for hypovascular solid pancreatic lesions.

RESULTS

Qualitative parameters such as peak enhancement pattern II/III/IV, penetrating vessels, centripetal enhancement, and early washout were reliable indicators of malignant lesions, and lesions scored based on these qualitative parameters, with a score ≥ 2, were highly suspected to be malignant lesions. Pattern I had an accuracy of 83.33% for predicting mass-forming pancreatitis (MFP), pattern V had an accuracy of 96.67% for predicting solid pseudopapillary tumors of the pancreas (SPTP), and pattern VI had an accuracy of 81.11% for predicting neuroendocrine tumors/carcinomas (NETs/NECs). For quantitative analysis, nodule/pancreatic parenchyma echo intensity reduction ratio was significantly greater in malignant lesions.

CONCLUSIONS

CEUS qualitative and TIC-based quantitative parameters have clinical value in distinguishing malignant from benign hypovascular pancreatic lesions.

KEY POINTS

• Contrast-enhanced ultrasound helps clinicians assess patients with pancreatic lesions. • Six peak enhancement patterns are proposed for differentiating pancreatic hypovascular lesions. • Qualitative parameters such as peak enhancement pattern II/III/IV, penetrating vessels, centripetal enhancement, early washout, and quantitative parameter nodule/pancreatic parenchyma echo intensity reduction ratio were important characteristics to discriminate malignant from hypovascular benign lesions.

Indian Outpatients with Idiopathic Chronic Pancreatitis Have Catastrophic Healthcare Expenditure, Malnutrition, Anxiety/Depression and Work-Impairment

INTRODUCTION

There is paucity of data regarding economic burden, employment affection, psychological and nutritional status of CP patients, of non-alcoholic etiology, especially during their periods of stable disease, i.e., without any complications and/or recent endoscopic/surgical interventions.

METHODS

In a prospective cohort study, conducted in outpatient clinic of a tertiary-care hospital, 66 consecutive adults with Idiopathic CP (± diabetes) and 152 matched (by age, socioeconomic status and monthly income) healthy controls were assessed for: (1) healthcare expenses in previous month by recall (catastrophic if > 40% of income); (2) nutritional status by anthropometry and food frequency questionnaire; (3) psychological status by Hospital Anxiety and Depression Scale (HADS); and (4) work-impairment by work productivity and activity impairment questionnaire: general health (WPAI-GH). CP patients were again reassessed for the above parameters after 6 and 12 month, respectively.

RESULTS

Seventy-six percent CP patients (vis-à-vis 0% controls) had catastrophic healthcare expenditure. Forty-nine percent of CP patients(vis-à-vis 0% controls) met their healthcare expenses by either selling assets or obtaining loans at high-interest or from charitable donations. CP patients had lower BMI, were more likely to be malnourished and had a lower calorie intake vis-à-vis controls (median (IQR) recommended daily allowance (RDA): 71(19)% vs 97(23)%; [p < 0.0001]). Their median HADS Anxiety and depression scores were significantly higher than controls. Thirty-one (47%) CP patients were employed vis-a-vis 102 (67%) controls (p = 0.006); they had significantly higher work impairment. After one year, there was improvement in some of these above parameters in CP patients.

CONCLUSION

Idiopathic CP outpatients had catastrophic healthcare expenditure, malnutrition, abnormal psychological scores and work-impairment vis-à-vis healthy controls. Some of these parameters improved on follow-up.

The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection

The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.

External validation of Chronic Pancreatitis Prognosis Score (COPPS): A prospective cohort study

BACKGROUND

Prognostic stratification in ChronicPancreatitis(CP) remains suboptimal and cumbersome. Chronic Pancreatitis Prognostic Score(COPPS) was recently developed to predict one-year hospitalisations in CP.

AIM

External validation of COPPS in a geographically divergent patient population.

METHODS

A single-center prospective cohort study, conducted on out-patients of a tertiary-care hospital. Consecutive adults with CP were assessed for COPPS risk predictors at baseline, similar to the original development cohort, and followed for one-year for: 1)hospitalisations; 2)development of pancreatitis-related complications; and 3)need for endoscopic and/or surgical interventions. Outcomes were compared by Kendall's tau-b(τ_b) and other statistical tests. Only those who had complete one-year follow-up were included in analysis.

RESULTS

There were 177 patients(mean±SD age: 35.9 ± 11.2 years), 116(65%) males and 117(66%) with Idiopathic CP. Despite being younger, with significantly more females and Idiopathic CP, than the original development cohort, our cohort was similar to the latter regarding COPPS severity at baseline. Eight patients died over one-year; 169 were evaluated for outcomes. Increasingly severe COPPS categories correlated with increasing number of hospitalisations(both overall and pancreatitis-related) and increasing number of days spent in hospital(both overall and pancreatitis-related) irrespective of age at symptoms-onset(≤35 vs >35years), etiology(idiopathic vs alcohol) and smoking-status.

CONCLUSIONS

COPPS is effective in a geographically distinct cohort having a different case-mix of CP patients(ClincialTrials.gov ID:NCT04907266).

Rising Prevalence of Anxiety and Depression in Chronic Pancreatitis: A Nationwide Analysis

OBJECTIVES

We aim to characterize the prevalence and impact of anxiety and depression (AD) in hospitalized patients with chronic pancreatitis (CP). Anxiety and depression have been shown to have a significant impact on mortality and length of stay in gastrointestinal diseases, but there are limited studies evaluating its impact on CP.

METHODS

We performed a retrospective analysis using the National Inpatient Sample from 2007 to 2014. The outcomes were the prevalence and trend of AD, impact on mortality, length of stay, and cost and independent predictors of AD.

RESULTS

A total of 75,744 patients with CP were included in our analysis, of which 23,323 (31%) had anxiety or depression. The prevalence of anxiety increased from 7.33% in 2007 to 20.02% in 2014. Depression increased from 18.49% in 2007 to 23.89% in 2014. Independent predictors of AD were decreasing age, female sex, and multiple comorbidities. Decreased risk was seen in African Americans, Hispanics, and those from the South and West. Anxiety and depression did not impact overall mortality or length of stay.

CONCLUSIONS

Anxiety and depression are increasingly recognized diagnosis in patients with CP. Careful management and treatment of psychiatric illnesses and improving quality of life need to be addressed for these patients.

Genetic and environmental influences on the progression from alcohol use disorder to alcohol-related medical conditions

BACKGROUND

Medical conditions related to alcohol use disorders (AUD) represent a substantial public health concern. However, only a subset of individuals with AUD develop these conditions and the extent to which genetic and environmental factors that are shared with AUD, versus those distinct from it, contribute to this progression has not yet been determined.

