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Chang M, Chen W, Xia R, Peng Y, Niu P, Fan H. Pancreatic Stellate Cells and the Targeted Therapeutic Strategies in Chronic Pancreatitis. Molecules 2023; 28:5586. [PMID: 37513458 PMCID: PMC10383437 DOI: 10.3390/molecules28145586] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Chronic pancreatitis (CP) is a disease characterized by inflammatory recurrence that accompanies the development of pancreatic fibrosis. As the mystery of CP pathogenesis is gradually revealed, accumulating evidence suggests that the activation of pancreatic stellate cells (PSCs) and the appearance of a myofibroblast-like phenotype are the key gatekeepers in the development of CP. Targeting PSCs to prevent their activation and conversion to a myofibroblast-like phenotype, as well as increasing antioxidant capacity to counteract ongoing oxidative stress, are effective strategies for preventing or treating CP. Therefore, we reviewed the crosstalk between CP and pancreatic fibrosis, summarized the activation mechanisms of PSCs, and investigated potential CP therapeutic strategies targeting PSCs, including, but not limited to, anti-fibrosis therapy, antioxidant therapy, and gene therapy. Meanwhile, the above therapeutic strategies are selected in order to update the available phytopharmaceuticals as novel complementary or alternative approaches for the prevention and treatment of CP to clarify their potential mechanisms of action and their relevant molecular targets, aiming to provide the most comprehensive therapeutic treatment direction for CP and to bring new hope to CP patients.
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Affiliation(s)
- Man Chang
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Wenjuan Chen
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Ruting Xia
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Yangyue Peng
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Pandi Niu
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Hui Fan
- Guangdong Metabolic Diseases Research Center of Integrated Chinese and Western Medicine, Guangzhou 510006, China
- Guangdong TCM Key Laboratory for Metabolic Diseases, Guangzhou 510006, China
- Key Laboratory of Glucolipid Metabolic Disorder, Ministry of Education of China, Guangzhou 510006, China
- Key Unit of Modulating Liver to Treat Hyperlipemia SATCM (State Administration of Traditional Chinese Medicine), Guangzhou 510006, China
- Institute of Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou 510006, China
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Ream C, Sabitsky M, Huang R, Hammelef E, Yeo TP, Lavu H, Yeo CJ, Bowne W, Nevler A. Association of Smoking and Respiratory Disease History with Pancreatic Pathologies Requiring Surgical Resection. Cancers (Basel) 2023; 15:cancers15112935. [PMID: 37296897 DOI: 10.3390/cancers15112935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND The purpose of this study was to examine the relationship between various respiratory conditions, including hypercapnic respiratory disease, and a multitude of resected pancreatic lesions. METHODS This retrospective case-control study queried a prospectively maintained database of patients who underwent pancreaticoduodenectomy between January 2015 and October 2021. Patient data, including smoking history, medical history, and pathology reports, were recorded. Patients with no smoking history and no concomitant respiratory conditions were designated as the control group. RESULTS A total of 723 patients with complete clinical and pathological data were identified. Male current smokers showed increased rates of PDAC (OR 2.33, 95% CI 1.07-5.08, p = 0.039). Male patients with COPD had a markedly increased association with IPMN (OR 3.02, CI 1.08-8.41, p = 0.039), while females with obstructive sleep apnea had a four-fold increase in risk of IPMN compared to women in the control group (OR 3.89, CI 1.46-10.37, p = 0.009). Surprisingly, female patients with asthma had a decreased incidence of pancreatic and periampullary adenocarcinoma (OR 0.36, 95% CI 0.18-0.71. p < 0.01). CONCLUSION This large cohort study reveals possible links between respiratory pathologies and various pancreatic mass-forming lesions.
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Affiliation(s)
- Carolyn Ream
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Matthew Sabitsky
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Rachel Huang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Emma Hammelef
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Theresa P Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Philadelphia, PA 19107, USA
| | - Harish Lavu
- Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Philadelphia, PA 19107, USA
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Philadelphia, PA 19107, USA
| | - Wilbur Bowne
- Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Philadelphia, PA 19107, USA
| | - Avinoam Nevler
- Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Philadelphia, PA 19107, USA
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3
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Pancreatic Cancer in Chronic Pancreatitis: Pathogenesis and Diagnostic Approach. Cancers (Basel) 2023; 15:cancers15030761. [PMID: 36765725 PMCID: PMC9913572 DOI: 10.3390/cancers15030761] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
Chronic pancreatitis is one of the main risk factors for pancreatic cancer, but it is a rare event. Inflammation and oncogenes work hand in hand as key promoters of this disease. Tobacco is another co-factor. During alcoholic chronic pancreatitis, the cumulative risk of cancer is estimated at 4% after 15 to 20 years. This cumulative risk is higher in hereditary pancreatitis: 19 and 12% in the case of PRSS1 and SPINK1 mutations, respectively, at an age of 60 years. The diagnosis is difficult due to: (i) clinical symptoms of cancer shared with those of chronic pancreatitis; (ii) the parenchymal and ductal remodeling of chronic pancreatitis rendering imaging analysis difficult; and (iii) differential diagnoses, such as pseudo-tumorous chronic pancreatitis and paraduodenal pancreatitis. Nevertheless, the occurrence of cancer during chronic pancreatitis must be suspected in the case of back pain, weight loss, unbalanced diabetes, and jaundice, despite alcohol withdrawal. Imaging must be systematically reviewed. Endoscopic ultrasound-guided fine-needle biopsy can contribute by targeting suspicious tissue areas with the help of molecular biology (search for KRAS, TP53, CDKN2A, DPC4 mutations). Short-term follow-up of patients is necessary at the clinical and paraclinical levels to try to diagnose cancer at a surgically curable stage. Pancreatic surgery is sometimes necessary if there is any doubt.
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Han SY, Conwell DL, Diaz PT, Ferketich A, Jeon CY, Yadav D, Hart PA. The deleterious effects of smoking on the development and progression of chronic pancreatitis. Pancreatology 2022; 22:683-687. [PMID: 35981948 PMCID: PMC9474634 DOI: 10.1016/j.pan.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/05/2022] [Accepted: 08/07/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Samuel Y Han
- Division of Gastroenterology, Hepatology, and Nutrition. the Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darwin L Conwell
- Department of Internal Medicine. University of Kentucky College of Medicine, Lexington, KY, USA
| | - Philip T Diaz
- Division of Pulmonary, Critical Care, and Sleep Medicine. the Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amy Ferketich
- Division of Epidemiology. the Ohio State University College of Public Health, Columbus, OH, USA
| | - Christie Y Jeon
- Cedars Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition. the Ohio State University Wexner Medical Center, Columbus, OH, USA.
