Epidemiology and Physiopathology of Chronic Pancreatitis and the Role of the Pancreatic Stone Protein

Serial monitoring of pancreatic stone protein for the detection of sepsis in intensive care unit patients with complicated abdominal surgery: A prospective, longitudinal cohort study

PURPOSE

The objective of this study was to assess the performance of pancreatic stone protein (PSP) monitoring for the detection of sepsis, prediction of outcome and distinction between bacterial and fungal infections in intensive care unit (ICU) patients with complicated abdominal surgery.

MATERIALS AND METHODS

In this prospective multicenter cohort study, patients with complicated abdominal surgery had serial PSP measurements during their ICU stay. Infectious episodes were classified as bacterial, fungal or mixed. PSPmax (maximal PSP value within 48 h of the diagnosis of infection) and ΔPSP (difference between PSPmax and the preceding PSP value) were used for analyses.

RESULTS

PSPmax was obtained for 118 infectious episodes (68 patients). ΔPSP was available for 73 episodes (48 patients). Both PSPmax and ΔPSP were significantly higher in patients with sepsis and in patients with a fatal outcome. A PSPmax ≥124 ng/ml and a ΔPSP ≥34 ng/ml could detect sepsis with a sensitivity/specificity of 84%/54% and 69%/76%, respectively. There was no significant difference of PSPmax or ΔPSP between patients with bacterial/mixed versus fungal infections.

CONCLUSIONS

Serial PSP monitoring may be an additional tool for the early detection of sepsis in patients with complicated abdominal surgery who are at high risk of severe infections.

Measurement of pancreatic stone protein in the identification and management of sepsis

Sepsis is a life-threatening syndrome characterized by a dysregulated host response to an infection resulting in multiple organ dysfunctions. Early diagnosis and management of sepsis is key to improve patient outcome but remains challenging. Despite extensive research, only few biomarkers have so far proven to be helpful in the diagnosis of sepsis. A novel protein biomarker, the pancreatic stone protein (PSP), is showing great promises. Several lines of evidences suggest that PSP has a higher diagnostic performance for the identification of sepsis than procalcitonin and C-reactive protein, and a strong prognostic value to predict unfavorable outcome at admission to intensive care unit. This review summarizes the current knowledge on the molecular mechanisms of PSP function and the clinical evidences available to highlight the relevance of this protein in the diagnosis and prognosis of sepsis.

Pathogenesis of alcohol-induced chronic pancreatitis: facts, perceptions, and misperceptions

The pathogenesis of chronic pancreatitis secondary to chronic alcoholism is not fully understood. A major hurdle in the understanding of the pathogenesis is the inability to study early lesions of the pancreas and the sequential changes. Facts are few; observations are many. Each new hypothesis argues against all previous hypotheses; however, clinical chronic pancreatitis is initiated by one or more of the mechanisms. Good experimental models for alcoholic pancreatitis are not available, limiting the ability to study the pathogenesis. Additional studies on genetic markers and immunologic mechanisms might explain acinar cell injury, which seems to be the earliest lesion in most, if not all, types of chronic pancreatitis. Opie's common channel and obstruction regurgitation theories seem unrelated to chronic pancreatitis. Although biochemical changes of the pancreatic secretion in alcoholic patients promote protein-plug formation, evidence is too weak to consider protein plug as the earliest change. The theory of necrosis of the acinar cell by some unknown mechanism, subsequently leading to fibrosis, is gaining support; however, it is clear that the pathogenesis of alcoholic pancreatitis is not yet fully understood.

Interventional treatment of acute and chronic pancreatitis. Endoscopic procedures

The role of therapeutic endoscopy in the treatment of acute and chronic pancreatitis has expanded dramatically over the past 10 years. Drainage of pseudocysts and even organized pancreatic necrosis when localized are becoming commonplace. Other areas in which therapeutic endoscopy has been shown to be efficacious include severe biliary pancreatitis, pancreatic duct disruptions, strictures, and obstructive calculi. Its role in the management of acute recurrent pancreatitis with presumed Oddi's sphincter dysfunction or pancreas divisum continues to be defined. The cost-effectiveness and minimally invasive nature of endoscopic therapy compared with surgery should ensure the continued development of these techniques. More controlled, prospective data are required.

