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Choate R, Wasilchenko C, Thakur K, Hill R, Wright E, Conwell DL. Financial Toxicity in Patients With Chronic Pancreatitis. Pancreas 2024; 53:e774-e779. [PMID: 38904700 DOI: 10.1097/mpa.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
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.
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Affiliation(s)
- Radmila Choate
- From the Department of Epidemiology and Environmental Health, University of Kentucky College of Public Health, Lexington, KY
| | - Carrigan Wasilchenko
- Department of Internal Medicine, University of Kentucky College of Medicine Department of Internal Medicine, University
| | - Kshitij Thakur
- Department of Internal Medicine, University of Kentucky College of Medicine Department of Internal Medicine, University
| | - Rachel Hill
- Division of Biomedical Informatics, University of Kentucky College of Medicine, Lexington, KY
| | - Elizabeth Wright
- Department of Internal Medicine, University of Kentucky College of Medicine Department of Internal Medicine, University
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine Department of Internal Medicine, University
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Chu P, Mioc J, Henry O, O’Donovan P. The clinical, economic, and humanistic burden of treatments for exocrine pancreatic insufficiency and cost-effectiveness of treatments: A systematic literature review. Medicine (Baltimore) 2024; 103:e39224. [PMID: 39151540 PMCID: PMC11332733 DOI: 10.1097/md.0000000000039224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND To examine the burden of exocrine pancreatic insufficiency (EPI), specifically the clinical impact of EPI on patients, their quality of life (QoL) and the cost-effectiveness of existing treatments. METHODS A systematic literature review was conducted using key search terms for the clinical, economic, and humanistic burden. Databases were searched from 2010 to 2022, with articles screened independently by 2 reviewers at abstract and full-text stage against pre-defined eligibility criteria. RESULTS Seventy-one publications were identified that reported relevant clinical, humanistic, and economic data. Prevalence and incidence of EPI varied across identified studies; EPI appears to be especially prevalent as a comorbid condition in patients with cystic fibrosis. EPI has a large impact on QoL, with lower QoL scores in patients with EPI compared with those without EPI. The instruments used to assess QoL, however, were inconsistent across studies. Where reported, economic burden studies highlighted that patients with EPI have higher healthcare resource utilization compared with those without, with costs increasing with disease severity. CONCLUSION This systematic literature review highlights that patients with EPI have higher treatment costs and lower QoL scores than patients without EPI. The prevalence of EPI as a comorbid condition is high, particularly in patients with cystic fibrosis.
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Affiliation(s)
- Paula Chu
- Organon International GmbH, Lucerne, Switzerland
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Han S, Conwell DL, Easler JJ, Yang Y, Andersen DK, Fisher WE, Fogel EL, Forsmark C, Hart PA, Hughes SJ, Li L, Pandol SJ, Park WG, Serrano J, Van Den Eeden SK, Vege SS, Yadav D. Use of pancreatic endotherapy in patients with chronic pancreatitis: results from a multicenter cohort study in the United States. Gastrointest Endosc 2024; 100:262-272.e1. [PMID: 38583544 DOI: 10.1016/j.gie.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/19/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND AIMS Although pancreatic endotherapy (PET) is commonly used for treating adverse events of chronic pancreatitis, data on the frequency and factors associated with the use of PET are limited. Our aim was to define the use of and factors predictive for receiving PET in a well-characterized chronic pancreatitis cohort. METHODS This is a cross-sectional analysis of data from PROCEED, a multicenter U.S. cohort study of chronic pancreatitis. PET modalities primarily consisted of ERCP. A treatment course was defined as the number of sessions performed for a specific indication. A repeat course was defined as PET >1 year after completion of the last course. Multivariable logistic regression identified predictive factors for receiving PET, and proportional rates model assessed risk factors for repeat PET. RESULTS Of 681 subjects, 238 (34.9%) received PET. Factors associated with receiving PET included female sex (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.03-1.53), lower education (OR, 1.30; 95% CI, 1.04-1.62), income ≤$50,000 per year (OR, 1.35; 95% CI, 1.07-1.71), and prior acute pancreatitis (OR, 1.74; 95% CI, 1.31-2.32). Of 238 subjects, 103 (43.3%) underwent repeat PET at a median duration of 2 years, with 23.1% receiving 2 courses, 9.7% receiving 3 courses, and 10.4% receiving ≥4 courses. CONCLUSIONS Nearly half of patients with chronic pancreatitis who undergo PET received 1 or more repeat courses within 2 to 3 years. In addition to a prior history of acute pancreatitis, demographic and socioeconomic factors were associated with receiving PET.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Yunlong Yang
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - William E Fisher
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Chris Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen J Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Walter G Park
- Division of Gastroenterology & Hepatology, Stanford University, Stanford, California, USA
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Vege SS, Yadav D, Chari S. Validation of the Distinct Entity "Chronic Pancreatitis Without Prior Acute Pancreatitis": Complementary Role of Population- and Clinic-Based Studies. Gastroenterology 2024; 166:1195-1196. [PMID: 38103841 PMCID: PMC11305104 DOI: 10.1053/j.gastro.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Chari
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, Texas
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Chhoda A, McHenry N, Liyen Cartelle A, Bocchino R, Kahan T, Shah I, Zuberi SA, Anderson K, Freedman SD, Sheth SG. Impact of Ethno-racial Factors on Clinical Outcomes and Health Care Utilization in Chronic Pancreatitis. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02017-w. [PMID: 38702491 DOI: 10.1007/s40615-024-02017-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/17/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Healthcare disparities adversely affect clinical outcomes in racial and ethnic minorities. Chronic pancreatitis (CP) is a complex disorder, and pressures for time and cost-containment may amplify the disparity for minorities in this condition. This study aimed to assess ethno-racial differences in the clinical outcomes of CP patients cared for at our institution. METHODS This is a study of CP patients with available ethno-racial information followed at our pancreas center. We reviewed their demographics, comorbidities, clinical outcomes, and resource utilization: pain, frequent flares (≥ 2/year), local complications, psychosocial variables, exocrine, and endocrine insufficiency, imaging, endoscopic procedures, and surgeries. The outcomes underwent logistic regression to ascertain association(s) with covariates and were expressed as odds ratio (95% confidence intervals). RESULTS Of the 445 CP patients, there were 23 Hispanics, 330 Non-Hispanic Whites, 47 Non-Hispanic Blacks, 16 Asian Americans, and 29 patients from Other/mixed races. Over a median follow-up of 7 years, no significant differences in the pain profile (p = 0.36), neuromodulator use (p = 0.94), and opioid use for intermittent (p = 0.34) and daily pain (p = 0.80) were observed. Frequent flares were associated with Hispanic ethnicity [2.98(1.20-7.36); p = 0.02], despite adjustment for smoking [2.21(1.11-4.41); p = 0.02)] and alcohol [1.88(1.06-3.35); p = 0.03]. Local complications (pseudocysts, mesenteric thrombosis, and biliary obstruction), exocrine and endocrine dysfunction, and healthcare resource utilization (cross-sectional imaging, endoscopic procedures, celiac blocks, or surgeries) were comparable across all ethno-racial groups. CONCLUSIONS Although no significant differences in clinical outcomes, and health resource utilization were noted across ethno-racial groups, Hispanic ethnicity had significant association with CP flares. This study calls for further investigation of an understudied minority population with CP.
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Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Nicole McHenry
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Anabel Liyen Cartelle
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Rachel Bocchino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Tamara Kahan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Ishani Shah
- Division of Gastroenterology, University of Utah Hospital, Salt Lake City, USA
| | - Shaharyar A Zuberi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Kelsey Anderson
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb 423, Boston, MA, 02215, USA.
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Wong T, Pattarapuntakul T, Netinatsunton N, Ovartlarnporn B, Sottisuporn J, Yaowmaneerat T, Attasaranya S, Cattapan K, Sripongpun P. Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy. Diagnostics (Basel) 2024; 14:172. [PMID: 38248049 PMCID: PMC10814896 DOI: 10.3390/diagnostics14020172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. METHODS We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). RESULTS Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. CONCLUSIONS Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.
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Affiliation(s)
- Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Nisa Netinatsunton
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Jaksin Sottisuporn
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Siriboon Attasaranya
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Kamonwon Cattapan
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
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Kňazovický M, Roškovičová V, Gajdzik T, Hildebrand T, Kaťuchová J, Radoňák J. The Role of Surgery in Chronic Pancreatitis. POLISH JOURNAL OF SURGERY 2023; 96:97-102. [PMID: 38348975 DOI: 10.5604/01.3001.0053.9841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Chronic pancreatitis is an inflammatory disease characterized by the progressive replacement of the functional pancreatic parenchyma with fibrotic tissue. This leads to exocrine and endocrine insufficiency. A typical clinical feature is recurrent, severe upper abdominal pain, which negatively affects the patient's quality of life. Conservative treatment as the method of first choice does not prevent irreversible changes in the pancreatic tissue. While endoscopic drainage can have some benefits in the early stages of the disease, it is generally unsuccessful in the long term. Based on recent studies, surgical intervention appears to be the most suitable treatment option for improving the patient's quality of life. It currently includes a wide range of effective, proven drainage and resection procedures. Advances in surgical techniques and postsurgical intensive care have increased the frequency of pancreatic surgeries, while improvements in diagnostic methods have increased the number of patients who meet the indications for such surgery, including elderly and chronically ill patients. However, despite mortality rates decreasing, high morbidity rates remain a problem. Currently, in patients with an inflammatory mass in the head of the pancreas, pyloric and duodenal-preserving resection offers the best results. Different variants of these techniques appear to produce similar results. Various techniques have shown similar outcomes in terms of mortality, morbidity, pain relief, life expectancy and improved quality of life. The optimal timing of surgery has been addressed by several studies and most surgeons now favor early surgical intervention in order to prevent extensive destruction of pancreatic tissue.
