Natural course of chronic pancreatitis and predictors of its progression

Acute pancreatitis as a risk factor of chronic pancreatitis and pancreatic cancer. An overview

This is an overview of relation between acute and chronic pancreatitis and between acute pancreatitis and pancreatic cancer. Acute pancreatitis and recurrent acute pancreatitis are an etiological factor of chronic pancreatitis. Population-based studies have calculated the risk of acute recurrent pancreatitis after the first attack of acute pancreatitis to be 20% and development of chronic pancreatitis after first attack of acute pancreatitis is 10%. An important risk factor is tobacco smoking. Acute and chronic pancreatitis are risk factors for pancreatic cancer. The risk of acute pancreatitis is related to the number of recurrences of acute pancreatitis, but not the etiology of acute pancreatitis. Acute pancreatitis, as well as chronic pancreatitis, are risk factors for pancreatic cancer. After an attack of acute pancreatitis or recurrent acute pancreatitis a patient should be regarded as a high risk.

Healthcare disparities in pancreatitis: knowledge gaps and next steps

PURPOSE OF REVIEW

This review examines current research on healthcare disparities in pancreatitis, identifies knowledge gaps, and proposes strategies to develop targeted multilevel interventions to address inequities in pancreatitis care.

RECENT FINDINGS

Current literature has identified patient, disease, and healthcare-level factors contributing to disparities in risk factors and health outcomes of pancreatitis. Moreover, social structures, economic systems, social vulnerability, and policy significantly influence the pancreatitis care continuum.

SUMMARY

Understanding the root causes of health inequities is critical to developing effective approaches for the prevention, early detection, and management of pancreatitis.

Combination of Serum CA 19-9 and Endoscopic Ultrasound Findings Can Predict Malignancy Risk in Patients With Chronic Pancreatitis Presenting With Pancreatic Head Mass: A Proof-of-Concept Study

BACKGROUND AND AIMS

Inflammatory head mass of pancreas (IMP) developing in background of chronic pancreatitis (CP) is difficult to distinguish from carcinoma pancreas. We aimed to delineate natural course of IMP and predict their malignancy risk, avoiding unnecessary biopsies.

MATERIALS AND METHODS

In this retrospective single-center study, clinical records of patients with CP with diagnosed pancreatic head mass were reviewed. Clinical, laboratory, imaging, endoscopic findings, and follow-up details were retrieved from prospectively maintained database. A diagnostic nomogram was developed combining serum cancer antigen 19-9 and endoscopic ultrasound (EUS) findings to predict the risk of malignancy.

RESULTS

We identified 107 patients with pancreatic head mass with CP of whom 87 (81.3%) were IMP and 20 (18.7%) were malignant. Patients with IMP were more frequently young males with alcohol-related CP and low CA 19-9 in comparison with those with malignancy (age IMP: 41.3 ± 11.3 vs carcinoma: 49.3 ± 14.5 years [ P = 0.009]; males 89.7% vs 65% [ P = 0.011]; alcoholic etiology: 71.3% vs 20% [ P < 0.001]; median CA 19-9: 25.78 [interquartile range, 7.20-120.60] vs 1034.50 [106.65-7808.25] [ P < 0.001]). A diagnostic nomogram combining CA 19-9 and EUS findings could identify malignancy with an optimism-corrected c-statistic of 0.905, which was better than both CA 19-9 (0.80) and EUS alone (0.826). Patients with IMP had relatively benign disease course with 40.2% biliary obstruction, 20.7% portal venous thrombosis, 14.9% gastric outlet obstruction, and 1-, 3-, and 5-year survival being 97.3%, 92.7%, and 92.0%, respectively. Surgery was required in only 12 patients (13.8%) with IMP.

CONCLUSIONS

Combination of CA 19-9 and EUS best identifies malignancy risk in patients with IMP, who have otherwise benign course.

Opportunistic screening for osteopathy with routine abdominal computed tomography scan in chronic pancreatitis

BACKGROUND AND AIMS

Lumbar vertebral bone attenuation, measured in Hounsfield units (HU) can indirectly indicate the bone mineral density (BMD). The aim of this study is to determine the optimal HU threshold on abdominal computed tomography (CT) scans to detect osteopathy in patients with chronic pancreatitis (CP).

