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Jose JR, Shankar T, Arora P, S P, Jayachandran S. Diabetic Ketoacidosis: A Rare Complication of Type 3c Diabetes. Cureus 2024; 16:e57873. [PMID: 38725776 PMCID: PMC11078895 DOI: 10.7759/cureus.57873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/12/2024] Open
Abstract
Recently termed pancreoprivic diabetes, type 3c diabetes refers to high blood sugar values secondary to disease of the exocrine pancreas. The disease is most commonly misdiagnosed as type 2 diabetes mellitus (DM) and is overlooked by physicians and the general public. Chronic pancreatitis (CP) accounts for most cases of type 3c diabetes. Diabetic ketoacidosis (DKA) is a rare occurrence in type 3c diabetes as both alpha and beta cell dysfunction occur concurrently. In this case, the major hormones involved in lipolysis and ketone body production would be catecholamines, cortisol, and growth hormone. We report a case of a 37-year-old female with a history of endocrine pancreatic insufficiency secondary to CP who presented with DKA, one of the life-threatening but preventable complications of diabetes. Noncompliance with insulin and concurrent urinary tract infection were the inciting factors. Her condition improved with DKA management according to standard protocol, intravenous antibiotics, and other supportive care. She got discharged after optimization of insulin therapy, with proper advice for home blood sugar monitoring and regular follow-up. A patient with pancreatic pathology may present to the emergency with DKA as the first manifestation, and if not properly evaluated, the diagnosis of type 3c diabetes can be missed.
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Affiliation(s)
- Jewel Rani Jose
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Takshak Shankar
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Poonam Arora
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Parvathy S
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Sreejith Jayachandran
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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2
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Cúrdia Gonçalves T, Capela TL, Cotter J. Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:1-13. [PMID: 38314032 PMCID: PMC10836866 DOI: 10.1159/000530835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/12/2023] [Indexed: 02/06/2024]
Abstract
While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.
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Affiliation(s)
- Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
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3
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Bahl G, Upadhyay DK, Varma M, Singh R, Das S, Hussain S. Persistent chronic calcific pancreatitis with intraductal calculi associated with secondary diabetes mellitus type 3 and diabetic ketoacidosis - A case report. Endocr Regul 2024; 58:101-104. [PMID: 38656253 DOI: 10.2478/enr-2024-0011] [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: 04/26/2024] Open
Abstract
Diabetes mellitus type 3 refers to diabetes secondary to an existing disease or condition of the exocrine pancreas and is an uncommon cause of diabetes occurring due to pancreatogenic pathology. It accounts for 15-20% of diabetic patients in Indian and Southeast Asian continents. This is case report of a rare case of type 3 diabetes mellitus (T3DM) presenting with diabetic ketoacidosis (DKA). The patient was admitted for DKA along with complaint of hyperglycemia, blood glucose of 405 mg/dl with HbA1c level of 13.7%. Computed tomography evidence revealed chronic calcific pancreatitis with intraductal calculi and dilated pancreatic duct.
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Affiliation(s)
- Gurusha Bahl
- 1School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
| | - Dinesh K Upadhyay
- 1School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
| | - Madhumati Varma
- 2Department of Medicine, Jaipur National University, Institute for Medical Sciences and Research Center, Jaipur, Rajasthan, India
| | - Rajveer Singh
- 1School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
| | - Subhankar Das
- 1School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
| | - Sadique Hussain
- 1School of Pharmaceutical Sciences, Jaipur National University, Jaipur, Rajasthan, India
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4
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Lamba M, Yadav A, Bhagchandani D, Reddy H, Vidyarthi VC. Type 2 Diabetes Mellitus in a Young Female Later Diagnosed as Pancreatogenic Diabetes: The Dilemma in Classifying Diabetes Mellitus. Cureus 2023; 15:e50828. [PMID: 38249240 PMCID: PMC10797847 DOI: 10.7759/cureus.50828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Diabetes mellitus type 3c (DM3c) is a diabetes caused by pancreatic pathology. It occurs due to the destruction of the endocrine islet cells. Diabetes diagnosed at the age of 20-30 years share a common dilemma in segregating between the type of diabetes the patient has, as its management varies depending on the type of diabetes the patient is harboring. However, insulin remains the treatment of choice in later decades as the pancreatic reserves of beta cells exhaust, although it takes decades to happen. We report a case of a woman who was diagnosed with diabetes mellitus at the age of 26, was on oral hypoglycemic agents (OHA), and was shifted to insulin therapy as she became non-responsive to OHA in a short span of six years, which was alarming. The patient presented to us with the chief complaints of recurrent abdominal pain that aggravated on taking meals and was associated with multiple episodes of vomiting for two months. Blood gas analysis on admission had no evidence of metabolic acidosis, urine ketones were negative, and a random blood sugar test (RBS:202) excluded the possibility of diabetic ketoacidosis. Serum amylase and serum lipase were within normal limits. Contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of the atrophic pancreas with the non-dilated main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) was done to rule out the congenital anomalies of the pancreas responsible for chronic pancreatitis, which showed no structural abnormalities. During our clinical workup, we postulated that the diabetes she was diagnosed with at the age of 26 was DM3c, i.e., pancreatogenic diabetes. The rapid shift of patients from OHA to subcutaneous insulin in a short span must be alarming to the physician managing diabetes and needs extensive workup to look upon the etiology of the same.
