Chronic pancreatitis and diabetes

Applications of bile acids as biomaterials-based modulators, in biomedical science and microfluidics

Chronic disorders such as diabetes mellitus are associated with multiple organ dysfunction, including retinopathy, neuropathy, nephropathy, peripheral vascular disease, and vascular disease. Lifelong subcutaneous insulin injections are currently the only treatment option for patients with Type 1 diabetes mellitus, and it poses numerous challenges. Since the breakthrough achieved from the Edmonton protocol in the year 2000, there has been important research to investigate whether islet cell transplantation can achieve long-term normoglycemia in patients without the need for insulin. The use of biopolymeric scaffold to enclose islet cells has also been explored to improve survivability and viability of islet cells. This review paper summarizes the latest research in using biopolymeric scaffolds in islet transplantation and how microfluidic devices can assist.

Partial pancreatic tail preserving subtotal pancreatectomy for pancreatic cancer: Improving glycemic control and quality of life without compromising oncological outcomes

BACKGROUND

Total pancreatectomy (TP) is usually considered a therapeutic option for pancreatic cancer in which Whipple surgery and distal pancreatectomy are undesirable, but brittle diabetes and poor quality of life (QoL) remain major concerns. A subset of patients who underwent TP even died due to severe hypoglycemia. For pancreatic cancer involving the pancreatic head and proximal body but without invasion to the pancreatic tail, we performed partial pancreatic tail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order to improve postoperative glycemic control and QoL without compromising oncological outcomes.

AIM

To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.

METHODS

We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinoma who underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014 to January 2019. Clinical outcomes were compared between the two groups, with an emphasis on oncological outcomes, postoperative glycemic control, and QoL. QoL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26). All patients were followed until May 2019 or until death.

RESULTS

A total of 56 consecutive patients were enrolled in this study. Perioperative outcomes, recurrence-free survival, and overall survival were comparable between the two groups. No patients in the PPTP-SP group developed cancer recurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreatic fistula. Patients who underwent PPTP-SP had significantly better glycemic control, based on their higher rate of insulin-independence (P = 0.014), lower hemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001), and less frequent hypoglycemic episodes (P < 0.001). Global health was similar in the two groups, but patients who underwent PPTP-SP had better functional status (P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011), and higher confidence regarding future life (P = 0.035).

CONCLUSION

For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SP achieves perioperative and oncological outcomes comparable to TP in selected patients while significantly improving long-term glycemic control and QoL.

Release of Cholecystokinin from Rat Intestinal Mucosal Cells and the Enteroendocrine Cell Line STC-1 in Response to Maleic and Succinic Acid, Fermentation Products of Alcoholic Beverages

Alcoholic beverages stimulate pancreatic enzyme secretions by inducing cholecystokinin (CCK) release. CCK is the major stimulatory hormone of pancreatic exocrine secretions, secreted from enteroendocrine I-cells of the intestine. Fermentation products of alcoholic beverages, such as maleic and succinic acids, influence gastric acid secretions. We hypothesize that maleic and succinic acids stimulate pancreatic exocrine secretions during beer and wine ingestion by increasing CCK secretions. Therefore, the effects of maleic and succinic acids on CCK release were studied in duodenal mucosal cells and the enteroendocrine cell line STC-1. Mucosal cells were perfused for 30 min with 5 min sampling intervals, STC-1 cells were studied under static incubation for 15 min, and supernatants were collected for CCK measurements. Succinate and maleate-induced CCK release were investigated. Succinate and maleate doses dependently stimulated CCK secretions from mucosal cells and STC-1 cells. Diltiazem, a calcium channel blocker, significantly inhibited succinate and maleate-induced CCK secretions from mucosal cells and STC-1 cells. Maleate and succinate did not show cytotoxicity in STC-1 cells. Our results indicate that succinate and maleate are novel CCK-releasing factors in fermented alcoholic beverages and could contribute to pancreatic exocrine secretions and their pathophysiology.