METHODS

This cross-sectional study included patients with CP who underwent CT scans to measure HU at L1 to L4 vertebrae. The mean lumbar vertebral attenuation of female renal transplant donors, aged 20-30 years was utilized to calculate the T-scoreHU of all patients at each vertebral level. Receiver operator characteristic analysis was used to determine the HU and T-scoreHU for diagnosis of osteopathy in patients with CP. Dual-energy X-ray absorptiometry value was used to categorize osteopenia and osteoporosis.

RESULTS

A total of 175 patients (mean age, 34.5 ± 10.9 years; 72 % males) and 33 female renal transplant donors (mean age, 28 ± 2.4 years) were included. A threshold HU value 212 or T scoreHU of -1.80 at L1 vertebra was found to have a 78 % sensitivity and 70 % specificity for differentiating between osteoporosis and non-osteoporosis (osteopenia and normal BMD). Similarly, a threshold HU value of 254 or a T-scoreHU of -0.46 at L1 vertebra had 78 % sensitivity and 71 % specificity for distinguishing between normal and low BMD (osteoporosis and osteopenia).

CONCLUSION

Abdominal CT images, which are routinely performed in chronic pancreatitis, can be used for opportunistic screening of osteoporosis and osteopenia without additional cost or radiation exposure.

Incidence and risk of pancreatic cancer in patients with acute or chronic pancreatitis: a population-based cohort study

We aimed to evaluate the incidence and risk of pancreatic cancer (PC) in pancreatitis. We identified patients with acute pancreatitis (AP) (n = 225,811, 50.0%) and chronic pancreatitis (CP) (n = 225,685, 50.0%) from Korean population-based data and matched them with age- and sex-matched controls (n = 4,514,960). We analyzed the incidence and adjusted hazard ratios (aHRs) of PC among patients followed for more than 2 years or 5 years, and assessed risk changes over time in single episode of AP (SAP), recurrent AP (RAP), CP with AP, and CP without AP groups. We also performed subgroup analysis for both sexes. The incidences (per 104 person-years) and risks (aHR) of PC were higher in the RAP (12.69, 5.00) or CP with AP (12.12, 5.74) groups compared to the SAP (2.31, 1.32) or CP without AP (2.28, 1.57) groups. The risks of PC decreased over time, however, the risk of PC remained elevated in the RAP and CP with AP groups for more than 8 years. Females with RAP, SAP, and CP with AP had higher risks of PC than males. The risk of PC is higher and persists for longer duration in patients with RAP and CP with AP compared to those with SAP or CP without AP.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.

The Impact of Chronic Pancreatitis on the Occurrences of Human Cancers: Real-World Data

Chronic pancreatitis (CP) may induce systemic inflammation, potentially increasing cancer susceptibility. However, the link between CP and extra-pancreatic cancer remains underexplored. Employing Taiwanese National Health Insurance Database data from 2000 to 2017, we compared 5394 CP patients with 21,576 non-CP individuals through propensity score matching. CP patients exhibited a significantly higher cancer risk (adjusted hazard ratio (aHR) of 1.32 for females and 1.68 for males) and cumulative incidence (p < 0.001) compared to non-CP individuals. CP showed notable associations with pancreatic (aHR = 3.51), liver (aHR = 1.62), stomach (aHR = 2.01), and other cancers (aHR = 2.09). In terms of liver cancer, CP was significantly associated with patients without viral hepatitis, regardless of gender (aHR = 2.01 for women; aHR = 1.54 for men). No significant cancer occurrences were observed within the first year following CP diagnosis. Pancreatic or liver cancer developed in approximately half of CP patients within 2-3 years, while gastric cancer in male CP patients predominantly occurred around the fifth year after diagnosis. These findings inform potential cancer-screening plans for CP patients.

Painless chronic pancreatitis: experiences from a high-volume center

INTRODUCTION

Although abdominal pain is the most prevalent and disabling symptom in patients with chronic pancreatitis (CP), there are also patients who have painless CP.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with a diagnosis of CP. A total of 279 patients with definite CP with completed demographic and clinical data were included in the final analysis.

RESULTS

There were 75 (26.9%) patients with painless CP. These patients had a significantly higher mean age at diagnosis, 61.7 years, than the 52.5 years of patients with pain (p < 0.001). Painless and painful CP had similar rates of diabetes mellitus (DM) (28.4% vs. 31.6%) and pancreatic exocrine insufficiency (PEI) (50.0% vs. 52.3%). Painless CP had lower rates of alcoholic etiology, 36.0%, than the 52.5% in painful CP (p < 0.05). Patients older than 55 at the time of CP diagnosis were associated with painless CP with an adjusted odds ratio (aOR) of 3.27 [95% confidence interval (CI): 1.62-6.60]. Alcoholic etiologies were not associated with painless CP, aOR of 0.51 (95% CI: 0.25-0.91).

