Prevalence and clinical features of chronic pancreatitis in China: a retrospective multicenter analysis over 10 years

Management of chronic pancreatitis

Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.

Incidence, prevalence, and comorbidities of chronic pancreatitis: A 7-year population-based study

BACKGROUND

Chronic pancreatitis (CP) is a fibroinflammatory syndrome leading to reduced quality of life and shortened life expectancy. Population-based estimates of the incidence, prevalence, and comorbidities of CP in China are scarce.

AIM

To characterize the incidence, prevalence, and comorbidities of CP in Sichuan Province, China, with population-based data.

METHODS

Data on CP from 2015 to 2021 were obtained from the Health Information Center of Sichuan Province. During the study period, a total of 38090 individuals were diagnosed with CP in Sichuan Province. The yearly incidence rate and point prevalence rate (December 31, 2021) of CP were calculated. The prevalence of comorbid conditions in CP patients was estimated. The annual number of CP-related hospitalizations, hospital length of stay, and hospitalization costs for CP were evaluated. Yearly incidence rates were standardized for age by the direct method using the permanent population of Sichuan Province in the 2020 census as the standard population. An analysis of variance test for the linearity of scaled variables and the Cochran-Armitage trend test for categorical data were performed to investigate the yearly trends, and a two-sided test with P < 0.05 was considered statistically significant.

RESULTS

The 38090 CP patients comprised 23280 males and 14810 females. The mean age of patients at CP diagnosis was 57.83 years, with male patients (55.87 years) being younger than female patients (60.11 years) (P < 0.001). The mean incidence rate of CP during the study period was 6.81 per 100000 person-years, and the incidence of CP increased each year, from 4.03 per 100000 person-years in 2015 to 8.27 per 100000 person-years in 2021 (P < 0.001). The point prevalence rate of CP in 2021 was 45.52 per 100000 individuals for the total population, with rates of 55.04 per 100000 individuals for men and 35.78 per 100000 individuals for women (P < 0.001). Individuals aged 65 years or older had the highest prevalence of CP (113.38 per 100000 individuals) (P < 0.001). Diabetes (26.32%) was the most common comorbidity in CP patients. The number of CP-related hospitalizations increased from 3739 in 2015 to 11009 in 2021. The total costs for CP-related hospitalizations for CP patients over the study period were 667.96 million yuan, with an average of 17538 yuan per patient.

CONCLUSION

The yearly incidence of CP is increasing, and the overall CP hospitalization cost has increased by 1.4 times during the last 7 years, indicating that CP remains a heavy health burden.

Age-period-cohort analysis of pancreatitis epidemiological trends from 1990 to 2019 and forecasts for 2044: a systematic analysis from the Global Burden of Disease Study 2019

Objective

Pancreatitis poses a serious medical problem worldwide. This study aims to explore the epidemiological trends of pancreatitis from 1990 to 2019, analyze the association between disease burden and age, period and birth cohort, and subsequently present a forecast of pancreatitis incidence and deaths.

Methods

Epidemiologic data were gathered from the Global Health Data Exchange query tool. Joinpoint regression model was used to calculate the average annual percentage changes (AAPCs). Age-period-cohort analysis was utilized to estimate the independent effects of age, period and birth cohort. We also predicted the global epidemiological trends to 2044.

Results

Globally, the incident cases and deaths of pancreatitis increased 1.63-and 1.65-fold from 1990 to 2019, respectively. Joinpoint regression analysis showed that the age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) decreased over the past three decades. The age effect indicates that older people have higher age-specific incidence and death rates. The period effect on incidence and deaths showed downward trends from 1990 to 2019. The cohort effect demonstrated that incidence and death risk peaked in the earlier birth cohort and were lower in the latest birth cohort. Incident cases and deaths of pancreatitis may significantly increase in the next 25 years. The ASIRs were predicted to slightly increase, while the ASDRs were predicted to decrease.

Conclusion

Epidemiologic patterns and trends of pancreatitis across age, period and birth cohort may provide novel insight into public health. Limitations of alcohol use and prevention strategies for pancreatitis are necessary to reduce future burden.

Anxiety, depression, and coping styles among patients with chronic pancreatitis in East China

BACKGROUND

Anxiety and depression are common psychological comorbidities in patients with chronic pancreatitis (CP). There is still a lack of epidemiological studies on anxiety and depression in Chinese CP patients. This study aimed to identify the incidence and related factor of anxiety and depression among East Chinese CP patients and explore the relationship between anxiety, depression, and coping styles.

METHODS

This prospective observational study was conducted from June 1, 2019 to March 31, 2021 in Shanghai, China. Patient diagnosed with CP were interviewed using the sociodemographic and clinical characteristics questionnaire, Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Coping Style Questionnaire (CSQ). Multivariate logistic regression analysis was conducted to identify the related factors of anxiety and depression. Correlation test was preformed to analyze the correlation between anxiety, depression, and coping styles.

RESULTS

The incidence of anxiety and depression in East Chinese CP patients was 22.64% and 38.61%, respectively. Patients' previous health status, level of disease coping, frequency of abdominal pain episodes, and pain severity were significantly associated with anxiety and depression. Mature coping styles (Problem solving, Seeking for help) had a positive impact on anxiety and depression, while immature coping styles (Self-blame, Fantasy, Repression, Rationalization) had negative effects on anxiety and depression.

CONCLUSION

Anxiety and depression were common in patients with CP in China. The factors identified in this study may provide references for the management of anxiety and depression in CP patients.

Immune cells and immune cell-targeted therapy in chronic pancreatitis

In recent years, studies have attempted to understand the immune cells and mechanisms underlying the pathogenesis of chronic pancreatitis (CP) by constructing a model of CP. Based on these studies, the innate immune response is a key factor in disease pathogenesis and inflammation severity. Novel mechanisms of crosstalk between immune and non-immune pancreatic cells, such as pancreatic stellate cells (PSC), have also been explored. Immune cells, immune responses, and signaling pathways in CP are important factors in the development and progression of pancreatitis. Based on these mechanisms, targeted therapy may provide a feasible scheme to stop or reverse the progression of the disease in the future and provide a new direction for the treatment of CP. This review summarizes the recent advances in research on immune mechanisms in CP and the new advances in treatment based on these mechanisms.

Natural History, Clinical Characteristics, and Outcomes in Idiopathic Chronic Pancreatitis

Background and Aims

Chronic pancreatitis (CP) is a fibroinflammatory syndrome of the pancreas associated with pain and poor quality of life. It has toxic and genetic risk factors but can also be idiopathic. The natural history of idiopathic CP (ICP) is not well-known. Therefore, we studied clinical characteristics and outcomes of these patients followed in our Pancreas Center.

Methods

Review of CP patients between January 1, 2016, and April 30, 2021. Patients were divided into 2 groups based on diagnosis, ICP vs non-ICP. CP patients with a smoking history were placed in the non-ICP group. Statistical analysis was performed to identify differences in demographics, comorbidities, complications, controlled medications, and resource utilization.