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Affiliation(s)
- Miloš Kňazovický
- Department of Surgery, Louis Pasteur University Hospital, Košice, Slovakia
| | | | - Tomáš Gajdzik
- Department of Surgery, Louis Pasteur University Hospital, Košice, Slovakia
| | - Tomáš Hildebrand
- Department of Surgery, Louis Pasteur University Hospital, Košice, Slovakia
| | - Jana Kaťuchová
- Department of Surgery, Louis Pasteur University Hospital, Košice, Slovakia
| | - Jozef Radoňák
- Department of Surgery, Louis Pasteur University Hospital, Košice, Slovakia
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8
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Kumar P, Chander A, Chittajallu V, Grewal US. Underutilization of pancreatic enzyme replacement therapy in pancreatic cancer and chronic pancreatitis. J Intern Med 2023; 294:679-681. [PMID: 37264522 DOI: 10.1111/joim.13671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, Ohio, USA
| | - Apoorva Chander
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Vibhu Chittajallu
- Department of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Udhayvir Singh Grewal
- Division of Hematology, Oncology, Bone and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Holden Comprehensive Cancer Center, Iowa City, Iowa, USA
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Murillo K, Simsek O, Göltl P, Wekerle M, Hardt P, Gubergrits N, Hetjens S, Ebert MP, Schneider A, Hirth M. Impact of etiology on disease course in chronic pancreatitis. Pancreatology 2023; 23:582-588. [PMID: 37393150 DOI: 10.1016/j.pan.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Complications in chronic pancreatitis (CP) can be grouped in inflammatory (ICC) and fibrotic (FCC) clusters and pancreatic insufficiency cluster (PIC). However, the association between etiological risk factors and the development of complication clusters remains obscure. In this study, the impact of the etiology and disease duration on disease onset and development of complications was investigated. METHODS This cross-sectional study recruited patients with CP from Mannheim/Germany (n = 870), Gieβen/Germany (n = 100) und Donetsk/Ukraine (n = 104). Etiological risk factors, disease stage, age at disease onset, complications, need for hospitalization and surgery were noted. RESULTS In 1074 patients diagnosed with CP, main risk factors were alcohol and nicotine abuse. An earlier onset of the disease was observed upon nicotine abuse (-4.0 years). Alcohol abuse was only associated with an earlier onset of the definite stage of CP. Alcohol abuse was the major risk factor for the development of ICC (p < 0.0001, multiple regression modeling). Abstinence of alcohol reduced ICC, whereas abstinence of nicotine showed no association. PIC correlated with efferent duct abnormalities and the disease duration. In contrast, FCC was mainly dependent on the disease duration (p < 0.0001; t-test). The presence of any complication cluster correlated with the need for surgery (p < 0.01; X2-test). However, only ICC correlated with a prolonged hospital stay (p < 0.05; t-test). CONCLUSIONS ICC is mainly dependent on alcohol abuse. In contrast, FCC and PIC are mainly dependent on the disease duration. The etiology and disease duration can be used as predictors of the course of disease to provide individual treatment and surveillance strategies.
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Affiliation(s)
- Katharina Murillo
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Onur Simsek
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Philipp Göltl
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Maximilian Wekerle
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Philip Hardt
- Department of Gastroenterology, University Hospital Gießen, Rudolf-Buchheim-Straße 8, 35392, Gießen, Germany
| | - Natalia Gubergrits
- Department of Gastroenterology, University Hospital Donetsk, Ukraine, Illicha Ave 16, 83000, Donetsk, Ukraine
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias P Ebert
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alexander Schneider
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany; Department of Gastroenterology and Hepatology, Medical Center Bad Hersfeld, Seilerweg 29, 36251, Bad Hersfeld, Germany
| | - Michael Hirth
- Department of Medicine II, Medical Faculty at Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Kalsi RS, Kreger AM, Saleh M, Yoshida S, Sharma K, Fusco J, Saloman JL, Zhang T, Thomas M, Sehrawat A, Wang Y, Reif J, Mills J, Raad S, Zengin B, Gomez A, Singhi A, Tadros S, Slivka A, Esni F, Prasadan K, Gittes G. Chemical pancreatectomy in non-human primates ablates the acini and ducts and enhances beta-cell function. Sci Rep 2023; 13:9113. [PMID: 37277426 PMCID: PMC10241801 DOI: 10.1038/s41598-023-35820-2] [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: 02/22/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain medications and may necessitate major surgeries with high morbidity and mortality. Previously, we demonstrated that "chemical pancreatectomy," a pancreatic intraductal infusion of dilute acetic acid solution, ablated the exocrine pancreas while preserving the endocrine pancreas. Notably, chemical pancreatectomy resolved chronic inflammation, alleviated allodynia in the cerulein pancreatitis model, and improved glucose homeostasis. Herein, we extensively tested the feasibility of a chemical pancreatectomy in NHPs and validated our previously published pilot study. We did serial computed tomography (CT) scans of the abdomen and pelvis, analyzed dorsal root ganglia, measured serum enzymes, and performed histological and ultrastructural assessments and pancreatic endocrine function assays. Based on serial CT scans, chemical pancreatectomy led to the loss of pancreatic volume. Immunohistochemistry and transmission electron microscopy demonstrated exocrine pancreatic ablation with endocrine islet preservation. Importantly, chemical pancreatectomy did not increase pro-nociceptive markers in harvested dorsal root ganglia. Also, chemical pancreatectomy improved insulin secretion to supranormal levels in vivo and in vitro. Thus, this study may provide a foundation for translating this procedure to patients with chronic pancreatitis or other conditions requiring a pancreatectomy.
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Affiliation(s)
- Ranjeet S Kalsi
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Alexander M Kreger
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Mohamed Saleh
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Division of Pediatric Endocrinology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Shiho Yoshida
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Kartikeya Sharma
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Joseph Fusco
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Jami L Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Department of Neurobiology, Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ting Zhang
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Madison Thomas
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Anuradha Sehrawat
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Yan Wang
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Jason Reif
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Juliana Mills
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Sarah Raad
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Bugra Zengin
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Ana Gomez
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Aatur Singhi
- Divisions of Anatomic Pathology and Molecular Genomic Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sameh Tadros
- Department of Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Farzad Esni
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Krishna Prasadan
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - George Gittes
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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11
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Wilson GC, Turner KM, Delman AM, Wahab S, Ofosu A, Smith MT, Choe KA, Patel SH, Ahmad SA. Long-Term Survival Outcomes after Operative Management of Chronic Pancreatitis: Two Decades of Experience. J Am Coll Surg 2023; 236:601-610. [PMID: 36727736 DOI: 10.1097/xcs.0000000000000575] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Chronic pancreatitis is a debilitating, life-altering disease; however, the long-term outcomes after operative intervention have not been established. STUDY DESIGN Patients who underwent operative intervention at a single institution between 2000 and 2020 for chronic pancreatitis were included, and survival was assessed using the National Death Index. RESULTS A total of 493 patients who underwent 555 operative interventions for chronic pancreatitis during 2 decades were included. Of these patients, 48.5% underwent total pancreatectomy ± islet autotransplantation, 21.7% underwent a duodenal preserving pancreatic head resection and/or drainage procedure, 16.2% underwent a pancreaticoduodenectomy, and 12.8% underwent a distal pancreatectomy. The most common etiology of chronic pancreatitis was idiopathic (41.8%), followed by alcohol (28.0%) and known genetic polymorphisms (9.9%). With a median follow-up of 83.9 months, median overall survival was 202.7 months, with a 5- and 10-year overall survival of 81.3% and 63.5%. One hundred sixty-five patients were deceased, and the most common causes of death included infections (16.4%, n=27), cardiovascular disease (12.7%, n=21), and diabetes-related causes (10.9%, n=18). On long-term follow-up, 73.1% (n=331) of patients remained opioid free, but 58.7% (n=266) had insulin-dependent diabetes. On multivariate Cox proportional hazards modeling, only persistent opioid use (hazard ratio 3.91 [95% CI 2.45 to 6.24], p < 0.01) was associated with worse overall survival. CONCLUSIONS Our results represent the largest series to date evaluating long-term survival outcomes in patients with chronic pancreatitis after operative intervention. Our data give insight into the cause of death and allow for the development of mitigation strategies and long-term monitoring of comorbid conditions.
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Affiliation(s)
- Gregory C Wilson
- From the University of Cincinnati Pancreatic Disease Center, University of Cincinnati College of Medicine, Cincinnati, OH
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12
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Zhang Y, Zhang WQ, Liu XY, Zhang Q, Mao T, Li XY. Immune cells and immune cell-targeted therapy in chronic pancreatitis. Front Oncol 2023; 13:1151103. [PMID: 36969002 PMCID: PMC10034053 DOI: 10.3389/fonc.2023.1151103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
In recent years, studies have attempted to understand the immune cells and mechanisms underlying the pathogenesis of chronic pancreatitis (CP) by constructing a model of CP. Based on these studies, the innate immune response is a key factor in disease pathogenesis and inflammation severity. Novel mechanisms of crosstalk between immune and non-immune pancreatic cells, such as pancreatic stellate cells (PSC), have also been explored. Immune cells, immune responses, and signaling pathways in CP are important factors in the development and progression of pancreatitis. Based on these mechanisms, targeted therapy may provide a feasible scheme to stop or reverse the progression of the disease in the future and provide a new direction for the treatment of CP. This review summarizes the recent advances in research on immune mechanisms in CP and the new advances in treatment based on these mechanisms.