CONCLUSION

Patients with painless CP had a significantly higher mean age than patients with painful CP and increased aOR for those older than 55 at CP diagnosis. Painless and painful CP patients had similar rates of DM and PEI, confirming the necessity of routine follow up in all patients with CP.

Utility of Fecal Elastase-1 to diagnose severe exocrine insufficiency in chronic pancreatitis: Real world experience

INTRODUCTION

Quantitative fecal fat estimation is the gold standard test to diagnose steatorrhea (fecal fat >7 g/day) in chronic pancreatitis (CP), but cumbersome and inconvenient. So, fecal elastase-1 (FE) is proposed as a good alternative but the data on the diagnostic utility of FE to diagnose steatorrhea is variable.

METHODS

This retrospective study included adult CP patients evaluated with both 24-h fecal-fat and FE tests within a 3-month period. The objective was to evaluate the diagnostic performance of FE to diagnose steatorrhea and to evaluate the FE progression over 9-month period.

RESULTS

Among the 147 included patients, the frequency of steatorrhea (fecal fat >7 g/day) was 34%. The sensitivity, specificity, and negative likelihood ratio (LR) of FE was 90%, 28.9% and 0.35 at cut-off of <100 μg/g stool to diagnose steatorrhea; and 96%, 11.3% and 0.35 at cut-off of <200 μg/g stool, respectively. The optimal cut-off of FE was <20 on receiver operating characteristic curve (sensitivity 66%; specificity 69%; positive LR 2.14). There was no statistically significant variation in FE levels over 9 months interval among a hundred patients.

CONCLUSION

Compared to FE ≥ 200 μg/g stool, FE ≥ 100 can used to exclude steatorrhea (better specificity and negative LR). FE < 20 alone cannot replace fecal fat estimation to confirm steatorrhea but to be interpreted with clinical features. Repeat FE testing for exocrine insufficiency progression can be done at least a year later.

Position statement on the definition, incidence, diagnosis and outcome of acute on chronic pancreatitis

BACKGROUND

Acute on chronic pancreatitis (ACP) is a relatively common condition, but there are significant gaps in our knowledge on the definition, incidence, diagnosis, treatment and prognosis.

METHODS

A systematic review that followed PICO (Population; Intervention; Comparator; Outcome) recommendation for quantitative questions and PICo (Population, Phenomenon of Interest, Context) for qualitative research was done to answer 10 of the most relevant questions about ACP. Quality of evidence was judged by the GRADE criteria (Grades of Recommendation, Assessment, Development and Evaluation). The manuscript was sent for review to 12 international experts from various disciplines and continents using a Delphi process.

RESULTS

The quality of evidence, for most statements, was low to very low, which means that the recommendations in general are only conditional. Despite that, it was possible to reach strong levels of agreement by the expert panel for all 10 questions. A new consensus definition of ACP was reached. Although common, the real incidence of ACP is not known, with alcohol as a major risk factor. Although pain dominates, other non-specific symptoms and signs can be present. Serum levels of pancreatic enzymes may be less than 3 times the upper limit of normal and cross-sectional imaging is considered more accurate for the diagnosis in many cases. It appears that it is less severe and with a lower mortality risk than acute pancreatitis.

CONCLUSIONS

Although the evidence base is poor, this position statement provides a foundation from which to advance management of ACP.

Surgical strategies for chronic pancreatitis in a 1,327- patient Scandinavian Baltic pancreatic Club (SBPC) register

BACKGROUND

Chronic pancreatitis (CP) may cause intermittent or continuous pain and complications requiring invasive interventions. No specific recommendations for surgical interventions have been presented. Our aim was to determine the surgical treatment strategies for the treatment of CP in the Scandinavian and Baltic countries.

METHODS

This multi-centre cross sectional study included 1327 CP patients from eight centres. The data was gathered from the Scandinavian Baltic Pancreatic Club (SBPC) database. Patients who underwent pancreatic surgery were analysed. The baseline CP population from the eight centres was used as a reference. The information registered included comorbidities, pancreatic function, previous interventions, time and type of surgery and the EORTC-30 quality of life (QOL) questionnaire.