Results

Out of 450 patients, 101 (22%) were diagnosed with ICP and 349 (78%) were non-ICP. ICP patients were mainly female (59.4% vs 40.5%; P = .005), had less comorbid anxiety (10.5% vs 22.1%; P = .002), depression (24.2% vs 35.8%; P < .001), disability (13% vs 16.3%; P = .021), exocrine pancreatic insufficiency (45.3% vs 62.6%; P = .004), splanchnic vein thrombosis (1.04% vs 14.9%; P < .001), pseudocysts (16.7% vs 41.6%; P < .001), and biliary obstruction (3.12% vs 19.2%; P < .001). They underwent less abdominal imaging (2.63 vs 3.42; P = .048) and endoscopic retrograde cholangiopancreatography (0.88 vs 1.32; P = .030). They also had less opioid use (29.6% vs 54.4%; P < .001), gabapentinoid use (34% vs 52.3%; P = .002), and celiac blocks (7.22% vs 16.1%; P < .041).

Conclusion

Our study demonstrates that the clinical course of ICP is less morbid compared to non-ICP. This study specifically removes smoking, a significant risk factor for CP, to study a truly idiopathic cohort.

Identification of novel factors that affect the onset of idiopathic chronic pancreatitis: The role for microRNA-323b-5p

BACKGROUND

The c.194+2 T>C variant of serine protease inhibitor Kazal type 1 (SPINK1) is a known genetic risk factor found in Chinese patients with idiopathic chronic pancreatitis (ICP), but the early-onset mechanisms of ICP are still unclear.

METHODS

Complementary experimental approaches were used to pursue other potential pathologies in the present study. The serum level of SPINK1 of ICP patients in the Han population in China was detected and verified by an enzyme-linked immunosorbent assay. Next, differentially expressed proteins and microRNAs from plasma samples of early-onset and late-onset ICP patients were screened by proteomic analysis and microarray, respectively.

RESULTS

Combined with these advanced methods, the data strongly suggest that the regulatory effects of microRNAs were involved in the early-onset mechanism of the ICP by in vitro experiments. There was no significant difference in the plasma SPINK1 expression between the early-onset ICP and the late-onset patients. However, the expression of plasma glutathione peroxidase (GPx3) in early-onset ICP patients was markedly lower than that in late-onset ICP patients, although the level of hsa-miR-323b-5p was lower in late-onset patients compared to the early-onset ICP group. In vitro experiments confirmed that hsa-miR-323b-5p could increase apoptosis in caerulein-treated pancreatic acinar cells and inhibit the expression of GPx3.

CONCLUSIONS

The up-regulated hsa-miR-323b-5p might play a crucial role in the early-onset mechanisms of ICP by diminishing the antioxidant activity through the down-regulation of GPx3.

Chronic Pancreatitis and Risk of Atherosclerotic Cardiovascular Disease: A US Cohort Propensity-Matched Study

OBJECTIVES

Worldwide prevalence of chronic pancreatitis (CP) has risen in recent years, with data suggesting an increased risk of atherosclerotic cardiovascular disease (ASCVD) in these patients. We assessed the incidence and risk of ASCVD in patients with CP.

METHODS

We compared the risk of ischemic heart disease, cerebrovascular accident, and peripheral arterial disease between CP and non-CP cohorts after propensity matching of known risk factors of ASCVD using TriNetX, a multi-institutional database. We also evaluated the risk of outcomes of ischemic heart disease including acute coronary syndrome, heart failure, cardiac arrest, and all-cause mortality between CP and non-CP cohorts.

RESULTS

Chronic pancreatitis cohort was also found to have an increased risk of ischemic heart disease (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.03-1.12), cerebrovascular accident (aOR, 1.12; 95% CI, 1.05-1.20), and peripheral arterial disease (aOR, 1.17; 95% CI, 1.1-1.24). Chronic pancreatitis patients with ischemic heart disease were also found to have an increased risk of acute coronary syndrome (aOR, 1.16; 95% CI, 1.04-1.30), cardiac arrest (aOR, 1.24; 95% CI, 1.01-1.53), and mortality (aOR, 1.60; 95% CI, 1.45-1.77).

CONCLUSIONS

Chronic pancreatitis patients are at a higher risk of ASCVD when compared with the general population, matched for confounding etiological, pharmacological, and comorbid variables.

Post-ERCP pancreatitis occurs more frequently in self-expandable metallic stents than multiple plastic stents on benign biliary strictures: a meta-analysis

BACKGROUND

The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes.

CONCLUSIONS

Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement.

METHODS

A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity.

RESULTS

Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, p = .64; and OR = 2.3, 95%CI: 0.68-7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, p = .07).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.

Epidemiology and Characteristics of Chronic Pancreatitis-Do the East and West Meet?

Background and Aims

Previous large studies on the epidemiology and clinical profile of chronic pancreatitis have suggested significant differences in presentation and management in the eastern and western hemispheres. The aim of this systematic review was to compare large multicenter studies across different geographic regions of the world to detect meaningful differences in the presentation and management of this poorly understood disease.

Methods

We identified 237 manuscripts through a comprehensive literature review aiming to identify multicenter studies enrolling more than 200 patients to limit reporting biases. After rigorous screening, 12 studies were included for the final analysis. The Asian studies were included in the eastern cohort, and the European and American studies were included in the western cohort. Reported demographics, risk factors, etiologies, clinical presentation, complications, and management strategies were then compared.

Results

We found similar demographics across both cohorts including age, prevalence among gender, and predominant etiology. Clinical manifestations including pain, pancreatic calcifications, and diabetes were similar between both cohorts although pseudocysts, pancreatic cancer, and strictures were more common in the west. Notably opioids and surgical/endotherapy management were more common in the west as well.

Conclusion

Chronic pancreatitis is a protracted disease affecting predominantly middle-aged people, leading to a decreased quality of life. Chronic pancreatitis now appears to have a fairly similar clinical profile and natural history in the east and west. There is notable variability in management. We hope that international collaboration may identify common targets for research which could lead to significant advances in the understanding and management of chronic pancreatitis.

Prodromal Signs and Symptoms of Chronic Pancreatitis: A Systematic Review

GOAL

We aimed to extract the percent of signs and symptoms at the time of diagnosis from published studies and to pool these using meta-analytic techniques.

BACKGROUND

Delayed or misdiagnosis of chronic pancreatitis may occur because the signs and symptoms are nonspecific and varied.

STUDY

We performed a systematic review of studies reporting the signs and symptoms of chronic pancreatitis at diagnosis. The percentage of patients with each sign and symptom was extracted and random-effects meta-analyses used to calculate pooled percentages.

RESULTS

In total, 22 observational studies were included. Across 14 studies, 55% of chronic pancreatitis patients were classified as having alcoholic etiology. Abdominal pain was the most common symptom (76%), and weight loss was reported in 22% of patients. Jaundice occurred in 11% of patients and steatorrhoea in 3%. Half of the patients had a history of acute pancreatitis, and 28% had diabetes mellitus at diagnosis. Heterogeneity between the studies was high for all signs and symptoms.

CONCLUSIONS

This research has identified some common features of patients with chronic pancreatitis, but the high heterogeneity makes it difficult to draw solid conclusions. Carefully designed studies to examine the signs and symptoms leading up to a diagnosis of chronic pancreatitis, and common combinations, are required. These would enable the development of a tool to aid in the early identification of chronic pancreatitis in the primary care setting, with potential for improved short-term and long-term outcomes for patients.