METHODS

Using data from Swedish national registries for a cohort born from 1932 to 1970 (N = 1,319,214, 48.9% women), we conducted twin-sibling biometric model fitting to examine the genetic and environmental sources of variance that contribute to the liability to alcohol-related medical conditions (AMC). Progression to AMC, determined using medical registry data, was contingent on an AUD registration, which was determined using medical and criminal registry data.

RESULTS

We identified AUD registrations in 3.2% of women and 9.2% of men. Among individuals with an AUD registration, 14.4% of women and 15.4% of men had an AMC registration. In the final models, we constrained the beta pathway from AUD to AMC and the genetic and unique environmental paths to be equal across sexes. The beta path was estimated at 0.59. AMC was modestly heritable in women (A = 0.32) and men (A = 0.30). The proportion of total heritability unique to AMC was 39.6% among women and 41.3% among men. A higher proportion of total environmental variance was unique to AMC: 76.7% for women and 77.2% for men. In a sensitivity analysis limited to liver-related AMC, we observed similar results, with a slightly lower beta path from AUD to AMC (0.46) and higher proportions of AMC-specific genetic (70.0% in women; 71.7% in men) and environmental (84.5% in both sexes) variance.

CONCLUSIONS

A moderate-to-substantial proportion of genetic and environmental variance that contributes to AMC risk is not shared with AUD, underscoring the need for additional gene identification efforts for AMC. Furthermore, the prominent influence of environmental factors specific to AMC provides a promising area for the identification of prevention targets. We did not observe significant sex differences in the etiology of AMC, although follow-up is warranted in other well-powered studies.

Efficacy of Pregabalin and Antioxidants Combination in Reducing Pain in Chronic Pancreatitis: A Double Blind Randomized Trial

BACKGROUND

In patients with chronic pancreatitis (CP), pain relief is a dilemma. Antioxidants with pregabalin therapy have been reported to be useful. Hence, this study was carried out to determine the efficacy of the combination of antioxidant and pregabalin therapy in reducing pain in patients with CP.

METHODS

This was a prospective, double blind, superiority, and randomized trial in patients with CP. The treatment group received pregabalin with antioxidants therapy for 8 weeks, and a similar placebo was administered to the controls. Primary outcome was to determine the change in maximum pain intensity assessed by visual analog scale (VAS) and Izbicki pain score. Secondary outcomes were the number of painful days, opioid and non-opioid requirements, improvement in quality of life, number of hospital admission, and overall patient satisfaction.

RESULTS

A total of 90 patients were randomized to 45 in each arm. Demographic profile and baseline pain score were comparable. Patients in treatment group when compared to placebo group had a significant reduction in pain intensity (VAS score 2 ± 0.8 vs. 1.3 ± 0.9; p = 0.007), non-opioid analgesic requirement in days (54.4±2.9 vs. 55.7±1.5; p = 0.014), and number of hospital admissions (0.2 ± 0.5 vs. 0.6 ± 0.7; p = 0.002), respectively. Significant proportion of patients was satisfied in the treatment group compared to placebo group (18% vs. 11%; p = 0.03).

CONCLUSION

The combination of pregabalin and antioxidant significantly reduces the pain, requirement of non-opioid analgesics, and the number of hospital admissions in patients with CP. It also significantly improves the overall patient satisfaction.

CLINICAL TRIALS REGISTER NUMBER

CTRI/2017/05/008492.

Chronic pancreatitis for the clinician. Part 2: Treatment and follow-up. Interdisciplinary Position Paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees

Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.

Pancreatic Disorders of Pregnancy

The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.

Increasing Prevalence of Anxiety and Depression Disorders After Diagnosis of Chronic Pancreatitis: A 5-Year Population-Based Study

OBJECTIVES

Chronic pancreatitis (CP) is often associated with poor quality of life. Only a few small associative studies have reported the prevalence of mood disorders in CP. Using a large database, we sought to describe the epidemiology and risk association of anxiety and depression in CP and evaluate their outcomes.

METHODS

A multicenter database (Explorys), an aggregate of electronic health record data from 26 US healthcare systems, was surveyed. A cohort of patients with a diagnosis of CP between 2014 and 2019 was identified. Within this cohort, rates of anxiety and depression were calculated. Demographics, comorbidities, and outcomes were described.

RESULTS

Of the 30,276,810 individuals in the database (2014-2019), 67,260 patients had a CP diagnosis (0.22%). When compared with patients with no history of CP, patients with CP were more likely to develop anxiety (odds ratio, 6.94; 95% confidence interval, 6.85-7.04) and depression (odds ratio, 5.09; 95% confidence interval, 5.01-5.17). Chronic pancreatitis patients with depression had an increased risk of suicidal ideation compared with controls.

CONCLUSIONS

Patients with CP are at a higher risk of developing anxiety and depression compared with those without CP, with overall worse outcomes. Clinicians should screen CP patients and make appropriate referral to psychiatry when indicated.

Total pancreatectomy with islet autotransplantation reduces resource utilization in pediatric patients

BACKGROUND

Chronic pancreatitis (CP) is associated with poor quality of life. Total pancreatectomy with islet autotransplantation (TPIAT) has traditionally been reserved for patients with refractory disease. We hypothesized TPIAT would lead to decreased costs and resource utilization after operation in children.

METHODS

Retrospective review of 39 patients who underwent TPIAT at a single children's hospital was performed. All inpatient admissions, imaging, endoscopic procedures, and operations were recorded for the year prior to and following operation. Costs were determined from Centers for Medicare and Medicaid Services.

RESULTS

Median hospital admissions before operation was 5 (IQR:2-7) and decreased to 2 (IQR:1-3) after (p < 0.01). Median total cost for the year before operation was $36,006 (IQR:$19,914-$47,680), decreasing to $24,900 postoperatively (IQR:$17,432-$44,005, p = 0.03). Removing cost of TPIAT itself, total cost was further reduced to $10,564 (IQR:$3096-$29,669, p < 0.01).

CONCLUSION

In children with debilitating CP, TPIAT has favorable impact on cost reduction, hospitalizations, and invasive procedures. Early intervention at a specialized pancreas center of excellence should be considered to decrease future resource utilization and costs among children.

Prevalence of Myocardial Infarction in Patients With Chronic Pancreatitis

OBJECTIVE

We conducted this study to ascertain whether chronic inflammation secondary to chronic pancreatitis (CP) has any association with myocardial infarction(MI).

METHODS

Data were collected from a commercial database (Explorys, Inc, IBM Watson, Ohio). Adults with the diagnosis of "chronic pancreatitis," based on Systematized Nomenclature of Medicine-Clinical Terms, were included in the CP group, and the rest of the patients were included in the non-CP group. The prevalence of MI was compared in both groups, and statistical multivariate model was performed.

