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Dalal A, Kamat N, Maydeo A, Patil G, Vadgaonkar A, Parekh S, Vora S. Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy. Endosc Int Open 2024; 12:E274-E281. [PMID: 38420153 PMCID: PMC10901651 DOI: 10.1055/a-2226-1464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/05/2023] [Indexed: 03/02/2024] Open
Abstract
Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.
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Affiliation(s)
- Ankit Dalal
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Nagesh Kamat
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Amit Maydeo
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Gaurav Patil
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Amol Vadgaonkar
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Sanil Parekh
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Sehajad Vora
- Institute of Gastrosciences, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, India
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Petrov MS, Olesen SS. Metabolic Sequelae: The Pancreatitis Zeitgeist of the 21st Century. Gastroenterology 2023; 165:1122-1135. [PMID: 37549751 DOI: 10.1053/j.gastro.2023.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023]
Abstract
Holistic management of pancreatitis means that gastroenterologists in the 21st Century should think beyond improving in-hospital outcomes of pancreatitis alone. In particular, there is considerable room for optimizing the management of new-onset diabetes, exocrine pancreatic insufficiency, and other metabolic sequelae of pancreatitis. The present article provides state-of-the-art information on classification, terminology, and burden of the common sequelae of pancreatitis. A high-risk group of patients with pancreatitis is identified, which is positioned to benefit the most from the metabolic sequelae surveillance program introduced in this article. The program involves continuous follow-up after pancreatitis diagnosis, with the focus on early identification of new-onset diabetes after pancreatitis and exocrine pancreatic insufficiency. The metabolic sequelae surveillance program is scalable and has the potential to reduce the burden of pancreatitis through tertiary prevention in the decades to come.
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Affiliation(s)
- Maxim S Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand.
| | - Søren S Olesen
- Department of Gastroenterology and Hepatology, Center for Pancreatic Diseases and Mech-Sense, Aalborg University Hospital, Aalborg, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark
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Parhiala M, Nøjgaard C, Bartholdy A, Waage A, Ignatavičius P, Engjom T, Dimcevski G, Nordaas IK, Kalaitzakis E, Drewes AM, Hadi A, Olesen SS, Poulsen JL, Laukkarinen J. Quality of life after endoscopic procedures for chronic pancreatitis: A multicentre study. United European Gastroenterol J 2023; 11:884-893. [PMID: 37812591 PMCID: PMC10637126 DOI: 10.1002/ueg2.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/14/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Chronic Pancreatitis (CP) causes morphological changes in the pancreatic tissue, leading to complications and pain, which may require endoscopic interventions. OBJECTIVE Our aim was to determine the frequency of endoscopic procedures (EP) in CP patients and to analyse pain and quality of life (QoL) in these patients after their EP. METHODS This study included 1327 CP patients from the Scandinavian Baltic Pancreatic Club (SBPC) database including four countries and eight centres. We analysed patients undergoing EPs and gathered information on the EP, pancreatic function, pain, disease and duration. The EORTC C-30 QoL questionnaire was gathered prospectively and multivariable analysis was conducted on independent parameters between the groups. The reference population had no interventions (n = 870). RESULTS 260 CP patients (22%) underwent EPs, median one year (range 0-39 years) after CP diagnosis. 68% were males. The median age was 59 (20-90) years. Most common aetiological factors were alcohol in 65% and smoking in 71%. Extracorporeal shock wave lithotripsy (ESWL) was used in 6% of the CP population and in 21% of the EP group. Biliary duct stenting was performed on 37% and pancreatic stenting was performed on 56% of the patients. There was no difference in pain patterns between patients who had pancreatic stenting and the reference population. The EP group had slightly better QoL (p = 0.047), functioning and fewer symptoms than the reference population, in the multivariable analysis there was no interaction effect analysis between the groups. The pancreatic stent group had better QoL and the same amount of pain than the reference group. The patients who needed later surgery (23%) had more pain (p = 0.043) and fatigue (p = 0.021). CONCLUSIONS One in five of the CP patients underwent EP. These patients scored higher on QoL responses and had better symptom scores. CP patients who had pancreatic stenting performed had the same pain patterns as the reference population. Randomised prospective trials are needed to determine the effect of endoscopy procedures on CP patients.