Endoscopic treatment of chronic idiopathic pancreatitis in children

The purpose of this study was to analyze the preliminary results obtained with endoscopic treatment of children with chronic idiopathic pancreatitis. The disease appears to be caused by a deficit of pancreatic stabilizing proteins that leads to precipitation of solutes contained in the pancreatic secretions; these precipitates are the cause of inflammation. The possible role of a congenital malformation in the pathogenesis of this disease is being regarded with increasing scepticism. Between October 1991 and April 1994, five cases of chronic pancreatitis were referred to the Division of Pediatric Surgery of the Policlinico "A. Gemelli" of Rome. The age range of the patients (3 boys, 2 girls) was 3 to 14 years (mean, 10.8 years); all had a history of acute attacks and had blood chemistry findings compatible with pancreatitis. None of the patients' families had a history of pancreatic disease. All diagnoses were confirmed by endoscopic retrograde cholangiopancreatography, and the disease was staged according to the criteria of Cremer et al. Endoscopic pancreatic sphincterotomy, with or without removal of calculi, was performed in four cases (2 in the authors' hospital, 2 in another institution). Three of the children have had no further symptoms (mean follow-up period, 20 months), and their growth and weight gain have been normal. The fourth child, a 3-year-old girl, has had two episodes of pain since treatment. These attacks, both of which subsided spontaneously, probably were caused by the passage of protein plugs through the sphincterotomy. The fifth patient received no treatment because she had remained asymptomatic since the first examination (28 months ago). The short-term effects observed in these children indicate that endoscopic treatment of chronic idiopathic pancreatitis is associated with a high rate of success with respect to pain control. Because of the short follow-up, the effects on endocrine and exocrine function have not been assessed. No deaths or complications occurred. Conservative treatment of this type can be repeated if pain recurs, an important factor given the chronic nature and early onset of this disease, and it does not preclude the possibility of subsequent surgery. The authors' experience indicates that this approach should be considered the initial treatment of choice for children with chronic pancreatitis.

An exceptional genealogy for hereditary chronic pancreatitis

Nearly one hundred families affected with hereditary chronic pancreatitis (HCP) have been reported in the literature. However, the fact that the disease involved only a few members of each family limits the informativeness of these reports and accounts for the infrequency and disappointing results of pathogenetic and genetic research. Our study concerned an exceptional HCP genealogy which would seem to provide an ideal model for the detection of a genetic anomaly linked to the expression of the disease. We studied 249 members of a family (214 still alive), covering eight generations born between 1800 and 1993. According to the customary criteria, 63 had definite and 17 probable HCP. Fifty-eight members under 18 years of age were still susceptible to developing the disease. This series confirms the mode of autosomal dominant heredity with variable penetrance. The clinical features and disease course were typical, except that symptoms tended to appear earlier. The series represents the most extensive HCP genealogy compiled and is one of the largest families studied in the field of genetic disease, regardless of etiology. Blood samples were taken from 146 subjects to facilitate pathogenetic and genetic research.

Trypsin(ogen) content of pancreatic calculi in chronic calcified pancreatitis in man

Protein analysis of intraductal precipitates and calculi is important to elucidate the mechanism of stone formation in chronic pancreatitis. We revealed human cationic trypsin immunoreactivity in protein extracts of pancreatic stones from 11 of 13 patients with chronic calcified pancreatitis, ranging from 0 to 42.3 ng/micrograms protein. On gel filtration the immunoreactivity eluted as one peak, which is identical to that of human cationic trypsinogen. On immunostaining of pancreatic stone, using an immunogold technic and scanning electron microscopy, the immunoreactivity was observed more densely in the amorphous portion of the center of the stones than in the concentric laminar layer of the periphery. Only negligible activity was detected for elastase 1 or amylase in the stone extracts. These results suggest that the presence of trypsinogen in pancreatic stone is not due to coprecipitation or adsorption of pancreatic enzymes but that trypsinogen is more likely involved in an initial step of intraductal precipitate formation than in a subsequent step of stone formation. However, the absence of trypsinogen in the stones from two of the 13 patients also suggests that trypsinogen is not the sole protein initiating precipitate formation.

Pancreatitis in Finland between 1970 and 1989

The incidence and mortality from pancreatitis in Finland between 1970 and 1989 were studied and compared with the alcohol consumption in the country and with the incidence of liver cirrhosis and gall stone disease. Hospital discharge data were obtained from the Finnish National Agency for Welfare and Health, the causes of deaths from the Finnish State Statistics, and annual alcohol consumption from the Finnish State Alcohol Company. There were 56,353 hospital treatment periods because of pancreatitis. The incidence of pancreatitis discharges increased from 46.6 to 73.4/100,000/year. In men it increased from 59.1 to 113.4, but in women it remained unchanged (mean 35.0). The incidence of pancreatitis discharges correlated with the alcohol consumption in Finland (r = 0.78, p = 0.0001). The incidence of pancreatitis discharges correlated in men, but not in women, with the incidence of liver cirrhosis (r = 0.81, p = 0.0001). In women, but not in men, the incidence of pancreatitis discharges correlated with the incidence of gall stone disease discharges (r = 0.77, p = 0.0001). The incidence of discharges due to haemorrhagic pancreatitis and pancreatic abscess doubled in men and remained unchanged in women. Pancreatitis death rate decreased from 5.9% (men 4.8%, women 7.0%) to 2.6% (men 2.4%, women 2.7%).