Type 1 Diabetes and Bone Fragility: Links and Risks

Type 1 diabetes (T1D) is associated with an increased fracture risk, which is present at young and old age. Reductions in bone mineral density do not explain the increased fracture risk. Novel scanning modalities suggest that structural deficits may contribute to the increased fracture risk. Furthermore, T1D may due to insulinopenia be a state of low bone turnover. However, diabetes complications and comorbidities may influence fracture risk. Patients with T1D are fearful of falls. The diabetes related complications, hypoglycemic events, and antihypertensive treatment may all lead to falls. Thus, the increased fracture risk in T1D seems to be multifactorial, and earlier intervention with antiosteoporotic medication and focus on fall prevention is needed. This systematic review addresses the epidemiology of fractures and osteoporosis in patients with T1D and the factors that influence fracture risk.

Epidemiology of Fractures in Diabetes

Diabetes mellitus is associated with an increased risk of fracture. The risk of a hip fracture is up to sevenfold increased in patients with type 1 diabetes and about 1.3-fold increased in patients with type 2 diabetes. However, these relative risk estimates may depend on the age and gender distribution of the population in question. Bone mineral density and the fracture risk assessment tool do not explain the increased fracture risk in patients with diabetes. Shared risk factors as pancreatitis, alcohol use, smoking and oral glucocorticoids may influence the observed fracture risk in patients with diabetes. This review examines the association between diabetes and fracture and attempts to disentangle the tight connection between diabetes per se, diabetes-related complications, comorbidities and shared risk factors. This is of great importance as the number of diabetes patients' increases with growing and aging populations and putting even more at risk of fracture.

The Certification of Fatalities Related to Diabetes Mellitus: A Shot in the Dark?

Worldwide, an estimated 415 million people have diabetes mellitus, which results in extensive morbidity and mortality. In order to track the effect of diabetes on mortality statistics, deaths in which diabetes mellitus caused or contributed to death must be recognized, included on the death certificate, and then properly coded for vital statistic purposes. For public health policy, this will help determine the extent of the disease and follow whether deaths increase or decrease. There is variation among death certifiers for when and how diabetes is included on the death certificate and among vital records bureaus as how to code diabetes-related deaths. Case scenarios are presented to highlight the certification issues that arise with deaths related to diabetes mellitus. This area of death certification may benefit from a consensus effort to standardize and enhance certification and coding of deaths due to diabetes in order to improve the reliability of these mortality statistics.

Pancreatitis: A Forensic Perspective

Among the numerous etiologies of acute and chronic pancreatitis, several underlying causes (e.g., chronic alcohol abuse, trauma, medical therapy) may result in a death that is reportable to the medical examiner/coroner. As such, forensic pathologists are likely to encounter pancreatitis at autopsy and therefore must be familiar with its etiologies, mechanisms of death, autopsy findings, and medicolegal investigation. This review will focus on the aspects of pancreatitis that may be useful to forensic pathologists in their daily practice. This includes determining if acute or chronic pancreatitis caused or contributed to death as well as determining the etiologically specific proximate cause of death. Current theories of how these various processes result in inflammation of the pancreas are reviewed.

Pancreatic stone protein/regenerating protein family in pancreatic and gastrointestinal diseases

Pancreatic stone protein (PSP; reported in 1979), pancreatitis-associated protein (PAP; 1984) and regenerating protein (Reg I; 1988) were discovered independently in the fields of the exocrine (pancreatitis) and endocrine (diabetes) pancreas. Subsequent analysis revealed that PSP and Reg I are identical and PAP belongs to the same protein family. PSP/Reg I and PAP share a selective and specific trypsin cleavage site and result in insoluble fibrils (PTP, PATP). Search for a functional role of PSP had led to the idea that it might serve as an inhibitor in pancreatic stone formation and PSP was renamed lithostathine. Inhibitory effects of lithostathine in stone formation have been questioned. Evidence so far obtained can support a lithogenic role rather than a lithostatic role of PSP. PAP and its isoforms have been investigated mainly regarding responses to inflammation and stress. Reg I and its isoforms have been examined on regeneration, growth and mitogenesis in gastrointestinal neoplastic diseases as well as diabetes. Evidence obtained can be applied in the prediction of prognosis and therapy for inflammatory and neoplastic diseases.