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Affiliation(s)
- Mahak Lamba
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Ambuj Yadav
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Deepak Bhagchandani
- Internal Medicine, Gastroenterology and Hepatology, King George's Medical University, Lucknow, IND
| | - Himanshu Reddy
- Internal Medicine, King George's Medical University, Lucknow, IND
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5
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Seguí Díaz M, Pérez Unanua MP, Peral Martínez I, López Serrano A, Aguirre Rodríguez JC. [Type 3 c diabetes: Approach from the first level doctor]. Semergen 2023; 49:102074. [PMID: 37672810 DOI: 10.1016/j.semerg.2023.102074] [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: 06/22/2023] [Accepted: 07/21/2023] [Indexed: 09/08/2023]
Abstract
DM3c is diabetes (DM) of the exocrine pancreas that must be suspected whenever there is a history of chronic pancreatitis (CP), acute pancreatitis (AP) or recurrence (80% of cases) or new-onset DM in individuals from over 50 years of age without any other justification (negative autoimmunity tests, Glutamic Acid Decarboxylase antibodies). It is an entity misdiagnosed as type 2 diabetes (DM2) (90%) and therefore, if it is not suspected, it can go unnoticed. For its diagnosis, abdominal ultrasound, determination of the CA 19.9 tumor antigen (carbohydrate antigen 19-9), nuclear magnetic resonance (NMR) or computerized axial tomography (CT) are useful. The treatment is the same as DM2, although certain specifications depend on the type of drugs and with the particularity that in dealing with «fragile diabetes» greater caution must be taken with hypoglycemia (monitoring). Likewise, as it is a disease of the exocrine pancreas, it will have to be specifically treated to avoid metabolic, malabsorptive and/or nutritional alterations.
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Affiliation(s)
- M Seguí Díaz
- Unidad Básica de Salud de Es Castell, Menorca, España.
| | | | | | | | - J C Aguirre Rodríguez
- Centro de Salud Fortuny Velutti, Distrito Sanitario Granada Metropolitano, Granada, España
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Keaskin L, Egan SM, Almirall-Sanchez A, Tewatia V, Jorba R, Ferreres J, Memba R, Ridgway PF, O'Connor DB, Duggan SN, Conlon KC. Development of a clinical score to estimate pancreatitis-related hospital admissions in patients with a new diagnosis of chronic pancreatitis: the trinity score. HPB (Oxford) 2023:S1365-182X(23)00131-4. [PMID: 37183126 DOI: 10.1016/j.hpb.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/20/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND The clinical course of chronic pancreatitis is unpredictable and there is no globally accepted score to predict the disease course. We developed a clinical score to estimate pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis. METHODS We conducted a retrospective cohort study using two clinical chronic pancreatitis databases held in tertiary referral centres in Dublin, Ireland, and in Tarragona, Spain. Individuals diagnosed with chronic pancreatitis between 2007 and 2014 were eligible for inclusion. Candidate predictors included aetiology, body mass index, exocrine dysfunction, smoking and alcohol history. We used multivariable logistic regression to develop the model. RESULTS We analysed data from 154 patients with newly diagnosed chronic pancreatitis. Of these, 105 patients (68%) had at least one hospital admission for pancreatitis-related reasons in the 6 years following diagnosis. Aetiology of chronic pancreatitis, body mass index, use of pain medications and gender were found to be predictive of more pancreatic-related hospital admissions. These predictors were used to develop a clinical score which showed acceptable discrimination (area under the ROC curve = 0.70). DISCUSSION We developed a clinical score based on easily accessible clinical parameters to predict pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis.
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Affiliation(s)
- Laura Keaskin
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland
| | - Suzanne M Egan
- Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | | | - Vikram Tewatia
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Rosa Jorba
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Joan Ferreres
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Robert Memba
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Paul F Ridgway
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Donal B O'Connor
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland.
| | - Kevin C Conlon
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
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7
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Campagnola P, de Pretis N, Zorzi A, Caldart F, Frulloni L. Chronic pancreatitis and nutritional support. Best Pract Res Clin Gastroenterol 2023; 62-63:101823. [PMID: 37094906 DOI: 10.1016/j.bpg.2023.101823] [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: 01/13/2023] [Accepted: 01/29/2023] [Indexed: 04/26/2023]
Abstract
Malnutrition in patients with chronic pancreatitis is common, but its evaluation is often missed in clinical practice. Pancreatic exocrine insufficiency is the single most important cause of malnutrition; therefore, it needs to be screened for and treated appropriately. Specific diet regimens in patients suffering from chronic pancreatitis are rarely reported in the literature. Patients suffering from chronic pancreatitis have a higher demand for energy but a lower caloric intake secondary to pancreatic exocrine insufficiency, combined with the malabsorption of liposoluble vitamin and micronutrients, which needs be corrected by appropriate dietary counselling. Diabetes is frequently observed in chronic pancreatitis and classified as type 3c, which is characterized by low levels of both serum insulin and glucagon; therefore, there is a tendency towards hypoglycaemia in patients treated with insulin. Diabetes contributes to malnutrition in chronic pancreatitis. Strategies to treat exocrine and endocrine insufficiency are important to achieve better control of the disease.
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Affiliation(s)
| | | | - Alberto Zorzi
- Department of Medicine, University of Verona, Verona, Italy
| | | | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
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8
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S19-S40. [PMID: 36507649 PMCID: PMC9810477 DOI: 10.2337/dc23-s002] [Citation(s) in RCA: 654] [Impact Index Per Article: 654.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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9
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Dugic A, Hagström H, Dahlman I, Rutkowski W, Daou D, Kulinski P, Löhr J, Vujasinovic M. Post-pancreatitis diabetes mellitus is common in chronic pancreatitis and is associated with adverse outcomes. United European Gastroenterol J 2022; 11:79-91. [PMID: 36454055 PMCID: PMC9892477 DOI: 10.1002/ueg2.12344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Post-pancreatitis diabetes mellitus (PPDM) is a common consequence of chronic pancreatitis (CP). We aimed to determine the incidence and predictors of PPDM after CP onset, as well as complications and antidiabetic therapy requirements, in a high-volume tertiary center. METHODS We did a cohort study with retrospectively collected data from patients with definite CP seen at the Karolinska University Hospital between January 1999 and December 2020. Cause-specific Cox regression analysis was used to assess PPDM predictors. To estimate risk of complications and need for therapy the Fine-Gray subdistribution hazard model was employed, accounting for death as a competing risk. RESULTS We identified 481 patients with CP. The cumulative incidence of PPDM was 5.1%, 13.2%, 27.5% and 38.9% at 5, 10, 15 and 20 years, respectively. Compared to CP patients without diabetes, patients with PPDM were predominantly male (55% vs. 75%), had more frequently alcoholic etiology (44% vs. 62%) and previous acute pancreatitis. The only independent predictor of PPDM was presence of pancreatic calcifications (aHR = 2.45, 95% CI 1.30-4.63). Patients with PPDM had higher rates of microangiopathy (aSHR = 1.59, 95% CI 1.02-2.52) and infection (aSHR = 4.53, 95% CI 2.60-9.09) compared to CP patients who had type 2 diabetes (T2DM). The rate of insulin use was three-fold higher, whereas metformin use rate was two-fold higher in the same comparison. CONCLUSIONS Patients with PPDM have a higher frequency of clinically significant complications and were more commonly prescribed insulin and metformin, suggesting a more aggressive phenotype than that of T2DM. Greater PPDM awareness is needed to optimize disease management.
