Chronic pancreatitis

Negotiating the complexities of exocrine and endocrine dysfunction in chronic pancreatitis

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.

The Belgian national registry on chronic pancreatitis: A prospective multi-centre study covering more than 800 patients in one year

BACKGROUND/OBJECTIVES

The epidemiology, natural history, complications, and therapeutic management of chronic pancreatitis (CP) are not well described at the national level. This multi-centre prospective observational study involving eight Belgian hospitals aimed to improve the understanding of these aspects of CP in Belgium.

METHODS

All patients with a diagnosis of CP based on imaging were eligible for this study. Data were gathered regarding epidemiology, etiology, CP complications, and treatment modalities.

RESULTS

A total of 809 patients were included between 1/9/2014 and 31/8/2015. Most patients (794) were adults ≥16-years old, 74% were male, the median age at symptom onset was 47 (38-57) years, the median disease duration was 7 (3-13) years, and the median Izbicki pain score (IPS) was 96 (0-195). The main etiological risk factors according to the TIGAR-O classification were alcohol and tobacco (67%). Current drinkers had lower body mass index (BMI) (21.4 kg/m² vs 24.1 kg/m²), higher IPS (110 vs 56), and longer inability to work than non-drinkers. Current smokers had lower BMI (21.5 kg/m² vs 25 kg/m²) and higher IPS (120 vs 30) than non-smokers. Endocrine insufficiency and/or clinical steatorrhea was recorded in 41% and 36% of patients, respectively. The highest IPS was reported in patients with ongoing endotherapy (166 vs 50 for patients who completed endoscopy).

CONCLUSION

This multicentric study on CP patients showed that current alcohol drinking and smoking are associated with pain and malnutrition. Pain scores were higher in patients with ongoing endotherapy, independently of surgery.

RESECTION OPERATIONS IN SURGICAL TREATMENT OF PATIENTS WITH CHRONIC PANCREATITIS COMPLICATED BY BILIARY HYPERTENSION

Surgical treatment was applied in 145 patients with complicated forms of chronic pancreatitis (CP) at the department of surgery of the Ivano-Frankivsk Regional Clinical Hospital in 2009–2016. Fourty-nine (33.7 %) patients had symptoms of biliary hypertension (BH); in five (3.4 %) of them BH was combined with chronic duodenal obstruction (CDO), the other 5 (3.4 %) patients had a combination of BH+CDP and local venous hypertension of pancreaticobiliary area vessels. Resection-type surgeries were applied in 28 (57.1 %) patients with CP complicated by BH. Intraoperative monitoring of biliary pressure was used in 17 patients in the process of duodenum-preserving resections of the pancreas. Frey’s procedure was applied to 20 (71.4 %) patients, in whom BH persisted after the resection stage of the surgery; Frey’s procedure was supplemented by interventions on bile ducts: hepaticoenteroanastomosis was applied in 12 patients, excision of pancreas lingula was applied in one patient, internal biliopancreatic anastomosis was applied in one patient. Berne modification was used in 2 (7.2 %) patients, and pancreaticoduodenal resection (PDR) according to Whipple – in 6 (21.4 %) patients. Remote results were studied in 19 (67.8 %) patients. Patients after duodenum-preserving resections had the best quality of life indicators, for BH signs were absent.

Etiology, pathology, management and prognosis of chronic pancreatitis in Chinese population: A retrospective study

The purpose of this study was to investigate the etiology, pathological characteristics, management and prognosis of chronic pancreatitis in the Chinese population. The clinical data of 142 patients with chronic pancreatitis were retrospectively studied. All patients were of Chinese nationality and hospitalized from January 2008 to December 2011. Their ages ranged from 14 to 76 years, with a mean of 43 years. Of 142 patients, there were 72 cases of obstructive chronic pancreatitis (50.70%), 19 cases of alcoholic chronic pancreatitis (13.38%), 14 cases of autoimmune pancreatitis (9.86%) and 37 cases of undetermined etiology (26.06%). Pathologically, the average inflammatory mass diameter was 3.8 ± 3.3 cm, biliary obstruction occurred in 36 cases, gall stones in 70 cases, calcification in 88 cases, ductal dilatation in 61 cases, side branch dilatation in 32 cases, ductal irregularity in 10 cases, lymphocytic inflammation in 23 cases, obliterative phlebitis in 14 cases, extra pancreatic lesion in 19 cases and fibrosis in 142 cases. Location of pancreatic lesion in the region of head (n=97), neck (n=16), body (n=12), tail (n=15) and whole pancreas (n=2) influenced the choice of surgical procedures. Ninety-four patients (66.20%) received surgical treatment and 33.80% received other treatments. After operation, 80.85% of 94 patients experienced decreased pain, and 8.51% of 94 showed recovery of endocrine function but with a complication rate of 12.77%. All the operations were performed successfully. According to the pain scale of European Organization for Research and Treatment of Cancer (QLQ-C30) a decrease from 76 ± 22 to 14 ± 18 was observed. Etiology, pathological characteristics, management and prognosis of chronic pancreatitis in the Chinese population vary from others.