Beer but not wine, hard liquors, or pure ethanol stimulates amylase secretion of rat pancreatic acinar cells in vitro

BACKGROUND

In contrast to pure ethanol, the effect of alcoholic beverages on the exocrine pancreas is greatly unknown. Besides ethanol, alcoholic beverages contain numerous nonalcoholic constituents which might have pathophysiological effects on the pancreas. The aim of the present study was to investigate whether some commonly used alcoholic beverages and pure ethanol influence the main function of rat pancreatic acinar cells, i.e., enzyme output in vitro.

METHODS

Rat pancreatic AR4-2J cells were differentiated by dexamethasone treatment for 72 hours and freshly isolated pancreatic acini were prepared from Sprague-Dawley rats using collagenase digestion. After incubation of cells in the absence or presence of 1 to 10% (v/v) beer (containing 4.7% v/v ethanol), 10% (v/v) wine (containing 10.5 to 12.5% v/v ethanol), 10% (v/v) hard liquor (such as whisky, rum, and gin), or of the corresponding ethanol concentrations (4.03 to 80.6 mM) for 60 minutes, protein secretion was measured using amylase activity assay.

RESULTS

Incubation of AR4-2J cells with beer caused a dose-dependent stimulation of basal amylase secretion that was significant at doses of beer above 0.5% (v/v). Stimulation with 10% (v/v) beer induced 92.7 +/- 25.2% of maximal amylase release in response to the most effective cholecystokinin (CCK) concentration (100 nM). In contrast, ethanol (up to 80.6 mM) did neither stimulate nor inhibit basal amylase release. Lactate dehydrogenase measurement after treatment of AR4-2J cells with beer for 24 hours indicated that the increase of amylase release was not due to cell membrane damage. Wine and hard liquor had no effect on basal amylase secretion neither diluted to the ethanol concentration of beer nor undiluted. In freshly isolated rat pancreatic acinar cells beer dose-dependently stimulated amylase secretion in a similar manner as in AR4-2J cells.

CONCLUSIONS

Our data demonstrate that beer dose-dependently increases amylase output. Since neither ethanol nor the other alcoholic beverages tested caused stimulation of amylase release, our findings indicate that nonalcoholic constituents specific for beer are responsible for this increase. These as yet unknown compounds have to be identified and considered in further studies of ethanol-induced pathological and functional changes of the pancreas.

Phosphatidylserine receptor in chronic pancreatitis: evidence for a macrophage independent role

OBJECTIVE

This study analyzes the role of phosphatidylserine receptor (PSR) in chronic pancreatitis.

SUMMARY BACKGROUND DATA

In chronic pancreatitis, destruction of parenchyma comes along with infiltration of lymphocytes and macrophages. The phosphatidylserine receptor is expressed on the surface of macrophages and is crucial for the recognition and engulfment of apoptotic cells. In the present study, we investigated the role of this receptor and its relation to apoptosis in chronic pancreatitis.

METHODS

The expression and localization of PSR were analyzed by Northern blot analysis, RT-PCR, Western blot analysis and immunohistochemistry. Apoptosis was detected by the TUNEL method, and the RNA protection assay (RPA) was used to compare activation of apoptosis with PSR mRNA expression levels. In addition, the molecular data were related to clinicopathological parameters.

RESULTS

PSR mRNA expression was low to absent in normal pancreatic tissue samples. In human chronic pancreatitis, increased expression of PSR mRNA was present in 12 of 29 samples (41%). Up-regulation of PSR could be confirmed by Western blot analysis. In chronic pancreatitis tissue, PSR immunoreactivity was present in all islets, in some ductal cells and in macrophages. The RNA protection assay revealed high mRNA levels of the antiapoptotic genes bcl-2 and bfl-1 (P < 0.05) in chronic pancreatitis tissues with high PSR mRNA expression. The TUNEL apoptosis in situ detection method showed positive signals in some redifferentiating acinar cells and focally in acinar cells adjacent to stromal fibroblasts in chronic pancreatitis tissue samples. The distribution pattern of PSR on pancreatic cells in chronic pancreatitis corresponded to a great extent with regions of high apoptotic activity.