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Affiliation(s)
- Mikael Parhiala
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Gastroenterology and Alimentary Tract SurgeryTampere University HospitalTampereFinland
| | - Camilla Nøjgaard
- Pancreatitis Centre East (PACE)Copenhagen University Hospital HvidovreCopenhagenDenmark
| | - Andreas Bartholdy
- Pancreatitis Centre East (PACE)Copenhagen University Hospital HvidovreCopenhagenDenmark
| | - Anne Waage
- Department of SurgeryOslo University HospitalOsloNorway
| | | | - Trond Engjom
- Department of GastroenterologyHaukeland University HospitalBergenNorway
| | - Georg Dimcevski
- Department of GastroenterologyHaukeland University HospitalBergenNorway
| | | | - Evangelos Kalaitzakis
- Division of GastroenterologyDigestive Disease Center KBispebjerg University HospitalCopenhagenDenmark
| | - Asbjørn M. Drewes
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Amer Hadi
- Division of GastroenterologyDigestive Disease Center KBispebjerg University HospitalCopenhagenDenmark
| | - Søren S. Olesen
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Jakob L. Poulsen
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Johanna Laukkarinen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Gastroenterology and Alimentary Tract SurgeryTampere University HospitalTampereFinland
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Zhang Y, Zhao L, Gao H, Zhai J, Song Y. Potential role of irisin in digestive system diseases. Biomed Pharmacother 2023; 166:115347. [PMID: 37625325 DOI: 10.1016/j.biopha.2023.115347] [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: 06/14/2023] [Revised: 08/15/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Digestive system diseases (DSD) are very complex conditions that severely threaten human health. Therefore, there is an urgent need to develop new pharmacological treatment strategies. Irisin, a myokine discovered in 2012, is produced by fibronectin type III domain-containing protein 5 (FNDC5), which is a transmembrane protein. Irisin is involved in promoting the browning of white adipose tissue, the regulation of energy metabolism, and the improvement of insulin resistance. Irisin is also an essential mediator of the inflammatory response, oxidative stress, and cell apoptosis. Recent studies have proved that irisin concentration is altered in DSD and exerts pivotal effects on the initiation, progression, and prognosis of these diseases through various mechanisms. Therefore, studying the expression and function of irisin may have great significance for the diagnosis and treatment of DSD. Here, we focus on irisin and explore the multiple molecular pathways targeted by irisin therapy. This review indicates that irisin can serve as a diagnostic marker or potential therapeutic agent for DSD. DATA AVAILABILITY: Not applicable.
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Affiliation(s)
- Yueming Zhang
- Department of Clinical Pharmacy, the First Hospital of Jilin University, Changchun 130021, China
| | - Linxian Zhao
- Department of General Surgery, the Second Hospital of Jilin University, Changchun 130041, China
| | - Huan Gao
- Department of Clinical Pharmacy, the First Hospital of Jilin University, Changchun 130021, China
| | - Jinghui Zhai
- Department of Clinical Pharmacy, the First Hospital of Jilin University, Changchun 130021, China
| | - Yanqing Song
- Department of Pharmacy, Lequn Branch, the First Hospital of Jilin University, Changchun 130021, China.