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Affiliation(s)
- Ana Dugic
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Hannes Hagström
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden,Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden,Clinical Epidemiology UnitDepartment of MedicineSolna, Karolinska InstituteStockholmSweden
| | - Ingrid Dahlman
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Wiktor Rutkowski
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Diana Daou
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - Paula Kulinski
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden
| | - J.‐Matthias Löhr
- Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden,Department of Clinical Science, Intervention, and Technology (CLINTEC)Karolinska InstituteStockholmSweden
| | - Miroslav Vujasinovic
- Department of MedicineHuddinge, Karolinska InstituteStockholmSweden,Department of Upper Abdominal DiseasesKarolinska University HospitalStockholmSweden
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Hernandez-Rienda L, del Olmo-García MI, Merino-Torres JF. Impact of Diabetes Mellitus in Patients with Pancreatic Neuro-Endocrine Tumors: Causes, Consequences, and Future Perspectives. Metabolites 2022; 12:1103. [PMID: 36422243 PMCID: PMC9698930 DOI: 10.3390/metabo12111103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 09/05/2023] Open
Abstract
Diabetes mellitus (DM) and pancreatic neuroendocrine tumors (pNETs) are two entities closely linked together. DM has been described as a risk factor for the development of pNETs and for the aggressiveness of the disease. On the other hand, DM due to pNETs is frequently undiagnosed or misclassified as type 2 DM when it is due to type 3 DM. In addition, metformin, a commonly prescribed drug for type 2 DM, has an antiproliferative property and is gaining increasing attention as an antitumor agent. This review article presents the findings published in the last few years on pNETs and DMs. Emphasis will be placed on DM as a risk factor, pNET as a risk factor for the development of type 3 DM, the management of type 3 DM on pNET, and DM as a prognostic factor in patients with pNET, as well as the future clinical implications of DM in these patients. The coexistence of DM and pNET is extensively presented. It is important to perform future clinical trials, which are necessary to establish the role of metformin on pNET disease. Increasing awareness among professionals managing pNET on the importance of a correct DM diagnosis and management of the disease must be a priority due to the implications on mortality and comorbidities it may have in these patients.
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Affiliation(s)
- Lorena Hernandez-Rienda
- Endocrinology and Nutrition Department, University and Politecnic Hospital La Fe, 46026 Valencia, Spain
- Joint Research Unit on Endocrinology, Nutrition and Clinical Dietetics, Health Research Institute Hospital La Fe-University of Valencia, 46026 Valencia, Spain
| | - Maria Isabel del Olmo-García
- Endocrinology and Nutrition Department, University and Politecnic Hospital La Fe, 46026 Valencia, Spain
- Joint Research Unit on Endocrinology, Nutrition and Clinical Dietetics, Health Research Institute Hospital La Fe-University of Valencia, 46026 Valencia, Spain
| | - Juan Francisco Merino-Torres
- Endocrinology and Nutrition Department, University and Politecnic Hospital La Fe, 46026 Valencia, Spain
- Joint Research Unit on Endocrinology, Nutrition and Clinical Dietetics, Health Research Institute Hospital La Fe-University of Valencia, 46026 Valencia, Spain
- Department of Medicine, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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Abstract
BACKGROUND Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress. METHODS The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions. RESULTS Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition. CONCLUSIONS These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.
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12
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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13
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Qi L, Wei Q, Ni M, Liu D, Bao J, Lv Y, Xia H, Wang Q, Wang L, Su J, Sj P, Li L. Pancreatic and gut hormone responses to mixed meal test in post-chronic pancreatitis diabetes mellitus. DIABETES & METABOLISM 2021; 48:101316. [PMID: 34929379 DOI: 10.1016/j.diabet.2021.101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE . - More than one-third of chronic pancreatitis patients will eventually develop diabetes, recently classified as post-chronic pancreatitis diabetes mellitus (PPDM-C). This study was aimed to investigate the pancreatic and gut hormone responses to a mixed meal test in PPDM-C patients, compared with non-diabetic chronic pancreatitis (CP), and type 2 diabetes patients or healthy controls. DESIGN AND METHODS .- Sixteen patients with PPDM-C, 12 with non-diabetic CP as well as 10 with type 2 diabetes and healthy controls were recruited. All participants underwent mixed meal tests, and blood samples were collected for measurements of blood glucose, C-peptide, insulin, glucagon, pancreatic polypeptide (PP), ghrelin, peptide YY, glucagon like peptide-1 (GLP-1) and gastric inhibitory peptide (GIP). Indices of insulin sensitivity and secretion were calculated. Repeated measures analysis of variance was performed. RESULTS . - Participants with PPDM-C exhibited decreases in both fasting and postprandial responses of C-peptide (P < 0.001), insulin (P < 0.001), ghrelin (P < 0.001) and PYY (P = 0.006) compared to participants with type 2 diabetes and healthy controls. Patients with CP showed blunted glucagon, PP and incretin reactions, while the responses were increased in patients with PPDM-C compared to controls. The level of insulin sensitivity was higher for PPDM-C than type 2 diabetes (P < 0.01), however the indices for early/late-phase and overall insulin secretion (P < 0.01) were lower. CONCLUSIONS .- Patients with PPDM-C are characterized by decreased C-peptide, insulin, ghrelin and PYY responses, and similar levels of glucagon, PP, GIP and GLP-1 compared to those with type 2 diabetes. The above findings, when confirmed in a larger population, may prove helpful to establish the diagnosis of PPDM-C, and should promote study on underlying pathophysiological mechanisms.