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13
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Kalsi RS, Kreger AM, Saleh M, Yoshida S, Sharma K, Fusco J, Saloman JL, Zhang T, Thomas M, Sehrawat A, Wang Y, Reif J, Mills J, Raad S, Zengin B, Gomez A, Singhi A, Tadros S, Slivka A, Esni F, Prasadan K, Gittes G. Chemical pancreatectomy in non-human primates ablates the acini and ducts and enhances beta-cell function. RESEARCH SQUARE 2023:rs.3.rs-2618133. [PMID: 36945494 PMCID: PMC10029118 DOI: 10.21203/rs.3.rs-2618133/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Chronic pancreatitis is a debilitating disease affecting millions worldwide. These patients suffer from bouts of severe pain that are minimally relieved by pain medications and may necessitate major surgeries with high morbidity and mortality. Previously, we demonstrated that "chemical pancreatectomy," a pancreatic intraductal infusion of dilute acetic acid solution, ablated the exocrine pancreas while preserving the endocrine pancreas. Notably, chemical pancreatectomy resolved chronic inflammation, alleviated allodynia in the cerulein pancreatitis model, and improved glucose homeostasis. Herein, we extensively tested the feasibility of a chemical pancreatectomy in NHPs and validated our previously published pilot study. We did serial computed tomography (CT) scans of the abdomen and pelvis, analyzed dorsal root ganglia, measured serum enzymes, and performed histological and ultrastructural assessments and pancreatic endocrine function assays. Based on serial CT scans, chemical pancreatectomy led to the loss of pancreatic volume. Immunohistochemistry and transmission electron microscopy demonstrated exocrine pancreatic ablation with endocrine islet preservation. Importantly, chemical pancreatectomy did not increase pro-nociceptive markers in harvested dorsal root ganglia. Also, chemical pancreatectomy improved insulin secretion to supranormal levels in vivo and in vitro. Thus, this study may provide a foundation for translating this procedure to patients with chronic pancreatitis or other conditions requiring a pancreatectomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Yan Wang
- UPMC Children's Hospital of Pittsburgh
| | | | | | | | | | - Ana Gomez
- UPMC Children's Hospital of Pittsburgh
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14
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Turner KM, Wahab SA, Delman AM, Brunner J, Smith MT, Choe KA, Patel SH, Ahmad SA, Wilson GC. Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis. Surgery 2023; 173:567-573. [PMID: 36241471 DOI: 10.1016/j.surg.2022.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. METHODS All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. RESULTS Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08-4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56-20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). CONCLUSION Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/KevinTurnerMD
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/ShaunWahabMD
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - John Brunner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Milton T Smith
- Department of Internal Medicine, Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH. https://twitter.com/SyedAAhmad5
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH.
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Llibre-Nieto G, Lira A, Vergara M, Casas M, Solé C, Ferrusquía-Acosta J, Puig-Diví V, Grau-López L, Barradas JM, Solà M, Miquel M, Sánchez-Delgado J. Prevalence of Radiological Chronic Pancreatitis and Exocrine Pancreatic Insufficiency in Patients with Decompensated Liver Disease: Is Fecal Elastase Useful in This Setting? Nutrients 2023; 15:nu15020375. [PMID: 36678246 PMCID: PMC9861070 DOI: 10.3390/nu15020375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Abstract
Chronic alcohol consumption is a well-known etiological factor for both chronic pancreatitis (CP) and liver cirrhosis. However, there is discussion over how often these two entities are present together in the same patient. The main goal of our study is to establish the prevalence of CP and low fecal elastase (FE-1) in patients with decompensated liver disease (DLD). In addition, we aim to identify the demographic, epidemiological and clinical factors associated with EPI and CP in patients with decompensated liver cirrhosis. This was an observational single-center study including 119 consecutive patients hospitalized for acute decompensation of cirrhosis, mostly of alcoholic etiology. Patients underwent computed tomography (CT) or magnetic resonance imaging (MRI) to assess the radiological features of CP. We also performed two FE-1 tests and complete blood tests to assess the presence of exocrine pancreatic insufficiency (EPI) and nutritional status, including micronutrients. The results of our study show that 32 patients (26.9%) had low fecal elastase suggesting EPI and 11 (9.2%) had CP. Patients meeting radiological CP criteria had lower FE-1 than patients without CP. There were no statistically significant differences in micronutrient deficiencies according to the presence of CP or not. Likewise, we did not find any statistically significant differences in micronutrient deficiencies among patients with normal and low FE-1 indicative of EPI. FE-1 alone may not be suitable for assessing EPI in patients with acute DLD. Detecting co-existing pancreatic disease may be important in a subset of patients with DLD, when the FE-1 levels are significantly low, potentially suggestive of a pancreatic anomaly. Moreover, the clinical manifestations of EPI and CP are not useful in detecting CP in DLD patients. Likewise, CP cannot explain all causes of EPI in these patients.
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Affiliation(s)
- Gemma Llibre-Nieto
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Hospital General de Granollers, 08402 Granollers, Spain
- Correspondence:
| | - Alba Lira
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
| | - Mercedes Vergara
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Meritxell Casas
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
| | - Cristina Solé
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - José Ferrusquía-Acosta
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Valentí Puig-Diví
- Unitat Gastroenterología, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigacio i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
| | - Laia Grau-López
- Estadística, Servei de Neurologia, Hospital Germans Trias i Pujol, 08916 Badalona, Spain
| | - Josep Maria Barradas
- Servei d’Infermeria, Unitat Hepatologia, Servei d’Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigacio i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
| | - Marta Solà
- Servei de Diagnòstic per la Imatge, Hospital Universitari Parc Taulí, Institut d’Investigacio i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
| | - Mireia Miquel
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Departament de Medicina, Universitat de Vic–Universitat Central de Catalunya (UVic-UCC), 08500 Vic, Spain
| | - Jordi Sánchez-Delgado
- Unitat Hepatologia, Servei Aparell Digestiu, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT), 08208 Sabadell, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
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16
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Ahmed A, Shah I, Bocchino R, Freedman SD, Kothari DJ, Sheth SG. Natural history, clinical characteristics, outcomes, and long-term follow-up of pain-free chronic pancreatitis. Gastroenterol Rep (Oxf) 2023; 11:goad024. [PMID: 37153703 PMCID: PMC10162807 DOI: 10.1093/gastro/goad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 05/10/2023] Open
Abstract
Background Chronic pancreatitis (CP) is characterized by chronic abdominal pain and functional insufficiency. However, a small subset of patients with prior acute pancreatitis (AP) and/or underlying risk factors for developing CP may be pain-free at diagnosis and may have a different clinical course. We aimed to compare the clinical characteristics, outcomes, and healthcare utilization between CP patients with and without pain. Methods Reviewed patients with established CP were followed in our Pancreas Center between January 2016 and April 2021. Patients without risk factors for developing CP and/or without AP prior to their diagnosis and only with incidental radiologic features of CP were excluded, so as to minimize confounding factors of pancreatopathy unrelated to CP. Patients were divided into painful and pain-free groups to analyze differences in demographics, outcomes, and healthcare utilization. Results Of 368 CP patients, 49 (13.3%) were pain-free at diagnosis and had remained so for >9 years. There were no significant differences in body mass index, race, sex, or co-morbidities between the two groups. Pain-free patients were older at diagnosis (53.9 vs 45.7, P = 0.004) and had less recurrent AP (RAP) (43.8% vs 72.5%, P < 0.001) and less exocrine pancreatic insufficiency (EPI) (34.7% vs 65.7%, P < 0.001). Pain-free patients had less disability (2.2% vs 22.0%, P = 0.003), mental illness (20.4% vs 61.0%, P < 0.001), surgery (0.0% vs 15.0%, P = 0.059), and therapeutic interventions (0.0% vs 16.4%, P = 0.005) for pain. Conclusions We described a unique subset of patients with underlying risk factors for CP and/or prior AP who were pain-free at diagnosis. They were older at diagnosis, had less EPI and RAP, and overall favorable outcomes with minimal resource utilization.
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Affiliation(s)
- Awais Ahmed
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ishani Shah
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rachel Bocchino
- Department of Medicine, Division of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Steven D Freedman
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Darshan J Kothari
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Sunil G Sheth
- Corresponding author. Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA.
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17
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Jeon C, Hart PA, Li L, Yang Y, Chang E, Bellin MD, Fisher WE, Fogel EL, Forsmark CE, Park WG, Van Den Eeden SK, Vege SS, Serrano J, Whitcomb DC, Andersen DK, Conwell DL, Yadav D, Goodarzi MO. Development of a Clinical Prediction Model for Diabetes in Chronic Pancreatitis: The PREDICT3c Study. Diabetes Care 2023; 46:46-55. [PMID: 36382801 PMCID: PMC9797648 DOI: 10.2337/dc22-1414] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Diabetes that arises from chronic pancreatitis (CP) is associated with increased morbidity and mortality. Methods to predict which patients with CP are at greatest risk for diabetes are urgently needed. We aimed to examine independent risk factors for diabetes in a large cohort of patients with CP. RESEARCH DESIGN AND METHODS This cross-sectional study comprised 645 individuals with CP enrolled in the PROCEED study, of whom 276 had diabetes. We conducted univariable and multivariable regression analyses of potential risk factors for diabetes. Model performance was assessed by area under the receiver operating characteristic curve (AUROC) analysis, and accuracy was evaluated by cross validation. Exploratory analyses were stratified according to the timing of development of diabetes relative to the diagnosis of pancreatitis. RESULTS Independent correlates of diabetes in CP included risk factors for type 2 diabetes (older age, overweight/obese status, male sex, non-White race, tobacco use) as well as pancreatic disease-related factors (history of acute pancreatitis complications, nonalcoholic etiology of CP, exocrine pancreatic dysfunction, pancreatic calcification, pancreatic atrophy) (AUROC 0.745). Type 2 diabetes risk factors were predominant for diabetes occurring before pancreatitis, and pancreatic disease-related factors were predominant for diabetes occurring after pancreatitis. CONCLUSIONS Multiple factors are associated with diabetes in CP, including canonical risk factors for type 2 diabetes and features associated with pancreatitis severity. This study lays the groundwork for the future development of models integrating clinical and nonclinical data to identify patients with CP at risk for diabetes and identifies modifiable risk factors (obesity, smoking) on which to focus for diabetes prevention.