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5
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Hao L, Liu Y, Dong ZQ, Yi JH, Wang D, Xin L, Guo HL, He L, Bi YW, Ji JT, Wang T, Du TT, Lin JH, Zhang D, Zeng XP, Zou WB, Chen H, Pan J, Liao Z, Xu GQ, Li ZS, Hu LH. Clinical characteristics of smoking-related chronic pancreatitis. Front Cell Infect Microbiol 2022; 12:939910. [PMID: 36061871 PMCID: PMC9433580 DOI: 10.3389/fcimb.2022.939910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The pathogenesis of chronic pancreatitis (CP) is not completely clear. With further studies, smoking is toxic to the pancreas. This study classified smoking-related CP as a new etiology of CP and defined the cutoff of smoking. Design Patients with CP admitted from January 2000 to December 2013 were included in the study. The characteristics were compared between smoking patients, drinking patients, and a group of patients who never smoke or drink (control group). The cumulative rates of steatorrhea, diabetes mellitus (DM), pancreatic pseudocyst (PPC), pancreatic stone, and biliary stricture after the onset of CP were calculated, respectively. Results A total of 1,324 patients were included. Among them, 55 were smoking patients, 80 were drinking patients, and 1,189 were controls. The characteristics of smokers are different from the other two groups, especially in age at the onset and diagnosis of CP, initial manifestation, and type of pain. The development of DM (P = 0.011) and PPC (P = 0.033) was significantly more common and earlier in the smokers than in the other two groups. Steatorrhea also developed significantly more in the smokers than in the controls (P = 0.029). Smokers tend to delay the formation of pancreatic stones and steatorrhea. Conclusion The clinical characteristics of smoking-related CP is different from CP of other etiologies. A new type of CP, smoking-related CP, was put forward. Smoking-related CP should be separated from idiopathic CP and defined as a new independent subtype of CP different from alcoholic CP or idiopathic CP.
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Affiliation(s)
- Lu Hao
- Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yu Liu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhi-Qi Dong
- Department of Gastroenterology, Shanghai Fourth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Hui Yi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lei Xin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hong-Lei Guo
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lin He
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- Department of Gastroenterology and Endocrinology, 969th Hospital of People's Liberation Army (PLA), Hohhot, China
| | - Ya-Wei Bi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jun-Tao Ji
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- Shanghai Guangming Middle School, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ting-Ting Du
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jin-Huan Lin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Di Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Xiang-Peng Zeng
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jun Pan
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Guo-Qiang Xu
- Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Guo-Qiang Xu, ; Zhao-Shen Li, ; Liang-Hao Hu,
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- *Correspondence: Guo-Qiang Xu, ; Zhao-Shen Li, ; Liang-Hao Hu,
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
- *Correspondence: Guo-Qiang Xu, ; Zhao-Shen Li, ; Liang-Hao Hu,
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Zheng M, Gao R. Vitamin D: A Potential Star for Treating Chronic Pancreatitis. Front Pharmacol 2022; 13:902639. [PMID: 35734414 PMCID: PMC9207250 DOI: 10.3389/fphar.2022.902639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas. The incidence of CP is increasing worldwide but the effective therapies are lacking. Hence, it is necessary to identify economical and effective agents for the treatment of CP patients. Vitamin D (VD) and its analogues have been confirmed as pleiotropic regulators of cell proliferation, apoptosis, differentiation and autophagy. Clinical studies show that VD deficiency is prevalent in CP patients. However, the correlation between VD level and the risk of CP remains controversial. VD and its analogues have been demonstrated to inhibit pancreatic fibrosis by suppressing the activation of pancreatic stellate cells and the production of extracellular matrix. Limited clinical trials have shown that the supplement of VD can improve VD deficiency in patients with CP, suggesting a potential therapeutic value of VD in CP. However, the mechanisms by which VD and its analogues inhibit pancreatic fibrosis have not been fully elucidated. We are reviewing the current literature concerning the risk factors for developing CP, prevalence of VD deficiency in CP, mechanisms of VD action in PSC-mediated fibrogenesis during the development of CP and potential therapeutic applications of VD and its analogues in the treatment of CP.
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7
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Liu Y, Yin XY, Wang D, Dong ZQ, Hao L, Chen C, Wang T, Zhang D, Ma JY, Yang HY, Li J, Zhang LL, Bi YW, Zhang Y, Xin L, Chen H, Zhang QS, Xie T, Lu GT, Li ZS, Liao Z, Hu LH. Risk factor analysis and nomogram development for steatorrhea in idiopathic chronic pancreatitis. J Dig Dis 2022; 23:331-340. [PMID: 35703114 DOI: 10.1111/1751-2980.13102] [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: 10/24/2021] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Steatorrhea, a sign of severe pancreatic exocrine insufficiency (PEI), is related to consequences caused by pancreatitis. This study aimed to identify predictors and to construct a nomogram for steatorrhea in idiopathic chronic pancreatitis (ICP). METHODS ICP patients admitted to our hospital from January 2000 to December 2013 were enrolled in this retrospective-prospective cohort study and randomly assigned to the training and validation cohorts. The cumulative rate of steatorrhea was calculated. A Cox proportional hazard regression model was used to identify predictors for steatorrhea and construct the nomogram. Internal and external validation of the nomogram was then performed. RESULTS There were 1633 ICP patients enrolled, with a median follow-up duration of 9.8 years and 20.8% (339/1633) of patients developed steatorrhea following onset of ICP. Steatorrhea was observed in 93, 115, and 133 patients at 1, 3, and 5 years following diagnosis of CP, with a cumulative rate of 6.5% (95% confidence interval [CI] 5.1%-7.9%), 8.0% (95% CI 6.2%-9.8%), and 9.3% (95% CI 6.6%-12.0%), respectively. Male sex (hazard ratio [HR] 2.479, P < 0.001), diabetes mellitus at/before diagnosis of ICP (HR 2.274, P = 0.003), and aged less than 18 years at onset of ICP (HR 0.095, P < 0.001) were identified risk factors for steatorrhea. Initial manifestations were associated with development of steatorrhea. The nomogram was proven to have good concordance indexes. CONCLUSIONS We identified predictors and developed a nomogram for predicting steatorrhea in ICP. It was recommended that high-risk populations be followed up closely, which might contribute to the early diagnosis and treatment of PEI.
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Affiliation(s)
- Yu Liu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu Province, China.,Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Xiao Yi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhi Qi Dong
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Hao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Cui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Di Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jia Yi Ma
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Huai Yu Yang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Juan Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ling Ling Zhang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ya Wei Bi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yuan Zhang
- Department of Ophthalmology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lei Xin
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Qi Sheng Zhang
- Department of Gastroenterology, Shanghai Fourth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Xie
- Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China
| | - Guo Tao Lu
- Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
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Roberts‐Thomson IC. Progression from acute to chronic pancreatitis. JGH Open 2021; 5:1321-1322. [PMID: 34950773 PMCID: PMC8674541 DOI: 10.1002/jgh3.12698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Ian C Roberts‐Thomson
- Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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9
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Surgical management of chronic calcified pancreatitis. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2021.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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10
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Freeman AJ, Maqbool A, Bellin MD, Goldschneider KR, Grover AS, Hartzell C, Piester TL, Szabo F, Kiernan BD, Khalaf R, Kumar R, Rios M, Husain SZ, Morinville VD, Abu-El-Haija M. Medical Management of Chronic Pancreatitis in Children: A Position Paper by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2021; 72:324-340. [PMID: 33230082 PMCID: PMC8054312 DOI: 10.1097/mpg.0000000000003001] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT This position paper summarizes the current understanding of the medical management of chronic pancreatitis (CP) in children in light of the existing medical literature, incorporating recent advances in understanding of nutrition, pain, lifestyle considerations, and sequelae of CP. This article complements and is intended to integrate with parallel position papers on endoscopic and surgical aspects of CP in children. Concepts and controversies related to pancreatic enzyme replacement therapy (PERT), the use of antioxidants and other CP medical therapies are also reviewed. Highlights include inclusion of tools for medical decision-making for PERT, CP-related diabetes, and multimodal pain management (including an analgesia ladder). Gaps in our understanding of CP in children and avenues for further investigations are also reviewed.