Inhibition of the formation of oral calcium phosphate precipitates: beneficial effects of Chinese traditional (kampo) medicines

Screening tests on the formation of calcium phosphate precipitates using 23 different kinds of Kampo medicines (Chinese traditional medicines) were carried out, at concentrations where the effects of chelation are not significant. Four of them, Hochu-ekki-to (TJ-41), Kyuki-kyogai-to (TJ-77), Oren-to (TJ-120) and Inchin-ko-to (TJ-135) showed an inhibitory effect on the formation of amorphous calcium phosphate (ACP). The inhibitory effect on the induction time and the rate of transformation to hydroxyapatite (HAP) varied greatly among the 23 Kampo medicines. We classified them according to their effects on increasing the induction time and/or decreasing the rate of HAP transformation. Ethane-1-hydroxy-1, 1-diphosphonate (EHDP) was used as the standard. This compound is a common toothpaste additive which decreases dental calculus formation. Two of the 23 Kampo medicines showed little or no inhibition either on the induction time or on the rate of HAP transformation. Twelve of them reduced the rate of HAP transformation by 20-40% and with 1.9- to 4.0-fold increases in the induction time. The remaining nine showed even greater activity. Keishi-ninjin-to (TJ-82), Dai-kenchu-to (TJ-100), Toki-to (TJ-102), Rikko-san (TJ-110) and San'o-shashin-to (TJ-113) showed the same inhibitory effect as EHDP. Shigyaku-san (TJ-35;5.2-fold), Dai-kanzo-to (TJ-84;4.9-fold), Oren-gedoku-to (TJ-15;12.7-fold) and Inchin-ko-to (TJ-135;9.5-fold) had a greater effect on the increase of induction time than EHDP and reduced the rate of HAP transformation by 50-60%. These results suggest that these nine kinds of Kampo medicines may have potential as anticalculus agents in toothpastes and mouthwashes.

Endoscopic clearance of the pancreatic duct in chronic pancreatitis with severe pain

In a phase I study endoscopic removal of pancreatic duct stones and protein plugs was attempted in five patients suffering from chronic pancreatitis with severe chronic pain. The pancreatic duct contents could be extracted after successful sphincterotomy in three patients. Clearance of the pancreatic duct was followed by complete or partial relief of pain. The follow-up period was 17-48 months. Endoscopic extraction is, however, not without complications; it is technically difficult, and many attempts may be required. The combination of endoscopic therapy and extracorporeal shock-wave lithotripsy may be a better alternative.

Pancreaticojejunostomy for chronic pancreatitis

The treatment of chronic pancreatitis commonly yields disappointing results. Patients with chronic pancreatitis and a dilated pancreatic duct can be treated by longitudinal pancreaticojejunostomy. In order to evaluate the procedure, 20 patients undergoing pancreaticojejunostomy were followed for a median time of more than 5 years. Their clinical characteristics and outcomes have been compared with a group of 43 patients with chronic pancreatitis and small pancreatic ducts. There were no differences between the two groups in the major epidemiological parameters, except that calcification in the gland was more frequently noted in those with large ducts. The operation of longitudinal pancreaticojejunostomy could be accomplished with an acceptable morbidity. There was one death in the postoperative period. Seventy-six per cent of patients were found to have benefited clinically at five years, compared with 48% of those with small duct disease. This difference was statistically significant. Patients who benefited were defined by four factors; they were carrying out their usual occupation at the time of surgery, they were not narcotic dependent at the time of surgery, they had a pancreatic duct width greater than 7 mm and, they had totally abstained from alcohol from before the operation to the time of follow-up. Longitudinal pancreaticojejunostomy probably remains the best surgical treatment for suitable patients with chronic pancreatitis. The operation should only be performed when the pancreatic duct is greater than 7 mm in width. In such patients the operation produces considerable improvement of pain with minimal metabolic disturbance.