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Affiliation(s)
- Christie Jeon
- Samuel Oschin Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX
| | - Yunlong Yang
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX
| | - Eleanor Chang
- Samuel Oschin Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Melena D. Bellin
- Division of Endocrinology and Metabolism, Department of Pediatrics, University of Minnesota Medical Center, Minneapolis, MN
| | | | - Evan L. Fogel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, IN
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - Walter G. Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | | | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - David C. Whitcomb
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh and UPMC Medical Center, Pittsburgh, PA
| | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh and UPMC Medical Center, Pittsburgh, PA
| | - Mark O. Goodarzi
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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18
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Singh VK, Whitcomb DC, Banks PA, AlKaade S, Anderson MA, Amann ST, Brand RE, Conwell DL, Cote GA, Gardner TB, Gelrud A, Guda N, Forsmark CE, Lewis M, Sherman S, Muniraj T, Romagnuolo J, Tan X, Tang G, Sandhu BS, Slivka A, Wilcox CM, Yadav D, Guda N, Banks P, Conwell D, Lo SK, Gelrud A, Gardner T, Baillie J, Forsmark CE, Muniraj T, Sherman S, Singh VK, Lewis M, Romagnuolo J, Hawes R, Cote GA, Lawrence C, Anderson MA, Amann ST, Etemad B, DeMeo M, Kochman M, Abberbock JN, Barmada MM, Bauer E, Brand RE, Kennard E, LaRusch J, O'Connell M, Stello K, Slivka A, Talluri J, Tang G, Whitcomb DC, Wisniewski SR, Yadav D, Burton F, AlKaade S, DiSario J, Sandhu BS, Money M, Steinberg W. Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium. Pancreatology 2022; 22:1091-1098. [PMID: 36404201 PMCID: PMC10122210 DOI: 10.1016/j.pan.2022.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort. METHODS We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP. RESULTS There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier. CONCLUSIONS Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A Banks
- Division of Gastroenterology, Brigham & Women's Hospital, Boston, MA, USA
| | | | | | | | - Randall E Brand
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health Science University, Portland, OR, USA
| | - Timothy B Gardner
- Division of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, Hanover, NH, USA
| | | | - Nalini Guda
- Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, FL, USA
| | - Michele Lewis
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Stuart Sherman
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | | | - Joseph Romagnuolo
- Palmetto Health, Columbia Gastroenterology Associates, Columbia, SC, USA
| | - Xiaoqing Tan
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - C Mel Wilcox
- Division of Gastroenterology & Hepatology, University of Alabama, Birmingham, AL, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability. HPB (Oxford) 2022; 24:2013-2021. [PMID: 35927127 DOI: 10.1016/j.hpb.2022.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 07/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years. METHODS Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively. RESULTS Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months. CONCLUSION This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.
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Clinical Course of Medically Managed Patients With Large and Small Duct Chronic Pancreatitis. Clin Transl Gastroenterol 2022; 14:e00537. [PMID: 36205696 PMCID: PMC9875973 DOI: 10.14309/ctg.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pancreatic duct obstruction is the primary indication for endoscopic and/or surgical therapy in patients with chronic pancreatitis (CP). However, the clinical course of medically managed patients in relation to pancreatic duct obstruction is largely unknown. METHODS This was a retrospective cohort study of medically managed patients with CP. We classified patients based on pancreatic duct obstruction from a stricture or stone using cross-sectional imaging (i.e., large vs small duct CP). We compared prevalence of diabetes and exocrine insufficiency (EPI) between subgroups at inclusion and investigated risk of new-onset diabetes, EPI, and all-cause mortality over a follow-up period of 5 years. Changes in pancreatic morphology were studied in patients who underwent follow-up imaging. RESULTS A total of 198 patients (mean age 58 ± 12 years, 70% male, 60% alcoholic etiology, 38% large duct CP) were evaluated. At inclusion, patients with large vs small duct CP had a higher prevalence of both diabetes (43% vs 24%, P = 0.004) and EPI (47% vs 28%, P = 0.007). There was an increased risk of new-onset EPI in patients with large duct CP (hazard ratio 1.72; 95% confidence interval [1.05-2.80], P = 0.031) and higher rates of pancreatic atrophy ( P < 0.001). No differences between groups were observed for new-onset diabetes and all-cause mortality. Conversion from small to large duct CP or vice versa during follow-up was observed in 14% of patients. DISCUSSION In a medically managed cohort of patients, large duct CP was associated with increased risk of EPI and pancreatic atrophy compared with small duct CP.
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Maev IV, Levchenko AI, Andreev DN. Changes in the Intestinal Microbiota in Patients with Chronic Pancreatitis: Systematizing Literature Data. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2022; 32:17-26. [DOI: 10.22416/1382-4376-2022-32-4-17-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
The purpose of the review. To systematize literature data on changes in the structure of the intestinal microbiota in patients with chronic pancreatitis (CP).Key findings. The human intestinal microbiota is a dynamically changing system that is constantly undergoing qualitative and quantitative changes, especially in several pathological conditions of the digestive system. At present, the differences in the intestinal microbiota in pancreatic diseases are poorly understood. The severe CP is associated with impaired synthesis of antimicrobial peptides, bicarbonates, and digestive enzymes by the pancreas, which is a risk factor for dysbiotic changes in the intestinal microbiota, consisting in the development of small intestinal bacterial overgrowth (SIBO) and gut dysbiosis. The results of two large meta-analyses show that about a third of CP patients have SIBO. The colonic microbiota in patients with CP is also characterized by dysbiotic disorders, primarily in the reduction of alpha-diversity. Some studies have shown that these patients have an increase in Firmicutes, while Bacteroides and Faecalibacterium are reduced. In addition, as a rule, in patients with CP, the growth of Escherichia, Shigella and Streptococcus is recorded.Conclusion. In general, scientific papers have revealed significant heterogeneity in the profiles of the intestinal microbiota in patients with CP. Thus, several questions remain open, prioritizing the further study of the intestinal microbiota in patients with CP for identifying the specifics of its structure that can personalize the selection of enzyme replacement therapy and restrict the unreasonable prescription of additional pharmacotherapy (the use of proton pump inhibitors and / or antibacterial drugs).
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Affiliation(s)
- I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - A. I. Levchenko
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - D. N. Andreev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
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Olesen SS, Toledo FGS, Hart PA. The spectrum of diabetes in acute and chronic pancreatitis. Curr Opin Gastroenterol 2022; 38:509-515. [PMID: 35881972 PMCID: PMC9379856 DOI: 10.1097/mog.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW To discuss the spectrum of diabetes related to acute and chronic pancreatitis (which are types of pancreatogenic diabetes) and its overlapping features with type 1 and type 2 diabetes. RECENT FINDINGS Patients with diabetes related to acute and chronic pancreatitis present clinically within a spectrum of overlapping features with other forms of diabetes. In this spectrum, glucose metabolism alterations range from increased insulin resistance following acute pancreatitis (resembling type 2 diabetes) towards a permanent loss of beta-cell function and impaired insulin secretion in end-stage chronic pancreatitis. Overlapping features with type 1 diabetes (beta cell autoantibodies) and type 2 diabetes (obesity, dyslipidemia, and hereditary/genetic factors) contribute to the heterogeneity of this spectrum. SUMMARY Pancreatogenic diabetes secondary to acute or chronic pancreatitis is a heterogeneous entity with a variable clinical presentation, including many cases that are misdiagnosed and treated as type 2 diabetes. This is problematic as pancreatogenic diabetes is associated with a poor prognosis and entails special considerations for management. Recent discoveries showing overlapping features with type 1 and type 2 diabetes along with an improved understanding of its pathophysiology are expected to improve the diagnosis and treatment of these and other forms of pancreatogenic diabetes.