RESULTS

Overall, 95/1327 (7%) patients underwent pancreatic surgery. Fifty-one (54%) of these underwent pancreatic surgery for chronic pain (PSCP) and formed the final study group. Median follow-up time was two (range 0-8) years after surgery and seven (1-46) years after diagnosis. The most common surgical procedures were pancreatic resection combined with drainage (54%) followed by pancreatic resections (32%) and drainage procedures (14%). Postoperatively, 47% of the patients were pain free with or without pain medication while 16% had chronic pain episodes, this did not differ from the base CP population. In QOL questionnaires, PSCP patients reported the same QOL but worse social functioning and more symptoms compared to the CP population.

CONCLUSIONS

Pancreatic surgery for CP is rare: surgical procedures were performed on only 7% of the CP patients in the SBPC database. In half of the patients the indication was pain. Most of these patients underwent endoscopic procedures before surgery. Half of the patients reported being pain-free after surgery.

Pancreatitis in Pregnancy-Comprehensive Review

Acute and chronic pancreatitis, until recently observed incidentally in pregnancy, has occurred much more frequently in the last 2-3 decades. Particularly severe complications for the mother and fetus may be a consequence of acute pancreatitis. Therefore, it is important to know more about the diagnostic and therapeutic possibilities of pancreatic diseases in the course of pregnancy. Epidemiology, causes, clinical characteristics, differential diagnosis, and complex management are presented in this review. Particular emphasis is on the prevention of acute pancreatitis (AP) through the proper diagnosis and treatment of cholelithiasis and hypertriglyceridemia, both before and during pregnancy. The most up-to-date reports and management strategies are presented. This publication contributes to a wide group of scientists and practitioners better understanding the discussed issues, and indicates the directions of research for the future.

Risk of cardiovascular disease and mortality in patients with diabetes and acute pancreatitis history: a nationwide cohort study

Patients with acute pancreatitis (AP) may have an increased risk of cardiovascular disease (CVD). Few studies have dealt with the association between AP and the risk of CVD in diabetic patients. This study aimed to investigate the risk of CVD and mortality in patients with diabetes and AP history by analyzing a large-scale national claims database in Korea. Data from the Korean National Health Insurance Service database was analyzed. A total of 2,746,988 participants with type 2 diabetes mellitus that underwent a general health examination between 2009 and 2012 were enrolled. The participants were divided into two groups according to AP history (yes or no) prior to the examination date, and follow-up data until 2018 was analyzed. The primary endpoint was the occurrence of stroke, myocardial infarction (MI), or death. The Cox proportional hazards regression analysis was used to evaluate the association between AP history and the risk of stroke, MI, and mortality. After exclusion, the included number of participants with and without AP history were 3,810 and 2,258,910, respectively. The presence of AP history showed a significantly higher incidence of stroke, MI, and mortality. The adjusted hazard ratios (95% confidence interval) for the risk of stroke, MI, and mortality were 1.534 (1.342-1.753), 1.998 (1.733-2.303), and 2.353 (2.200-2.515), respectively. Age < 65, male sex, current smoking, and drinking significantly increased the risk of death in the subgroup analyses. The risk of stroke, MI, and mortality was significantly higher in diabetic participants with AP history than those without AP history at 9-year follow-up. This suggests that active management of cardiovascular risk factors is necessary in diabetic patients with AP history.

Clinical Characteristics of Patients With Chronic Pancreatitis With or Without Prior Acute Pancreatitis Are Different

OBJECTIVE

The aim of the study is to clarify the clinical characteristics of patients with chronic pancreatitis (CP) who had no prior acute pancreatitis (AP) attack.

METHODS

We retrospectively analyzed patients with CP who were admitted to our center between January 2012 and January 2020.

RESULTS

A total of 274 patients were divided into the following 3 groups: group A: CP without prior AP (n = 103 [37.6%]), group B: CP preceded by a single episode of AP (n = 39 [14.23%]), and group C: CP preceded by recurrent AP (n = 132 [48.18%]). At the diagnosis, patients in group A had a higher incidence of pancreatic duct stones (41.7% vs 25.8%, P = 0.012), higher proportion of idiopathic CP (68.9% vs 48.5%, P = 0.001), and higher mean pancreatic volume change rate (37.61% vs 10.48%, P = 0.007) compared with Group C. Patients in group A underwent the most episodes of extracorporeal shockwave lithotripsy therapy among the 3 groups (P < 0.001).

CONCLUSIONS

Approximately 37.6% of patients had no prior AP attack before CP diagnosis. Patients with CP without prior AP had higher incidence of pancreatic duct stones and pancreas volume shrank faster.