[Chronic pancreatitis: update diagnostic and therapeutic concepts]

INTRODUCTION

Chronic pancreatitis (CP) is a frequent cause for hospitalization and is associated with impaired quality of life and reduced overall survival. The German Society for Gastroenterology (DGVS) has recently completed the S3-Guideline "Pancreatitis" that summarizes key findings on epidemiology, diagnostic and therapeutic concepts for acute and chronic pancreatitis. Here, we recapitulate the most relevant findings for clinicians regarding CP.

RESULTS

The most common cause of CP is chronic alcohol abuse, other causes are hereditary pancreatitis, autoimmune pancreatitis, hyperparathyroidism and idiopathic forms. Apart from the classical hereditary pancreatitis (PRSS1 mutation), a number of genetic associations have been discovered over the last years that are associated with an increased risk to develop idiopathic CP. The conservative management of CP is focused on the appropriate management of exocrine and endocrine insufficiency, and the prevention and treatment of secondary complications such as osteoporosis, vitamin deficiencies and malnutrition. Local complications (bile duct stenosis, duodenal stenosis, pseudocysts and chronic pain) should be managed in multidisciplinary teams in specialized pancreas centres with expert surgeons, radiologists and gastroenterologists. Infected or symptomatic pseudocysts should be primarily addressed by endoscopic drainage. In contrast, patients with chronic pain, dilated pancreas duct and opioid use should be considered for early surgical intervention.

CONCLUSION

Chronic pancreatitis is associated with increased morbidity and mortality and often leads to hospital admissions. The clinical management of complex patients with local complications requires an interdisciplinary approach to tailor available therapeutic modalities depending on the stage of the disease and pre-existing comorbidities.

Relationship between pancreatic parenchyma loss and early postoperative hyperglycemia in patients with benign pancreatic diseases

Objective

To evaluate the relationship between pancreatic parenchyma loss and early postoperative hyperglycemia in patients with benign pancreatic diseases.

Methods

A total of 171 patients with benign pancreatic tumors or chronic pancreatitis, whose preoperative fasting blood glucose (FBG) was normal and who underwent partial pancreatectomy were reviewed. The pancreatic volume was measured by CT imaging before and after the operation. According to their different pancreatic resection volume (PRV), 171 patients were divided into five groups: < 30%, 30%–39%, 40%–49%, 50%–59%, and ≥ 60%. The correlation between the PRV and postoperative FBG was investigated. According to the postoperative FBG value, the patients were divided into a hyperglycemia group (HG) and nonhyperglycemia group (non-HG) to explore the best cutoff value of the PRV between the two groups.

Results

There were significant differences in the postoperative FBG among the five groups (PRV < 30%, 30%–39%, 40%–49%, 50%–59%, and ≥ 60%). The PRV was positively correlated with postoperative FBG in the benign tumor group and chronic pancreatitis group (R = 0.727 and 0.651, respectively). ROC curve analysis showed that the best cutoff value of the PRV between the HG (n = 84) and non-HG (n = 87) was 39.95% with an AUC = 0.898; the sensitivity was 89.29%, and the specificity was 82.76%.

Conclusion

There was a linear positive correlation between the postoperative FBG level and PRV. Patients with a PRV ≥ 40% are more likely to develop early postoperative hyperglycemia.

Molecular mechanisms of pancreatic myofibroblast activation in chronic pancreatitis and pancreatic ductal adenocarcinoma

Pancreatic fibrosis (PF) is an essential component of the pathobiology of chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC). Activated pancreatic myofibroblasts (PMFs) are crucial for the deposition of the extracellular matrix, and fibrotic reaction in response to sustained signaling. Consequently, understanding of the molecular mechanisms of PMF activation is not only critical for understanding CP and PDAC biology but is also a fertile area of research for the development of novel therapeutic strategies for pancreatic pathologies. This review analyzes the key signaling events that drive PMF activation including, initiating signals from transforming growth factor-β1, platelet derived growth factor, as well as other microenvironmental cues, like hypoxia and extracellular matrix rigidity. Further, we discussed the intracellular signal events contributing to PMF activation, and crosstalk with different components of tumor microenvironment. Additionally, association of epidemiologically established risk factors for CP and PDAC, like alcohol intake, tobacco exposure, and metabolic factors with PMF activation, is discussed to comprehend the role of lifestyle factors on pancreatic pathologies. Overall, this analysis provides insight into the biology of PMF activation and highlights salient features of this process, which offer promising therapeutic targets.

Endoscopic versus Surgical Intervention for Painful Obstructive Chronic Pancreatitis: A Systematic Review and Meta-Analysis

There is limited evidence on the standard care for painful obstructive chronic pancreatitis (CP), while comparisons of endoscopic and surgical modes for pain relief have yielded conflicting results from small sample sizes. We aimed to obtain a clear picture of the matter by a meta-analysis of these results. We searched the Pubmed, Embase, and Cochrane Library databases to identify studies comparing endoscopic and surgical treatments for painful obstructive CP. Pooled effects were calculated by the random effect model. Primary outcomes were overall pain relief (complete and partial), and secondary outcomes were complete and partial pain relief, complication rate, hospitalization duration, and endocrine insufficiency. Seven studies with 570 patients were included in the final analysis. Surgical drainage was associated with superior overall pain relief [OR 0.33, 95% CI 0.23–0.47, p < 0.001, I² = 4%] and lesser incidence of endocrine insufficiency [OR 2.10, 95% CI 1.20–3.67, p = 0.01, I² = 0%], but no significant difference in the subgroup of complete [OR 0.57, 95% CI 0.32–1.01, p = 0.054, I² = 0%] or partial [OR 0.67, 95% CI 0.37–1.22, p = 0.19, I² = 0%] pain relief, complication rates [OR 1.00, 95% CI 0.41–2.46, p = 0.99, I² = 49%], and hospital stay [OR −0.54, 95% CI −1.23–0.15, p = 0.13, I² = 87%] was found. Surgery is associated with significantly better overall pain relief and lesser endocrine insufficiency in patients with painful obstructive CP. However, considering the invasiveness of surgery, no significant differences in complete or partial pain relief, and heterogeneity of a few parameters between two groups, endoscopic drainage may be firstly performed and surgical drainage may be considered when endoscopic drainage fails.

Disordered Gut Microbiota in Children Who Have Chronic Pancreatitis and Different Functional Gene Mutations

Chronic pancreatitis (CP) is a serious condition whose pathogenic mechanism is unclear. Interactions of host genetic factors with gut microbiota have a role, but little is known, especially in children with CP (CCP), in which the external factors are less important. Our objective was to identify the main gut microbiota genera in CCP and to characterize the functional mutations of these patients.

Swedish national guidelines for chronic pancreatitis

Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.

Risk factors for development of endocrine insufficiency in chronic pancreatitis

Endocrine insufficiency is a common and frequent complication of chronic pancreatitis. Identifying the role of pancreatic damage in the development of diabetes is important for early identification and appropriate management.

METHODS

All consecutive CP patients between January 2019 and May 2020 were retrospectively studied. Relevant statistical tests were performed. A two sided p value < 0.05 was considered statistically significant.