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Affiliation(s)
- A. Jay Freeman
- Department of Gastroenterology, Hepatology and Nutrition, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Asim Maqbool
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Melena D. Bellin
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN
| | | | - Amit S. Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Cheryl Hartzell
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Travis L. Piester
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Flora Szabo
- Division of Pediatric Gastroenterology and Nutrition, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | - Bridget Dowd Kiernan
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Racha Khalaf
- Digestive Health Institute, Children’s Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Rakesh Kumar
- Department of Gastroenterology, Hepatology and Nutrition, Promedica Toledo Children’s Hospital, Toledo, OH
| | - Mirta Rios
- Food and Nutrition Department, Nicklaus Children’s Hospital, Miami, FL
| | - Sohail Z. Husain
- Department of Pediatrics, Stanford University, and the Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Veronique D. Morinville
- Division of Pediatric Gastroenterology and Nutrition, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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11
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Barreto SG, Habtezion A, Gukovskaya A, Lugea A, Jeon C, Yadav D, Hegyi P, Venglovecz V, Sutton R, Pandol SJ. Critical thresholds: key to unlocking the door to the prevention and specific treatments for acute pancreatitis. Gut 2021; 70:194-203. [PMID: 32973069 PMCID: PMC7816970 DOI: 10.1136/gutjnl-2020-322163] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/01/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP), an acute inflammatory disorder of the exocrine pancreas, is one of the most common gastrointestinal diseases encountered in emergency departments with no specific treatments. Laboratory-based research has formed the cornerstone of endeavours to decipher the pathophysiology of AP, because of the limitations of such study in human beings. While this has provided us with substantial understanding, we cannot answer several pressing questions. These are: (a) Why is it that only a minority of individuals with gallstones, or who drink alcohol excessively, or are exposed to other causative factors develop AP? (b) Why do only some develop more severe manifestations of AP with necrosis and/or organ failure? (c) Why have we been unable to find an effective therapeutic for AP? This manuscript provides a state-of-the-art review of our current understanding of the pathophysiology of AP providing insights into the unanswered clinical questions. We describe multiple protective factors operating in most people, and multiple stressors that in a minority induce AP, independently or together, via amplification loops. We present testable hypotheses aimed at halting progression of severity for the development of effective treatments for this common unpredictable disease.
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Affiliation(s)
- Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Anna Gukovskaya
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
- Department of Medicine, West Los Angeles VA Healthcare Center, Los Angeles, California, USA
| | - Aurelia Lugea
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christie Jeon
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dhiraj Yadav
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter Hegyi
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine and First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
- Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Viktória Venglovecz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Robert Sutton
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
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12
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Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet 2020; 396:499-512. [PMID: 32798493 DOI: 10.1016/s0140-6736(20)31318-0] [Citation(s) in RCA: 238] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Georg Beyer
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine, University of Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Medical Department II, University Hospital, LMU Munich, Munich, Germany.
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The Lived Experience of Inpatients With Acute Recurrent Pancreatitis: A Qualitative Research Study From West China. Gastroenterol Nurs 2020; 43:249-257. [PMID: 32487957 DOI: 10.1097/sga.0000000000000442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The incidence of acute pancreatitis (AP) has increased year by year. Approximately 20%-30% of these patients will have further subsequent attacks, described as acute recurrent pancreatitis (ARP). Patients who are repeatedly admitted to hospitals suffer significant psychological problems and mental hardships. In the current study, we aimed to illuminate the lived experience of inpatients with ARP from Chongqing, China. A purposive sample of 13 ARP patients was recruited from the First Affiliated Hospital of Chongqing Medical University. Semistructured and in-depth qualitative interviews were adopted in this phenomenological research. Data were analyzed by Colaizzi's Method of descriptive phenomenology and feedback on early findings from the participants. All interviews were audio-recorded and transcribed with the permission of the participants. Five themes presented in the study: anxiety and fear, lack of related knowledge, inevitability and helplessness, guilt and shame, hope, and perseverance. Overall, the ARP inpatients showed complexed experience, both active and positive. They also performed poor compliance during their hospitalization but wished for professional knowledge. Nurses should pay attention to their psychological changes to take effective interventions for them.
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Żorniak M, Sirtl S, Mayerle J, Beyer G. What Do We Currently Know about the Pathophysiology of Alcoholic Pancreatitis: A Brief Review. Visc Med 2020; 36:182-190. [PMID: 32775348 PMCID: PMC7383280 DOI: 10.1159/000508173] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Alcoholic pancreatitis is a serious medical concern worldwide and remains to be one of the common causes of pancreatic disease. SUMMARY While alcohol consumption causes direct damage to pancreatic tissue, only a small percentage of active drinkers will develop pancreatitis. An explanation of this phenomenon is probably that alcohol increases pancreatic vulnerability to damage; however, the simultaneous presence of additional risk factors and pancreatic costressors is required to increase the risk of pancreatitis and its complications caused by alcohol misuse. Recently, a number of important genetic as well as environmental factors influencing the risk of alcoholic pancreatitis have been described. KEY MESSAGES In brief, this review reports established factors for the development of alcoholic pancreatitis and summarizes recent progress made in basic and clinical research.
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Affiliation(s)
- Michał Żorniak
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
- Department of Gastroenterology, Medical University of Silesia, Katowice, Poland
| | - Simon Sirtl
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
| | - Georg Beyer
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
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15
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Chou CY, Chang CT, Chen CJ. Analytically validated protein biomarkers of chronic pancreatitis and pancreatic cancer for potential clinical diagnosis with mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2020; 34 Suppl 1:e8580. [PMID: 31502717 DOI: 10.1002/rcm.8580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
RATIONALE Chronic pancreatitis (CP) is a pancreatic disease with poor prognosis and pancreatic cancer (PC) is one of the most lethal types of cancer that is symptomless in the early stage. Because the clinical and image findings of CP can overlap that of pancreatic cancer (PC) which leads to confusion in the diagnosis and treatment of PC, discovery/verification/validation of more accurate protein biomarkers to diagnose CP and PC is in urgent need. METHODS The PubMed, Web of Science, and Google Scholar were searched using the keywords: 'biomarker', 'marker', 'chronic pancreatitis', "pancreatic cancer" or "proteomics" for highly related researches. We focused on the articles published after the year 2005 in this review. RESULTS We introduce the background to CP and PC and summarize the diagnosis of CP and PC, analytically validated protein biomarkers, and proteomic approaches for discovery/verification/validation. The potential use of mass spectrometry (MS) in clinical diagnosis is also discussed. CONCLUSIONS Continuously improving sensitivity of MS can provide deeper proteome for new marker discovery and high reliability for protein marker verification, validation, and clinical diagnosis. The analytically validated protein markers could be considered as targeted protein biomarkers for developing a MS platform in the clinical validation process or clinical diagnosis of CP and PC.