The Impacts of Genetic and Environmental Factors on the Progression of Chronic Pancreatitis

BACKGROUND & AIMS

Both environmental factors, such as alcohol consumption and smoking, and genetic factors are strongly associated with the risk of developing chronic pancreatitis (CP). However, comprehensive understanding of their impacts on the progression of CP remains elusive.

METHODS

A prospective cohort study was performed on a large cohort of CP patients with known genetic backgrounds. The cumulative incidence of pancreatic insufficiency after the onset of CP was analyzed using Kaplan-Meier survival curves. Multivariate Cox proportional hazards regression analysis also was performed.

RESULTS

A total of 798 patients were enrolled in the study and followed up for 10.5 years. Rare pathogenic genotypes in the SPINK1, PRSS1, CTRC, or CFTR genes were identified in 410 (51.4%) patients. The development of pancreatic insufficiency was significantly earlier in patients with a history of smoking and/or alcohol consumption in both the positive (P < .001) and negative (P = .001) gene mutation groups. However, the development of pancreatic insufficiency did not differ significantly between patients with and without gene mutations despite alcohol and/or smoking status, with P values of .064 and .115, respectively. Multivariate Cox regression analysis showed that age at onset of CP (hazard ratio, [HR], 1.02; P < .001) and alcohol consumption (HR, 1.86; P < .001) were independent risk factors for the development of diabetes, while male sex (HR, 1.84; P = .022) and smoking (HR, 1.56; P = .028) were predictors of steatorrhea.

CONCLUSIONS

Although rare pathogenic mutations in the 4 major susceptibility genes for CP were not correlated significantly with the development of pancreatic insufficiency, environmental factors (either alcohol consumption or smoking) significantly accelerated disease progression (ClinicalTrials.gov: NCT04574297).

Chronic Pancreatitis in Females is Not Associated With Adverse Pregnancy Outcomes: A Retrospective Analysis

BACKGROUND

The effects of chronic pancreatitis (CP) on pregnancy and vice versa have not been studied well. We aimed to study the impact of CP on pregnancy-related outcomes and the effect of pregnancy on clinical profile of CP.

STUDY AND GOALS

We did a retrospective analysis of all female patients of CP of child-bearing age (above 18 y). The pregnancy-related outcomes of patients with CP were compared with the age-matched 115 controls from the low-risk pregnancy group identified using a simplified antepartum high-risk pregnancy scoring form. The clinical course of CP during pregnancy was compared with the pre-pregnancy course.

RESULTS

Among the 338 eligible patients, 46 patients were included after exclusions. All these 46 patients had at least 1 conception and 41 had at least 1 completed pregnancy with a total of 117 conceptions and 96 completed pregnancies. The pregnancy-related outcomes in patients with CP like abortions (21.7% vs. 11.3%;P=0.087), preterm deliveries (14.6% vs. 10.4%;P=0.47), antepartum course (82.7% vs. 82.6%;P=0.58), stillbirths (4.9% vs. 4.3%;P=0.88), cesarean section (36.6% vs. 34%;P=0.849) were comparable with controls. There was overall improvement in the severity and frequency of pain during pregnancy as compared with the pre-pregnancy symptoms (P=0.001).

CONCLUSION

CP is not associated with adverse pregnancy outcomes. Also, there is trend toward improvement in the clinical symptoms because of CP during the pregnancy.

Malnutrition by GLIM criteria in chronic pancreatitis: Prevalence, predictors, and its impact on quality of life

INTRODUCTION

Malnutrition in chronic pancreatitis (CP) has prognostic value and there is limited data on the prevalence, predictors of malnutrition in CP and its effect on Quality of life (QoL).

METHODS

A retrospective study was conducted in patients with CP to assess the prevalence of malnutrition as per the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariable-adjusted regression was used to identify independent predictors of both malnutrition and global QoL.

RESULTS

A total of 297 patients were included and the most common etiology of CP was idiopathic (75%) and alcohol (25%). The prevalence of malnutrition was 46.4% as per GLIM criteria. On univariate analysis, the risk of malnutrition was significantly higher in alcoholic etiology (p = 0.001), current alcohol consumption (p = 0.001), smokers (p < 0.001), those having higher cumulative days of pain in last 6 months (p < 0.001) and lower daily calorie intake (p = 0.019). On multivariate analysis, malnutrition was independently associated with current alcohol consumption (Odds ratio: 3.22, p = 0.017), current smokers (OR: 2.23, p = 0.042) and those having higher cumulative days of abdominal pain (OR: 1.01, p < 0.001), while higher daily calorie intake (per 100 kcal) (OR:0.94, p = 0.023) has reduced risk of malnutrition. Malnutrition (p = 0.015) and higher cumulative days of abdominal pain (p < 0.001) were independently associated with lower global QoL in patients with CP.