RESULTS

Total 587 chronic pancreatitis patients were included of which 118 (20.1%) patients developed diabetes with duration of 12 (IQR 4-48) months. Older age (OR 1.079; 95% CI 1.045-1.113; p < 0.001), presence of pancreatic parenchymal (OR 2.284; 95% CI 1.036-5.038; p = 0.041) and ductal (OR 2.351; 95% CI 1.062-5.207; p = 0.035) calcifications, exocrine insufficiency (OR 6.287; 95% CI 2.258-17.504; p < 0.001), and pancreatic duct stricture (OR 3.358; 95% CI 1.138-9.912; p = 0.028) were independently associated with development of diabetes mellitus in chronic pancreatitis patients. On cox-regression analysis, smoking (HR 2.370; 95% CI 1.290-4.354; p = 0.005) and pancreatic ductal calcification (HR 2.033; 95% CI 1.286-3.212; p = 0.002) were independently associated with earlier onset of diabetes mellitus in patients with chronic pancreatitis.

CONCLUSION

Pancreatic calcification, pancreatic duct stricture and pancreatic exocrine insufficiency are associated with development of diabetes mellitus in chronic pancreatitis indicating disease progression. Smoking is the modifiable risk factors associated with early onset of diabetes mellitus in CP patients.

Outcomes of pain management in chronic pancreatitis: experience from a tertiary care hospital in India

OBJECTIVES

Chronic pancreatitis (CP) is a progressive inflammatory disorder that leads to irreversible destruction of exocrine and endocrine parenchyma. Little is known about outcomes of CP in the Indian subcontinent. We aim to study the treatment outcomes of CP in terms of pain severity in a tertiary hospital in India.

MATERIAL AND METHODS

This is a prospective cohort study of 75 patients diagnosed with CP. Data regarding patient demographics, symptoms, and imaging findings were recorded. Pain severity was recorded objectively by the visual analogue scale (VAS). Cambridge score was calculated, and patients were classified into mild, moderate and severe categories. Patients were treated appropriately, and pain scores were monitored at 3 months and 6 months after initial visit.

RESULTS

Alcohol was the most common etiology (54%) followed by idiopathic/unknown causes (34%). Cambridge score or morphology on imaging did not affect pain severity (p>0.05). History of smoking and larger duct diameter decreased the effectiveness of treatment in reducing pain while higher post prandial sugar levels increased effectiveness (p<0.05). Pain relief did not differ between the treatment groups including analgesics, endoscopic or surgery (p>0.05).

CONCLUSION

CP presents earlier in the Indian population and represents a unique population with a greater proportion of idiopathic cases than western countries. Rather than pancreatic morphology or Cambridge score alone, a combination of morphology, pain severity and functional status can be utilized for formulating an individualized treatment plan. Present treatment strategies prove effective in treatment of CP.

Risk factors for the concomitant occurrence of alcoholic chronic pancreatitis and alcoholic liver cirrhosis: a 10-years cohort study at a tertiary hospital in China

OBJECTIVE

Concomitant occurrence of alcoholic chronic pancreatitis (ACP) and alcoholic liver cirrhosis (ALC) is rare with few reported cases. The present study aimed to identify the potential risk factors of chronic pancreatitis (CP) and liver cirrhosis (LC) in ALC patients and ACP patients, respectively.

METHODS

A retrospective analysis was performed on 536 patients with CP and 647 ALC patients without CP (Group A). Among the 536 CP patients, 213 ACP cases were divided into two groups: ACP with LC (Group B, n = 52) and ACP without LC (Group C, n = 161). A comparison between Group A and B was carried out to identify the potential risk factors of CP in ALC patients, while Group B and C were compared to determine the independent risk factors of LC in ACP patients.

RESULTS

Concomitant occurrence of ACP and ALC accounted for 24.4% (52/213) in this cohort. Significant risk factors for CP in ALC patients included smoking [odds ratio (OR), 2.557; 95% confidence interval (CI): 1.531-5.489; P = 0.003] and multiple bouts of acute pancreatitis (OR, 4.813; 95% CI: 3.625-12.971; P < 0.001). Hepatitis B virus (HBV) infection (OR, 4.237; 95% CI: 1.742-7.629; P = 0.012) was the only independent risk factor associated with LC in ACP patients.

CONCLUSION

HBV infection exacerbated liver damage in ACP patients. Alcoholic patients who smoked and suffered from ongoing bouts of acute pancreatitis are prone to develop CP.

Role of the Immune System and the Circadian Rhythm in the Pathogenesis of Chronic Pancreatitis: Establishing a Personalized Signature for Improving the Effect of Immunotherapies for Chronic Pancreatitis

Pancreatitis, in both acute and chronic forms, poses a major therapeutic challenge and is associated with great morbidity and several complications. The nature of pancreatic injury in chronic pancreatitis (CP) and the wide range of causative processes that lead to CP have made effective therapy a true unmet need. Multiple physiological, genetic, environmental, and behavioral factors contribute to the development of CP. As a result, several fields of research are aimed at identifying and addressing the factors that contribute to pancreatic injury. In this article, we review the current understanding of the pathogenesis and natural history of CP. We focus on the autonomous nervous system, immune system, and role of a chronobiological therapeutic approach to alleviate symptoms and prevent or reverse pancreatic injury associated with CP. We aim to demonstrate that individualizing chronopharmacological treatments for CP is a promising direction for future treatment using immune, nervous, and circadian systems.

Chronic pancreatitis

Chronic pancreatitis is a multifactorial, fibroinflammatory syndrome in which repetitive episodes of pancreatic inflammation lead to extensive fibrotic tissue replacement, resulting in chronic pain, exocrine and endocrine pancreatic insufficiency, reduced quality of life, and a shorter life expectancy. The incidence and prevalence of chronic pancreatitis is rising and no curative treatment is available. Using novel diagnostic algorithms, definitive chronic pancreatitis can be diagnosed by imaging criteria alone, whereas probable chronic pancreatitis requires clinical features and imaging criteria. Criteria for the diagnosis of early chronic pancreatitis are still under discussion and need prospective validation in clinical trials. Cross-sectional imaging should be used first; endoscopic ultrasound is needed only when CT or MRI are inconclusive or to plan therapeutic interventions. Management of chronic pancreatitis requires an interdisciplinary approach including primary care practitioners, gastroenterologists, surgeons, radiologists, pain specialists, and nutritional therapists. Patients with chronic pancreatitis should be seen at least once a year and re-evaluated for causal risk factors, symptom control, and complications such as malnutrition, pancreatic exocrine insufficiency, and diabetes; refer to a specialised centre if symptoms are poorly controlled or there is risk of deterioration. Scoring systems to monitor disease progression have been developed and validated internationally. Interventional treatments for pain or cholestasis should be done by specialists only, and early discussion of treatment approaches should include all medical disciplines involved in care. Throughout this Seminar, we address research needs such as staging of pancreatitis, aspects of malnutrition and pain, and cancer surveillance, to help improve the care of patients.

Five-year mortality trends associated with chronic pancreatitis in South Korea: A population based cohort study

BACKGROUND

Chronic pancreatitis (CP) is associated with all-cause and cancer-related mortality; however, the risk of mortality associated with alcoholic and non-alcoholic CP remains controversial. This study investigated whether CP increased the risk of 5-year all-cause and cancer-specific mortality compared to a control population.