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Affiliation(s)
- Che-Yi Chou
- Division of Nephrology, Asia University Hospital, Taichung, Taiwan
- Department of Post-baccalaureate Veterinary Medicine, Asia University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- College of Medicine, China Medical University, Taichung, Taiwan
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, 40447, Taiwan
| | - Chao-Jung Chen
- Proteomics Core Laboratory, Department of Medical Research, China Medical University Hospital, Taichung, 40402, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, 40402, Taiwan
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16
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Orekhova A, Geisz A, Sahin-Tóth M. Ethanol feeding accelerates pancreatitis progression in CPA1 N256K mutant mice. Am J Physiol Gastrointest Liver Physiol 2020; 318:G694-G704. [PMID: 32116022 PMCID: PMC7191466 DOI: 10.1152/ajpgi.00007.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcoholic pancreatitis is a multifactorial, progressive, inflammatory disorder of the pancreas. Alcohol initiates pancreatitis and promotes its progression in the context of genetic susceptibility and/or other environmental risk factors such as smoking. Genetic mutations can cause digestive enzyme misfolding, which induces endoplasmic reticulum (ER) stress and elicits pancreatitis. Here, we tested the hypothesis that alcohol synergizes with misfolding in promoting ER stress and thereby accelerates chronic pancreatitis progression. To this end, we fed an ethanol-containing diet to CPA1 N256K mice, which carry the human p.N256K CPA1 mutation and develop spontaneous chronic pancreatitis. Inexplicably, CPA1 N256K mice suffered generalized seizures after 2-3 wk of ethanol feeding, which resulted in high mortality and the early termination of the study. Analysis of CPA1 N256K mice euthanized after 3-3.5 wk of ethanol feeding revealed more severe chronic pancreatitis associated with significantly increased Hspa5 [ER chaperone immunoglobulin heavy chain-binding protein (BiP)] mRNA levels when compared with CPA1 N256K mice on a control liquid diet. In contrast, ethanol feeding of C57BL/6N mice for 4 wk increased Hspa5 levels to a lesser degree and caused no pancreatitis. We conclude that ethanol feeding synergizes with the misfolding CPA1 mutant in promoting ER stress and thereby accelerates progression of chronic pancreatitis in CPA1 N256K mice.NEW & NOTEWORTHY Alcoholic pancreatitis is a multifactorial, progressive, inflammatory disorder of the pancreas. This study demonstrates that alcohol synergizes with digestive enzyme misfolding in promoting endoplasmic reticulum stress and thereby accelerates progression of chronic pancreatitis.
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Affiliation(s)
- Anna Orekhova
- 1Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University, Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
| | - Andrea Geisz
- 1Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University, Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
| | - Miklós Sahin-Tóth
- 1Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University, Henry M. Goldman School of Dental Medicine, Boston, Massachusetts,2Department of Surgery, University of California Los Angeles, Los Angeles, California
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17
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Seppänen H, Puolakkainen P. Classification, Severity Assessment, and Prevention of Recurrences in Acute Pancreatitis. Scand J Surg 2020; 109:53-58. [PMID: 32192420 DOI: 10.1177/1457496920910007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pancreatitis is a common disease, the incidence of which is 75-100/100,000/year in Finland. The worldwide incidence of acute pancreatitis is increasing. The identified mildcases usually show rapid recovery with conservative treatment allowing early discharge. Severe cases need early intensive care to reduce the risk of serious complications such as multi-organ failure. The revised Atlanta classification of acute pancreatitis was introduced in 2012-2013. A recurrent acute pancreatitis is defined as two or more well-documented separate attacks of acute pancreatitis with complete resolution in between. Alcoholic pancreatitis is the most common recurrent acute pancreatitis type. METHODS In this review current severity classifications and literature on the prevention of recurrent acute pancreatitis are analyzed. RESULTS The severity of the disease is classified as mild, moderately severe, and severe acute pancreatitis. Novel entities include acute peripancreatic fluid collections in mild acute pancreatitis and acute necrotic collections in necrotizing acute pancreatitis lesser than 4 weeks after the onset and pancreatic pseudocyst in mild acute pancreatitis and walled-off necrosis in necrotizing acute pancreatitis more than 4 weeks after the onset of the disease. After the first attack of alcohol-induced acute pancreatitis, 46% of the patients develop at least one recurrence within 10- to 20-year follow-up. With repeated intervention against alcohol consumption, it is possible to reduce the recurrences. Removing the gall bladder after biliary pancreatitis is the key preventing recurrences. In mild cases, even during the index admission; in severe cases, it is recommended to wait until the inflammatory changes have resolved. Of total, 59% of the idiopathic pancreatitis had sludge of stones in the gall bladder. In other etiologies, addressing the etiological factor may prevent recurrent acute pancreatitis. CONCLUSIONS This review describes current use of novel severity classifications and also different possibilities to prevent recurrent acute pancreatitis with different etiologies including idiopathic.
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Affiliation(s)
- H Seppänen
- Department of Surgery, Translational Cancer Medicine Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Puolakkainen
- Department of Surgery, Translational Cancer Medicine Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Venkatesh NR, Vijayakumar C, Balasubramaniyan G, Chinnakkulam Kandhasamy S, Sundaramurthi S, G S S, Srinivasan K. Comparison of Different Scoring Systems in Predicting the Severity of Acute Pancreatitis: A Prospective Observational Study. Cureus 2020; 12:e6943. [PMID: 32190494 PMCID: PMC7067369 DOI: 10.7759/cureus.6943] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Acute pancreatitis (AP) is an inflammatory condition of the pancreas mostly due to alcohol or gallstones. Various scoring systems were involved in identifying the severity of the disease. The standard single score to identifying the severity remains uncertain. Methodology This prospective observational study was carried out for two years in a tertiary care center from South India. The diagnosis of AP was made based on Atlanta criteria, and a total of 164 patients were included. All patients were assessed by acute physiology and chronic health evaluation ll (APACHE II), bedside index for severity in AP (BISAP), modified Glasgow score (MGS), and Ranson score on admission and 48 hours after admission scores. Procalcitonin was done in all patients with AP. Contrast-enhanced computed tomography (CT) of the abdomen was done in 69 patients who had features of severe acute pancreatitis (SAP). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for each score, and procalcitonin for CT documented severe patients and organ failure patients together. Results A total of 164 patients were included in this study. CT abdomen showed a modified CT severity index (MCSI) ≥8 in all 69 (100%) patients. APACHE II score could predict SAP based on CT findings in 44 patients (63.76%), BISAP score in 22 patients (31.88%), MGS in 55 patients (79.71%), Ranson score at admission in 31 patients (44.92%), Ranson score 48 hours after admission in 44 patients (63.76%), and procalcitonin on admission in 69 patients (100%) when cut-off used as per the literature. APACHE II score could predict SAP in cases of AP (n=164) in 52 patients (50%), BISAP score in 27 patients (26%), MGS in 79 patients (76%), Ranson score at admission in 34 patients (33%), and Ranson score 48 hours after admission in 61 (59%) patients when cut-off was used as per the literature. This study demonstrated that Ranson score on admission had a good area under the curve (AUC). AUC (0.8483), APACHE II (AUC 0.7708), and Ranson score 48 hours after admission (AUC 0.8167) had a fair accuracy. BISAP (AUC 0.6399) and MGS (AUC 0.6486) had poor accuracy for the prediction of severity in AP based on receiver operator characteristic (ROC) curves. Conclusion Among the scoring system compared, MGS had the highest sensitivity for predicting the severity of AP. However, Ranson score on admission had better diagnostic accuracy for predicting severity, organ failure, and mortality based on ROC curves. Procalcitonin had the best sensitivity, specificity, PPV, NPV, and diagnostic accuracy for association with severity in AP.