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Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frederico G S Toledo
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Turner KM, Delman AM, Johnston Ii ME, Hanseman D, Wilson GC, Ahmad SA, Patel SH. Is endocrine and exocrine function improved following duodenal preserving pancreatic head resection over whipple for chronic pancreatitis? HPB (Oxford) 2022; 24:1194-1200. [PMID: 35090793 DOI: 10.1016/j.hpb.2021.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of our study was to evaluate the rates of treatment for post-operative exocrine pancreatic insufficiency (EPI) and diabetes mellites (DM) between Duodenal Preserving Pancreatic Head Resections (DPPHR) and Pancreaticoduodenectomy (PD) from a prospectively maintained database of patients with chronic pancreatitis. METHODS 104 patients were identified for inclusion, 62 of whom underwent DPPHR and 42 underwent PD. Study endpoints included changes in treatment for EPI and DM. RESULTS In the DPPHR group, the vast majority (n = 55) received a Frey procedure, with a small minority of patients undergoing a Beger procedure (n = 4) or Berne modification (n = 3). Patients in the DPPHR group had a lower rate of new persistent treatment for EPI post-operatively compared to patients who underwent PD (28.0% vs. 76.5%, p = 0.002). There was no difference in the rate of new onset DM, with low rates of new insulin dependent diabetics in both groups. Both groups had equal efficacy in terms of pain control, with 67.7% of the DPPHR group and 61.9% of the PD group remaining opioid free at long-term follow-up (p = 0.539). CONCLUSION In patients with head-predominant chronic pancreatitis, DPPHR was associated with reduced rates of new EPI treatment and similar endocrine function compared with PD.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Johnston Ii
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dennis Hanseman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Screening for gastrointestinal and pancreatic diseases. Adv Clin Chem 2022; 108:129-153. [PMID: 35659059 DOI: 10.1016/bs.acc.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diagnosis of chronic gastrointestinal and pancreatic diseases is challenging because patients generally present with nonspecific symptoms, such as abdominal pain and chronic diarrhea, some of which can last for many years. Although stool assays are more sensitive than serum assays, the former has unique limitations that healthcare providers should be aware of. One algorithm to screen for chronic gastrointestinal and pancreatic issues is to perform stool testing to assess inflammatory, watery (osmotic) and malabsorptive conditions. This chapter will discuss several stool-based screening tests, the major disorders they screen for and clinical performance. Sections on assay and sample limitations are also included. Stool testing can provide valuable diagnostic, prognostic and treatment response information if both the laboratory and clinician understand the benefits and limitations of these assays.
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Clinical and Analytical Characterization of the DiaSorin and ScheBo Fecal Pancreatic Elastase 1 Assays. Pancreas 2022; 51:243-249. [PMID: 35584381 DOI: 10.1097/mpa.0000000000002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Fecal pancreatic elastase (PE) assays are screening tests for exocrine pancreatic insufficiency (EPI). We analytically evaluated a new PE assay and retrospectively analyzed data from an academic hospital and reference laboratory to understand the clinical utility. METHODS Forty stool samples with different PE concentrations were tested on the ScheBo enzyme-linked immunosorbent assay (ELISA) versus DiaSorin LIAISON immunoassay; a simple-to-use extraction device was assessed. The cross-reactivity of porcine enzymes was investigated in the immunoassay. Charts of 207 patients with PE results less than 250 μg/g at an academic hospital were reviewed, and data were analyzed for 5136 patients with repeat PE results from a reference laboratory. RESULTS The LIAISON immunoassay gave comparable results to the ScheBo ELISA, with 87.5% agreement of PE results in classifying as sufficient, mild/moderate insufficiency, or severe insufficiency. The extraction device worked well compared with manual weighing, and no cross reactivity with porcine enzymes was observed. In agreement with prior studies, our clinical data suggested that PE assays were most useful in detecting severe EPI. CONCLUSIONS The new DiaSorin LIAISON immunoassay preforms similarly to the well-known ScheBo ELISA. Pancreatic elastase assays can help identify patients with severe EPI but are not as useful in classifying mild/moderate EPI.
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Bhullar FA, Faghih M, Akshintala VS, Ahmed AI, Lobner K, Afghani E, Phillips AE, Hart PA, Ramsey ML, Bick BL, Kuhlmann L, Drewes AM, Yadav D, Olesen SS, Singh VK. Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:20-29. [PMID: 34840065 PMCID: PMC8785146 DOI: 10.1016/j.pan.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/OBJECTIVES While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP. METHODS MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI). RESULTS Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively. CONCLUSION Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.
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Affiliation(s)
- Furqan A. Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata S. Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmed I. Ahmed
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Katie Lobner
- William H. Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mitchell L. Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Benjamin L. Bick
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indiana, USA
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M. Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Søren S. Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Vikesh K. Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Prodromal Signs and Symptoms of Chronic Pancreatitis: A Systematic Review. J Clin Gastroenterol 2022; 56:e1-e10. [PMID: 34049375 DOI: 10.1097/mcg.0000000000001544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/08/2021] [Indexed: 01/10/2023]
Abstract
GOAL We aimed to extract the percent of signs and symptoms at the time of diagnosis from published studies and to pool these using meta-analytic techniques. BACKGROUND Delayed or misdiagnosis of chronic pancreatitis may occur because the signs and symptoms are nonspecific and varied. STUDY We performed a systematic review of studies reporting the signs and symptoms of chronic pancreatitis at diagnosis. The percentage of patients with each sign and symptom was extracted and random-effects meta-analyses used to calculate pooled percentages. RESULTS In total, 22 observational studies were included. Across 14 studies, 55% of chronic pancreatitis patients were classified as having alcoholic etiology. Abdominal pain was the most common symptom (76%), and weight loss was reported in 22% of patients. Jaundice occurred in 11% of patients and steatorrhoea in 3%. Half of the patients had a history of acute pancreatitis, and 28% had diabetes mellitus at diagnosis. Heterogeneity between the studies was high for all signs and symptoms. CONCLUSIONS This research has identified some common features of patients with chronic pancreatitis, but the high heterogeneity makes it difficult to draw solid conclusions. Carefully designed studies to examine the signs and symptoms leading up to a diagnosis of chronic pancreatitis, and common combinations, are required. These would enable the development of a tool to aid in the early identification of chronic pancreatitis in the primary care setting, with potential for improved short-term and long-term outcomes for patients.
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Shandro BM, Chen J, Ritehnia J, Poullis A. Associations with pancreatic exocrine insufficiency: An United Kingdom single-centre study. World J Clin Cases 2021; 9:9469-9480. [PMID: 34877281 PMCID: PMC8610880 DOI: 10.12998/wjcc.v9.i31.9469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/03/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) is said to be associated with numerous conditions both within and outside the gastrointestinal (GI) system. The majority of research has been concerned with conditions that reduce the volume of functioning pancreatic tissue or prevent adequate drainage to the small bowel, such as chronic pancreatitis, cystic fibrosis, pancreatic cancer and pancreatic resection. However, the evidence base supporting an association with extra-pancreatic conditions, such as coeliac disease, diabetes mellitus and congestive cardiac failure, is heterogeneous.
AIM To strengthen the evidence base by studying all previously reported associations with PEI in a large cohort of outpatients.
METHODS A single-centre retrospective study was performed. General gastroenterology outpatients tested for PEI with faecal elastase-1 (FE1) were identified and information retrieved from the electronic patient record. PEI was defined as FE1 < 200 μg/g. Patients already taking pancreatic enzyme replacement therapy were excluded. Multiple imputation was used to handle missing data. Univariable logistic regression was used to study which presenting symptoms predicted PEI. Multivariable logistic regression was used to explore the relationship between all previously reported associations and PEI.
RESULTS Of 1027 patients were included. 182 patients (17.7%) were diagnosed with PEI. Steatorrhoea [odds ratios (OR): 2.51, 95% confidence intervals (CI): 1.58-3.98] and weight loss (OR: 1.49, 95%CI: 1.08-2.06) were the only presenting symptoms that predicted PEI. Chronic pancreatitis (OR: 7.98, 95%CI: 3.95-16.15), pancreatic cancer (OR: 6.58, 95%CI: 1.67-25.98), upper GI surgery (OR: 2.62, 95%CI: 1.32-5.19), type 2 diabetes (OR: 1.84, 95%CI: 1.18-2.87), proton pump inhibitor therapy (OR: 1.87, 95%CI: 1.25-2.80) and Asian ethnicity (OR: 2.11, 95%CI: 1.30-3.42) were significantly associated with PEI in the multivariable analysis. None of the other historically reported associations with PEI were significant after adjustment for the other variables included in our multivariable analysis.
CONCLUSION PEI is common in patients with chronic pancreatitis, pancreatic cancer, upper GI surgery and type 2 diabetes. Proton pump inhibitor therapy may also be associated with PEI or a false positive FE1.
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Affiliation(s)
- Benjamin M Shandro
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
| | - Joshua Chen
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
| | - Jennifer Ritehnia
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
| | - Andrew Poullis
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
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Abstract
PURPOSE OF REVIEW The purpose of this review is to delineate risk factors for the development of diabetes in patients with chronic pancreatitis. The natural history including progression to diabetes and complications that develop once diabetes occurs in chronic pancreatitis is also reviewed. RECENT FINDINGS Studies have found that predictors of diabetes in chronic pancreatitis include both risk factors for type 2 diabetes (e.g., obesity, genetic variants) as well as pancreas-specific factors (e.g., pancreatic calcification, exocrine insufficiency). Rates of diabetes in chronic pancreatitis are strongly related to the duration of chronic pancreatitis, reflecting progressive dysfunction and damage to the insulin-secreting beta cells. Patients with diabetes and chronic pancreatitis experience an excess burden of complications, including higher all-cause and cancer-related mortality. SUMMARY The high incidence and significant impact of diabetes on the morbidity and mortality of patients with chronic pancreatitis highlights the urgent need for clinically applicable models to predict diabetes in those with chronic pancreatitis, allowing efforts for targeted interventions to prevent diabetes. Research being carried out in the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer holds promise to fulfill these goals.