CONCLUSIONS

We show for the first time the presence of PSR in chronic pancreatitis on pancreatic cells other than macrophages in regions with high apoptotic activity. The coexpression and colocalization of this gene with other apoptosis mediators suggest its involvement in apoptotic processes. However, in chronic pancreatitis PSR is not only involved in phagocytosis of apoptotic cells by macrophages.

Fat malabsorption screening in chronic pancreatitis

OBJECTIVES

As the major metabolic complications of chronic pancreatitis are exocrine and endocrine dysfunction, leading to malabsorption and diabetes, the aims of this study were to screen patients with chronic pancreatitis for exocrine dysfunction, to correlate the prevalence of such dysfunction with the etiology and severity of pancreatitis, and to evaluate the effect of dysfunction on weight loss.

METHODS

Sixty patients were studied. In 44 patients, pancreatitis was alcoholic, and in 16, idiopathic. Patients' age, sex, alcohol consumption and smoking habits, duration of the disease, body mass index, and the presence of steatorrhea were recorded. The severity of pancreatitis was assessed by imaging procedures, including secretin-enhanced magnetic resonance cholangiopancreatography, and patients were classified according to the Cambridge system. Exocrine function was evaluated by the triolein breath test and acid steatocrit.

RESULTS

A significant positive correlation was found between breath test and steatocrit values. As a screening test for exocrine pancreatic dysfunction, the sensitivity of clinical steatorrhea was insufficient (38%). Of the 60 patients, 38 (63%) developed exocrine dysfunction within 5 yr of the onset of the pancreatitis and 56 (94%) after 10 yr. Moreover, undetected or untreated malabsorption had a harmful effect on weight, even in the absence of overt clinical steatorrhea.

CONCLUSIONS

To avoid nutritional deterioration, early screening for fat malabsorption should be recommended in chronic pancreatitis, whatever its etiology, using the acid steatocrit, a reliable, easy, and inexpensive test.

Use of the time-signal intensity curve from dynamic magnetic resonance imaging to evaluate remnant pancreatic fibrosis after pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy

BACKGROUND

This study assessed the value of the time-signal intensity curve (TIC) obtained from dynamic magnetic resonance imaging (MRI) in the evaluation of remnant pancreatic fibrosis after pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy.

METHODS

Two modes of pancreaticojejunostomy-duct-to-mucosa anastomosis (DMA; 24 patients) and pancreatojejunoserosal anastomosis (PJSA; 22 patients)-were used in 46 consecutive patients undergoing pancreaticoduodenectomy. All patients underwent dynamic contrast-enhanced MRI of the pancreas before pancreaticoduodenectomy. Retrospective review of the pancreatic magnetic resonance images and histological examination of the pancreas were performed, and the patterns of TICs from dynamic MRI were compared with the degree of pancreatic fibrosis. Dynamic MRI of the residual pancreas was carried out for 1-3 years after pancreaticoduodenectomy in 26 patients (14 DMA, 12 PJSA) who had a histologically verified normal pancreas with no fibrosis at the time of pancreaticoduodenectomy.

RESULTS

Evaluation of preoperative dynamic magnetic resonance images showed that a pancreatic TIC with a rapid rise to a peak followed by a rapid decline (type I) was characteristic of a normal pancreas without fibrosis. Pancreatic TICs with a slow rise to a peak followed by a slow decline or a plateau (types II and III) indicated a fibrotic pancreas. Postoperative pancreatic MRI demonstrated that six of 12 patients with a PJSA had a type II TIC, whereas 12 of 14 patients with a DMA had a type I curve (P = 0.046).

CONCLUSION

The TIC obtained from dynamic MRI is a reliable indicator of fibrosis in the remnant pancreas after pancreaticoduodenectomy. Use of a DMA was associated with a lower risk of pancreatic fibrosis 1-3 years after surgery than a PJSA.