METHODS

This population-based study used data from a sample cohort of the National Health Insurance Service (NHIS) database in South Korea. CP was defined as disease code K86.0 (alcohol-induced CP) and K86.1 (other CP and non-alcoholic CP) from the tenth edition of the International Classification of Diseases.

RESULTS

The prevalence of chronic alcoholic pancreatitis increased from 0.01% in 2002 to 0.07% in 2015, and the prevalence of chronic non-alcoholic pancreatitis increased from 0.08% in 2002 to 0.50% in 2015. In the 2010 NHIS cohort (n = 826,909), CP was associated with an increased risk of 5-year all-cause mortality (hazard ratio [HR] = 1.25, 95% confidence interval [CI]: 1.25 to 1.66, P < 0.001). Additionally, non-alcoholic CP was associated with an increased risk of 5-year all-cause mortality (HR = 1.47, 95% CI: 1.27 to 1.71, P < 0.001); in contrast, alcohol-induced CP was not significantly associated with mortality risk (P = 0.569). Similar tendencies were observed for the 5-year cancer-related mortality risk.

CONCLUSIONS

In South Korea, the prevalence of alcoholic and non-alcoholic CP increased during 2002-2015. CP may be an independent risk factor for 5-year all-cause and cancer-related mortality. In this study, this association was more evident in patients with non-alcoholic CP.

Risk of head and neck cancer after chronic pancreatitis

Background

To evaluate the relation of head and neck cancer to chronic pancreatitis by analyzing Taiwan’s National Health Insurance Research Database.

Methods

We identified 11,237 patients with chronic pancreatitis as the case cohort, which was propensity score matched with another 11,237 patients without chronic pancreatitis by sex, age, index year, and comorbidities. We followed both cohorts between January 1, 2000, and December 31, 2011 to measure the incidence of head and neck cancer.

Results

Compared with patients without chronic pancreatitis, those with chronic pancreatitis were associated a greater risk of head and neck cancer [adjusted HR (aHR) =1.31, 95% confidence interval (CI): 1.07–1.60] and had a higher incidence of head and neck cancer (log-rank test, P<0.001). The experimental event rate of head and neck cancer for the chronic pancreatitis cohort was 1.90% (213/11,237) and control event rate of head and neck cancer for the non-chronic pancreatitis cohort was 1.60% (180/11,237), respectively. Therefore, the chronic pancreatitis cohort had a 0.30% of absolute risk increase and approximately 333 of number needed to harm for the development of head and neck cancer, respectively. Compared with the individuals without chronic pancreatitis and any other comorbidity, the risk of head and neck cancer for the chronic pancreatitis patients without comorbidities was 2.79 folds and the risk increased to 4.32, 3.33, 3.22, 4.44, and 5.78 folds in the presence of any one, any two, any three, any four, and more than five comorbidities, respectively.

Conclusions

Chronic pancreatitis is related to an increased risk of head and neck cancer, and the presence of comorbidity increases the risk more. It requires more studies to find more co-existing risk factors or comorbidities to recommend a screening program for the CP patients. Moreover, it needs more studies to ascertain the pathogenesis for the aforementioned association and the limited knowledge of the patients' smoking habits and alcohol drinking is the major limitation of this observational study.

The Role of Endoscopic and Surgical Treatment in Chronic Pancreatitis

Chronic pancreatitis is a long-term illness leading to hospital admissions and readmission. This disease is often caused by heavy alcohol consumption and smoking. Patients with chronic pancreatitis suffer from acute or chronic pain episodes, recurrent pancreatitis, and complications, such as pseudocysts, biliary duct strictures, and pancreatic duct fistulas. Pancreatic duct strictures and stones may increase intraductal pressure and cause pain. Endoscopic therapy is aiming at decompressing the pressure and relieving the pain, most commonly with pancreatic duct stents and pancreatic duct stone retrieval. Early surgery is another option to treat the pain. In addition, endotherapy has been successful in treating complications related to chronic pancreatitis. The therapy should be individually chosen in a multidisciplinary meeting. Endoscopic therapy and surgery as treatment options for chronic pancreatitis are discussed in this review.

Period prevalence of chronic pancreatitis diagnosis from 2001-2013 in the commercially insured population of the United States

BACKGROUND

Prevalence estimates of chronic pancreatitis (CP) in the US are scarce. We aimed to determine the prevalence of CP in the commercially insured population of the US.

METHODS

We analyzed the IQVIA Legacy PharMetrics database to calculate the period prevalence of CP from 2001 to 2013 among individuals with ≥1 year of enrollment. CP was defined as ≥1 healthcare contacts associated with a non-ancillary claim for a primary diagnosis of CP (ICD-9-CM 577.1). Prevalence estimates were age- and sex- adjusted to the 2010 US population. Sensitivity analysis was performed by using more stringent criteria: a) 1 claim of CP + [≥1 claims of acute pancreatitis (AP), CP or pancreatic cyst/pseudocyst]; b) 1 claim of CP + [≥1 claims for AP, CP or pancreatic cyst/pseudocyst in ≥3 months before or after the index CP claim]; c) ≥2 claims for CP; and d) ≥2 claims for CP separated by ≥ 6 months.

RESULTS

Of 48.67 million eligible enrollees, 37,061 received the diagnosis of CP (mean age, 51.2 ± 15.2 years; 49% male). The age- and sex- adjusted period prevalence of CP per 100,000 was 73.4 (95% CI, 72.6-74.1), 98.7 (95% CI, 97.7-99.7) for adults and 8.3 (95% CI, 7.8-8.8) for children. Prevalence of CP was slightly higher in males (sex ratio, 1.05) and highest in the age group of 46-55 years (135/100,000). On sensitivity analysis, the prevalence of CP per 100,000 decreased to 60.2, 39.7, 38.8, and 18.8 with each of the alternative definitions.

CONCLUSION

Prevalence estimates reported in our study provide an insight into the population burden of CP in the US.

Practical guide to the management of chronic pancreatitis

Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.

Benign biliary strictures: prevalence, impact, and management strategies

Benign biliary strictures (BBSs) may form from chronic inflammatory pancreaticobiliary pathologies, postoperative bile-duct injury, or at biliary anastomoses following liver transplantation. Treatment aims to relieve symptoms of biliary obstruction, maintain long-term drainage, and preserve liver function. Endoscopic therapy, including stricture dilatation and stenting, is effective in most cases and the first-line treatment of BBS. Radiological and surgical therapies are reserved for patients whose strictures are refractory to endoscopic interventions. Response to treatment is dependent upon the technique and accessories used, as well as stricture etiology. In this review, we discuss the various BBS etiologies and their management strategies.

Risk factors and prediction score for chronic pancreatitis: A nationwide population-based cohort study

AIM

To explore the risk factors of developing chronic pancreatitis (CP) in patients with acute pancreatitis (AP) and develop a prediction score for CP.

METHODS

Using the National Health Insurance Research Database in Taiwan, we obtained large, population-based data of 5971 eligible patients diagnosed with AP from 2000 to 2013. After excluding patients with obstructive pancreatitis and biliary pancreatitis and those with a follow-up period of less than 1 year, we conducted a multivariate analysis using the data of 3739 patients to identify the risk factors of CP and subsequently develop a scoring system that could predict the development of CP in patients with AP. In addition, we validated the scoring system using a validation cohort.