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Affiliation(s)
- N R Venkatesh
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gopal Balasubramaniyan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | | | | | - Sreenath G S
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
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19
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Tang XY, Zou WB, Yu FF, Wang L, Ru N, Zhu JH, Li ZS, Liao Z. Meta-analysis of the impact of the SPINK1 c.194 + 2T > C variant in chronic pancreatitis. Dig Liver Dis 2020; 52:143-148. [PMID: 31401021 DOI: 10.1016/j.dld.2019.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The SPINK1 c.194 + 2T > C variant has been increasingly recognized as an important risk factor for chronic pancreatitis (CP). However, there is no clear agreement on its contribution to different ethnicities and CP etiologies. To address this issue, a meta-analysis of literature was performed. METHODS Studies addressing the presence of the SPINK1 c.194 + 2T > C variant in CP patients and controls were retrieved from the PubMed, EMBASE and Cochrane databases. Initial analysis included all CP patients, followed by subgroup analyses for East Asian and non-East Asian patients, and for idiopathic CP (ICP) and non-ICP. RESULTS A total of 13 studies were retrieved for analysis, comprising 2097 cases and 4019 controls. There were 126 cases (10.01%) carrying the SPINK1 c.194 + 2T > C variant in cases, while only two controls were carriers (0.05%). Overall, the variant was significantly associated with an increased risk of CP (OR = 25.73). In the subgroup, the variant was significantly associated with increased risk of CP in East Asians (OR = 73.16), and in non-East Asians (OR = 10.21). Further, the contribution of the variant in ICP (OR = 35.31) was found to be higher than in non-ICP (25.75). CONCLUSIONS The SPINK1 c.194 + 2T > C variant is a strong risk factor for CP, especially in East Asian patients with ICP.
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Affiliation(s)
- Xin-Ying Tang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Fei-Fei Yu
- Medical Service Research Division, The Naval Medical Research Institute, Second Military Medical University, Shanghai, China
| | - Lei Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Jia-Hui Zhu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China.
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China; Shanghai Institute of Pancreatic Diseases, Shanghai, China.
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Rodrigues-Pinto E, Caldeira A, Soares JB, Antunes T, Carvalho JR, Costa-Maia J, Oliveira P, Azevedo R, Liberal R, Bouça Machado T, Magno-Pereira V, Moutinho-Ribeiro P. Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Medical, Endoscopic, and Surgical Treatment (Part II). GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:404-413. [PMID: 31832495 DOI: 10.1159/000497389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/31/2019] [Indexed: 01/21/2023]
Abstract
Chronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part II.
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Affiliation(s)
| | - Ana Caldeira
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | | | - Teresa Antunes
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Joana Rita Carvalho
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Costa-Maia
- Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Pedro Oliveira
- Radiology Department, Hospital de Braga, Braga, Portugal
| | - Richard Azevedo
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal
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SPINK1, PRSS1, CTRC, and CFTR Genotypes Influence Disease Onset and Clinical Outcomes in Chronic Pancreatitis. Clin Transl Gastroenterol 2018; 9:204. [PMID: 30420730 PMCID: PMC6232107 DOI: 10.1038/s41424-018-0069-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/27/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022] Open
Abstract
Objectives Rare pathogenic variants in the SPINK1, PRSS1, CTRC, and CFTR genes have been strongly associated with a risk of developing chronic pancreatitis (CP). However, their potential impact on the age of disease onset and clinical outcomes, as well as their potential interactions with environmental risk factors, remain unclear. These issues are addressed here in a large Chinese CP cohort. Methods We performed targeted next-generation sequencing of the four CP-associated genes in 1061 Han Chinese CP patients and 1196 controls. To evaluate gene–environment interactions, the patients were divided into three subgroups, idiopathic CP (ICP; n = 715), alcoholic CP (ACP; n = 206), and smoking-associated CP (SCP; n = 140). The potential impact of rare pathogenic variants on the age of onset of CP and clinical outcomes was evaluated using the Kaplan–Meier model. Results We identified rare pathogenic genotypes involving the SPINK1, PRSS1, CTRC, and/or CFTR genes in 535 (50.42%) CP patients but in only 71 (5.94%) controls (odds ratio = 16.12; P < 0.001). Mutation-positive patients had significantly earlier median ages at disease onset and at diagnosis of pancreatic stones, diabetes mellitus and steatorrhea than mutation-negative ICP patients. Pathogenic genotypes were present in 57.1, 39.8, and 32.1% of the ICP, ACP, and SCP patients, respectively, and influenced age at disease onset and clinical outcomes in all subgroups. Conclusions We provide evidence that rare pathogenic variants in the SPINK1, PRSS1, CTRC, and CFTR genes significantly influence the age of onset and clinical outcomes of CP. Extensive gene–environment interactions were also identified.
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Waller A, Long B, Koyfman A, Gottlieb M. Acute Pancreatitis: Updates for Emergency Clinicians. J Emerg Med 2018; 55:769-779. [PMID: 30268599 DOI: 10.1016/j.jemermed.2018.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis. OBJECTIVE This review article provides emergency clinicians with a focused overview of the diagnosis and management of pancreatitis. DISCUSSION Pancreatitis is an inflammatory process within the pancreas. While the disease is often mild, severe forms can have a mortality rate of up to 30%. The diagnosis of pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation. The most common etiologies include gallbladder disease and alcohol use. After the diagnosis has been made, it is important to identify underlying etiologies requiring specific intervention, as well as obtain a right upper quadrant ultrasound. The initial management of choice is fluid resuscitation and pain control. Recent data have suggested that more cautious fluid resuscitation in the first 24 h might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously. Appropriate disposition is a multifactorial decision, which can be facilitated by using Ranson criteria or the Bedside Index of Severity in Acute Pancreatitis score. Complications, though rare, can be severe. CONCLUSIONS Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.