RESULTS

A total of 28,842,210 patients were included in the study. The overall prevalence of MI was 14.22% in the CP group as compared with 3.23% in the non-CP group (P < 0.0001). In the multivariate analysis, the odds ratio (OR) for MI in CP group was 1.453 (95% confidence interval, 1.418-1.488, P < 0.0001). Hypertension was a strong predictor for MI in the CP group with an OR of 3.2 (95% confidence interval, 3.0-3.5), followed by chronic kidney disease, older than 65 years, dyslipidemia, diabetes mellitus, obesity, alcohol abuse, smoking, White race, and male sex.

CONCLUSIONS

This study showed that CP is associated with comorbidities, which can increase the prevalence and OR of MI.

The influence of erythropoietin on apoptosis and fibrosis in the early phase of chronic pancreatitis in rats

INTRODUCTION

Chronic pancreatitis (CP) is a continuing, inflammatory process of the pancreas, characterised by irreversible morphological changes. The identification of pancreatic stellate cells resulted in the development of research on the pathogenesis of CP. Erythropoietin (Epo) regulates the interaction between apoptosis and inflammation of the brain, kidney, and heart muscle. Erythropoietin receptors were also found in the pancreas, in particular on the islet cells. Our objective was to evaluate the influence of Epo on fibrosis and apoptosis in experimental CP.

MATERIAL AND METHODS

The experiments were performed on 48 male Wistar rats (250-350 g). The animals were divided into six equal groups (I - control, II - chronic cerulein - induced pancreatitis, III - 1 ml of Epo sc, IV - 0.5 ml of Epo sc, V - CP treated with 1 ml Epo, VI - CP treated with 0.5 ml Epo). The blood for gelatinases and pancreata for the morphological examinations and immunohistochemistry were collected.

RESULTS

A slight reduction of interstitial oedema and less severe fibrosis were noticed in the groups treated with Epo. Reduced expression of caspase-3 and α-actin, and a lack of Bcl-2 expression were observed in areas with inflammation. There was no expression of caspase-9 observed in all groups. There were no statistically significant differences between the groups in the activity of gelatinases.

CONCLUSIONS

Erythropoietin seems to have the effect of reducing fibrosis and apoptosis in an experimental model of CP.

Diagnostic and therapeutic considerations in biopsy-proven type 2 autoimmune pancreatitis: comparative analysis with biopsy-proven type 1 autoimmune pancreatitis

BACKGROUND

Autoimmune processes are now an increasingly recognized cause of acute and chronic pancreatitis. Autoimmune pancreatitis is a rare, benign pathology with two distinct clinicopathologic subtypes. The aim of this study was to compare the presentation, diagnostic considerations and outcomes of patients with biopsy-proven type 1 and 2 autoimmune pancreatitis (AIP).

METHODS

A retrospective review of the Queensland Health pathology database of histologically proven AIP was conducted. Parameters compared included demographics, diagnostic criterion and post-treatment outcomes.

RESULTS

Twenty-three patients had a confirmed histological diagnosis of AIP (type 1 = 13, type 2 = 10). Patients with type 2 AIP were younger (median age 49 versus 59 years, P < 0.05). There was no significant difference in gender distribution of disease at presentation. Type 2 AIP presented with significant increased focal pancreatic changes on cross-sectional imaging (80% versus 54%, P < 0.05). Serum IgG4 levels were raised (>1.40 g/L) in 69% of patients with type 1 AIP and not detected in type 2 (P < 0.01). Concurrent underlying inflammatory bowel disease was present in a higher proportion of type 2 AIP (40% versus 15%, P < 0.05). A significantly increased proportion of patients with type 2 AIP underwent surgical resection (70% versus 30%, P < 0.05). Conservative management was utilized in more patients with type 1 disease (54% versus 30%). On follow-up, two patients have experienced symptomatic relapse at 6-18 months.

CONCLUSIONS

Diagnostic challenges do exist and clinicians must suspect 2 type AIP in young, serum IgG4-negative inflammatory bowel disease patients with recurrent pancreatitis.

A Network Meta-analysis of Surgery for Chronic Pancreatitis: Impact on Pain and Quality of Life

BACKGROUND

The surgical operation associated with improved pain and quality of life (QoL) in patients with chronic pancreatitis (CP) is unknown.

METHOD

The Scopus, EMBASE, Medline and Cochrane databases were systematically searched until May 2019, and all randomised trials (RCTs) comparing surgical operations for CP pain were included in a network meta-analysis (NMA).

RESULTS

Four surgical operations for treating CP were directly compared in eight RCTs including 597 patients. Patients were mainly male (79%, 474/597) with alcoholic CP (85%, 382/452). Surgical operations included were pancreatoduodenectomy (224, 38%), Berne procedure (168, 28%), Beger procedure (133, 22%) and Frey procedure (72, 12%). The NMA revealed that the Beger procedure ranked best for pain relief, whilst the Frey procedure ranked best for postoperative QoL, postoperative pancreatic fistula rate and postoperative exocrine insufficiency rate during a median follow-up of 26 months (reported range 6-58 months). Overall the Frey procedure ranked best for the combination of primary outcome measures based on surface under cumulative ranking curve scores.

CONCLUSIONS

Overall the Frey procedure may perform the best for both pain relief and postoperative QoL in patients with CP. Further trials are warranted in defining the role of surgery in relation to endotherapy.

A Study on the Effect of Patient Characteristics, Geographical Utilization, and Patient Outcomes for Total Pancreatectomy Alone and Total Pancreatectomy With Islet Autotransplantation in Patients With Pancreatitis in the United States

OBJECTIVES

A selective therapy for pancreatitis is total pancreatectomy and islet autotransplantation. Outcomes and geographical variability of patients who had total pancreatectomy (TP) alone or total pancreatectomy with islet autotransplantation (TPIAT) were assessed.

METHODS

Data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Weighed univariate and multivariate analyses were performed to determine the effect of measured variables on outcomes.

RESULTS

Between 2002 and 2013, there were 1006 TP and 825 TPIAT in patients with a diagnosis of chronic pancreatitis, and 1705 TP and 830 TPIAT for any diagnosis of pancreatitis. The majority of the TP and TPIAT were performed in larger urban hospitals. Costs were similar for TP and TPIAT for chronic pancreatitis but were lower for TPIAT compared with TP for any type of pancreatitis. The trend for TP and TPIAT was significant in all geographical areas during the study period.

CONCLUSIONS

There is an increasing trend of both TP and TPIAT. Certain groups are more likely to be offered TPIAT compared with TP alone. More data are needed to understand disparities and barriers to TPIAT, and long-term outcomes of TPIAT such as pain control and glucose intolerance need further study.