CONCLUSION

Malnutrition is frequent in patients with CP; and current alcohol consumption, smoking and higher cumulative days of abdominal pain independently predicts risk of developing malnutrition. Patients with malnutrition and higher cumulative days of pain has poorer quality of life.

Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis

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.

Prodromal Signs and Symptoms of Chronic Pancreatitis: A Systematic Review

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.

Surgery for chronic pancreatitis in Finland is rare but seems to produce good long-term results

BACKGROUND

Abdominal pain in chronic pancreatitis (CP) may require invasive interventions. Surgical procedures are rare, and little is known about the long-term results.

AIM

To study the nationwide frequency of pancreatic surgery for CP in Finland, and postoperative symptoms and quality of life (QoL).

METHODS

All patients in Finland with a diagnosis of CP who had undergone pancreatic surgery during 2000-2008 were selected from a national register. Only patients with CP as an indication for pancreatic surgery were included. Medical records were studied and questionnaires QLQ-C30, PAN26 and AUDIT, and symptom questionnaires were sent out.

RESULTS

During the 9-year period, pancreatic surgery for CP was performed on 30 patients [77% men, median age 45 (21-62) years]. Eighty-three percent underwent endoscopic procedures before surgery. Surgery was performed a median 2 (0-10) years after the original CP diagnosis, and 17% developed postoperative complications. Primary pain relief after surgery was reported in 70% of cases. Need for strong pain medication was lower after surgery. Eight of 21 (38%) returned the questionnaires and 88% reported that surgery had reduced their pain and 63% were almost or entirely pain-free at a median 14 (10-18) years after surgery. QoL results did not differ from those in our control Finnish CP group.

CONCLUSION

Surgery for CP is rare in Finland and most patients had prior endoscopic procedures. Patients who returned the questionnaires reported less pain and good QoL during the 14-year follow-up.

Pancreatic Cancer-Related Mutational Burden Is Not Increased in a Patient Cohort With Clinically Severe Chronic Pancreatitis

INTRODUCTION

Chronic pancreatitis is associated with an increased risk of developing pancreatic cancer, and patients with inherited forms of pancreatitis are at greatest risk. We investigated whether clinical severity of pancreatitis could also be an indicator of cancer risk independent of etiology by performing targeted DNA sequencing to assess the mutational burden in 55 cancer-associated genes.

METHODS

Using picodroplet digital polymerase chain reaction and next-generation sequencing, we reported the genomic profiles of pancreases from severe clinical cases of chronic pancreatitis that necessitated palliative total pancreatectomy with islet autotransplantation.

RESULTS

We assessed 57 tissue samples from 39 patients with genetic and idiopathic etiologies and found that despite the clinical severity of disease, there was no corresponding increase in mutational burden. The average allele frequency of somatic variants was 1.19% (range 1.00%-5.97%), and distinct regions from the same patient displayed genomic heterogeneity, suggesting that these variants are subclonal. Few oncogenic KRAS mutations were discovered (7% of all samples), although we detected evidence of frequent cancer-related variants in other genes such as TP53, CDKN2A, and SMAD4. Of note, tissue samples with oncogenic KRAS mutations and samples from patients with PRSS1 mutations harbored an increased total number of somatic variants, suggesting that these patients may have increased genomic instability and could be at an increased risk of developing pancreatic cancer.

DISCUSSION

Overall, we showed that even in those patients with chronic pancreatitis severe enough to warrant total pancreatectomy with islet autotransplantation, pancreatic cancer-related mutational burden is not appreciably increased.

Factors associated with prior acute pancreatitis episodes among patients with chronic pancreatitis

BACKGROUND

The relationship between chronic pancreatitis (CP) and acute pancreatitis (AP) is complex and not well understood. CP could be preceded by antecedent episodes of AP.

AIMS

The aim of this study was to explore both genetic and environmental factors associated with AP episodes before the diagnosis of CP.

METHODS

This was a cross-sectional study including 1022 patients. Detailed demographic, genetic, and clinical data were collected. Based on the presence of AP episode(s) before diagnosis of CP, patients were divided into AP group (further classified into single episode of AP group and recurrent AP group) and non-AP group. Related factors among these groups were assessed using multivariate logistic regression model.