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Affiliation(s)
- Anna Waller
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Quality of life comparison between smokers and non-smokers with chronic pancreatitis. Pancreatology 2018; 18:269-274. [PMID: 29500114 PMCID: PMC5879011 DOI: 10.1016/j.pan.2018.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the impact of smoking on quality of life in patients with chronic pancreatitis. METHODS This is a cross-sectional study of chronic pancreatitis patients followed at a single institution comparing smokers with non-smokers. The primary outcome was quality of life and secondary outcomes included demographics, drug and alcohol use, anxiety and depression, pain level, nutritional status, and metabolic factors. RESULTS 48 smokers and 45 non-smokers participated in this study. Smokers had a worse overall quality of life and higher rates of opioid addiction and depression than non-smokers. Smokers also had less racial diversity, lower education levels, and higher amounts of narcotic use than non-smokers. Furthermore, smokers had a lower BMI and a higher proportional use of pancreatic enzyme replacement therapy. Smoking was found to be independently associated with worse quality of life on multivariable regression. CONCLUSIONS The worse overall quality of life and higher rates of depression and anxiety create cause for concern in chronic pancreatitis patients who smoke. Smoking cessation should be an important target in chronic pancreatitis patients. Multicenter, multiethnic studies are needed to further elucidate this relationship.
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Durie P, Baillargeon JD, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin 2018; 34:25-33. [PMID: 28985688 DOI: 10.1080/03007995.2017.1389704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release. PURPOSE To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI. METHODS For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? FINDINGS The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist. CONCLUSIONS In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.
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Affiliation(s)
- P Durie
- a Hospital for Sick Children and University of Toronto , Toronto , ON , Canada
| | - J-D Baillargeon
- b Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke , Sherbrooke , QC , Canada
| | - S Bouchard
- c Centre Hospitalier de l'Université de Montréal , Montréal , QC , Canada
| | - F Donnellan
- d Vancouver General Hospital , Vancouver , BC , Canada
| | | | - C Teshima
- f St. Michael's Hospital and University of Toronto , Toronto , ON , Canada
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Xiang JX, Hu LS, Liu P, Tian BY, Su Q, Ji YC, Zhang XF, Liu XM, Wu Z, Lv Y. Impact of cigarette smoking on recurrence of hyperlipidemic acute pancreatitis. World J Gastroenterol 2017; 23:8387-8394. [PMID: 29307998 PMCID: PMC5743509 DOI: 10.3748/wjg.v23.i47.8387] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/11/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the impact of cigarette smoking on the recurrence rate and recurrence-free survival in patients with hyperlipidemic acute pancreatitis (HLAP).
METHODS A total of 863 patients were admitted to our hospital for acute pancreatitis (AP) from January 2013 to March 2016, of whom 88 diagnosed with HLAP were enrolled in this retrospective study. Demographic data, medical history, previous episodes of pancreatitis, consumption of alcohol and cigarettes, as well as biochemical and hematological data were carefully recorded for univariate and multivariate analyses. During follow-up, the information on current smoking status and recurrent AP was gathered. Recurrence-free survival (RFS) was calculated using the Kaplan-Meier method, and the differences between groups were compared using the log-rank test.
RESULTS No significant differences were observed between the three groups in age or medical history of hyperlipidemia, fatty liver, diabetes mellitus, hypertension, or AP. The current smokers had a remarkably higher recurrence rate and a greater incidence of repeated episodes of AP (50.0% and 77.8%, respectively) than non-smokers (9.8% and 39.0%), and these two percentages were reduced to 9.1% and 36.4% for patients who gave up smoking. The median follow-up time was 13.5 mo and HLAP recurred after hospital discharge in 23 (26.1%) patients. Multivariate analysis identified current smoking (HR = 6.3, P = 0.020) as an independent risk factor contributing to HLAP recurrence. Current smokers had significantly worse RFS than non-smokers (23 mo vs 42 mo), but no significant difference was documented between ex-smokers (34 mo) and non-smokers. The RFS was not significantly different between light and heavy smokers.
CONCLUSION Smoking is associated with worse RFS and an increased rate of HLAP recurrence. Continued smoking correlates with a compromised survival and smoking cessation should be recommended.
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Affiliation(s)
- Jun-Xi Xiang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
| | - Liang-Shuo Hu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
| | - Peng Liu
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
| | - Bo-Yan Tian
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Qing Su
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yi-Chun Ji
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- Regenerative Medicine and Surgery Engineering Research Center of Shaanxi Province, Xi’an 710061, Shaanxi Province, China
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Prevalence of exocrine pancreatic insufficiency in patients with chronic pancreatitis without follow-up. PANCR-EVOL Study. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:77-86. [PMID: 28935122 DOI: 10.1016/j.gastrohep.2017.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/20/2017] [Accepted: 08/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Exocrine pancreatic insufficiency (EPI) is an important complication of chronic pancreatitis (CP). Guidelines recommend to rule out EPI in CP, to detect those patients who would benefit from pancreatic enzyme replacement therapy. The aim of this study was to evaluate the prevalence of EPI in patients with CP without follow-up in the last 2 years and to describe their nutritional status and quality of life (QoL). METHODS This was a cross-sectional, multicenter Spanish study. CP patients without follow-up by a gastroenterologist or surgeon in at least 2 years were included. EPI was defined as fecal elastase test <200mcg/g. For nutritional assessment, laboratory and anthropometric data were obtained. QoL was investigated using the EORTC QLQ-C30 questionnaire. RESULTS 64 patients (mean age 58.8±10.3 years, 85.9% men) from 10 centers were included. Median time since diagnosis of CP was 58.7 months [37.7-95.4]. Forty-one patients (64.1%) had EPI. Regarding nutritional status, the following differences were observed (EPI vs. Non-EPI): BMI (23.9±3.5kg/m2 vs. 25.7±2.5, p=0.03); glucose (121 [96-189] mg/dL vs. 98 [90-116], p=0.006); HbA1c 6.6% [6.0-8.4] vs. 5.5 [5.3-6.0], p=0.0005); Vitamin A (0.44mg/L [0.35-0.57] vs. 0.53 [0.47-0.63], p=0.048) and Vitamin E (11.2±5.0μg/ml vs. 14.4±4.3, p=0.03). EPI group showed a worse EORTC QLQ-C30 score on physical (93.3 [66.7-100] vs. 100 [93.3-100], p=0.048) and cognitive function (100 [83.3-100] vs. 100 [100-100], p=0.04). CONCLUSIONS Prevalence of EPI is high in patients with CP without follow-up. EPI group had higher levels of glucose, lower levels of vitamins A and E and worse QoL.
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Abstract
Chronic pancreatitis is defined 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. Potential causes can include toxic factors (such as alcohol or smoking), metabolic abnormalities, idiopathic mechanisms, genetics, autoimmune responses and obstructive mechanisms. The pathophysiology of chronic pancreatitis is fairly complex and includes acinar cell injury, acinar stress responses, duct dysfunction, persistent or altered inflammation, and/or neuro-immune crosstalk, but these mechanisms are not completely understood. Chronic pancreatitis is characterized by ongoing inflammation of the pancreas that results in progressive loss of the endocrine and exocrine compartment owing to atrophy and/or replacement with fibrotic tissue. Functional consequences include recurrent or constant abdominal pain, diabetes mellitus (endocrine insufficiency) and maldigestion (exocrine insufficiency). Diagnosing early-stage chronic pancreatitis is challenging as changes are subtle, ill-defined and overlap those of other disorders. Later stages are characterized by variable fibrosis and calcification of the pancreatic parenchyma; dilatation, distortion and stricturing of the pancreatic ducts; pseudocysts; intrapancreatic bile duct stricturing; narrowing of the duodenum; and superior mesenteric, portal and/or splenic vein thrombosis. Treatment options comprise medical, radiological, endoscopic and surgical interventions, but evidence-based approaches are limited. This Primer highlights the major progress that has been made in understanding the pathophysiology, presentation, prevalence and management of chronic pancreatitis and its complications.