Incidence, Admission Rates, and Economic Burden of Adult Emergency Visits for Chronic Pancreatitis: Data From the National Emergency Department Sample, 2006 to 2012

INTRODUCTION

Chronic pancreatitis (CP) is a common reason for emergency department (ED) visits, but little research has examined ED use by patients with CP.

MATERIALS AND METHODS

The Nationwide Emergency Department Sample (2006 to 2012) was interrogated to evaluate trends in adult ED visits for a primary diagnosis of CP (International Classification of Disease, 9th revision, Clinical Modification code: 577.1), the rates of subsequent hospital admission, and total charges. A survey logistic regression model was used to determine factors associated with hospitalization from the ED.

RESULTS

We identified 253,753 ED visits with a primary diagnosis of CP. No significant trends in annual incidence were noted. However, the ED-to-hospitalization rates decreased by 3% per year (P<0.001) and mean ED charges after adjusting for inflation increased by 11.8% per year (P<0.001). Higher Charlson comorbidity index, current smoker status, alcohol use, and biliary-related CP were associated with hospitalization. In hospitalized patients, length of stay decreased by 2.2% per year (P=0.003) and inpatient charges increased by 2.9% per year (P=0.004).

CONCLUSIONS

Patient characteristics associated with higher risk of hospitalization from the ED deserve further attention.

Characterisation of the fibroinflammatory process involved in progression from acute to chronic pancreatitis: study protocol for a multicentre, prospective cohort study

INTRODUCTION

Chronic pancreatitis (CP) is thought to present the end stage of a continuous disease process evolving from acute pancreatitis (AP), over recurrent AP, to early and end-stage CP. Due to the irreversible nature of CP, early detection and prevention is key. Prospective assessment based on advanced imaging modalities as well as biochemical markers of inflammation, fibrosis and oxidative stress may provide a better understanding of the underlying pathological processes and help identify novel biomarkers of disease with the ultimate goal of early diagnosis, intervention and prevention of disease progression. This paper describes the protocol of a prospective multicentre cohort study investigating the fibroinflammatory process involved in progression from acute to CP using state-of-the-art diagnostic imaging modalities and circulating biomarkers of inflammation, fibrosis and oxidative stress.

METHODS AND ANALYSIS

Adult control subjects and patients at different stages of CP according to the M-ANNHEIM system will be recruited from outpatient clinics at the participating sites and form three cohorts: controls (n=40), suspected CP (n=60) and definitive CP (n=60). Included patients will be followed prospectively for 15 years with advanced MRI and contrast-enhanced endoscopic ultrasound with elastography, assessment of endocrine and exocrine pancreatic function, biochemical and nutritional assessment, and evaluation of pain processing using quantitative sensory testing. Blood samples for a biobank will be obtained. The purpose of the biobank is to allow analyses of potential circulating biomarkers of disease progression, including markers of inflammation, fibrosis and oxidative stress.

ETHICS AND DISSEMINATION

Permissions from the Regional Science Ethics committee and the Regional Data Protection Agency have been obtained. We will submit the results of the study for publication in peer-reviewed journals regardless of whether the results are positive, negative or inconclusive.

Systemic inflammation contributes to impairment of quality of life in chronic pancreatitis

Chronic pancreatitis (CP) is a fibrotic disorder of the pancreas leading to clinical sequelae like pain and an excess of comorbidity including cardiovascular disease and cancers. The aim of this study was to determine the relationship between systemic inflammation and quality of life in patients with CP. Patients were prospectively recruited and underwent a quality of life assessment (EORTC QLQ-C30 and PAN 28). The serum inflammatory profile was assessed using an MSD 30-plex array. The relationship between clinical variables, inflammatory cytokines and quality of life was determined by a GLM-MANOVA and the individual impact of significant variables evaluated by a second ANOVA. In total, 211 patients with a median age of 53 years were recruited across 5 European centres. Gender, age, nicotine and alcohol abuse were clinical variables associated with altered quality of life. Systemic inflammation with high levels of pro-inflammatory cytokines (Eotaxin, IL-1β, IL-7, IL-8, IL-12/IL-23p40, IL-12p70, IL-13, IL-16, IP-10, MCP-1, MCP-4, MDC, MIP-1a, TARC, TNFß) was associated with diminished quality of life in general and specific domains including pain, physical and cognitive functioning. As conclusion, CP is associated with a systemic inflammatory response that has a negative impact on quality of life and accelerates aging.

Endoscopic treatment of pain in chronic pancreatitis

PURPOSE OF REVIEW

Pain is the most common symptom of chronic pancreatitis, having a profound effect on patients and a broad socioeconomic impact. Endoscopy is guideline recommended as first-line management for chronic pancreatitis pain in certain clinical scenarios. Herein, we provide an evidence-based review of the endoscopic treatment of pain due to chronic pancreatitis while highlighting some important confounders in the measurement of this outcome in clinical practice and research.

RECENT FINDINGS

Multiple recent studies have reported on the efficacy of current endoscopic therapies for chronic pancreatitis pain. Despite the high technical success rates of these procedures, pain outcomes remain disappointing. Complex mechanisms beyond ductal hypertension, such as central sensitization, visceral hypersensitivity and inflammatory neuritis account for some of the discordance observed between the rates of technical and clinical success. In addition, the sham effect is increasingly recognized as a confounder when interpreting the procedural benefit. Nevertheless, there are multiple promising innovations in the field of pancreatic endoscopy that are aimed to improve technical and clinical outcomes, but rigorous investigation is necessary to establish their role in clinical practice.

SUMMARY

Endoscopic therapy for chronic pancreatitis pain appears to be safe and effective in certain contexts and recent innovations in the field will hopefully further improve outcomes. In addition to evaluating the technical success of endotherapy in chronic pancreatitis, methodologically rigorous research focusing on patient-centered outcomes and accounting for the sham effect is necessary to advance this field.

Incidence and Predictors of 30-Day Readmission Among Patients Hospitalized for Chronic Pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) hospitalizations along with associated morbidity and costs are increasing. The goal of this study was to use the National Readmission Database to identify the incidence and risk factors for 30-day readmissions among patients with CP.

METHODS

We performed a retrospective analysis of National Readmission Database from January 2013 to December 2013 to determine patient demographic and clinical characteristics predictive of 30-day hospital readmission for adult patients (aged >18 years) discharged with a principle diagnosis of CP. A survey logistic regression model was used to determine the predictive value of selected variables for 30-day readmission.