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Affiliation(s)
- Liang Qi
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qiong Wei
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China; Institute of Pancreas, Southeast University, Nanjing, China
| | - Muhan Ni
- Department of Gastroenterology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Dechen Liu
- Institute of Pancreas, Southeast University, Nanjing, China; Department of Clinical Science and Research, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jiantong Bao
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yingqi Lv
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hong Xia
- Department of Endocrinology, Jintan District People's Hospital Affiliated to Jiangsu University, Changzhou, China
| | - Qian Wang
- Department of Endocrinology, Jintan District People's Hospital Affiliated to Jiangsu University, Changzhou, China
| | - Lei Wang
- Department of Gastroenterology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
| | - Jianhua Su
- Jintan District People's Hospital Affiliated to Jiangsu University, Changzhou, China.
| | - Pandol Sj
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Ling Li
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China; Institute of Pancreas, Southeast University, Nanjing, China.
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Rivelsrud M, Paur I, Sygnestveit K, Nilsen RM, Tangvik RJ. Nutritional treatment is associated with longer survival in patients with pancreatic disease and concomitant risk of malnutrition. Clin Nutr 2021; 40:2128-2137. [PMID: 33059912 DOI: 10.1016/j.clnu.2020.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pancreatic diseases involve complex nutritional challenges. Despite this, conflicting evidence exists regarding the clinical relevance of detecting the risk of malnutrition and implementing systematic nutrition support for these patients. Thus, our aims were to investigate whether screening for malnutrition risk and initiating nutrition support are predictive of mortality for hospitalized patients with pancreatic diseases. DESIGN From 2008 to 2018, 34 prevalence surveys of nutrition were conducted at Haukeland University Hospital (HUH), Norway. Risk of malnutrition was defined by a score of ≥3 in Nutritional Risk Screening 2002 (NRS 2002). Primary outcomes included overall, one-year, and one-month mortality, and were compared according to malnutrition risk and nutrition support for adult patients with ICD-10 codes of K85: acute pancreatitis, K86: other diseases of pancreas, and C25: malignant neoplasm of pancreas. Length of hospital stay (LOS) was included as a secondary outcome. RESULTS Of the 283 patients investigated, risk of malnutrition was present in 61.5%. Risk of malnutrition was associated with higher overall mortality (Hazard Ratio (HR) = 1.67, 95% confidence interval (CI): 1.2-2.4, P = 0.003) and one-year mortality (HR = 1.89, 95% CI: 1.2-2.9, P = 0.004) compared to patients not at risk. Not receiving nutrition support for at-risk patients was associated with higher overall mortality (HR = 1.60, 95% CI: 1.1-2.4, P = 0.019) and one-year mortality (HR = 1.64, 95% CI: 1.04-2.6, P = 0.034) compared to patients at risk who received nutrition support. Patients at risk of malnutrition had increased LOS (20.5 nights vs 15.2 nights, P = 0.044) compared to patients not at risk of malnutrition. CONCLUSION This study of hospitalized patients with pancreatic disease suggests that risk of malnutrition may be associated with higher mortality rates, whereas nutrition support may decrease mortality rates. CLINICAL TRIAL REGISTRY Not registered.
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Affiliation(s)
- Mari Rivelsrud
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
| | - Ingvild Paur
- Norwegian Advisory Unit on Disease-Related Undernutrition, Oslo University Hospital, Norway
| | - Kari Sygnestveit
- Norwegian Advisory Unit on Disease-Related Undernutrition, Oslo University Hospital, Norway; Department of Research and Development, Haukeland University Hospital, Norway
| | - Roy M Nilsen
- Department of Research and Development, Haukeland University Hospital, Norway; Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Inndalsveien, 28, 5063, Bergen, Norway
| | - Randi J Tangvik
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway; Department of Research and Development, Haukeland University Hospital, Norway.
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15
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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17
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Vujasinovic M, Dugic A, Maisonneuve P, Aljic A, Berggren R, Panic N, Valente R, Pozzi Mucelli R, Waldthaler A, Ghorbani P, Kordes M, Hagström H, Löhr JM. Risk of Developing Pancreatic Cancer in Patients with Chronic Pancreatitis. J Clin Med 2020; 9:jcm9113720. [PMID: 33228173 PMCID: PMC7699479 DOI: 10.3390/jcm9113720] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
- Correspondence: ; Tel.: +46-72-469-4938
| | - Ana Dugic
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Amer Aljic
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
| | - Robin Berggren
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
| | - Nikola Panic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
| | - Roberto Valente
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
| | - Raffaella Pozzi Mucelli
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden;
- Department of Abdominal Radiology, Karolinska University Hospital, 14186 Stockholm, Sweden
| | - Alexander Waldthaler
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
| | - Poya Ghorbani
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden;
| | - Maximilian Kordes
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden;
| | - Hannes Hagström
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden; (A.D.); (A.A.); (R.B.); (R.V.)
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Johannes-Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden; (N.P.); (A.W.); (P.G.); (M.K.); (H.H.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden;
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18
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Jimenez-Luna C, Martin-Blazquez A, Dieguez-Castillo C, Diaz C, Martin-Ruiz JL, Genilloud O, Vicente F, del Palacio JP, Prados J, Caba O. Novel Biomarkers to Distinguish between Type 3c and Type 2 Diabetes Mellitus by Untargeted Metabolomics. Metabolites 2020; 10:metabo10110423. [PMID: 33105675 PMCID: PMC7690399 DOI: 10.3390/metabo10110423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 01/05/2023] Open
Abstract
Pancreatogenic diabetes mellitus (T3cDM) is a highly frequent complication of pancreatic disease, especially chronic pancreatitis, and it is often misdiagnosed as type 2 diabetes mellitus (T2DM). A correct diagnosis allows the appropriate treatment of these patients, improving their quality of life, and various technologies have been employed over recent years to search for specific biomarkers of each disease. The main aim of this metabolomic project was to find differential metabolites between T3cDM and T2DM. Reverse-phase liquid chromatography coupled to high-resolution mass spectrometry was performed in serum samples from patients with T3cDM and T2DM. Multivariate Principal Component and Partial Least Squares-Discriminant analyses were employed to evaluate between-group variations. Univariate and multivariate analyses were used to identify potential candidates and the area under the receiver-operating characteristic (ROC) curve was calculated to evaluate their diagnostic value. A panel of five differential metabolites obtained an area under the ROC curve of 0.946. In this study, we demonstrate the usefulness of untargeted metabolomics for the differential diagnosis between T3cDM and T2DM and propose a panel of five metabolites that appear altered in the comparison between patients with these diseases.