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Szücs Á, Marjai T, Szentesi A, Farkas N, Párniczky A, Nagy G, Kui B, Takács T, Czakó L, Szepes Z, Németh BC, Vincze Á, Pár G, Szabó I, Sarlós P, Illés A, Gódi S, Izbéki F, Gervain J, Halász A, Farkas G, Leindler L, Kelemen D, Papp R, Szmola R, Varga M, Hamvas J, Novák J, Bod B, Sahin-Tóth M, Hegyi P. Chronic pancreatitis: Multicentre prospective data collection and analysis by the Hungarian Pancreatic Study Group. PLoS One 2017; 12:e0171420. [PMID: 28207747 PMCID: PMC5313152 DOI: 10.1371/journal.pone.0171420] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 01/20/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life. Aims and methods Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions. Results Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004). Conclusions According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.
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Affiliation(s)
- Ákos Szücs
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Tamás Marjai
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs, Hungary
| | | | - György Nagy
- Second Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás Takács
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | | | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Anita Illés
- Division of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Division of Translational Medicine, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Ferenc Izbéki
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Judit Gervain
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Adrienn Halász
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Gyula Farkas
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - László Leindler
- Department of Surgery, University of Szeged, Szeged, Hungary
| | - Dezső Kelemen
- Department of Surgery, University of Pécs, Pécs, Hungary
| | - Róbert Papp
- Department of Surgery, University of Pécs, Pécs, Hungary
| | - Richárd Szmola
- Department of Interventional Gastroenterology, National Institute of Oncology, Budapest, Hungary
| | | | | | - János Novák
- Pándy Kálmán Hospital of Békés County, Gyula, Hungary
| | | | - Miklós Sahin-Tóth
- Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Division of Translational Medicine, First Department of Medicine, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences—University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
- * E-mail:
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Abstract
OBJECTIVES Tobacco exposure is an established risk factor for pancreatic cancer and chronic pancreatitis; however, its role in pancreatic insufficiency is not clear. METHODS This controlled, cross-sectional study examined smokers and nonsmokers with no history of pancreatic disease. Histories and validated inventories of alcohol and tobacco use were obtained, and pancreatic insufficiency was assessed using the fecal elastase-1 assay. RESULTS Of 7854 patients approached, 226 were interviewed and 200 enrolled. The rates of pancreatic insufficiency [18% (18/100)] and severe pancreatic insufficiency [10% (10/100)] were significantly higher in smokers than in controls [6% (6/100), P = 0.009 and 1% (1/100), P = 0.010, respectively]. On multivariate logistic regression, the risk of pancreatic insufficiency in smokers was significantly increased [odds ratio, 4.34 (1.37-13.75); P = 0.012], controlling for alcohol use and relevant covariates. Tobacco exposure was associated with the highest odds ratio for pancreatic insufficiency. Alcohol consumption was strongly associated with tobacco exposure (P < 0.001), but not with pancreatic insufficiency by multivariate analysis (P = 0.792). CONCLUSIONS This study suggests that tobacco exposure is independently associated with pancreatic exocrine insufficiency in patients without a prior diagnosis of pancreatic disease. Tobacco exposure seems to have greater detrimental effects on pancreatic function than alcohol in this population.
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Blayney MJ, Nguyen A, Aboulafia DM. Diagnosis and Management of a Pancreaticopleural Fistula in a Patient with AIDS and a Large Pleural Effusion. J Int Assoc Provid AIDS Care 2016; 15:459-462. [PMID: 27655836 DOI: 10.1177/2325957416668578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pleural effusions typically present with nonspecific pulmonary complaints in the setting of either acute or chronic diseases. In the general population, these illnesses include congestive heart failure, infection, and malignancy. However, in people living with HIV/AIDS (PLWHA), pleural effusions often result from opportunistic infections and AIDS-defining malignancies, such as Kaposi sarcoma and non-Hodgkin lymphoma. Since the introduction of highly active antiretroviral therapy, there has been a decline in the frequency of AIDS-defining opportunistic infections and AIDS-defining cancers and an increase in certain non-AIDS-defining malignancies including lung cancer. Throughout this period, longer life expectancy in PLWHA has contributed to an increased risk of those chronic diseases that can result in pleural effusions. This case describes an HIV-infected man who was an active cigarette smoker and alcoholic and who presented with a large pleural effusion of uncertain etiology. The authors review several important noncardiac risk factors associated with pleural effusions in PLWHA. The authors also emphasize the importance of obtaining a detailed medical history and the use of appropriate imaging and laboratory tests in order to identify an underlying cause and to provide optimal treatment.
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Affiliation(s)
- Margaret J Blayney
- Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA
| | - Andy Nguyen
- Graduate Medical Education, Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Section of Hematology Oncology, Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington, Seattle, WA, USA
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Das R, Clarke B, Tang G, Papachristou GI, Whitcomb DC, Slivka A, Yadav D. Endoscopic sphincterotomy (ES) may not alter the natural history of idiopathic recurrent acute pancreatitis (IRAP). Pancreatology 2016; 16:770-7. [PMID: 27450967 DOI: 10.1016/j.pan.2016.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of endoscopic sphincterotomy (ES) in idiopathic recurrent acute pancreatitis (IRAP) is unclear. We hypothesized that ES will alter the natural history of IRAP. METHODS We retrospectively studied the course of 50 IRAP patients from the NAPS2 study from UPMC based on whether they underwent ES or were managed medically. Data included age at first AP, rate of attacks, and history of severe AP. Primary outcomes were any subsequent AP and rate of attacks; secondary outcome was chronic pancreatitis (CP) diagnosis during follow-up. Similar data was abstracted for alcoholic RAP. RESULTS When compared with medically managed IRAP patients (n = 24, 48%), those who underwent ES (n = 26, 52%) had similar rate of attacks/year (median 1.54 vs. 1.41, p = 0.63), but significantly more attacks (median 3 vs. 2, p = 0.04) at baseline. During follow-up (median 7 years), rate of attacks/year decreased significantly, and were similar in both groups (median 0.16 vs. 0, p = ns). Predictors for rate of attacks during follow-up were sex (ratio 0.54 in females, p = 0.045) and rate of attacks at baseline (ratio for doubling 1.2, p = 0.025), but not ES. Alcoholic RAP patients had lower rate of attacks at baseline, but higher risk of subsequent AP (80 vs. 46%, p = 0.021) and rate of attacks/year (median 0.25 vs. 0, p = 0.016) during follow-up. Progression to CP occurred in IRAP and ES, medically managed IRAP, and alcoholic RAP in 27%, 8% and 27% respectively (p = ns). CONCLUSIONS ES, chosen in patients with higher burden of attacks, does not seem to impact the natural history of IRAP.