RESULTS

In 2013, 12,545 admissions with primary diagnosis of CP were noted, and 30.4% were readmitted within 30 days. Cholecystectomy (odds ratio [OR], 0.53; P = 0.0024) or endoscopic retrograde cholangiopancreatography (OR, 0.70; P = 0.01) during index admission was associated with decreased all-cause readmissions. Pancreatectomy during index admission was associated with reduced (OR, 0.2; P = 0.0005) pancreatitis-related readmissions.

CONCLUSIONS

Hospital readmissions for CP are frequent and pose a significant healthcare burden. Performing cholecystectomy, endoscopic retrograde cholangiopancreatography, or pancreatectomy during index admission was associated with reduced odds of readmission.

Clinical Value of Contrast-Enhanced Ultrasound Enhancement Patterns for Differentiating Focal Pancreatitis From Pancreatic Carcinoma: A Comparison Study With Conventional Ultrasound

OBJECTIVES

We explored the clinical value of using contrast-enhanced ultrasound (US) enhancement patterns for the differential diagnosis of focal pancreatitis from pancreatic carcinoma.

METHODS

A total of 136 solid pancreatic lesions with final diagnoses from January 2010 to February 2016 were enrolled in this study. Twenty-five cases were focal pancreatitis; 86 cases were pancreatic carcinoma; and 25 cases were other types. All of the patients received conventional and contrast-enhanced US examinations. Two experienced US physicians analyzed the contrast-enhanced US enhancement patterns and made diagnoses according to the conventional and contrast-enhanced US manifestations. The inter-rater agreement for the contrast enhancement patterns between the readers was analyzed. The diagnostic efficiency of contrast enhancement patterns for differentiating focal pancreatitis from pancreatic carcinoma was analyzed and compared with that of conventional US.

RESULTS

The κ test showed good concordance for contrast enhancement patterns between the readers (P < .05). The diagnostic sensitivity, specificity, and accuracy of isoenhancement or isoenhancement with focal hypoenhancement in both the early and late phases for diagnosing focal pancreatitis were 72.0%, 95.5%, and 91.2%, respectively. The diagnostic sensitivity of isoenhancement or isoenhancement with focal hypoenhancement in both the early and late phases greatly increased for diagnosing focal pancreatitis in comparison with isoenhancement (72.0% versus 32.0%; P < .05). The diagnostic accuracy of contrast-enhanced US was greatly increased over that of conventional US (85.6% versus 49.5%; P < .001).

CONCLUSIONS

Contrast-enhanced US is a valuable tool for differentiating focal pancreatitis from pancreatic carcinoma and can greatly increase the diagnostic accuracy over conventional US.

The relationship between the use of statins and mortality, severity, and pancreatic cancer in Danish patients with chronic pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) is associated with a shortened life expectancy. Statins have anti-inflammatory properties and we aimed to evaluate the association between the use of statins and the risk of death, progression of CP, and pancreatic cancer in patients with CP.

PATIENTS AND METHODS

We carried out a nested case-cohort study and included patients with CP. We used claims of proton pump inhibitors as an active comparator. Patients with cirrhosis or cancer were excluded. We evaluated the exposure on the basis of pharmacy claims of statins. We used propensity score matching with a statins : nonstatins ratio of 1 : 1.

RESULTS

A total of 4807 patients were eligible for propensity score matching; 33% were women and the mean (SD) age at cohort entry was 56 (10) years. During follow-up, a total of 2073 (43%) patients had died and the risk of death was significantly lower among patients using statins versus no statins among 678 matched patients [hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.49-0.83]. Use of statins versus no statins was associated with decreased progression of CP, with an HR of 0.21 (95% CI: 0.17-0.26). Pancreatic cancer occurred in 117 (2.4%) patients and we found a lower risk of pancreatic cancer in statin-treated patients compared with no statins, with a HR of 0.21 (95% CI: 0.06-0.70).

CONCLUSION

In this nationwide study, we found lower risks of mortality, disease progression, and pancreatic cancer in patients with CP using statins. The study is limited by its retrospective design, but supports the hypothesis that statins may affect the course of CP.

Prevalence of exocrine pancreatic insufficiency in patients with chronic pancreatitis without follow-up. PANCR-EVOL Study

BACKGROUND/OBJECTIVES

Exocrine pancreatic insufficiency (EPI) is an important complication of chronic pancreatitis (CP). Guidelines recommend to rule out EPI in CP, to detect those patients who would benefit from pancreatic enzyme replacement therapy. The aim of this study was to evaluate the prevalence of EPI in patients with CP without follow-up in the last 2 years and to describe their nutritional status and quality of life (QoL).

METHODS

This was a cross-sectional, multicenter Spanish study. CP patients without follow-up by a gastroenterologist or surgeon in at least 2 years were included. EPI was defined as fecal elastase test <200mcg/g. For nutritional assessment, laboratory and anthropometric data were obtained. QoL was investigated using the EORTC QLQ-C30 questionnaire.

RESULTS

64 patients (mean age 58.8±10.3 years, 85.9% men) from 10 centers were included. Median time since diagnosis of CP was 58.7 months [37.7-95.4]. Forty-one patients (64.1%) had EPI. Regarding nutritional status, the following differences were observed (EPI vs. Non-EPI): BMI (23.9±3.5kg/m² vs. 25.7±2.5, p=0.03); glucose (121 [96-189] mg/dL vs. 98 [90-116], p=0.006); HbA1c 6.6% [6.0-8.4] vs. 5.5 [5.3-6.0], p=0.0005); Vitamin A (0.44mg/L [0.35-0.57] vs. 0.53 [0.47-0.63], p=0.048) and Vitamin E (11.2±5.0μg/ml vs. 14.4±4.3, p=0.03). EPI group showed a worse EORTC QLQ-C30 score on physical (93.3 [66.7-100] vs. 100 [93.3-100], p=0.048) and cognitive function (100 [83.3-100] vs. 100 [100-100], p=0.04).

CONCLUSIONS

Prevalence of EPI is high in patients with CP without follow-up. EPI group had higher levels of glucose, lower levels of vitamins A and E and worse QoL.

Management of pancreatic pseudocysts-A retrospective analysis

Background

Pancreatic pseudocysts arise mostly in patients with alcohol induced chronic pancreatitis causing various symptoms and complications. However, data on the optimal management are rare. To address this problem, we analysed patients with pancreatic pseudocysts treated at our clinic retrospectively.

Methods

We searched our clinical database for the diagnosis pancreatitis from 2004 till 2014, selected patients with pseudocysts larger than 10 mm and entered all relevant information in a database for statistical analysis.