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Affiliation(s)
- Mark O. Goodarzi
- Division of Endocrinology, Diabetes, and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maxim S. Petrov
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - 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
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Chronic pancreatitis for the clinician. Part 1: Etiology and diagnosis. Interdisciplinary position paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:231-248. [PMID: 34157366 DOI: 10.1016/j.gastrohep.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/13/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
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31
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Maev IV, Kucheryavyy YA, Andreev DN. Exocrine pancreas insufficiency: clinical significance and approaches to correction from evidence medicine. TERAPEVT ARKH 2021; 93:509-515. [PMID: 36286789 DOI: 10.26442/00403660.2021.04.200800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
Exocrine pancreatic insufficiency (EPI) is a common complication of both benign and malignant diseases of the pancreas, as well as a consequence of radical surgical operations on the pancreas and a whole range of other variable extra-pancreatic causes. In clinical practice in the adult population, most cases of EPI are associated with chronic pancreatitis, while in the pediatric population with cystic fibrosis. The regression of the production of digestive enzymes in EPI mediates the development of the syndrome of maldigestion and malabsorption, leading to the progressive development of malnutrition, the importance of which is often underestimated by practitioners. At the same time, the development of nutritional deficiency is not just a complication of EPI, but also has an important effect on the course of the underlying causative disease, worsening the prognosis and quality of life of the patient, and is also a proven risk factor for osteoporosis and sarcopenia. To date, compensation for the absolute deficiency of pancreatic enzymes using enzyme replacement therapy is the only possible way to correct the EPI and prevent nutritional deficiency.
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Vipperla K, Kanakis A, Slivka A, Althouse AD, Brand RE, Phillips AE, Chennat J, Papachristou GI, Lee KK, Zureikat AH, Whitcomb DC, Yadav D. Natural course of pain in chronic pancreatitis is independent of disease duration. Pancreatology 2021; 21:649-657. [PMID: 33674197 DOI: 10.1016/j.pan.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Pain burn-out during the course of chronic pancreatitis (CP), proposed in the 1980s, remains controversial, and has clinical implications. We aimed to describe the natural course of pain in a well-characterized cohort. METHODS We constructed the clinical course of 279 C P patients enrolled from 2000 to 2014 in the North American Pancreatitis Studies from UPMC by retrospectively reviewing their medical records (median observation period, 12.4 years). We assessed abdominal pain at different time points, characterized pain pattern (Type A [short-lived pain episodes] or B [persistent pain and/or clusters of recurrent severe pain]) and recorded information on relevant covariates. RESULTS Pain at any time, at the end of follow-up, Type A pain pattern or B pain pattern was reported by 89.6%, 46.6%, 34% and 66% patients, respectively. In multivariable analyses, disease duration (time from first diagnosis of pancreatitis to end of observation) did not associate with pain - at last clinical contact (OR, 1.0, 95% CI 0.96-1.03), at NAPS2 enrollment (OR 1.02, 95% CI 0.96-1.07) or Type B pain pattern (OR 1.01, 95% CI 0.97-1.04). Patients needing endoscopic or surgical therapy (97.8 vs. 75.2%, p < 0.001) and those with alcohol etiology (94.7 vs. 84.9%, p = 0.007) had a higher prevalence of pain. In multivariable analyses, invasive therapy associated with Type B pain and pain at last clinical contact. CONCLUSIONS Only a subset of CP patients achieve durable pain relief. There is urgent need to develop new strategies to evaluate and manage pain, and to identify predictors of response to pain therapies for CP.
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Affiliation(s)
- Kishore Vipperla
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allison Kanakis
- Division of General Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Center for Research on Health Care Data Center, Department of Medicine, University of Pittsburgh, PA, USA
| | - Randall E Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anna E Phillips
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Chennat
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Vascular complications of chronic pancreatitis: A tertiary center experience. Pancreatology 2020; 20:1796. [PMID: 33158774 DOI: 10.1016/j.pan.2020.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022]
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Soytürk M, Bengi G, Oğuz D, Kalkan İH, Yalnız M, Tahtacı M, Demir K, Kasap E, Oruç N, Ünal NG, Sezgin O, Özdoğan O, Altıntaş E, Yaraş S, Parlak E, Köksal AŞ, Saruç M, Ünal H, Ünsal B, Günay S, Duman D, Yurçi A, Kacar S, Filik L. Turkish Gastroenterology Association, Pancreas Study Group, Chronic Pancreatitis Committee Consensus Report. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2020; 31:S1-S41. [PMID: 33210608 PMCID: PMC7752168 DOI: 10.5152/tjg.2020.220920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Müjde Soytürk
- Department of Gastroenterology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Göksel Bengi
- Department of Gastroenterology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Dilek Oğuz
- Department of Gastroenterology, Kırıkkale University School of Medicine, Kırıkkale, Turkey
| | - İsmail Hakkı Kalkan
- Department of Gastroenterology, TOBB University of Economics and Technology School of Medicine, Ankara, Turkey
| | - Mehmet Yalnız
- Department of Gastroenterology, Fırat University School of Medicine, Elazığ, Turkey
| | - Mustafa Tahtacı
- Department of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Kadir Demir
- Department of Gastroenterology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Elmas Kasap
- Department of Gastroenterology, Celal Bayar University School of Medicine, Manisa, Turkey
| | - Nevin Oruç
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Nalan Gülşen Ünal
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Orhan Sezgin
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Osman Özdoğan
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Engin Altıntaş
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Serkan Yaraş
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Murat Saruç
- Department of Gastroenterology, Acibadem University School of Medicine, İstanbul, Turkey
| | - Hakan Ünal
- Department of Gastroenterology, Acibadem University School of Medicine, İstanbul, Turkey
| | - Belkıs Ünsal
- Health Sciences University, Katip Çelebi Training and Research Hospital, İzmir, Turkey
| | - Süleyman Günay
- Health Sciences University, Katip Çelebi Training and Research Hospital, İzmir, Turkey
| | - Deniz Duman
- Department of Gastroenterology, Marmara University School of Medicine, İstanbul, Turkey
| | - Alper Yurçi
- Department of Gastroenterology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Sabite Kacar
- Health Sciences University, Ankara State Hospital, Ankara, Turkey
| | - Levent Filik
- Health Sciences University, Ankara Training and Research Hospital, Ankara, Turkey
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Hollenbach M, Barresi L. Shedding light on painless chronic pancreatitis. Dig Liver Dis 2020; 52:1331-1332. [PMID: 32712287 DOI: 10.1016/j.dld.2020.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Marcus Hollenbach
- Division of Gastroenterology, Medical Department II - Oncology, Gastroenterology, Hepatology, Pulmonology, Infectious Diseases, University of Leipzig Medical Center, Leipzig, Germany.
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS - ISMETT), Palermo, Italy
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Macrophages in pancreatitis: Mechanisms and therapeutic potential. Biomed Pharmacother 2020; 131:110693. [PMID: 32882586 DOI: 10.1016/j.biopha.2020.110693] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023] Open
Abstract
Macrophages play a crucial role in the pathogenesis of pancreatitis that is a common gastrointestinal disease. Particularly, macrophages differentiate into different phenotypes and exert diverse functions in acute pancreatitis (AP) and chronic pancreatitis (CP), respectively. In AP, macrophages in the pancreas and other related organs are mainly activated and differentiated into a pro-inflammatory M1 phenotype, and furthermore secrete inflammatory cytokines and mediators, causing local inflammation of the pancreas, and even intractable systemic inflammatory response or multiple organ failure. In CP, macrophages often exhibit a M2 polarisation and interact with pancreatic stellate cells (PSCs) in an autocrine and paracrine cytokine-dependent manner to promote the progression of pancreatic fibrosis. As the severity of pancreatic fibrosis aggravates, the proportion of M2/M1 macrophage cytokines in the pancreas increases. The discovery of macrophages in the pathogenesis of pancreatitis has promoted the research of targeted drugs, which provides great potential for the effective treatment of pancreatitis. This paper provides an overview of the roles of various macrophages in the pathogenesis of pancreatitis and the current research status of pancreatitis immunotherapy targeting macrophages. The findings addressed in this review are of considerable significance for understanding the pivotal role of macrophages in pancreatitis.
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Anand A, Gunjan D, Agarwal S, Kaushal K, Sharma S, Gopi S, Mohta S, Madhusudhan KS, Singh N, Saraya A. Vascular complications of chronic pancreatitis: A tertiary center experience. Pancreatology 2020; 20:1085-1091. [PMID: 32800648 DOI: 10.1016/j.pan.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Vascular complications such as venous thrombosis (VT) and pseudoaneurysm are not uncommon in patients with chronic pancreatitis (CP). The aim of this study to was to evaluate the prevalence and risk factors for vascular complications in patients with CP. METHODS A retrospective analysis of a prospectively maintained database of patients with CP presenting from January 2002 to August 2019 was performed. Venous thrombosis and pseudoaneurysm were identified using radiological imaging, and their risk factors were identified using multivariate Cox-proportional hazards. RESULTS Of 1363 patients with CP, 166 (12.2%) had vascular complications. Isolated VT was present in 132, pseudoaneurysm in 17, and both in 17 patients. They were more commonly seen in males and alcoholic CP (ACP), and less commonly in patients with pancreatic atrophy and calcification. It involved the vessels in the closest proximity to the pancreas, VT most commonly involving the splenic vein whereas pseudoaneurysm most commonly involved the splenic artery. Alcoholic CP [odds ratio (OR) 2.1, p = 0.002], pseudocyst (OR 4.6, p < 0.001) and inflammatory head mass (OR 3.1, p = 0.006) were independent risk factors for VT, whereas ACP (OR 3.49, p = 0.006) and pseudocyst (OR 3.2, p = 0.002) were independent risk factors for pseudoaneurysm. Gastrointestinal bleed occurred in 3.5% patients, and more commonly in patients with pseudoaneurysm than VT (64.7% vs 15.9%), and in patients with ACP in comparison to other etiologies (p < 0.001). CONCLUSION Vascular complications are a common complication of CP, VT being more frequent than pseudoaneurysm. Pseudocyst and ACP are independent risk factors for the development of vascular complications.