RESULTS

Before diagnosis of CP, 737 patients (72.1%) had a history of AP. Smoking(P = 0.005) and heavy alcohol consumption(P = 0.002) were risk factors for AP while age at CP onset(P < 0.001), harboring the SPINK1 mutation(P < 0.001), diabetes(P < 0.001) and steatorrhea(P < 0.001) were protective factors. Further, alcoholic CP(P = 0.019) was the only independent risk factor for recurrent AP attacks while age at onset of CP(P < 0.001), pancreatic stones(P = 0.024). and pseudocysts(P = 0.018) served as protective factors.

CONCLUSIONS

SPINK1 mutations served as protective factor for AP episodes, suggesting SPINK1 mutation might play a pathogenic role in CP occurrence with occult clinical manifestations.

Impact of surgery for chronic pancreatitis on the risk of pancreatic cancer: Untying the Gordian knot

Pancreatic ductal adenocarcinoma is an aggressive tumor with poor long-term outcomes. Chronic pancreatitis (CP) is considered a risk factor for the development of pancreatic cancer (PC). Persistent pancreatic inflammation and activation of pancreatic stellate cells play a crucial role in the pathogenesis of CP-related PC by activating the oncogene pathway. While genetic mutations increase the possibility of recurrent and persistent pancreatic inflammation, they are not directly associated with the development of PC. Recent studies suggest that early surgical intervention for CP might have a protective role in the development of CP-related PC. Hence, the physician faces the clinical question of whether early surgical intervention should be recommended in patients with CP to prevent the development of PC. However, the varying relative risk of PC in different subsets of CP underlines the complex gene-environment interactions in the disease pathogenesis. Hence, it is essential to stratify the risk of PC in each individual patient. This review focuses on the complex relationship between CP and PC and the impact of surgical intervention on PC risk. The proposed risk stratification based on the genetic and environmental factors could guide future research and select patients for prophylactic surgery.

Comprehensive review of diagnostic modalities for early chronic pancreatitis

Chronic pancreatitis (CP) is a progressive condition caused by several factors and characterised by pancreatic fibrosis and dysfunction. However, CP is difficult to diagnose at an early stage. Various advanced methods including endoscopic ultrasound based elastography and confocal laser endomicroscopy have been used to diagnose early CP, although no unified diagnostic standards have been established. In the past, the diagnosis was mainly based on imaging, and no comprehensive evaluations were performed. This review describes and compares the advantages and limitations of the traditional and latest diagnostic modalities and suggests guidelines for the standardisation of the methods used to diagnose early CP.

Systematic review and meta-analysis: Is there any role for antioxidant therapy for pain in chronic pancreatitis

Chronic pancreatitis (CP) is an irreversible disease with increased oxidative stress. The therapeutic role of antioxidants for pain reduction in CP is debatable. A systematic review of articles in PubMed and Embase until February 2020 was performed. Only randomized controlled trials conducted on humans to evaluate the therapeutic effects of antioxidants for pain in CP were included. Studies of other design, nonhuman studies, and those that did not objectively assess pain were excluded. Twelve articles and four articles were eligible for qualitative and quantitative analysis, respectively. The four included studies had a total of 352 participants. Pain reduction as measured by a visual analog scale was not significantly different in the antioxidant group compared to placebo (standardized mean difference = -0.14 [95% confidence interval [CI] = -0.44 to 0.17]; P = 0.38). Number of pain-free participants was also similar (odds ratio [OR] = 1.59 [0.97-2.59]; P = 0.06). There was no difference in outcome when comparing different etiologies of CP or age group. The reduction in the number of analgesics used did not differ between both groups. Antioxidants were not associated with increased adverse events (OR = 2.59 [CI = 0.77-8.69]; P = 0.12). A qualitative analysis on the effect on quality of life did not suggest any significant improvement with antioxidants. There was no significant pain reduction or change in quality of life in CP patients with use of antioxidants. This makes their routine use in the management of CP questionable. However, further studies may identify a subgroup where they are more useful.

Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis

BACKGROUND

This study aimed to analyze the genetics and treatments of the patients with the triad of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis (AP).

METHODS

We conducted a retrospective study of six patients with the triad of AP, hypertriglyceridemia, and DKA at our hospital. All patients underwent plasmapheresis as part of their treatment. The clinical characteristics of the patients were obtained from the hospital information system and analyzed. Whole exome sequencing was performed using samples of one patient (case 6) and his family members.