Results

In total, 129 patients with pancreatic pseudocysts were treated at our institution during the study period. Most patients suffered from alcohol induced chronic pancreatitis (43.4%; 56/129). Pseudocysts were more frequent in female than in male (2:1) and were mainly located in the pancreatic head (47.3%; 61/129). Local complications like obstructive jaundice were associated with the diameter of the cysts (AUC 0.697 in ROC-curve analysis). However, even cysts up to a diameter of 160 mm can regress spontaneously. Besides a lower re-intervention rate in surgically treated patients, endoscopic, percutaneous and surgical drainage are equally effective. Most treatment related complications occur in large pseudocysts located in the pancreatic head.

Conclusion

Conservative management of large pseudocysts is successful in many patients. Therefore, indication for treatment should be made carefully considering the presence and risk of local complications. Endoscopic and surgical drainage are equally effective.

Predictive value of C-reactive protein/albumin ratio in acute pancreatitis

BACKGROUND

Serum C-reactive protein (CRP) increases and albumin decreases in patients with inflammation and infection. However, their role in patients with acute pancreatitis is not clear. The present study was to investigate the predictive significance of the CRP/albumin ratio for the prognosis and mortality in acute pancreatitis patients.

METHODS

This study was performed retrospectively with 192 acute pancreatitis patients between January 2002 and June 2015. Ranson scores, Atlanta classification and CRP/albumin ratios of the patients were calculated.

RESULTS

The CRP/albumin ratio was higher in deceased patients compared to survivors. The CRP/albumin ratio was positively correlated with Ranson score and Atlanta classification in particular and with important prognostic markers such as hospitalization time, CRP and erythrocyte sedimentation rate. In addition to the CRP/albumin ratio, necrotizing pancreatitis type, moderately severe and severe Atlanta classification, and total Ranson score were independent risk factors of mortality. It was found that an increase of 1 unit in the CRP/albumin ratio resulted in an increase of 1.52 times in mortality risk. A prediction value about CRP/albumin ratio >16.28 was found to be a significant marker in predicting mortality with 92.1% sensitivity and 58.0% specificity. It was seen that Ranson and Atlanta classification were higher in patients with CRP/albumin ratio >16.28 compared with those with CRP/albumin ratio ≤16.28. Patients with CRP/albumin ratio >16.28 had a 19.3 times higher chance of death.

CONCLUSION

The CRP/albumin ratio is a novel but promising, easy-to-measure, repeatable, non-invasive inflammation-based prognostic score in acute pancreatitis.

Prevalence and predictors of pain and opioid analgesic use following total pancreatectomy with islet autotransplantation for pancreatitis

BACKGROUND & OBJECTIVES

Total pancreatectomy with islet autotransplantation (TPIAT) is employed for the management of refractory pain in chronic pancreatitis (CP) with the prospect of partial beta cell preservation. The primary aim of this study is to evaluate the prevalence and predictors of abdominal pain and opioid use following TPIAT.

METHODS

A single center cohort study of all adult patients who underwent TPIAT from 2011 to 2015 for CP. Postoperative pain outcomes included: opioid use, ongoing abdominal pain and new characteristic abdominal pain. Multiple logistic regression analysis was used to evaluate known and potential predictors of postoperative pain outcomes.

RESULTS

During the study period, 46 patients underwent TPIAT. Following surgery, 89% of patients had resolution of their pre-operative abdominal pain; however, 83% of patients developed a new characteristic abdominal pain. Opioid independence was achieved in 46% of patients. Acute recurrent pancreatitis (ARP) (OR: 11.66; 95%CI: 1.47-92.39; p = 0.02) but not pain duration >3 years or ≥ 5 ERCPs was independently associated with resolution of pre-operative abdominal pain on multiple logistic regression. None of these factors were associated with cessation of opioid use.

CONCLUSION

While the majority of patients have resolution of their initial abdominal pain following TPIAT, many will also develop a new characteristic abdominal pain and only half of all patients achieve opioid independence. ARP is the only independent factor associated with positive postoperative pain outcomes and should be considered a standard criterion for patient selection.

The Belgian national registry on chronic pancreatitis: A prospective multi-centre study covering more than 800 patients in one year

BACKGROUND/OBJECTIVES

The epidemiology, natural history, complications, and therapeutic management of chronic pancreatitis (CP) are not well described at the national level. This multi-centre prospective observational study involving eight Belgian hospitals aimed to improve the understanding of these aspects of CP in Belgium.

METHODS

All patients with a diagnosis of CP based on imaging were eligible for this study. Data were gathered regarding epidemiology, etiology, CP complications, and treatment modalities.

RESULTS

A total of 809 patients were included between 1/9/2014 and 31/8/2015. Most patients (794) were adults ≥16-years old, 74% were male, the median age at symptom onset was 47 (38-57) years, the median disease duration was 7 (3-13) years, and the median Izbicki pain score (IPS) was 96 (0-195). The main etiological risk factors according to the TIGAR-O classification were alcohol and tobacco (67%). Current drinkers had lower body mass index (BMI) (21.4 kg/m² vs 24.1 kg/m²), higher IPS (110 vs 56), and longer inability to work than non-drinkers. Current smokers had lower BMI (21.5 kg/m² vs 25 kg/m²) and higher IPS (120 vs 30) than non-smokers. Endocrine insufficiency and/or clinical steatorrhea was recorded in 41% and 36% of patients, respectively. The highest IPS was reported in patients with ongoing endotherapy (166 vs 50 for patients who completed endoscopy).

CONCLUSION

This multicentric study on CP patients showed that current alcohol drinking and smoking are associated with pain and malnutrition. Pain scores were higher in patients with ongoing endotherapy, independently of surgery.

Imaging Macrophage Accumulation in a Murine Model of Chronic Pancreatitis with 125I-Iodo-DPA-713 SPECT/CT

Pancreatitis remains a diagnostic challenge in patients with mild to moderate disease, with current imaging modalities being inadequate. Given the prominent macrophage infiltration in chronic pancreatitis, we hypothesized that ¹²⁵I-iodo-DPA-713, a small-molecule radiotracer that specifically targets macrophages, could be used with SPECT/CT to image pancreatic inflammation in a relevant experimental model. Methods: Chronic pancreatitis was induced with cerulein in C57BL/6 mice, which were contrasted with saline-injected control mice. The animals were imaged at 7 wk after induction using N,N-diethyl-2-(2-(3-¹²⁵I-iodo-4-methoxyphenyl)-5,7-dimethylpyrazolo[1,5-a]pyrimidin-3-yl)acetamide (¹²⁵I-iodo-DPA-713) SPECT/CT or ¹⁸F-FDG PET/CT. The biodistribution of ¹²⁵I-iodo-DPA-713 was determined under the same conditions, and a pair of mice was imaged using a fluorescent analog of ¹²⁵I-iodo-DPA-713, DPA-713-IRDye800CW, for correlative histology. Results: Pancreatic ¹²⁵I-iodo-DPA-713 uptake was significantly higher in treated mice than control mice (5.17% ± 1.18% vs. 2.41% ± 0.34% injected dose/g, P = 0.02), as corroborated by imaging. Mice imaged with ¹⁸F-FDG PET/CT showed cerulein-enhanced pancreatic uptake in addition to a moderate signal from healthy pancreas. Near-infrared fluorescence imaging with DPA-713-IRDye800CW showed strong pancreatic uptake, focal liver uptake, and gastrointestinal uptake in the treated mice, whereas the control mice showed only urinary excretion. Ex vivo fluorescence microscopy revealed a large influx of macrophages in the pancreas colocalizing with the retained fluorescent probe in the treated but not the control mice. Conclusion: These data support the application of both ¹²⁵I-iodo-DPA-713 SPECT/CT and DPA-713-IRDye800CW near-infrared fluorescence to delineate pancreatic, liver, or intestinal inflammation in living mice.