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Affiliation(s)
- Cristina Jimenez-Luna
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, 18012 Granada, Spain; (C.J.-L.); (J.P.); (O.C.)
| | - Ariadna Martin-Blazquez
- Fundación MEDINA, Centro de Excelencia para la Investigación en Medicamentos Innovadores en Andalucía, 18012 Granada, Spain; (A.M.-B.); (C.D.); (O.G.); (F.V.)
| | - Carmelo Dieguez-Castillo
- Department of Gastroenterology, San Cecilio University Hospital, 18012 Granada, Spain; (C.D.-C.), (J.L.M.-R.)
| | - Caridad Diaz
- Fundación MEDINA, Centro de Excelencia para la Investigación en Medicamentos Innovadores en Andalucía, 18012 Granada, Spain; (A.M.-B.); (C.D.); (O.G.); (F.V.)
| | - Jose Luis Martin-Ruiz
- Department of Gastroenterology, San Cecilio University Hospital, 18012 Granada, Spain; (C.D.-C.), (J.L.M.-R.)
| | - Olga Genilloud
- Fundación MEDINA, Centro de Excelencia para la Investigación en Medicamentos Innovadores en Andalucía, 18012 Granada, Spain; (A.M.-B.); (C.D.); (O.G.); (F.V.)
| | - Francisca Vicente
- Fundación MEDINA, Centro de Excelencia para la Investigación en Medicamentos Innovadores en Andalucía, 18012 Granada, Spain; (A.M.-B.); (C.D.); (O.G.); (F.V.)
| | - Jose Perez del Palacio
- Fundación MEDINA, Centro de Excelencia para la Investigación en Medicamentos Innovadores en Andalucía, 18012 Granada, Spain; (A.M.-B.); (C.D.); (O.G.); (F.V.)
- Correspondence: ; Tel.: +34-958-993965
| | - Jose Prados
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, 18012 Granada, Spain; (C.J.-L.); (J.P.); (O.C.)
| | - Octavio Caba
- Institute of Biopathology and Regenerative Medicine (IBIMER), Center of Biomedical Research (CIBM), University of Granada, 18012 Granada, Spain; (C.J.-L.); (J.P.); (O.C.)
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19
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Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
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Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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20
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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21
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Abstract
Chronic pancreatitis is a complex and irreversible disease of the pancreas and is associated with significant morbidity and mortality. Nutrition deficiencies in chronic pancreatitis are common and can be atypical in nature. As such, the management of these deficiencies can be individualized for patients. The aim of this review is to discuss the components of nutrition deficiencies in chronic pancreatitis, their management, and the current areas of research that are being explored. The clinical guidelines of major national and international societies were analyzed for recommendations on the nutrition management of chronic pancreatitis. The etiology of nutrition deficiencies in chronic pancreatitis is multifactorial and includes aspects of exocrine and/or endocrine dysfunction, significant abdominal pain, often persistent alcohol consumption, and increased metabolic activity. A large number of patients with nutrition deficiencies are underrecognized and undertreated. Although the majority of these patients can be managed by oral and pancreatic enzyme supplementation, some patients may require enteral tube feeding and, in rare cases, parenteral feeding. Current areas of research include the accurate identification of patients at risk for nutrition deficiencies, optimization of feeding regimens, and research into islet cell autotransplantation.
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Affiliation(s)
- Stephen J O'Brien
- Price Institute of Surgical Research, The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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22
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Duggan SN, O'Connor DB, Antanaitis A, Campion JR, Lawal O, Ahmed M, Tisdall AR, Sherlock M, Boran G, le Roux C, Gibney J, Conlon KC. Metabolic dysfunction and diabetes mellitus during long-term follow-up of severe acute pancreatitis: A case-matched study. Pancreatology 2020; 20:813-821. [PMID: 32522508 DOI: 10.1016/j.pan.2020.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/07/2020] [Accepted: 03/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Endocrine insufficiency following severe acute pancreatitis (SAP) leads to diabetes of the exocrine pancreas, (type 3c diabetes mellitus), however it is not known how this metabolic phenotype differs from that of type 2 diabetes, or how the two subtypes can be differentiated. We sought to determine the prevalence of diabetes following SAP, and to analyse the behaviour of glucose and pancreatic hormones across a 2-h oral glucose tolerance test (OGTT). METHODS Twenty-six patients following SAP (mean (range) duration of first SAP episode to study time of 119.3 (14.8-208.9) months) along with 26 matched controls underwent an OGTT with measurement of glucose, insulin, c-peptide, glucagon and pancreatic polypeptide (PP) at fasting/15/90/120min. Beta-cell area was estimated using the 15min c-peptide/glucose ratio, and insulin resistance (IR) using homeostasis model assessment (HOMA) and oral glucose insulin sensitivity (OGIS) models. RESULTS The prevalence of diabetes/prediabetes was 54% following SAP (38.5% newly-diagnosed compared to 19.2% newly-diagnosed controls). Estimated beta-cell area and IR did not differ between groups. AUC c-peptide was lower in SAP versus controls. AUC insulin and AUC c-peptide were lower in SAP patients with diabetes versus controls with diabetes; between-group differences were observed at the 90 and 120 min time-points only. Half of new diabetes cases in SAP patients were only identified at the 120min timepoint. CONCLUSIONS Diabetes and pre-diabetes occur frequently following SAP and are difficult to distinguish from type 2 diabetes in controls but are characterised by reduced insulin and c-peptide at later stages of an OGTT. Consistent with this observation, most new post SAP diabetes cases were diagnosed by 2-h glucose levels only.