Spirits and gastrectomy increase risk for chronic pancreatitis in Japanese male alcoholics

INTRODUCTION

Most cases of chronic pancreatitis are alcohol-related, but not all alcoholics develop pancreatitis.

AIM

To elucidate historical and biologic risk factors for this disease.

METHODOLOGY

Alcoholic Japanese men (n = 132) consecutively admitted to the National Alcoholism Center over 24 months, including 54 with chronic pancreatitis (diagnosed by endoscopic retrograde cholangiopancreatography) and 78 without, were surveyed about drinking history, smoking, education, and marital status, and tested for amylase, glycosylated hemoglobin, body mass, alcohol and aldehyde dehydrogenase genotypes, and K-ras gene mutations in pancreatic juice.

RESULTS

Higher risk for chronic pancreatitis was associated with drinking spirits rather than lower-alcohol beverages (odds ratio [OR], 2.58; p= 0.01). Daily ethanol consumption by those who drank spirits was greater than that among those who drank lower-alcohol beverages; however, no differences in either daily ethanol consumption or duration of drinking were observed between alcoholics with and without chronic pancreatitis. Postgastrectomy patients were at higher risk for chronic pancreatitis than unoperated comparison subjects (OR, 4.35, P< 0.05). Elevated glycosylated hemoglobin (OR, 4.62, p< 0.01), decreased amylase (OR 4.20, P<0.02), and low body mass (OR 1.89, P<0.1) were more frequent in alcoholics with chronic pancreatitis. K- gene mutations existed in 18.8% of alcoholics with chronic pancreatitis but in only 11.4% of those without the disorder. The frequencies of alcohol and aldehyde dehydrogenase genotypes in alcoholics with and without pancreatitis did not differ significantly.

CONCLUSION

Our study strongly suggested that spirits and partial gastrectomy increase the risk for chronic pancreatitis in male alcoholics.

Effects of long-term low-dose cyanide administration to rats

Chronic exposure to cyanide has been associated with development of pancreatic diabetes, hypothyroidism, and several neurological diseases in both humans and animals. However, there is a limited number of experimental models for these pathologies. Thus, in the present study 0, 0.15, 0.3, or 0.6 mg KCN/kg body weight/day was administered for 3 months to 26 rats. On the last day, plasma samples were obtained for glucose, cholesterol, and thyroidal hormone measurement, and the pancreas, thyroids, and whole central nervous system were collected for histopathologic study. There were no significant difference in plasma concentrations of the substances measured between groups, and no lesions were found in the pancrease or thyroid. The CNS of experimental animals revealed the presence of spheroids on the ventral horn of the spinal cord, neuron loss in the hippocampus, damaged Purkinje cells, and loss of cerebellar white matter. In conclusion, cyanide administration could promote neuropathological lesions in rats without affecting pancreas or thyroid gland metabolism.

Chronic pancreatitis: diagnosis, classification, and new genetic developments

The utilization of recent advances in molecular and genomic technologies and progress in pancreatic imaging techniques provided remarkable insight into genetic, environmental, immunologic, and pathobiological factors leading to chronic pancreatitis. Translation of these advances into clinical practice demands a reassessment of current approaches to diagnosis, classification, and staging. We conclude that an adequate pancreatic biopsy must be the gold standard against which all diagnostic approaches are judged. Although computed tomography remains the initial test of choice for the diagnosis of chronic pancreatitis, the roles of endoscopic retrograde pancreatography, endoscopic ultrasonography, and magnetic resonance imaging are considered. Once chronic pancreatitis is diagnosed, proper classification becomes important. Major predisposing risk factors to chronic pancreatitis may be categorized as either (1) toxic-metabolic, (2) idiopathic, (3) genetic, (4) autoimmune, (5) recurrent and severe acute pancreatitis, or (6) obstructive (TIGAR-O system). After classification, staging of pancreatic function, injury, and fibrosis becomes the next major concern. Further research is needed to determine the clinical and natural history of chronic pancreatitis developing in the context of various risk factors. New methods are needed for early diagnosis of chronic pancreatitis, and new therapies are needed to determine whether interventions will delay or prevent the progression of the irreversible damage characterizing end-stage chronic pancreatitis.