Prevalence of chronic pancreatitis: Results of a primary care physician-based population study

BACKGROUND

Data on chronic pancreatitis prevalence are scanty and usually limited to hospital-based studies.

AIM

Investigating chronic pancreatitis prevalence in primary care.

METHODS

Participating primary care physicians reported the prevalence of chronic pancreatitis among their registered patients, environmental factors and disease characteristics. The data were centrally reviewed and chronic pancreatitis cases defined according to M-ANNHEIM criteria for diagnosis and severity and TIGAR-O classification for etiology.

RESULTS

Twenty-three primary care physicians participated in the study. According to their judgment, 51 of 36.401 patients had chronic pancreatitis. After reviewing each patient data, 11 turned out to have definite, 5 probable, 19 borderline and 16 uncertain disease. Prevalence was 30.2/100.000 for definite cases and 44.0/100.000 for definite plus probable cases. Of the 16 patients with definite/probable diagnosis, 8 were male, with mean age of 55.6 (±16.7). Four patients had alcoholic etiology, 5 post-acute/recurrent pancreatitis, 6 were deemed to be idiopathic. Four had pancreatic exocrine insufficiency, 10 were receiving pancreatic enzymes, and six had pain. Most patients had initial stage and non-severe disease.

CONCLUSIONS

This is the first study investigating the prevalence of chronic pancreatitis in primary care. Results suggest that the prevalence in this context is higher than in hospital-based studies, with specific features, possibly representing an earlier disease stage.

Hospital discharges and patient activity associated with chronic pancreatitis in Ireland 2009-2013

OBJECTIVE

To investigate trends in acute public hospital patient discharges in Ireland, to analyse hospital discharge activity for geographical variations, aetiological differences, and to estimate a national prevalence for chronic pancreatitis.

METHOD

We performed a nationwide retrospective study of all in-patient discharges from acute public hospitals in Ireland, participating in the Hospital In-Patient Enquiry (HIPE) reporting system. We searched for International Classification of Disease, Tenth Revision, Australian Modification (ICD-10-AM) codes K86.0 alcohol-induced chronic pancreatitis, and K86.1 other chronic pancreatitis, and data were extracted for the years 2009-2013.

RESULTS

There were 4098 emergency admissions for any aetiology chronic pancreatitis during the 5 year study period. Total discharges ranged from 753 in 2009 to 999 in 2013. Total patients ranged from 530 in 2009 to 601 in 2013. Prevalence of chronic pancreatitis is estimated at 11.6 per 100,000 to 13.0 per 100,000 over the five years. 'Other aetiology chronic pancreatitis' discharges were almost double that of 'alcohol chronic pancreatitis'. We found notable geographical variation in hospital discharge activity for chronic pancreatitis.

CONCLUSIONS

We report a prevalence which is similar to those worldwide studies who adopted a similar methodology utilising exact counts of patients. Our data are an underestimated as they are based on in-patient discharges only, excluding those attending primary care, outpatient or emergency room visits without admission. Despite studying this disease in a population with high per capita alcohol consumption, we report almost twice as many discharges for non-alcohol aetiology chronic pancreatitis.

Animal models of gastrointestinal and liver diseases. Animal models of acute and chronic pancreatitis

Animal models of pancreatitis are useful for elucidating the pathogenesis of pancreatitis and developing and testing novel interventions. In this review, we aim to summarize the most commonly used animal models, overview their pathophysiology, and discuss their strengths and limitations. We will also briefly describe common animal study procedures and refer readers to more detailed protocols in the literature. Although animal models include pigs, dogs, opossums, and other animals, we will mainly focus on rodent models because of their popularity. Autoimmune pancreatitis and genetically engineered animal models will be reviewed elsewhere.

Chronic pancreatitis: Do serum biomarkers provide an association with an inflammageing phenotype?

BACKGROUND

Chronic pancreatitis is an inflammatory disorder of the pancreas that is associated with accelerated mortality for patients suffering from this disease. The association between chronic inflammation and accelerated biological ageing has been well described and is often referred to as "inflammageing". In this review we seek to determine how systemic inflammation in chronic pancreatitis may contribute to an accelerated ageing phenotype.

METHODS

A systematic literature search with a predefined search protocol was performed on Medline, Embase and Cochrane libraries according to the PRISMA guidelines.

RESULTS

The initial search identified 499 studies. After title, abstract and full text screen of the search results, 20 were included for further evaluation. In the 20 remaining articles 41 inflammatory mediators were identified - mainly involved in chronic inflammation, fibrosis and particularly cardinal features of inflammageing such as sarcopenia and osteoporosis.

CONCLUSION

Chronic pancreatitis is associated with elevated levels of inflammatory mediators many of which are associated with an accelerated ageing phenotype and may explain some of the clinical sequelae of this disease.

The nutritional management of type 3c (pancreatogenic) diabetes in chronic pancreatitis

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic diabetes, refers to diabetes caused by disease of the exocrine pancreas. T3cDM is not commonly recognised by clinicians and frequently it is misclassified as T1DM, or more commonly, T2DM. T3cDM can be difficult to distinguish from T1DM and T2DM, and it often co-exists with the latter. The aim of this review is to describe T3cDM, along with its complications, diagnosis and management. We focus on the nutritional implications of T3cDM for those with chronic pancreatitis, and provide a practical guide to the nutritional management of this condition.

Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Chronic Pancreatitis in the United States

GOALS

The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis.

BACKGROUND

Historically, ERCP was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging and endoscopic ultrasound, indications for ERCP are being redefined.

STUDY

We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998 to 2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients diagnosed with biliary, gallbladder, or pancreatic neoplasm and patients who underwent gallbladder or pancreatic operation during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema.