RESULTS

Among the study subjects, 142 patients (12.98%) developed CP among patients with RAP. On the other hand, only 32 patients (1.21%) developed CP among patients with only one episode of AP. The multivariate analysis revealed that the presence of recurrent AP (RAP), alcoholism, smoking habit, and age of onset of < 55 years were the four important risk factors for CP. We developed a scoring system (risk score 1 and risk score 2) from the derivation cohort by classifying the patients into low-risk, moderate-risk, and high-risk categories based on similar magnitudes of hazard and validated the performance using another validation cohort. Using the prediction score model, the area under the curve (AUC) [95% confidence interval (CI)] in predicting the 5-year CP incidence in risk score 1 (without the number of AP episodes) was 0.83 (0.79, 0.87), whereas the AUC (95%CI) in risk score 2 (including the number of AP episodes) was 0.84 (0.80, 0.88). This result demonstrated that the risk score 2 has somewhat better prediction performance than risk score 1. However, both of them had similar performance between the derivation and validation cohorts.

CONCLUSION

In the study,we identified the risk factors of CP and developed a prediction score model for CP.

Identification of risk factors for pancreatic pseudocysts formation, intervention and recurrence: a 15-year retrospective analysis in a tertiary hospital in China

BACKGROUND

Pancreatic pseudocyst (PPC) is a common complication of acute and chronic pancreatitis. To our knowledge no study has systematically reported the risk factors for the formation, intervention and recurrence of PPC. Therefore, the present study aimed to investigate the potential risk factors for PPC, with regards to its formation, intervention and recurrence.

METHODS

A database containing 5106 pancreatitis patients was retrospectively analyzed. As a result, a total of 4379 eligible patients were identified and divided into 2 groups: PPC group (group A, n = 759) and non-PPC group (group B, n = 3620). The PPC group was subdivided into 2 groups: intervention PPC (group C, n = 347) and resolution PPC (group D, n = 412). The differences in surgical complication and recurrence rates were compared among 347 PPC patients receiving different interventions, including surgical, endoscopic and percutaneous drainages. Furthermore, group C was subdivided into 2 groups: recurrent PPC (group E, n = 34) and non-recurrent PPC (group F, n = 313). All possible risk factors for PPC formation, intervention and recurrence were determined by multivariate regression analysis.

RESULTS

In this study, PPC was developed in 17.3% (759/4379) of pancreatitis patients. The significant risk factors for PPC formation included alcoholic pancreatitis (OR, 6.332; 95% CI, 2.164-11.628; p = 0.031), chronic pancreatitis (CP) (OR, 5.822; 95% CI, 1.921-10.723; p = 0.006) and infected pancreatic necrosis (OR, 4.253; 95% CI, 3.574-7.339; p = 0.021). Meanwhile, the significant risk factors of PPC patients who received intervention were alcoholic pancreatitis (OR, 7.634; 95% CI, 2.125-13.558; p = 0.016), size over 6 cm (OR, 8.834; 95% CI, 2.017-16.649; p = 0.002) and CP (OR, 4.782; 95% CI, 1.897-10.173; p = 0.038). In addition, the recurrence rate in PPC patients treated with percutaneous drainage was found to be the highest (16.3%) among the three intervention groups. Furthermore, percutaneous drainage was the only risk factor of PPC recurrence (OR, 7.812; 95% CI, 3.109-23.072; p = 0.013) identified from this retrospective cohort study.

CONCLUSIONS

Alcoholic pancreatitis and CP are the main risk factors for PPC formation and intervention, but not PPC recurrence. A higher recurrence rate is found in PPC patients treated with percutaneous drainage, as compared to endoscopic and surgical interventions.

Metabolic and lifestyle risk factors for acute pancreatitis in Chinese adults: A prospective cohort study of 0.5 million people

BACKGROUND

Little prospective evidence exists about risk factors and prognosis of acute pancreatitis in China. We examined the associations of certain metabolic and lifestyle factors with risk of acute pancreatitis in Chinese adults.

METHODS AND FINDINGS

The prospective China Kadoorie Biobank (CKB) recruited 512,891 adults aged 30 to 79 years from 5 urban and 5 rural areas between 25 June 2004 and 15 July 2008. During 9.2 years of follow-up (to 1 January 2015), 1,079 cases of acute pancreatitis were recorded. Cox regression was used to estimate adjusted hazard ratios (HRs) for acute pancreatitis associated with various metabolic and lifestyle factors among all or male (for smoking and alcohol drinking) participants. Overall, the mean waist circumference (WC) was 82.1 cm (SD 9.8) cm in men and 79.0 cm (SD 9.5) cm in women, 6% had diabetes, and 6% had gallbladder disease at baseline. WC was positively associated with risk of acute pancreatitis, with an adjusted HR of 1.35 (95% CI 1.27-1.43; p < 0.001) per 1-SD-higher WC. Individuals with diabetes or gallbladder disease had HRs of 1.34 (1.07-1.69; p = 0.01) and 2.42 (2.03-2.88; p < 0.001), respectively. Physical activity was inversely associated with risk of acute pancreatitis, with each 4 metabolic equivalent of task (MET) hours per day (MET-h/day) higher physical activity associated with an adjusted HR of 0.95 (0.91-0.99; p = 0.03). Compared with those without any metabolic risk factors (i.e., obesity, diabetes, gallbladder disease, and physical inactivity), the HRs of acute pancreatitis for those with 1, 2, or ≥3 risk factors were 1.61 (1.47-1.76), 2.36 (2.01-2.78), and 3.41 (2.46-4.72), respectively (p < 0.001). Among men, heavy alcohol drinkers (≥420 g/week) had an HR of 1.52 (1.11-2.09; p = 0.04, compared with abstainers), and current regular smokers had an HR of 1.45 (1.28-1.64; p = 0.02, compared with never smokers). Following a diagnosis of acute pancreatitis, there were higher risks of pancreatic cancer (HR = 8.26 [3.42-19.98]; p < 0.001; 13 pancreatic cancer cases) and death (1.53 [1.17-2.01]; p = 0.002; 89 deaths). Other diseases of the pancreas had similar risk factor profiles and prognosis to acute pancreatitis. The main study limitations are ascertainment of pancreatitis using hospital records and residual confounding.

CONCLUSIONS

In this relatively lean Chinese population, several modifiable metabolic and lifestyle factors were associated with higher risks of acute pancreatitis, and individuals with acute pancreatitis had higher risks of pancreatic cancer and death.

The different course of alcoholic and idiopathic chronic pancreatitis: A long-term study of 2,037 patients

Background

Chronic pancreatitis (CP) is a chronic inflammatory disease of the pancreas. This study aimed to compare the natural course of alcoholic chronic pancreatitis (ACP) and idiopathic chronic pancreatitis (ICP).

Methods

CP patients admitted to our center from January 2000 to December 2013 were enrolled. Characteristics were compared between ACP and ICP patients. Cumulative rates of diabetes mellitus (DM), steatorrhea, pancreatic stone, pancreatic pseudocyst, biliary stricture, and pancreatic cancer after the onset and the diagnosis of CP were calculated, respectively. The cumulative rates of DM and steatorrhea after diagnosis of pancreatic stone were also calculated.