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Affiliation(s)
- Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kanav Kaushal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Patient reported exposure to smoking and alcohol abuse are associated with pain and other complications in patients with chronic pancreatitis. Pancreatology 2020; 20:844-851. [PMID: 32507681 DOI: 10.1016/j.pan.2020.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/25/2020] [Accepted: 05/01/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Smoking and alcohol abuse are established risk factors for chronic pancreatitis (CP). Few studies have examined how exposure to smoking and alcohol abuse act as risk factors for complications in CP. Our aim was to examine associations between patient reported exposure to smoking and alcohol abuse and complications in CP in a large cohort of patients from the Scandinavian and Baltic countries. METHODS We retrieved data on demographics, CP related complications and patients' histories of exposure to smoking and alcohol abuse from the Scandinavian Baltic Pancreatic Club database. Associations were investigated by univariate and multivariate logistic regression analyses. Results are presented as odds ratios (OR) with 95% confidence intervals. RESULTS A complete history of smoking and alcohol exposure was available for 932 patients. In multivariate regression analyses, the presence of pain and exocrine pancreatic insufficiency were both significantly associated with history of smoking (OR 1.94 (1.40-2.68), p < 0.001 and OR 1.89 (1.36-2.62), p < 0.001, respectively) and alcohol abuse (OR 1.66 (1.21-2.26), p = 0.001 and 1.55 (1.14-2.11), p = 0.005, respectively). Smoking was associated with calcifications (OR 2.89 (2.09-3.96), p < 0.001), moderate to severe ductal changes (OR 1.42 (1.05-1.92), p = 0.02), and underweight (OR 4.73 (2.23-10.02), p < 0.001). History of alcohol abuse was associated with pseudocysts (OR 1.38 (1.00-1.90) p = 0.05) and diabetes mellitus (OR 1.44 (1.03-2.01), p = 0.03). There were significantly increased odds-ratios for several complications with increasing exposure to smoking and alcohol abuse. CONCLUSION Smoking and alcohol abuse are both independently associated with development of complications in patients with CP. There seems to be a dose-dependent relationship between smoking and alcohol abuse and complications in CP.
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Voiosu T, Boškoski I, Tringali A, Quero G, Voiosu A, Costamagna G. Chronic pancreatitis: an overview of diagnosis and management. Expert Rev Gastroenterol Hepatol 2020; 14:515-526. [PMID: 32511055 DOI: 10.1080/17474124.2020.1774365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Chronic pancreatitis entails a heavy burden on the healthcare system because of its often protracted evolution, requiring complex diagnostic and therapeutic procedures. AREAS COVERED This review focuses on novel imaging and endoscopic diagnostic and therapeutic interventions that have changed the management of patients with chronic pancreatitis. We have conducted an extensive search of original papers and guidelines, in order to provide a comprehensive and up to date review of available evidence in these areas of interest. EXPERT OPINION The traditional challenges in managing chronic pancreatitis patients stemmed from the limitations of diagnostic modalities, which could not correctly identify patients in an early stage of the disease, as well as from the scarcity of therapeutic options available. Advances in imaging of CT-scan, MRI, and EUS have opened the way for early diagnosis and staging. This has allowed more aggressive and tailored therapeutic modalities, particularly in endoscopic therapy and minimally invasive surgical interventions. Although high-quality data from large RCTs is still scarce, evidence-based algorithms for diagnosis and therapy are now changing the way we address this chronic disease. In the near future, we can expect a tailored approach based on patient and disease-related predictive factors, relying on a vast armamentarium of endoscopic and surgical solutions.
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Affiliation(s)
- Theodor Voiosu
- Internal Medicine, Carol Davila School of Medicine , Bucharest, Romania.,Gastroenterology Department, Colentina Clinical Hospital , Bucharest, Romania
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
| | - Giuseppe Quero
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy
| | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital , Bucharest, Romania
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS , Rome, Italy.,Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore Di Roma , Rome, Italy
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Machicado JD, Papachristou GI. Pancreatogenic diabetes, acute pancreatitis management, and pancreatic tuberculosis: Appraising the present and setting goals for the future. United European Gastroenterol J 2020; 8:365-368. [PMID: 32364055 PMCID: PMC7226692 DOI: 10.1177/2050640620917017] [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: 11/16/2022] Open
Affiliation(s)
- Jorge D Machicado
- Division of Gastroenterology and Hepatology, Mayo Clinic Health System,
Eau Claire, Wisconsin, USA
| | - Georgios I Papachristou
- Division of Gastroenterology and Hepatology, The Ohio State University
Wexner Medical Center, Columbus, Ohio, USA
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Parhiala M, Sand J, Laukkarinen J. A population-based study of chronic pancreatitis in Finland: Effects on quality of life. Pancreatology 2020; 20:338-346. [PMID: 32147309 DOI: 10.1016/j.pan.2020.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 12/01/2019] [Accepted: 02/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES In Finland the incidence of chronic pancreatitis (CP) is high compared to that in most European countries. Recent epidemiological data is lacking. Our aim was to investigate the current epidemiologic and behavioural data on CP patients in Finland. METHODS CP patients according to M-ANNHEIM criteria in Tampere University Hospital (TAUH) during 2014-2015 were included. Aetiology, time from diagnosis, pancreatic function, treatment, complications, smoking, alcohol consumption (AUDIT) and quality of life (QoL) (QLQ C30, PAN26) were gathered. RESULTS 235 CP patients (57 (26-88) years, 65% men) were included. Time since diagnosis was 5.5 (1-41) years. Aetiology was alcohol in 67%, and smoking contributed in 54%. Of these patients 78% continued smoking and 58% continued to consume alcohol even after CP diagnosis. CP related complications were common. Pseudocysts were more common in alcohol related CP than in non-alcohol related CP (60% vs. 38%, p < 0.05). Reported QoL and pain were worse in the CP patients than in controls. Alcohol consumption differed from that of the Finnish population; the CP patients were either total abstainers or heavy alcohol consumers. CONCLUSIONS CP constitutes a great burden on the health care system and on the patients. The patients frequently develop complications and symptoms and their QoL is inferior to that of controls. The most important measure to halt the progression of CP would be to prevent acute phases and for patients to stop smoking, which does not happen in many CP patients. It would be beneficial to increase awareness among CP patients and medical professionals.
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Affiliation(s)
- Mikael Parhiala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juhani Sand
- Dept of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Johanna Laukkarinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Dept of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.
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Napolitano M, Brody F, Lee KB, Rosenfeld E, Chen S, Murillo-Berlioz AE, Amdur R. 30-Day outcomes and predictors of complications after Puestow procedure. Am J Surg 2020; 220:372-375. [PMID: 31894016 DOI: 10.1016/j.amjsurg.2019.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND A lateral pancreaticojejunostomy, or a Puestow procedure, is used in chronic pancreatitis with ductal dilation and pain. The current literature on the Puestow is sparse. This study examines outcomes of Puestow procedures nationwide. METHODS Using ACS-NSQIP database, patients who underwent a Puestow procedure from 2010 to 2016 were identified. Univariate analysis and multivariable regression models were used to identify predictors of mortality and morbidities. Covariates included in the regression models were chosen based on clinical significance. RESULTS The cohort included 524 patients. The 30-day mortality rate was 1.2%(n = 6). At least one major complication occurred in 19.1% of patients including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical site infections (13.0%). Diabetes, COPD, and transfusions were the strongest predictors of complications. CONCLUSIONS The Puestow procedure is an acceptable treatment modality with low rates of morbidity and mortality. Minimizing transfusions and optimizing pulmonary status may improve 30-day outcomes.
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Affiliation(s)
- Michael Napolitano
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Fred Brody
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA.
| | - Kyongjune Benjamin Lee
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Ethan Rosenfeld
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Sheena Chen
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Alejandro Ernesto Murillo-Berlioz
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Richard Amdur
- Department of Surgery, George Washington University Hospital, Washington D.C., USA
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Abstract
Chronic pancreatitis is characterized by progressive, irreversible morphologic and functional changes that are most commonly attributed to environmental insults, particularly when there is a genetic or anatomic predisposition. Heavy alcohol use and cigarette smoking are the most common environmental risk factors, but both may be absent. Antecedent episodes of acute pancreatitis occur in about half of patients. Abdominal pain is the most common symptom and requires a tailored approach depending on the anatomic changes in the pancreas. Other clinical manifestations include diabetes mellitus, exocrine pancreatic insufficiency, metabolic bone disease, pancreatic cancer, and anatomic complications. Current disease management is centered on risk factor reduction and screening for and treating disease complications. There are no current therapies to delay or retard disease progression, but there are ongoing efforts to more fully understand the natural history of chronic pancreatitis and underlying mechanisms of disease. These studies are expected to provide insights that will transform our approach to disease management and provide increased hope to patients.