Treatment options in painful chronic pancreatitis: a systematic review

BACKGROUND

Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options.

METHODS

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction.

RESULTS

A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed.

CONCLUSIONS

First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.

Quantitative MRCP assessment of pancreatic exocrine reserve and its correlation with faecal elastase-1 in patients with chronic pancreatitis

PURPOSE

This retrospective study was done to correlate a quantitative assessment of the pancreatic exocrine reserve by dynamic secretin magnetic resonance cholangiopancreatography (MRCPQ) with the faecal elastase-1 (FE-1) test in patients with chronic pancreatitis.

MATERIALS AND METHODS

Thirty-five patients with a clinical diagnosis of chronic (CP) or acute recurrent (ARP) pancreatitis were enrolled. FE-1 was indicative of the pancreatic exocrine reserve. Subsequently, the patient population was subdivided into two groups according to a clinical threshold value of 200 μg/g. All patients underwent MRCP examination during secretin administration. Duodenal filling volume was calculated on T2-weigthed rapid acquisition with relaxation enhancement (RARE) MRCP images obtained 10 min after secretin injection. Duodenal filling volumes were compared with FE-1 values. Scatter plots, Pearson correlation coefficient and the Mann-Whitney U test were performed.

RESULTS

Thirty-five paired MRCPQ-FE1 data sets were analysed. MRCPQ was significantly different (p=0.007) between patients with impaired and preserved pancreatic function; median and interquartile range (IQR) were 150.7 ml (137.3-205.5 ml; n=9) and 332.4 ml (190.6-506.9 ml; n=26). Both Pearson correlation coefficient (p<0.001) and the Mann-Whitney U test (p=0.007) were significant.

CONCLUSIONS

MRCPQ significantly correlates with FE-1 values. It is possible to discriminate impaired and preserved pancreatic exocrine function using MRCPQ.

[Surgical treatment of chronic pancreatitis, 2010]

INTRODUCTION

Chronic pancreatitis (CP) is a benign inflammatory process, which can cause enlargement of the pancreatic head accompanied by severe pain and weight loss, and often leads to a significant reduction in quality of life (QoL). Basically, the disease is characterised by pain and functional disorders which are initially treated with conservative therapy, but in case of complications (uncontrollable pain or obstruction) surgical treatment is required.

METHODS

This article reviews the relevant literature of CP treatment, in particular randomized controlled trials and meta-analyses were involved with a comparison of different surgical treatment options for the management of CP complications.

RESULTS

Recent studies have demonstrated that surgical procedures are superior to endoscopic therapy as regards long-term results of QoL and pain control. There was no significant difference found in postoperative pain relief and overall mortality when duodenum-preserving pancreatic head resection (DPPHR) of Beger and its modification (duodenum and organ-preserving pancreatic head resection [DOPPHR]) were compared with pancreatoduodenectomy (PD), but hospital stay, weight gain, exocrine and endocrine insufficiency, and QoL were significantly better in the DPPHR and DOPPHR groups.

CONCLUSION

DPPHR and PD seem to be equally effective in terms of postoperative pain relief and overall mortality. However, recent data suggest that DOPPHR is superior in the treatment of CP with regard to several peri- and postoperative outcome parameters and QoL. Therefore, this should be the preferable treatment option for CP complications.

Nutrition treatment of deficiency and malnutrition in chronic pancreatitis: a review

Chronic pancreatitis results in exocrine and endocrine dysfunction, affecting normal digestion and absorption of nutrients. In individuals with chronic pancreatitis, nutrition status may be further affected by poor dietary intake, often related to alcoholism. However, some deficiencies may be overlooked, potentially leading to nutrition-related problems with bone health and fatigue. The aim of this article is to describe the deficiencies that occur and to propose an evidence-based algorithm for the nutrition assessment and treatment of patients with chronic pancreatitis.

Long-term quality of life after surgery for chronic pancreatitis

Background

Surgery for chronic pancreatitis is indicated for intractable pain or the treatment of complications. This retrospective cohort study evaluated the applicability of pain coping and quality-of-life (QOL) scoring in patients with chronic pancreatitis.

Methods

Between 1995 and 2008, 155 patients underwent surgery for chronic pancreatitis in two Dutch university hospitals. Medical charts were reviewed, and QOL and coping with pain were assessed by two validated questionnaires.