Response to insulin treatment and survival in 104 cats with diabetes mellitus (1985-1995)

Medical records of 104 cats with diabetes mellitus were reviewed. Information from 54 cats that had multiple blood glucose concentrations evaluated at least 5 times over a minimum of 3 months, beginning at the time insulin treatment was initiated, was used to evaluate the efficacy of insulin in treating diabetes mellitus. Fourteen of 54 cats were treated with protamine zinc insulin (PZI), 26 with ultralente insulin, and 14 with lente insulin. Six, 29, and 19 cats had good, mediocre, and poor glycemic control, respectively, based on mean blood glucose concentrations, whereas 31, 21, and 2 owners thought clinical response was good, mediocre, and poor, respectively. No significant difference was found in glycemic control among cats treated with PZI, ultralente, or lente insulin. Glycemic control was significantly (P < .05) better in 33 cats without than in 21 cats with concurrent disease. All 104 cats were used to calculate survival data. Fifty-one of 104 cats were alive at the time of the study. Mean (+/- standard deviation [SD]) and median survival times were 24 (+/- 16) and 20 months, respectively, in the 51 cats still alive at the end of the evaluation, and 25 (+/- 4) and 17 months, respectively, in the 53 cats that had died during the period of evaluation. Pancreatic abnormalities identified in 37 cats that underwent necropsy included chronic pancreatitis (n = 17), acute to subacute pancreatitis (n = 2), exocrine pancreatic adenocarcinoma (n = 7) and adenoma (n = 1), islet cell atrophy and vacuolar degeneration (n = 27), and islet amyloidosis (n = 8). No association was found between glycemic control and islet amyloidosis or exocrine pancreatic neoplasia, or between survival time and chronic pancreatitis, islet amyloidosis, or exocrine pancreatic neoplasia. In conclusion, diabetic cats evaluated in this study showed a variable response to exogenously administered insulin, ranging from excellent to poor. By maintaining mean blood glucose concentrations under 300 mg/dL, clinical signs were improved, and owners were satisfied with insulin treatment. Concurrent potentially insulin-antagonistic diseases were common and deleteriously affected glycemic control and survival time.

Histometric analysis of the distal pancreas in pancreatic head cancer

To clarify the histological status of the pancreas tail after pancreatoduodenectomy (PD), fibrosis, islets of Langerhans, and A, B, and D cells were examined histometrically in surgical cases of pancreatic cancer. The same investigations were also performed during an autopsy examination of the pancreas tail of survivors of surgery who had received either PD or total pancreatectomy with segmental autotransplantation (SAT). In the surgical cases, fibrosis and the islet percentage compared with nonpancreatic cancer cases were significantly higher while the B cell ratio was significantly lower. In addition, in pancreatic cancer patients, the fibrosis and islet ratio in the group with a blocked pancreatic duct were higher while the B cell ratio was lower than in the group with an open pancreatic duct. A direct relationship between the islet ratio and the degree of fibrosis, and an inverse relationship between the B cell ratio and the degree of fibrosis, were thus found. From the autopsy cases, the fibrosis progressed and the islet ratio increased following PD, but after SAT only the islet ratio increased compared to the time of surgery. The progression of fibrosis after PD thus suggests the presence of some problems in both the surgical method and postoperative management.

Long-term complications of diabetes mellitus, Part II: Gastrointestinal and infectious

Numerous gastrointestinal and infectious diseases are associated with long-standing and often poorly controlled DM in humans. Although not as well documented in veterinary patients, the veterinary practitioner must always have an index of suspicion for the possibility of these complications. Because the clinical signs of a number of these problems are identical, proper diagnostic procedures need to be used to differentiate among the gastrointestinal and even infectious problems. In all cases, stringent blood glucose control is the common denominator in effective treatment. Other agents can be used both to assist in short-term control and for long-term therapy.