Surgical management of chronic pancreatitis on the continent of Europe

Surgical management of chronic pancreatitis remains a difficult problem. On the continent of Europe, the main etiology of the disease is alcoholism; thus, alcohol withdrawal is mandatory before surgical treatment. Left splanchnicectomy is no longer used. Total and left subtotal pancreatectomy are abandoned due to their high mortality rates and their severe metabolic sequelae. Distal pancreatectomy is presently reserved for the cases in which the head of the pancreas is least involved. The choice between pancreaticojejunostomy and pancreaticoduodenectomy remains debated. The former has a low postoperative mortality rate while reoperation is less frequent after the latter. Current trends in Europe are to perform more anastomoses and less resections than some years ago. Pancreaticoduodenectomy, however, retains an important role in cases with biliary or duodenal involvement. Whatever the choice of the procedure, the surgical treatment of chronic pancreatitis remains palliative and does not alter the natural course of the disease. The quality and duration of the results depend mainly on alcohol withdrawal.

Observations and surgical management of tropical pancreatitis in Kerala and southern India

This article describes the surgery of tropical pancreatitis as practiced in a region of high incidence, based on the experience at 2 centers: the Department of Surgical Gastroenterology and Proctology, Government General Hospital, Madras, Tamilnadu (a tertiary-care referral unit) where 52 patients were diagnosed and 40 were operated on between 1982 and 1987; and the Department of Gastroenterology, Deva Matha Hospital, Koothattukulam (a specialized center located in the main endemic area of Kerala), where 116 patients were diagnosed and 33 operated on between 1983 and 1988. The latter series is described in detail with emphasis on the preoperative imaging, operative findings, surgical procedures, complications, and results of surgery. The experience of other centers in southern India is summarized and discussed. The disease is obviously different from chronic pancreatitis in the West. Special problems of tropical pancreatitis, particularly the management of diabetes and the association of pancreatic carcinoma at a young age, are discussed.

Evolution and regression of pancreatic calcification in chronic pancreatitis. A prospective long-term study of 107 patients

Pancreatic calcifications are virtually pathognomonic of chronic pancreatitis and develop in up to 90% of patients with alcoholic chronic pancreatitis in series with long-term results. We investigated the natural course of pancreatic calcification in a prospective longitudinal study over the past 23 yr. All patients were studied at regular intervals with particular regard to etiology, clinical findings, surgery, pancreatic function, and pancreatic calcification visible by x-ray (e.g., film series in three projections centered on the pancreas). We evaluated the findings of 107 patients with x-ray documentation of pancreatic calcification in at least three film series over a period of 4 yr or longer. Eighty-four patients had alcoholic chronic pancreatitis (group A) and 23 patients had nonalcoholic chronic pancreatitis (group B). Four hundred seventy-two film series of group A and one hundred forty-two film series of group B were reviewed independently by two expert teams. Both series were graded according to a score system in terms of intensity and distribution of pancreatic calcification (correlation of grading r = 0.91). The duration of calcification averaged 10 yr in group A and 12.6 yr in group B. Similar dynamic changes of pancreatic calcification were noted in groups A and B. Chronologically, three phases of evolution could be distinguished. After an initial increase (phase 1), greater than 50% of cases reached a plateau of stationary calcification (phase 2). Approximately one-third of cases showed a marked decrease of calcification in late phases of chronic pancreatitis (phase 3). Dissolution of pancreatic stones was related primarily to duration of chronic pancreatitis (duration of calcification and marked pancreatic dysfunction), and occurred frequently (but not exclusively) in patients after ductal drainage procedures. These results indicate that spontaneous dissolution of pancreatic stones is a rather common biologic phenomenon. The factors responsible for dissolution of stones remain to be elucidated.

Surgery in tropical pancreatitis

Nineteen consecutive patients with tropical pancreatitis and chronic pancreatic pain operated upon over a 3-year period in Kerala, India, are reported. The pancreatic ductal morphology was studied by ultrasound scan, endoscopic retrograde cholangiopancreatography and/or operative pancreatography. In 17 patients, duct drainage by lateral pancreatojejunostomy and/or transduodenal pancreatic sphincteroplasty constituted the main surgical procedure. Caudal pancreatic resection was required in six of these patients. Unresectable pancreatic masses were found in two patients. Three patients died. Of the 16 survivors, 14 had good relief of pain within the limits of the available follow-up. In analysing the results, patients with 'obstructive pancreatitis' were found to have increased morbidity and mortality. The need to diagnose this subgroup of chronic pancreatitis pre-operatively is discussed.