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Affiliation(s)
- Sinead N Duggan
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland.
| | - Donal B O'Connor
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
| | - Andrius Antanaitis
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - John R Campion
- Department of Gastroenterology, Tallaght University Hospital, Dublin 24, Ireland
| | - Oladapo Lawal
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
| | - Mohamed Ahmed
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland
| | - Ana Rakovac Tisdall
- Department of Clinical Chemistry, Tallaght University Hospital, Dublin 24, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland; Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons, Ireland
| | - Gerard Boran
- Department of Clinical Chemistry, Tallaght University Hospital, Dublin 24, Ireland
| | - Carel le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - James Gibney
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
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23
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Abstract
PURPOSE OF REVIEW The aim was to review evidence about diabetes secondary to hereditary pancreatitis, seeking novel diagnostic and treatment features. RECENT FINDINGS Hereditary pancreatitis (HP) is an autosomal dominant condition, characterized by recurrent episodes of acute pancreatitis, progression to fibrosis, and chronic pancreatitis. Clinical presentation includes diabetes of the exocrine pancreas (DEP). HP prevalence ranges from 0.3 to 0.57 per 100,000 people, with up to 80% of these develop DEP. This condition often requires specific interventions: with regard to metabolic control, metformin is the first choice for those with mild DEP, and for those in advanced disease, insulin is considered the first-line therapy. Insulin analogues and insulin pump therapy are preferred due to the brittle glycemic pattern and risk of hypoglycemia. In case of exocrine insufficiency, pancreatic enzyme replacement therapy is recommended. Pancreatic polypeptide administration is a promising novel treatment feature. DEP due to HP appears to be a misdiagnosed condition. The requirement of specific management demonstrates the importance of this matter; therefore, appropriate recognition and classification are important.
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Affiliation(s)
- Gabriel Xavier Ramalho
- School of Medicine, Faculty of Education and Health Sciences, University Center of Brasilia (UniCEUB), Brasilia, Brazil
| | - Marcio Garrison Dytz
- School of Medicine, Faculty of Education and Health Sciences, University Center of Brasilia (UniCEUB), Brasilia, Brazil.
- Endocrinology Division, Department of Intern Medicine, Sobradinho Regional Hospital, Brasilia, Brazil.
- Endocrinology and Metabolism Medical Residency, Superior School of Health Sciences (ESCS), Brasilia, Brazil.
- Institute of Diabetes and Endocrinology of Brasilia, SHS Qd. 6 Cj. A Bl. E Sl 1119, Brasilia, DF, 70316-902, Brazil.
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24
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee (https://doi.org/10.2337/dc20-SPPC), a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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25
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Melki G, Laham L, Karim G, Komal F, Kumar V, Barham S, Grossman M, Kuru S, Mohamed H, Garris R, Baddoura W. Chronic Pancreatitis Leading to Pancreatogenic Diabetes Presenting in Diabetic Ketoacidosis: A Rare Entity. Gastroenterology Res 2019; 12:208-210. [PMID: 31523331 PMCID: PMC6731042 DOI: 10.14740/gr1203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 01/24/2023] Open
Abstract
Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient's anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.
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Affiliation(s)
- Gabriel Melki
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Linda Laham
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Gres Karim
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Fnu Komal
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Vinod Kumar
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Shaker Barham
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Matthew Grossman
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Sugabramya Kuru
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Hadir Mohamed
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Rana Garris
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Walid Baddoura
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
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26
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Ribichini E, Stigliano S, Rossi S, Zaccari P, Sacchi MC, Bruno G, Badiali D, Severi C. Role of Fibre in Nutritional Management of Pancreatic Diseases. Nutrients 2019; 11:nu11092219. [PMID: 31540004 PMCID: PMC6770015 DOI: 10.3390/nu11092219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022] Open
Abstract
The role of fibre intake in the management of patients with pancreatic disease is still controversial. In acute pancreatitis, a prebiotic enriched diet is associated with low rates of pancreatic necrosis infection, hospital stay, systemic inflammatory response syndrome and multiorgan failure. This protective effect seems to be connected with the ability of fibre to stabilise the disturbed intestinal barrier homeostasis and to reduce the infection rate. On the other hand, in patients with exocrine pancreatic insufficiency, a high content fibre diet is associated with an increased wet fecal weight and fecal fat excretion because of the fibre inhibition of pancreatic enzymes. The mechanism by which dietary fibre reduces the pancreatic enzyme activity is still not clear. It seems likely that pancreatic enzymes are absorbed on the fibre surface or entrapped in pectin, a gel-like substance, and are likely inactivated by anti-nutrient compounds present in some foods. The aim of the present review is to highlight the current knowledge on the role of fibre in the nutritional management of patients with pancreatic disorders.