Results

A total of 2,037 patients were enrolled. Among them, 19.8% (404/2,037) were ACP and 80.2% (1,633/2,037) were ICP patients. ACP and ICP differs in many aspects, especially in gender, age, smoking, complications, morphology of pancreatic duct, and type of pain. The development of DM, steatorrhea, PPC, pancreatic stone, and biliary stricture were significantly earlier and more common in ACP patients. No significant difference was observed for pancreatic cancer development. There was a rather close correlation between exocrine/endocrine insufficiency and pancreatic stone in ACP patients, which was much less correlated in ICP patients.

Conclusion

The long-term profile of ACP and ICP differs in some important aspects. ACP patients usually have a more severe course of CP. These differences should be recognized in the diagnosis and treatment of CP.

Prevalence of Panoramically Imaged Carotid Atheromas in Alcoholic Patients With Chronic Pancreatitis and Comorbid Diabetes

PURPOSE

Men with alcohol-related chronic pancreatitis (ARCP) resulting in type 3c diabetes mellitus (DM) are at a uniquely elevated risk of adverse ischemic events given the role of inflammation in both the underlying disease processes and atherosclerosis. We hypothesized that their panoramic images would show a prevalence of calcified carotid artery atheromas (calcified carotid artery plaques [CCAPs]) significantly more often than a general population of similarly aged men.

PATIENTS AND METHODS

We implemented a retrospective observational study. The sample was composed of male patients older than 30 years having panoramic images. The predictor variable was a diagnosis of ARCP-DM, and the outcome variable was the prevalence rate of CCAPs. The prevalence of CCAPs among the patients with ARCP-DM was then compared with that of a historical general population composed of similarly aged men. Descriptive and bivariate statistics were computed, and the P value was set at .05.

RESULTS

Of the 32 men (mean age, 61.7 ± 11.2 years) with ARCP-DM, 8 (25%) (mean age, 63.3 ± 4.80 years) had atheromas (CCAPs). There was a statistically significant (P < .05) association between a diagnosis of ARCP-DM and the presence of an atheroma on the panoramic image in comparison with the 3% rate manifested by the historical general-population cohort. The presence or absence of classic atherogenic risk factors within the ARCP-DM cohort failed to distinguish between individuals with and individuals without atheroma formation on their panoramic images.

CONCLUSIONS

The results of this study suggest that CCAP, a risk indicator for future adverse cardiovascular events, is frequently seen on the panoramic images of male patients with ARCP-DM. Dentists treating male patients with the disorder must be uniquely vigilant for the presence of these lesions.

Association between chronic pancreatitis and urolithiasis: A population-based cohort study

Purpose

Chronic pancreatitis (CP) can cause fat or bile acid malabsorption due to exocrine insufficiency. Fat or bile acid malabsorption has been reported to increase the risk of urolithiasis through increased intestinal oxalate absorption. However, no studies have reported an association between CP and urolithiasis.

Methods

We identified 15,848 patients (age: ≥20 years) diagnosed as having CP between 2000 and 2010 from the National Health Insurance Research Database as the study cohort. Beneficiaries without a history of CP were randomly selected and propensity-matched with the study cohort in a 1:4 ratio according to age; sex; comorbidities of hyperlipidemia, diabetes, obesity, hypertension, chronic obstructive pulmonary disease, alcohol-related illness, stroke, and coronary artery disease; and the index date. The prevalence of inflammatory bowel disease (0.44%), hyperparathyroidism (0.10%), or end stage renal disease (1.55%) in CP patients was low, but these comorbidities were also considered in the analysis. All patients were followed until the end of 2011 or withdrawal from the National Health Insurance program to determine the incidence of urolithiasis.

Results

The cumulative incidence of urolithiasis was higher in the CP cohort than that in the non-CP cohort (log-rank test, P < 0.001) with a 1.89-fold risk of urolithiasis (95% confidence interval [CI] = 1.74–2.06). The prevalence of CP was higher in men (81.9%) and in patients younger than 49 years (63.5%; mean age: 48.5 ± 15.3 years). CP was associated with the development of urolithiasis in each age group (≤49 years: aHR = 2.00, 95% CI = 1.81–2.22; 50–64 years: aHR = 1.71, 95% CI = 1.40–2.09; ≥65 years: aHR = 1.54, 95% CI = 1.20–1.98) and each sex (women: aHR = 2.10, 95% CI = 1.67–2.66; men; aHR = 1.86, 95% CI = 1.70–2.04). Among the patients without comorbidities, the rate of urolithiasis increased from 2.93/1,000 person-years in non-CP patients to 8.28/1,000 person-years in CP patients. Among the patients with comorbidities, the rate of urolithiasis increased from 6.12/1,000 person-years in non-CP patients to 10.9/1,000 person-years in CP patients. The contribution of CP to the relative risk of urolithiasis was greater in patients without comorbidities (without comorbidities: aHR = 2.81, 95% CI = 2.30–3.44) than in those with comorbidities (aHR = 1.76, 95% CI = 1.61–1.94).

Conclusion

CP is associated with urolithiasis in this population-based cohort study. The contribution of CP to the relative risk of urolithiasis was even greater in patients with a lower risk of urolithiasis, such as those without other comorbidities. Our findings warrant a survey and education on urolithiasis for patients with CP.

A Retrospective Administrative Database Analysis of Suicide Attempts and Completed Suicide in Patients With Chronic Pancreatitis

Background: The actual incidence rate of suicide attempt and the suicide-related fatality rate (completed suicide) in patients with chronic pancreatitis (CP) have not been mentioned in the literature. Methods: We conducted a nationwide population-based cohort study by analyzing data from Taiwan's National Health Insurance Research Database (NHIRD) to compare the rate of suicide attempt between a CP cohort and a non-CP cohort. For the study cohort, we identified 17,733 patients (age ≥ 20 years) diagnosed as having CP between 2000 and 2010 from the NHIRD in Taiwan. Beneficiaries with no history of CP were matched with the study cohort at a 2:1 ratio according to age, sex, and index date. To determine the incidence of suicide, all patients were followed until the end of 2011 or until their withdrawal from the Taiwan National Health Insurance program. Results: Patients with CP had an increased risk of suicide attempt, compared with those without CP (adjusted hazard ratio [aHR] = 2.72, 95% confidence interval [CI] = 1.69-4.37). The suicide-related fatality in the CP cohort was higher than that in the non-CP cohort, but the difference was not statistically significant (aHR = 1.21, 95% CI = 0.39-3.78). Conclusion: Our population-based cohort study reveals a close association between CP and subsequent suicide attempt. Compared with the non-CP cohort, the suicide-related fatality was higher in the CP cohort, although the result was not statistically significant. These findings necessitate surveying patients with CP and providing psychological support to prevent suicide.

Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study

BACKGROUND

The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research.

METHODS

An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG.

RESULTS

A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment.