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Abstract
IMPORTANCE Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas with a prevalence of 42 to 73 per 100 000 adults in the United States. OBSERVATIONS Both genetic and environmental factors are thought to contribute to the pathogenesis of CP. Environmental factors associated with CP include alcohol abuse (odds ratio [OR], 3.1; 95% CI, 1.87-5.14) for 5 or more drinks per day vs abstainers and light drinkers as well as smoking (OR, 4.59; 95% CI, 2.91-7.25) for more than 35 pack-years in a case-control study involving 971 participants. Between 28% to 80% of patients are classified as having "idiopathic CP." Up to 50% of these individuals have mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 1% of people diagnosed with CP may have hereditary pancreatitis, associated with cationic trypsinogen (PRSS1) gene mutations. Approximately 80% of people with CP present with recurrent or chronic upper abdominal pain. Long-term sequelae include diabetes in 38% to 40% and exocrine insufficiency in 30% to 48%. The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both. Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal. The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol). A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients. Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, such as pancreaticojejunostomy with or without pancreatic head resection, which may provide better pain relief among people who do not respond to endoscopic therapy. CONCLUSIONS AND RELEVANCE Chronic pancreatitis often results in chronic abdominal pain and is most commonly caused by excessive alcohol use, smoking, or genetic mutations. Treatment consists primarily of alcohol and smoking cessation, pain control, replacement of pancreatic insufficiency, or mechanical drainage of obstructed pancreatic ducts for some patients.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Dhiraj Yadav
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Olesen SS, Lisitskaya MV, Drewes AM, Novovic S, Nøjgaard C, Kalaitzakis E, Jensen NM, Engjom T, Erchinger F, Waage A, Hauge T, Haas SL, Vujasinovic M, Lindkvist B, Zviniene K, Pukitis A, Ozola-Zālīte I, Okhlobystin A, Parhiala M, Laukkarinen J, Frøkjær JB. Pancreatic calcifications associate with diverse aetiological risk factors in patients with chronic pancreatitis: A multicentre study of 1500 cases. Pancreatology 2019; 19:922-928. [PMID: 31462382 DOI: 10.1016/j.pan.2019.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/08/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic calcifications is a common finding in patients with chronic pancreatitis (CP), but the underlying pathophysiology is incompletely understood. Past studies for risk factors of calcifications have generally been focused on single parameters or limited by small sample sizes. The aim of this study was to explore several patient and disease characteristics and their associations with pancreatic calcifications in a large cohort of CP patients with diverse aetiological risk factors. METHODS This was a multicentre, cross-sectional study including 1509 patients with CP. Patient and disease characteristics were compared for patients with calcifications (n = 912) vs. without calcifications (n = 597). Multivariable logistic regression was performed to assess the parameters independently associated with calcifications. RESULTS The mean age of patients was 53.9 ± 14.5 years and 1006 (67%) were men. The prevalence of calcifications was 60.4% in the overall patient cohort, but highly variable between patients with different aetiological risk factors (range: 2-69%). On multivariate analysis, alcoholic aetiology (OR 1.76 [95% CI, 1.39-2.24]; p < 0.001) and smoking aetiology (OR 1.77 [95% CI, 1.39-2.26], p < 0.001) were positively associated with the presence of calcifications, while an autoimmune aetiology was negatively associated with calcifications (OR 0.15 [95% CI, 0.08-0.27], p < 0.001). Patients with pancreatic calcifications were more likely to have undergone pancreatic duct stenting (OR 1.59 [95%CI, 1.16-2.19], p = 0.004). CONCLUSION The presence of pancreatic calcifications is associated with diverse aetiological risk factors in patients with CP. This observation attest to the understanding of CP as a complex disease and may have implications for disease classification.
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Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark.
| | - Maria Valeryevna Lisitskaya
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Evangelos Kalaitzakis
- Copenhagen University Hospital/Herlev, University of Copenhagen, Copenhagen, Denmark
| | - Nanna M Jensen
- Abdominalcenter K, Bispebjerg Hospital, Copenhagen, Denmark
| | - Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Haukeland University Hospital, Department of Medicine, Bergen, Norway
| | | | - Anne Waage
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stephan L Haas
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Lindkvist
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Zviniene
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Aldis Pukitis
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Imanta Ozola-Zālīte
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Alexey Okhlobystin
- Chair of Internal Diseases Propedeutics, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Mikael Parhiala
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Cancer Center, Faculty of Medicine and Heath Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Cancer Center, Faculty of Medicine and Heath Technology, Tampere University, Tampere, Finland
| | - Jens B Frøkjær
- Clinical Institute, Aalborg University, Aalborg, Denmark; Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
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Abstract
PURPOSE OF REVIEW Pancreatic exocrine insufficiency (PEI) is one of the well known causes of malabsorption syndrome. An insufficient secretion of pancreatic enzymes and bicarbonate secondary to different pancreatic diseases and upper gastrointestinal and pancreatic surgery leads to maldigestion and malabsorption of nutrients. Patients with PEI may present with symptoms of malabsorption and different nutritional deficiencies. Recent data support the high clinical relevance of PEI and its treatment. RECENT FINDINGS Deficiencies of fat-soluble vitamins, proteins, micronutrients and antioxidants in patients with PEI are associated not only with an increased risk of osteoporosis and sarcopenia but also of cardiovascular events and mortality. Pancreatic enzyme replacement therapy (PERT) allows improving fat and protein digestion, relieving maldigestion-related symptoms, normalizing the nutritional status, and improving quality of life of patients with PEI. Recent data support the efficacy of PERT on survival in patients with pancreatic cancer. Dose of oral pancreatic enzymes should be adequate to normalize the nutritional status of PEI patients. SUMMARY Increasing evidence supports the relevance of PEI management by dietary advice and appropriate PERT. Well designed and powered randomized, placebo-controlled clinical trials are needed to further evaluate the clinical impact of PEI and its treatment in clinical practice.
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Abstract
OBJECTIVES The aim of this study was to assess the occurrence of new-onset diabetes mellitus (DM) after chronic pancreatitis (CP) diagnosis via systematic review and meta-analysis. METHODS A systematic review of literature and meta-analysis of relevant reports were performed. The primary outcome measures studied were newly diagnosed DM and DM treated with insulin. For the binary outcomes, pooled prevalence and 95% confidence interval (CI) were calculated. METHODS Fifteen studies involving 8970 patients were eligible. The incidence of new-onset DM after CP diagnosis was 30% (95% CI, 27%-33%). Among all patients, 17% (95% CI, 13%-22%) developed insulin-dependent new-onset DM. The prevalence of newly diagnosed DM after CP diagnosis increased from 15% within 36 months to 33% after 60 months. The proportion of alcoholic CP, sex, age, and body mass index had minimal effect on the studied outcomes. CONCLUSIONS This systematic review identified a clinically relevant risk of new-onset DM after CP diagnosis. Therefore, patients should be informed of the risk of DM and monitored.
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Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol 2019; 12:129-139. [PMID: 30962702 PMCID: PMC6432881 DOI: 10.2147/ceg.s168266] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular. EPI can result in clinical manifestation and biochemical alterations causing reduced quality of life and life-threating complications. EPI is common in pancreatic disorders, where it should be suspected and actively investigated, and in many extrapancreatic conditions. There are various tests available to diagnose EPI, with indirect, noninvasive ones, such as concentration of fecal elastase being more commonly employed. Administration of pancreatic enzymes replacement therapy remains the mainstay of EPI treatment. The present review article will discuss current evidence regarding the prevalence of EPI, the available tests to diagnose it and its treatment.
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Affiliation(s)
- Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
| | - Mariaemilia Traini
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
| | - Matteo Piciucchi
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Marianna Signoretti
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
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49
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Abstract
Knowledge of pancreatitis in the 20th century was shaped predominantly by animal data and clinical trials. Several large general population-based cohort studies and comprehensive systematic literature reviews in the 21st century have had a major effect on our understanding of pancreatitis and its sequelae. This Review provides precise and up-to-date data on the burden of acute pancreatitis, chronic pancreatitis and post-pancreatitis diabetes mellitus. Exocrine pancreatic insufficiency and altered bone metabolism following pancreatitis are also discussed. Furthermore, the article introduces a framework for the holistic prevention of pancreatitis with a view to providing guidance on strategies and intervention objectives at primary, secondary and tertiary levels. Concerted efforts by not only gastroenterologists and surgeons but also primary care physicians, endocrinologists, radiologists, pain specialists, dietitians, epidemiologists and public health specialists will be required to reduce meaningfully the burden of pancreatitis and its sequelae over the ensuing decades.
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Affiliation(s)
- Maxim S. Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,
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50
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Abstract
PURPOSE OF REVIEW Pancreatic exocrine insufficiency (PEI), defined as a secretion of pancreatic enzymes and bicarbonate insufficient to maintain a normal digestion, is a frequent but frequently underdiagnosed and undertreated condition. PEI may be secondary to different pancreatic diseases and extrapancreatic conditions. Recent data support the high clinical relevance of PEI and its treatment. RECENT FINDINGS Together with symptoms of maldigestion, PEI is associated with nutritional deficiencies leading to osteoporosis, low-trauma fractures, sarcopenia and increased mortality. No single widely available test allows to diagnose PEI accurately. Diagnosis of PEI requires the evaluation of symptoms, nutritional markers and a noninvasive pancreatic function test in the appropriate clinical context. Pancreatic enzyme replacement therapy (PERT) improves digestion, symptoms, nutritional status and quality of life of patients with PEI. In addition, PERT is associated with a longer survival in patients with unresectable pancreatic cancer and after surgery for pancreatic cancer or chronic pancreatitis. SUMMARY Awareness of PEI in different clinical conditions is required. Nutritional advice and appropriate PERT are mandatory to reduce the morbidity and mortality associated with PEI. Further studies on the clinical impact of PEI and its treatment are needed, especially in diseases other than chronic pancreatitis and cystic fibrosis.
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