Results

Median follow-up was 5·6 years. The aetiology was alcohol related in 48·3 per cent. Some 111 resections and 46 drainage procedures were performed. Fifty-seven patients had major complications and the hospital mortality rate was 1·3 per cent. After surgery the number of patients needing analgesics was reduced (P &lt; 0·001). Alcohol consumption significantly reduced pain coping mechanisms (P = 0·032). Overall, QOL remained poor after surgery. Scores on three dimensions of the QOL questionnaire were significantly better after drainage than after resection procedures.

Conclusion

In general, QOL after surgery for chronic pancreatitis remains poor, owing to pre-existing lifestyle and co-morbidity. Patients selected for a pancreatic duct drainage procedure have a better postoperative QOL than those undergoing resectional procedures. Alcohol consumption is associated with poor ability to cope with pain after surgery and should be discouraged.

Exocrine and endocrine pancreatic function in 21 patients suffering from autoimmune pancreatitis before and after steroid treatment

BACKGROUND/AIM

Autoimmune pancreatitis (AIP) responds rapidly and dramatically to steroid therapy. The aim of this study was to evaluate pancreatic exocrine and endocrine function in patients suffering from AIP both before and after steroid therapy.

PATIENTS AND METHODS

Fecal elastase 1 and diabetes were evaluated before steroid therapy and within 1 month of its suspension in 21 patients (13 males and 8 females, mean age 43 +/- 16.5 years) diagnosed as having AIP between 2006 and 2008.

RESULTS

At clinical onset, fecal elastase 1 was 107 +/- 126 microg/g stool. Thirteen patients (62%) showed severe pancreatic insufficiency (<100 microg/g stool), 4 (19%) had mild insufficiency (100-200 microg/g stool), while 4 (19%) had normal pancreatic function (>200 microg/g stool). Before steroids, diabetes was diagnosed in 5 patients (24%), all of whom had very low levels of fecal elastase 1 (<19 microg/g stool). Following steroids, fecal elastase 1 increased in all patients (237 +/- 193 microg/g stool) and observed levels were significantly higher than those seen before steroids (p = 0.001).

CONCLUSIONS

Patients suffering from AIP display exocrine and/or endocrine pancreatic insufficiency at clinical onset. These insufficiencies improve after steroid therapy.

Survival rates and cause of death in 174 patients with chronic pancreatitis

BACKGROUND

The natural history after surgery for chronic pancreatitis is rarely reported.

METHODS

Between 1970 and 1999, 174 patients underwent surgery for chronic pancreatitis and were followed until December 2006. They were divided in four groups: (1) resection 62; (2) drainage 82; (3) external drainage 7; (4) non-pancreas-directed surgery 23. A second procedure was required by 25 patients and a third by four: group 1 = 6 + 0, group 2 = 10 + 2, group 3 = 3 + 1, group 4 = 6 + 1.

RESULTS

Hospital mortality was four of 174 (2.3%). Fifty-seven patients are alive; 49 of 170 developed cancer, and 38 died: lung (22), oral, pharynx, larynx (eight), esophagus, kidney, pancreas, colon, liver (two each), breast, stomach, mediastinum, prostate, melanoma, chronic myelogenous leukemia, squamous cancer of the auricle (one each), liver metastasis from unknown primary (two). Fifteen patients died of liver cirrhosis, 13 of myocardial infarction/decompensation, six of vascular problems, five each of acute renal insufficiency or cerebral diseases, four each of acute pancreatitis, accidental trauma, complications of diabetes, bronchopneumonia, and 19 of other causes. The overall 5-, 10-, 15-, 20-, 25-, and 30-year survival rate was 84.7, 65.6, 51.6, 38.0, 28.1, and 23.5.

CONCLUSIONS

Incidence of pancreatic cancer was 1.2%. The high incidence of smoking cancers (18.8%) is explained by the smoking habits of almost 100% of our patients. Eliminating smoking and increasing tests on organs at risk may prolong survival.

[Autoimmune pancreatitis]

Autoimmune pancreatitis is a rare form of chronic pancreatitis. Its clinical relevance, however, cannot be dismissed, as it can be difficult to distinguish autoimmune pancreatitis from malignant pancreatic cancer and in contrast with the majority of chronic pancreatitis forms it can be efficiently treated, even complete remission can be achieved on steroid therapy. The clinical picture of autoimmune pancreatitis is not characteristic, obstructive jaundice, abdominal pain, weight loss are frequently observed. Imaging studies often show diffuse pancreas enlargement and irregular narrowing of the main pancreatic duct. Elevated serum IgG4 immunoglobulin concentrations, some autoantibodies and the presence of IgG4 positive immune cells were observed in addition to other histological features. Apart from pancreatic manifestations, other organs may also be affected, thus associations with sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, Riedel thyroiditis and inflammatory bowel diseases have been described. Based on these findings, autoimmune pancreatitis should be regarded as a systemic disease, as a manifestation of systemic IgG4-related sclerosing disease.