RESULTS

The average triglyceride level before plasmapheresis was 3282.17 ± 2975.43 mg/dL (range: 1646-9332 mg/dL). The triglyceride levels dropped by approximately 80% after plasmapheresis. None of the patients developed complications related from plasmapheresis. During follow-up, patients 5 and 6 developed recurrent pancreatitis for several times and showed the formation of pancreatic pseudocysts. We identified three novel heterozygous missense mutations in the family of patient 6, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD.

CONCLUSIONS

Three novel heterozygous missense mutations, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD were first identified in a patient with the triad of DKA, hypertriglyceridemia, and AP. The combination of plasmapheresis, hydration, and insulin therapy may have the greatest clinical benefits for these patients.

Clinical Course of Chronic Pancreatitis During Pregnancy and its Effect on Maternal and Fetal Outcomes

INTRODUCTION

There are limited data on the effect of chronic pancreatitis (CP) on pregnancy outcomes and vice versa. Our aim was to evaluate the clinical trajectory of CP during pregnancy and its effect on pregnancy outcomes.

METHODS

All female patients of child-bearing age (≥15 years) diagnosed with CP were studied from January 2004 to July 2019. The change in frequency of painful episodes was assessed before, during, and after pregnancy. Maternal and fetal outcomes were compared between pregnant women (early onset) and women presenting with CP after completion of all pregnancies (late onset).

RESULTS

Of 187 women with CP, pregnancy outcomes and clinical course were assessed in 99 patients. The frequency of painful exacerbations was significantly lower during pregnancy compared with prepregnancy and postpregnancy periods (P < 0.001). The median pain score decreased significantly to 0 (0-2) during pregnancy from 3 (0-6) before conception and increased to 4 (0-8) after pregnancy (P = 0.002). Women with early onset CP (n = 57) had their first child later and had fewer pregnancies compared with those with late onset CP (n = 42). There was no difference in maternal outcomes such as gestational diabetes, hypertension, and preterm delivery, and fetal outcomes such as abortion, low birth weight, and still birth between the groups. There was no reported congenital anomaly.

DISCUSSION

Younger patients with CP had later and fewer pregnancies, but there was no increased risk of adverse maternal and fetal outcomes. The clinical course of CP was usually benign during pregnancy with decreased frequency and severity of pain.

Risk of Developing Pancreatic Cancer in Patients with Chronic Pancreatitis

Background: Patients with chronic pancreatitis (CP) have an increased risk of developing pancreatic ductal adenocarcinoma (PDAC). We present data on PDAC in one of the most extensive European single-centre cohort studies of patients with CP. Methods: Retrospective analysis of prospectively collected data of patients with CP was performed. Aetiology of CP was determined according to the M-ANNHEIM classification system and only patients with definite CP > 18 years at data analysis were included. The final dataset included 581 patients with definite CP diagnosed between 2003 and 2018. Results: At CP diagnosis, there were 371 (63.9%) males and 210 (36.1%) females (median age 57 years, range 2–86). During 3423 person-years of observation, six pancreatic cancers were diagnosed (0.2% year). The mean time between diagnosis of CP and the occurrence of PDAC was 5.0 years (range 2.7–8.6). None of the cancer patients had a family history of PDAC. Diabetes mellitus (DM) was present in five of six (83.3%) patients with PDAC: in three patients before and in two after CP diagnosis. Clinical/laboratory signs of pancreatic exocrine insufficiency (PEI) were present in five of six (83.3%) patients with PDAC: in two at diagnosis of CP and in three after diagnosis. The mean survival time was 4 months after the diagnosis of PDAC (range 0.5–13). PDAC occurred significantly more often (p < 0.001) in two groups of patients without previous acute pancreatitis (AP): 2 of 20 patients (10%) with low body mass index (BMI) and PEI and in 3 of 10 (30%) patients with high BMI and DM at diagnosis of CP. Conclusions: Patients with CP have a high risk of developing PDAC, although risk is low in absolute terms. Our data suggest the possibility of defining subgroups of patients with a particularly elevated risk of PDAC. Such a possibility would open a path to personalised decision making on initiation of PDAC surveillance of patients with no previous episode of AP, (i) with low BMI and PEI, or (ii) elevated BMI and DM.

Macrophages in pancreatitis: Mechanisms and therapeutic potential

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.

Vascular complications of chronic pancreatitis: A tertiary center experience

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.