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Vujasinovic M, Asplund E, Kourie M, Guliaieva M, Dugic A, Waldthaler A, Baldaque-Silva F, Löhr JM, Ghorbani P. Painless chronic pancreatitis: experiences from a high-volume center. Scand J Gastroenterol 2023; 58:417-421. [PMID: 36300843 DOI: 10.1080/00365521.2022.2137692] [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] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Ebba Asplund
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mourad Kourie
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Margaryta Guliaieva
- Alby Health Centre, Health Care Services Stockholm County, Stockholm, Sweden
| | - Ana Dugic
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Waldthaler
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Francisco Baldaque-Silva
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Gastroenterology Department, Advanced Endoscopy Center Carlos Moreira da Silva, Hospital Pedro Hispano, ULS Matosinhos, Porto, Portugal
| | - J Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Poya Ghorbani
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Alby Health Centre, Health Care Services Stockholm County, Stockholm, Sweden
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Chen C, Zhou Y, Wang D, Li G, Yin K, Tao H, Wang CY, Li ZS, Wei C, Hu LH. Anxiety, depression, and coping styles among patients with chronic pancreatitis in East China. BMC Psychiatry 2023; 23:212. [PMID: 36991480 PMCID: PMC10061863 DOI: 10.1186/s12888-023-04691-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Anxiety and depression are common psychological comorbidities in patients with chronic pancreatitis (CP). There is still a lack of epidemiological studies on anxiety and depression in Chinese CP patients. This study aimed to identify the incidence and related factor of anxiety and depression among East Chinese CP patients and explore the relationship between anxiety, depression, and coping styles. METHODS This prospective observational study was conducted from June 1, 2019 to March 31, 2021 in Shanghai, China. Patient diagnosed with CP were interviewed using the sociodemographic and clinical characteristics questionnaire, Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Coping Style Questionnaire (CSQ). Multivariate logistic regression analysis was conducted to identify the related factors of anxiety and depression. Correlation test was preformed to analyze the correlation between anxiety, depression, and coping styles. RESULTS The incidence of anxiety and depression in East Chinese CP patients was 22.64% and 38.61%, respectively. Patients' previous health status, level of disease coping, frequency of abdominal pain episodes, and pain severity were significantly associated with anxiety and depression. Mature coping styles (Problem solving, Seeking for help) had a positive impact on anxiety and depression, while immature coping styles (Self-blame, Fantasy, Repression, Rationalization) had negative effects on anxiety and depression. CONCLUSION Anxiety and depression were common in patients with CP in China. The factors identified in this study may provide references for the management of anxiety and depression in CP patients.
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Affiliation(s)
- Cui Chen
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - You Zhou
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
- Department of Nursing, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Dan Wang
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Ge Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Kun Yin
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Hong Tao
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Chun-Yan Wang
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China.
| | - Cun Wei
- Department of Naval Psychology, Faculty of Psychology, Naval Medical University, No. 800 Xiangyin Road, Yangpu District, Shanghai, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China.
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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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Shimosegawa T. Between early and established chronic pancreatitis: A proposal of "acinar-ductal hybrid mechanism". Pancreatology 2022; 22:831-837. [PMID: 36163223 DOI: 10.1016/j.pan.2022.09.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The recently proposed "new mechanistic definition of chronic pancreatitis (CP)" categorized early CP as a reversible condition. However, there is no clear explanation regarding the pathological condition of early CP, the reason for the development of the disease in only a small portion of the patients with risk factors, and the mechanism for transition from a reversible pathological condition to an irreversible one. METHODS Based on the available information, a mechanism that could provide answers to the queries associated with CP was proposed. RESULTS Acinar-ductal coordination is very important for the physiological secretion of pancreatic juice. Inflammation originating from acinar cells undermines the function of proximal ducts and leads to a vicious cycle of sustained inflammation by increasing the viscosity and decreasing the alkalinity of pancreatic juice. Persistent elevation of ductal pressure due to stagnation of pancreatic juice caused by protein plugs, stones, or fibrous scar of ducts converts the reversible pathological condition of early CP to an irreversible one. Diagnostic criteria for early CP proposed by Japanese researchers have enabled to the recognition of patients showing a progression from early to established CP. However, most patients diagnosed with early CP do not experience progression of the disease, suggesting the inadequate specificity of the criteria. CONCLUSION The "acinar-ductal hybrid mechanism" may explain the pathological condition and progression of early CP. To diagnose early CP more accurately, it is essential to discover specific biomarkers that can discriminate "early CP" from "acute pancreatitis (AP)/recurrent acute pancreatitis (RAP)" and "established CP." Therapeutic intervention in clinical practices through various new approaches is expected to improve the prognosis of patients with CP.
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Affiliation(s)
- Tooru Shimosegawa
- Department of Gastroenterology, South-Miyagi Medical Center, 38-1 Aza-nishi, Ohgawara, Shibata-gun, Miyagi, 989-1253, Japan; Department of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi, 980-8574, Japan.
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