CONCLUSION

Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

Alcohol, smoking and benign hepato-biliary disease

Gallstone disease and pancreatitis are the most frequent benign hepato-biliary causes of hospital admissions. Gallstone disease is prevalent, but symptomatic disease develops only in about one out of five carriers. Alcohol intake seems to protect gallstone formation in cohort studies possibly through effects on bile cholesterol metabolism, the enterohepatic circulation, and gallbladder function. The impact of smoking on gallstone formation seems minor. Both alcohol intake and smoking do not alter the clinical course of gallstone disease carriers. Cholecystectomy is the preferred treatment for symptomatic gallstone disease. Studies about the impact of alcohol and smoking on the post-cholecystectomy state are few and future studies should be performed. Pancreatitis is associated with both excessive alcohol intake and smoking in observational studies. Interpretation of associations with pancreatitis is hampered by an incomplete understanding of underlying mechanisms and by the co-existence of excessive alcohol intake and smoking. Smoking cessation and alcohol abstinence is recommended in the treatment of pancreatitis, but higher-level evidence is needed.

Chronic Pancreatitis: Current Status and Challenges for Prevention and Treatment

This paper reviews the current status of our understanding of the epidemiology, diagnosis, and management of the continuum of pancreatic diseases from acute and recurrent acute pancreatitis to chronic pancreatitis and the diseases that are often linked with pancreatitis including diabetes mellitus and pancreatic cancer. In addition to reviewing the current state of the field, we identify gaps in knowledge that are necessary to address to improve patient outcomes in these conditions.

Epidemiology of Recurrent Acute and Chronic Pancreatitis: Similarities and Differences

Emerging data in the past few years suggest that acute, recurrent acute (RAP), and chronic pancreatitis (CP) represent a disease continuum. This review discusses the similarities and differences in the epidemiology of RAP and CP. RAP is a high-risk group, comprised of individuals at varying risk of progression. The premise is that RAP is an intermediary stage in the pathogenesis of CP, and a subset of RAP patients during their natural course transition to CP. Although many clinical factors have been identified, accurately predicting the probability of disease course in individual patients remains difficult. Future studies should focus on providing more precise estimates of the risk of disease transition in a cohort of patients, quantification of clinical events during the natural course of disease, and discovery of biomarkers of the different stages of the disease continuum. Availability of clinically relevant endpoints and linked biomarkers will allow more accurate prediction of the natural course of disease over intermediate- or long-term-based characteristics of an individual patient. These endpoints will also provide objective measures for use in clinical trials of interventions that aim to alter the natural course of disease.

Prevalence of chronic pancreatitis: Results of a primary care physician-based population study

BACKGROUND

Data on chronic pancreatitis prevalence are scanty and usually limited to hospital-based studies.

AIM

Investigating chronic pancreatitis prevalence in primary care.

METHODS

Participating primary care physicians reported the prevalence of chronic pancreatitis among their registered patients, environmental factors and disease characteristics. The data were centrally reviewed and chronic pancreatitis cases defined according to M-ANNHEIM criteria for diagnosis and severity and TIGAR-O classification for etiology.

RESULTS

Twenty-three primary care physicians participated in the study. According to their judgment, 51 of 36.401 patients had chronic pancreatitis. After reviewing each patient data, 11 turned out to have definite, 5 probable, 19 borderline and 16 uncertain disease. Prevalence was 30.2/100.000 for definite cases and 44.0/100.000 for definite plus probable cases. Of the 16 patients with definite/probable diagnosis, 8 were male, with mean age of 55.6 (±16.7). Four patients had alcoholic etiology, 5 post-acute/recurrent pancreatitis, 6 were deemed to be idiopathic. Four had pancreatic exocrine insufficiency, 10 were receiving pancreatic enzymes, and six had pain. Most patients had initial stage and non-severe disease.

CONCLUSIONS

This is the first study investigating the prevalence of chronic pancreatitis in primary care. Results suggest that the prevalence in this context is higher than in hospital-based studies, with specific features, possibly representing an earlier disease stage.

Early diagnosis of chronic pancreatitis: understanding the factors associated with the development of chronic pancreatitis

The prognosis of advanced chronic pancreatitis (CP) is poor with the mortality rate approximately two-fold higher than the general population according to a survey of the prognosis of CP.　From this standpoint, the concept of early CP was propagated in Japan in 2009 to encourage the medical treatment for the earlier stages of CP.　That is, picking up the patients suspicious for early CP and then providing medical treatment for them are very important not only for patients, but also for health care economics.　In this review, we described some potential factors associated with the development of CP (alcohol, smoking, past history of acute pancreatitis, aging, gallstone, and gender) that are extremely important to discover patients with early-stage CP.

Genetic Background and Clinical Characters of Pediatric Chronic Pancreatitis: Data and Implications from the East

Background. The clinical pattern and genetic background of juvenile idiopathic chronic pancreatitis (ICP) are yet unclear. Methods. A retrospective study of 73 Chinese juvenile ICP patients was performed, and genetic tests were carried out to detect relevant mutations using direct sequencing technique and high-resolution melting technique. Subjects without pancreatitis served as controls. Results. The SPINK1 c.194+2T>C variant was present in 56.16% and 42.00% of juvenile and adult ICP patients, respectively (p = 0.020), but was not present in any of the control subjects. Thirty-four (46.58%) of the 73 juvenile ICP patients were male, and a significantly higher ratio of male patients in the adult group was identified (46.58% versus 64.00%, p = 0.022). Although most of the juvenile patients presented with abdominal pain (70/73, 95.89%), the patterns of pain attack are significantly different in patients with or without SPINK1 c.194+2T>C mutation. Patients carrying the mutation are more likely to present with recurrent acute pancreatitis (70.70%). Conclusions. The main symptom of pediatric ICP was abdominal pain. SPINK1 c.194+2T>C mutation had a higher occurrence in juvenile ICP patients than in adult group and typically presented with recurrent acute pancreatitis. There may be unidentified factors that lead to a greater incidence rate of ICP in adult male population.

Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis

OBJECTIVES

Obtain summary estimates of sensitivity and specificity for imaging modalities for chronic pancreatitis (CP) assessment.

METHODS

A systematic search was performed in Cochrane Library, MEDLINE, Embase and CINAHL databases for studies evaluating imaging modalities for the diagnosis of CP up to September 2016. A bivariate random-effects modeling was used to obtain summary estimates of sensitivity and specificity.

RESULTS

We included 43 studies evaluating 3460 patients. Sensitivity of endoscopic retrograde cholangiopancreatography (ERCP) (82%; 95%CI: 76%-87%) was significant higher than that of abdominal ultrasonography (US) (67%; 95%CI: 53%-78%; P=0.018). The sensitivity estimates of endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and computed tomography (CT) were 81% (95%CI: 70%-89%), 78% (95%CI: 69%-85%), and 75% (95%CI: 66%-83%), respectively, and did not differ significantly from each other. Estimates of specificity were comparable for EUS (90%; 95%CI: 82%-95%), ERCP (94%; 95%CI: 87%-98%), CT (91%; 95% CI: 81%-96%), MRI (96%; 95%CI: 90%-98%), and US (98%; 95%CI: 89%-100%).

CONCLUSIONS

EUS, ERCP, MRI and CT all have comparable high diagnostic accuracy in the initial diagnosis of CP. EUS and ERCP are outperformers and US has the lowest accuracy. The choice of imaging modality can therefore be made based on invasiveness, local availability, experience and costs.

KEY POINTS

• EUS, ERCP, MRI and CT have high diagnostic sensitivity for chronic pancreatitis • Diagnostic specificity is comparable for all imaging modalities • EUS and ERCP are outperformers and US has the lowest accuracy • The choice of imaging can be made based on clinical considerations.