Diagnosis and grading of chronic pancreatitis by morphological criteria derived by ultrasound and pancreatography

The most commonly used modalities in the diagnosis of chronic pancreatitis are ultrasonography, computed tomography (CT) and endoscopic retrograde pancreatography (ERP). Computed tomography scanning is only of value in severe chronic pancreatitis. Both ultrasound and pancreatography are capable of showing ductal changes in mild forms of the disease, but comparison of the two methods has been difficult. A scheme of morphological criteria and descriptive terminology of pancreatitis was applied to 58 out of 85 patients with a firm clinical diagnosis of chronic pancreatitis. Twenty-seven patients were excluded from the study, four with a faulty clinical diagnosis and 23 with non-diagnostic pancreatograms. There was an exact classification into normal, equivocal, mild, moderate or marked chronic pancreatitis in 50 out of 58 patients (86%) and an almost perfect correlation (+ or - one grade) in 54 out of 58 (93%). There were four discrepancies. Ultrasound examination missed focal pancreatitis in the tail, a small cavity in the uncinate process and a variant of chronic pancreatitis. One ultrasound scan was of poor quality. Morphological grading by different techniques is feasible and use of this scheme can reduce diagnosis to a simple and specific set of rules.

Quantitative tissue characterisation in pancreatic disease using magnetic resonance imaging

Twenty-nine patients, 27 of whom had either inflammatory disease of the pancreas or pancreatic tumour, were studied by magnetic resonance imaging (MRI) and computed tomography (CT). Six healthy volunteers were studied by MRI alone. The pancreatic T1 and T2 relaxation times were calculated using a multipoint iterative method with data from seven total saturation recovery and six spin echo sequences. Magnetic resonance imaging can demonstrate the normal pancreas and a variety of pathological processes greater than 1-2 cm in size, but with less spatial resolution than CT. The relaxation-time results indicated no significant discrimination between chronic pancreatitis and pancreatic tumour. A significant elevation in the relaxation times was observed, however, in those patients with calcific chronic pancreatitis compared with the non-calcific chronic pancreatitic group and normal controls, suggesting a different pathophysiology for the two subgroups of chronic pancreatitis. The active phase of acute pancreatitis was associated with significantly elevated relaxation times, which returned to normal levels during the resolved phase of the disease. Associated extrapancreatic fluid collections were characterised by their very long relaxation times. The problems associated with spatial resolution, respiratory motion and lack of quantitative tissue characterisation suggest that MRI of the pancreas, using present methods, is unlikely to contribute to the overall management of patients with exocrine pancreatic disease.

Saturation of human salivary secretions with respect to calcite and inhibition of calcium carbonate precipitation by salivary constituents

The state of saturation of human salivary secretions with respect to calcite has been investigated. This property cannot be calculated exactly because of uncertainties in the values of the solubility product constant of calcite, the dissociation constants of carbonic acid, and PCO2 values of saliva. Minimum and maximum limits for this saturation, however, can be established using appropriate values for the constants and salivary PCO2. Values that give the minimum degree of saturation show that 8 of the 70 samples of human saliva investigated would be supersaturated with respect to calcite, while 64 of the 70 samples appeared to be supersaturated when values giving the maximum degree of saturation were used. In the latter case, the ratio of ionic activity products to solubility product was above 10 for several samples and over 18 for the most supersaturated sample. Since these results show that supersaturation of saliva with respect to calcite may be a common condition, human salivary secretions were investigated for the presence of inhibitors of calcite precipitation. Inorganic phosphate and the acidic proline-rich proteins, known to be inhibitors of calcite precipitation, and human salivary statherin, now shown to have a similar activity, are present in saliva at concentrations considerably higher than those required to inhibit calcite precipitation under salivary conditions. Quantitatively, phosphate is by far the most important inhibitor of calcite precipitation present in saliva, suggesting that inhibition of calcite precipitation by the macromolecules may be of secondary significance. It seems more likely that the function of these molecules is to inhibit precipitation of calcium phosphate salts, as previously proposed. These different inhibitory activities, however, are likely to be factors in the differences in composition of oral and dental calculi in different species, and may need to be considered in the formation of calcite stones in the pancreas.

Etiopathogenesis and definition of chronic pancreatitis

This is a critical review of papers published on definition, classification, etiology, and pathogenesis of chronic pancreatitis from 1981 to 1985. Articles published earlier will only be mentioned when they are necessary to the understanding of the present knowledge or when they are insufficiently known. The more ancient literature has been reviewed elsewhere. The etiology and pathogenesis section will be limited to calcifying pancreatitis which is the most frequent form of chronic pancreatitis. The etiology of chronic obstructive pancreatitis has been studied in another review. The simple fibrosis of the pancreas is excluded from this chapter.