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Affiliation(s)
- Emanuela Ribichini
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Serena Stigliano
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Sara Rossi
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Piera Zaccari
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Maria Carlotta Sacchi
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Giovanni Bruno
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Danilo Badiali
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
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27
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Wynne K, Devereaux B, Dornhorst A. Diabetes of the exocrine pancreas. J Gastroenterol Hepatol 2019; 34:346-354. [PMID: 30151918 DOI: 10.1111/jgh.14451] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/31/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
Diabetes of the exocrine pancreas (DEP) is a form of diabetes that occurs due to pancreatic disease. It is far more common than has been previously considered, with a recent study showing 1.8% of adults with new-onset diabetes should have been classified as DEP. The majority is misdiagnosed as type 2 diabetes mellitus (T2DM). Patients with DEP exhibit varying degrees of exocrine and endocrine dysfunction. Damage to the islet of Langerhans effects the secretion of hormones from the β, α, and pancreatic polypeptide cells; the combination of low insulin, glucagon, and pancreatic polypeptide contributes to rapid fluctuations in glucose levels. This form of "brittle diabetes" may result in the poorer glycemic control observed in patients with DEP, when compared with those with T2DM. Diabetes of the exocrine pancreas has a different natural history to other forms of diabetes; patients are more likely to require early insulin initiation compared with those with T2DM. Therefore, individuals with DEP should be advised about the symptoms of decompensated hyperglycemia, although they are less likely to develop ketoacidosis. Clinicians should screen for DEP in patients with acute or chronic pancreatitis, following pancreatic resection, or with co-existing cystic fibrosis or hemochromatosis. Incident diabetes may herald the onset of pancreatic ductal carcinoma in a small subset of patients. Once identified, patients with DEP can benefit from specific lifestyle advice, pancreatic enzyme replacement therapy, metformin treatment, appropriate insulin dosing, and monitoring. Further research is needed to establish the ideal treatment regimens to provide optimal clinical outcomes for this unique form of diabetes.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes and Endocrinology, John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Benedict Devereaux
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Anne Dornhorst
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Imperial College London, London, UK
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Jawahar AP, Narayanan S, Loganathan G, Pradeep J, Vitale GC, Jones CM, Hughes MG, Williams SK, Balamurugan AN. Ductal Cell Reprogramming to Insulin-Producing Beta-Like Cells as a Potential Beta Cell Replacement Source for Chronic Pancreatitis. Curr Stem Cell Res Ther 2019; 14:65-74. [DOI: 10.2174/1574888x13666180918092729] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 01/19/2023]
Abstract
Islet cell auto-transplantation is a novel strategy for maintaining blood glucose levels and
improving the quality of life in patients with chronic pancreatitis (CP). Despite the many recent advances
associated with this therapy, obtaining a good yield of islet infusate still remains a pressing
challenge. Reprogramming technology, by making use of the pancreatic exocrine compartment, can
open the possibility of generating novel insulin-producing cells. Several lineage-tracing studies present
evidence that exocrine cells undergo dedifferentiation into a progenitor-like state from which they can
be manipulated to form insulin-producing cells. This review will present an overview of recent reports
that demonstrate the potential of utilizing pancreatic ductal cells (PDCs) for reprogramming into insulin-
producing cells, focusing on the recent advances and the conflicting views. A large pool of ductal
cells is released along with islets during the human islet isolation process, but these cells are separated
from the pure islets during the purification process. By identifying and improving existing ductal cell
culture methods and developing a better understanding of mechanisms by which these cells can be manipulated
to form hormone-producing islet-like cells, PDCs could prove to be a strong clinical tool in
providing an alternative beta cell source, thus helping CP patients maintain their long-term glucose levels.
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Affiliation(s)
- Aravinth P. Jawahar
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Siddharth Narayanan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Gopalakrishnan Loganathan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Jithu Pradeep
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Gary C. Vitale
- Division of General Surgery, University of Louisville, Louisville, KY, 40202, United States
| | - Christopher M. Jones
- Division of Transplant Surgery, University of Louisville, Louisville, KY, 40202, United States
| | - Michael G. Hughes
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
| | - Stuart K. Williams
- Department of Physiology, University of Louisville, Louisville, KY, 40202, United States
| | - Appakalai N. Balamurugan
- Clinical Islet Cell Laboratory, Center for Cellular Transplantation, Cardiovascular Innovation Institute, Department of Surgery, University of Louisville, Louisville, KY 40202, United States
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Bhattamisra SK, Siang TC, Rong CY, Annan NC, Sean EHY, Xi LW, Lyn OS, Shan LH, Choudhury H, Pandey M, Gorain B. Type-3c Diabetes Mellitus, Diabetes of Exocrine Pancreas - An Update. Curr Diabetes Rev 2019; 15:382-394. [PMID: 30648511 DOI: 10.2174/1573399815666190115145702] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 11/02/2018] [Accepted: 01/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of diabetes is increasing steeply; the number of diabetics has doubled over the past three decades. Surprisingly, the knowledge of type 3c diabetes mellitus (T3cDM) is still unclear to the researchers, scientist and medical practitioners, leading towards erroneous diagnosis, which is sometimes misdiagnosed as type 1 diabetes mellitus (T1DM), or more frequently type 2 diabetes mellitus (T2DM). This review is aimed to outline recent information on the etiology, pathophysiology, diagnostic procedures, and therapeutic management of T3cDM patients. METHODS The literature related to T3cDM was thoroughly searched from the public domains and reviewed extensively to construct this article. Further, existing literature related to the other forms of diabetes is reviewed for projecting the differences among the different forms of diabetes. Detailed and updated information related to epidemiological evidence, risk factors, symptoms, diagnosis, pathogenesis and management is structured in this review. RESULTS T3cDM is often misdiagnosed as T2DM due to the insufficient knowledge differentiating between T2DM and T3cDM. The pathogenesis of T3cDM is explained which is often linked to the history of chronic pancreatitis, pancreatic cancer. Inflammation, and fibrosis in pancreatic tissue lead to damage both endocrine and exocrine functions, thus leading to insulin/glucagon insufficiency and pancreatic enzyme deficiency. CONCLUSION Future advancements should be accompanied by the establishment of a quick diagnostic tool through the understanding of potential biomarkers of the disease and newer treatments for better control of the diseased condition.
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Affiliation(s)
- Subrat Kumar Bhattamisra
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Tiew Chin Siang
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Chieng Yi Rong
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Naveenya Chetty Annan
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Esther Ho Yung Sean
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Lim Wen Xi
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Ong Siu Lyn
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Liew Hui Shan
- School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Hira Choudhury
- Department of Pharmaceutical Technology, School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Manisha Pandey
- Department of Pharmaceutical Technology, School of Pharmacy, International Medical University, Bukit Jalil 57000, Kuala Lumpur, Malaysia
| | - Bapi Gorain
- School of Pharmacy, Taylor's University, 1, Jalan Taylors, 47500 Subang Jaya, Selangor, Malaysia
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Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group. J Pediatr Gastroenterol Nutr 2018; 67:131-143. [PMID: 29927872 PMCID: PMC6020697 DOI: 10.1097/mpg.0000000000002023] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed. METHODS This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified. RESULTS AND DISCUSSION The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies. CONCLUSIONS This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.
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Abstract
Malnutrition is a frequent complication in patients with chronic pancreatitis. Maldigestion as a consequence of pancreatic exocrine insufficiency is the major cause of malnutrition in these patients. Together with that, toxic habits and alterations of the gastroduodenal transit may play a relevant role. Malnutrition in chronic pancreatitis is associated with osteoporosis, sarcopenia, poor quality of life, and increased mortality. An adequate nutritional evaluation including anthropometric, biochemical, and morphologic parameters is recommended in these patients. Nutritional advice and support together with an adequate pancreatic enzyme replacement therapy are indicated.