RESULTS

During the study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. The majority of patients were white (56.1%). The majority of procedures were performed at large (72.4%), urban (95.2%), and academic (69.0%) hospitals. Mean hospital charges were $32,929 (SE= $1605). Mean length of stay was 6 days (SE=0.3), with in-hospital mortality of 0.76%. Over the study period, the number of procedures has decreased significantly (P<0.001).

CONCLUSIONS

In the United States, ERCP has been an important diagnostic and therapeutic tool for chronic pancreatitis. Over the last decade, ERCP has become an uncommon inpatient procedure for chronic pancreatitis.

Increased Risk of Acute Coronary Syndrome in Patients With Chronic Pancreatitis: A Nationwide Cohort Analysis

Chronic inflammation may promote development of coronary heart disease. Studies on the relationship between chronic pancreatitis (CP) and cardiovascular diseases are scant.We conducted a nationwide retrospective cohort study to determine the risk of acute coronary syndrome (ACS) in patients with CP.We randomly selected a comparison cohort of individuals without CP from the Taiwan National Health Insurance Research Database (N = 23.74 million) and frequency-matched them with patients with CP from 2000 to 2010 in a 1:4 ratio according to age, sex, and index year. The follow-up period lasted from the index date of the new CP diagnosis to the date of ACS diagnosis, censoring, or the end of 2011. We analyzed the risk of ACS by using Cox proportional-hazard models.In total, 17,405 patients with CP and 69,620 individuals without CP were followed for 84,430 and 417,426 person-years. Most patients with CP were men, and the mean age of the patients was 48.3 ± 15.0 years. The overall ACS incidence was 2.15-fold higher in the CP cohort than in the non-CP cohort (4.89 vs 2.28 per 10,000 person-years) with an adjusted hazard ratio (aHR) of 1.40 (95% confidence interval [CI] 1.20-1.64). Compared with individuals without CP, patients with CP aged ≤39 years exhibited the highest risk of ACS (aHR 2.14, 95% CI 1.13-4.02), followed by those aged 40 to 54 years (aHR 1.66, 95% CI 1.23-2.24) and those aged 55 to 69 years (aHR 1.53, 95% CI 1.15-2.03).CP may become an independent risk factor for ACS.

Chronic pancreatitis: A diagnostic dilemma

Typical clinical symptoms of chronic pancreatitis are vague and non-specific and therefore diagnostic tests are required, none of which provide absolute diagnostic certainly, especially in the early stages of disease. Recently-published guidelines bring much needed structure to the diagnostic work-up of patients with suspected chronic pancreatitis. In addition, novel diagnostic modalities bring promise for the future. The assessment and diagnosis of pancreatic exocrine insufficiency remains challenging and this review contests the accepted perspective that steatorrhea only occurs with > 90% destruction of the gland.

Model-based iterative reconstruction and adaptive statistical iterative reconstruction: dose-reduced CT for detecting pancreatic calcification

Background

Iterative reconstruction methods have attracted attention for reducing radiation doses in computed tomography (CT).

Purpose

To investigate the detectability of pancreatic calcification using dose-reduced CT reconstructed with model-based iterative construction (MBIR) and adaptive statistical iterative reconstruction (ASIR).

Material and Methods

This prospective study approved by Institutional Review Board included 85 patients (57 men, 28 women; mean age, 69.9 years; mean body weight, 61.2 kg). Unenhanced CT was performed three times with different radiation doses (reference-dose CT [RDCT], low-dose CT [LDCT], ultralow-dose CT [ULDCT]). From RDCT, LDCT, and ULDCT, images were reconstructed with filtered-back projection (R-FBP, used for establishing reference standard), ASIR (L-ASIR), and MBIR and ASIR (UL-MBIR and UL-ASIR), respectively. A lesion (pancreatic calcification) detection test was performed by two blinded radiologists with a five-point certainty level scale.

Results

Dose-length products of RDCT, LDCT, and ULDCT were 410, 97, and 36 mGy-cm, respectively. Nine patients had pancreatic calcification. The sensitivity for detecting pancreatic calcification with UL-MBIR was high (0.67–0.89) compared to L-ASIR or UL-ASIR (0.11–0.44), and a significant difference was seen between UL-MBIR and UL-ASIR for one reader (P = 0.014). The area under the receiver-operating characteristic curve for UL-MBIR (0.818–0.860) was comparable to that for L-ASIR (0.696–0.844). The specificity was lower with UL-MBIR (0.79–0.92) than with L-ASIR or UL-ASIR (0.96–0.99), and a significant difference was seen for one reader (P < 0.01).

Conclusion

In UL-MBIR, pancreatic calcification can be detected with high sensitivity, however, we should pay attention to the slightly lower specificity.

Comorbid risks of deep vein thrombosis and pulmonary thromboembolism in patients with chronic pancreatitis: a nationwide cohort study

ESSENTIALS: Risks of deep vein thrombosis (DVT) and pulmonary embolism (PE) in chronic pancreatitis (CP) are unclear. We conducted a nationwide cohort study to evaluate the risks of DVT and PE in CP patients. 17 778 patients with CP and 71 106 without CP were followed for 86 740 and 429 116 person-years, respectively. Patients with CP had a 2.95-fold increased rate of DVT and a 4.51-fold increased rate of PE.

BACKGROUND

Studies on the association between chronic pancreatitis (CP) and cardiovascular diseases are scarce. We conducted a nationwide cohort study to evaluate the risks of deep vein thrombosis (DVT) and pulmonary embolism (PE) in CP patients.

METHODS

Using the data from the Taiwan National Health Insurance Research Database, we randomly selected a non-CP cohort from insurants without a history of CP, and frequency-matched them at a ratio of 4 : 1 according to age, sex and index year with each patient newly diagnosed with CP between 2000 and 2010. The follow-up period ranged from the index date of new CP diagnosis to the diagnosis of DVT or PE, censoring, or the end of 2011. We used univariable and multivariable Cox proportional hazard regression models to determine the risks of DVT and PE.

RESULTS

In total, 17 778 patients in the CP cohort (82.6% men; mean age of 48.6 years) and 71 106 persons in the non-CP cohort were observed for 86 740 and 429 116 person-years, respectively. The CP cohort showed a 2.95-fold greater adjusted hazard ratio (aHR) for DVT (95% confidence interval [CI] 2.06-4.22) and a 4.51-fold greater aHR for PE (95% CI 2.86-7.11) than the non-CP cohort. Substantial risks of DVT and PE were evident in patients with CP aged < 55 years. The CP cohort with comorbidities showed increased risks of DVT and PE as compared with the non-CP cohort with no comorbidities.

CONCLUSIONS

The risks of DVT and PE are significantly higher in CP patients than in the general population.