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Woodmansey C, McGovern AP, McCullough KA, Whyte MB, Munro NM, Correa AC, Gatenby PAC, Jones SA, de Lusignan S. Incidence, Demographics, and Clinical Characteristics of Diabetes of the Exocrine Pancreas (Type 3c): A Retrospective Cohort Study. Diabetes Care 2017; 40:1486-1493. [PMID: 28860126 DOI: 10.2337/dc17-0542] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/05/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study was conducted to describe the incidence of diabetes following pancreatic disease, assess how these patients are classified by clinicians, and compare clinical characteristics with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS Primary care records in England (n = 2,360,631) were searched for incident cases of adult-onset diabetes between 1 January 2005 and 31 March 2016. We examined demographics, diabetes classification, glycemic control, and insulin use in those with and without pancreatic disease (subcategorized into acute pancreatitis or chronic pancreatic disease) before diabetes diagnosis. Regression analysis was used to control for baseline potential risk factors for poor glycemic control (HbA1c ≥7% [53 mmol/mol]) and insulin requirement. RESULTS We identified 31,789 new diagnoses of adult-onset diabetes. Diabetes following pancreatic disease (2.59 [95% CI 2.38-2.81] per 100,000 person-years) was more common than type 1 diabetes (1.64 [1.47-1.82]; P < 0.001). The 559 cases of diabetes following pancreatic disease were mostly classified by clinicians as type 2 diabetes (87.8%) and uncommonly as diabetes of the exocrine pancreas (2.7%). Diabetes following pancreatic disease was diagnosed at a median age of 59 years and BMI of 29.2 kg/m2. Diabetes following pancreatic disease was associated with poor glycemic control (adjusted odds ratio, 1.7 [1.3-2.2]; P < 0.001) compared with type 2 diabetes. Insulin use within 5 years was 4.1% (3.8-4.4) with type 2 diabetes, 20.9% (14.6-28.9) with diabetes following acute pancreatitis, and 45.8% (34.2-57.9) with diabetes following chronic pancreatic disease. CONCLUSIONS Diabetes of the exocrine pancreas is frequently labeled type 2 diabetes but has worse glycemic control and a markedly greater requirement for insulin.
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Affiliation(s)
- Chris Woodmansey
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K
| | - Andrew P McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K
| | - Katherine A McCullough
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K.,The Centre for Diabetes, Endocrinology and Research (CEDAR), Royal Surrey County Hospital, Guildford, Surrey, U.K
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K.,The Centre for Diabetes, Endocrinology and Research (CEDAR), Royal Surrey County Hospital, Guildford, Surrey, U.K
| | - Neil M Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K
| | - Ana C Correa
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K
| | - Piers A C Gatenby
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K.,Regional Oesophagogastric Unit/Gastrointestinal Surgery, Royal Surrey County Hospital, Guildford, Surrey, U.K
| | - Simon A Jones
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K.,Division of Healthcare Delivery Science/Center for Healthcare Innovation and Delivery Science (CHIDS), Department of Population Health, New York University, Langone Medical Centre, New York, NY
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, U.K. .,Royal College of General Practitioners Research and Surveillance Centre, London, U.K
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Abstract
PURPOSE OF REVIEW Summarize key clinical advances in chronic pancreatitis reported in 2016. RECENT FINDINGS Early diagnosis of chronic pancreatitis remains elusive. Recent studies suggest that endoscopic ultrasound may be less accurate than previously thought and new MRI techniques may be helpful. Genetic predisposition may independently affect the clinical course of chronic pancreatitis and the risk for pancreatic cancer. Cigarette smoking may have a greater negative impact on chronic pancreatitis than previously thought and moderate alcohol consumption may be protective. A multidisciplinary approach is necessary for the treatment of type 3 diabetes and nutritional deficiencies in chronic pancreatitis. Although endoscopic therapy remains a reasonable first-line option in treating chronic pancreatitis and its complications, early surgical intervention may be indicated for pain in select patients. SUMMARY Newer endoscopic ultrasound and MRI techniques are being evaluated to help with the early diagnosis of chronic pancreatitis. Both genetic predisposition and cigarette smoking are increasingly recognized as having a major impact in the course of the disease and the risk for pancreatic cancer. Endoscopic therapy is well tolerated and effective for the treatment of chronic pancreatitis and its complications although an early surgical approach for pain may be associated with improved clinical outcomes.
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Abstract
Chronic pancreatitis is a chronic inflammatory disease of the pancreas characterised by irreversible morphological change and typically causing pain and/or permanent loss of function. This progressive, irreversible disease results in destruction of healthy pancreatic tissue and the development of fibrous scar tissue. Gradual loss of exocrine and endocrine function follows, along with clinical manifestations such as steatorrhoea, abdominal pain and diabetes. Nutrition in chronic pancreatitis has been described as a problem area and, until recently, there was little research on the topic. It is often asserted that >90 % of the pancreas must be damaged before exocrine insufficiency occurs; however, an exploration of the original studies from the 1970s found that the data do not support this assertion. The management of steatorrhoea with pancreatic enzyme replacement therapy is the mainstay of nutritional management, and early identification and treatment is a key. The presence of steatorrhoea, coupled with poor dietary intake (due to intractable abdominal pain, gastrointestinal side effects and often alcoholism) renders the chronic pancreatitis patients at considerable risk for undernutrition, muscle depletion and fat-soluble vitamin deficiency. Premature osteoporosis/osteopenia afflicts two-thirds of patients as a consequence of poor dietary intake of calcium and vitamin D, low physical activity, low sunlight exposure, heavy smoking, as well as chronic low-grade inflammation. Bone metabolism studies show increased bone formation as well as bone resorption in chronic pancreatitis, indicating that bone turnover is abnormally high. Loss of the pancreatic islet cells occurs later in the disease process as the endocrine cells are diffusely distributed throughout the pancreatic parenchyma. Patients may develop type 3c (pancreatogenic) diabetes, which is complicated by concurrent decreased glucagon secretion, and hence an increased risk of hypoglycaemia. Diabetes control is further complicated by poor diet, malabsorption and (for some) alcoholism, and therefore those with type 3c diabetes have clinical characteristics and therapeutic goals that are different from that of type 1 and type 2 diabetes patients. This review describes emerging research and clinical guidelines for nutrition in chronic pancreatitis.
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