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Affiliation(s)
- Rohit Das
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bridger Clarke
- South Hills Gastroenterology Associates, Clairton, PA, USA
| | - Gong Tang
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Toxic-metabolic Risk Factors in Pediatric Pancreatitis: Recommendations for Diagnosis, Management, and Future Research. J Pediatr Gastroenterol Nutr 2016; 62:609-17. [PMID: 26594832 PMCID: PMC4805437 DOI: 10.1097/mpg.0000000000001035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatitis in children can result from metabolic and toxic risk factors, but the evidence linking these factors is sparse. We review the evidence for association or causality of these risk factors in pancreatitis, discuss management strategies, and their rationale. We conducted a review of the pediatric pancreatitis literature with respect to the following risk factors: hyperlipidemia, hypercalcemia, chronic renal failure, smoking exposure, alcohol, and medications. Areas of additional research were identified. Hypertriglyceridemia of 1000 mg/dL or greater poses an absolute risk for pancreatitis; persistent elevations of calcium are predisposing. Further research is necessary to determine whether end-stage renal disease leads to increased pancreatitis in children similar to adults. It is unknown whether cigarette smoking exposure, which clearly increases risk in adults, also increases risk in children. The role of alcohol in pediatric pancreatitis, whether direct or modifying, needs to be elucidated. The evidence supporting most cases of medication-induced pancreatitis is poor. Drug structure, improper handling of drug by host, and bystander status may be implicated. Other pancreatitis risk factors must be sought in all cases. The quality of evidence supporting causative role of various toxic and metabolic factors in pediatric pancreatitis is variable. Careful phenotyping is essential, including search for other etiologic risk factors. Directed therapy includes correction/removal of any agent identified, and general supportive measures. Further research is necessary to improve our understanding of these pancreatitis risk factors in children.
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Parekh D, Natarajan S. Surgical Management of Chronic Pancreatitis. Indian J Surg 2015; 77:453-69. [PMID: 26722211 DOI: 10.1007/s12262-015-1362-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.
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Affiliation(s)
- Dilip Parekh
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033 USA
| | - Sathima Natarajan
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033 USA ; Department of Pathology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
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Heavy Smoking Is Associated With Lower Age at First Episode of Acute Pancreatitis and a Higher Risk of Recurrence. Pancreas 2015; 44:876-81. [PMID: 25906444 DOI: 10.1097/mpa.0000000000000364] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE There is limited data on cigarette smoking and the risk of acute pancreatitis (AP). We evaluated the influence of cigarette smoking on AP risk and clinical presentation in a large cohort of Veteran's Administration (VA) patients. METHODS Retrospective study of VA patients from 1998 to 2007. Exclusion criteria included (1) history of chronic pancreatitis (n = 3222) or gallstones (n = 14,574) and (2) age younger than 15 years (n = 270). A 2-year washout period was used to exclude patients with pre-existing recurrent AP. RESULTS The study included 484,624 patients. From 2001 to 2007, a total of 6799 (1.4%) patients had AP. Alcohol (risk ratio, 4.20) and smoking (risk ratio, 1.78) were independent significant risk factors of AP on multiple regression analysis. Smoking increased the risk of AP in both nonalcoholics (0.57% vs 1.1%) and alcoholics (2.6% vs 4.1%). Smoking was associated with younger mean age at first episode of AP and higher likelihood of recurrent AP (≥4 episodes) in both nonalcoholics and alcoholics. The interval between recurrent episodes was not altered by alcohol or smoking. CONCLUSIONS In a large cohort of VA patients, smoking is an independent risk factor for AP and augmented the effect of alcohol on the risk, age of onset, and recurrence of AP.
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Abstract
Acute pancreatitis, an inflammatory disorder of the pancreas, is the leading cause of admission to hospital for gastrointestinal disorders in the USA and many other countries. Gallstones and alcohol misuse are long-established risk factors, but several new causes have emerged that, together with new aspects of pathophysiology, improve understanding of the disorder. As incidence (and admission rates) of acute pancreatitis increase, so does the demand for effective management. We review how to manage patients with acute pancreatitis, paying attention to diagnosis, differential diagnosis, complications, prognostic factors, treatment, and prevention of second attacks, and the possible transition from acute to chronic pancreatitis.
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Affiliation(s)
- Paul Georg Lankisch
- Department of General Internal Medicine and Gastroenterology, Clinical Centre of Lüneburg, Lüneburg, Germany.
| | - Minoti Apte
- Pancreatic Research Group, South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter A Banks
- Division of Gastroenterology, Hepatology, and Endoscopy, Harvard Medical School, and Brigham and Women's Hospital, Boston, MA, USA
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Abstract
OBJECTIVES Cigarette smoking is an independent risk factor for chronic pancreatitis. We conducted a systematic review of the literature assessing whether cigarette smoking is a risk factor for acute pancreatitis (AP) and recurrent AP (RAP). METHODS MEDLINE, PubMed, Embase, and Cochrane Database of Systematic Reviews were searched for studies published from database inception through March 2013. Two investigators independently reviewed articles for eligibility; discordant decisions were resolved by a third investigator's review and consensus. When there were sufficient studies, random-effects meta-analyses were performed by estimating pooled hazards ratios (HRs) with 95% confidence intervals (CIs). RESULTS Twelve studies met the eligibility criteria: 7 for AP, 5 for RAP. Compared with never smokers, the risk for AP was significantly increased in current smokers (6 studies; HR, 1.75; 95% CI, 1.26-2.44) and former smokers (5 studies; HR, 1.63; 95% CI, 1.18-2.27). Compared with never smokers, ever smokers were at higher risk for developing RAP (5 studies; HR, 1.59; 95% CI, 1.19-2.12). CONCLUSIONS This meta-analysis provides supportive evidence for the association of smoking status and AP. This effect is most pronounced for current smokers, but the risk exists among the former smokers compared with never smokers. There was an increased risk for RAP among ever smokers compared with that among never smokers.
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Maire F, Rebours V, Vullierme MP, Couvelard A, Lévy P, Hentic O, Palazzo M, Hammel P, Ruszniewski P. Does tobacco influence the natural history of autoimmune pancreatitis? Pancreatology 2014; 14:284-8. [PMID: 25062878 DOI: 10.1016/j.pan.2014.05.793] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/19/2014] [Accepted: 05/20/2014] [Indexed: 02/07/2023]
Abstract
UNLABELLED Tobacco recently appeared as a major independent factor adversely influencing the natural course of alcoholic chronic pancreatitis. However, the role of tobacco in patients with autoimmune pancreatitis (AIP) has never been studied. Type 2 AIP is associated with inflammatory bowel disease, especially ulcerative colitis in which smoking is protective. The aim of our study was to evaluate the influence of smoking on course of AIP. PATIENTS AND METHODS All consecutive patients followed in our centre for AIP according to ICDC were studied. Tobacco consumption was recorded. A relation between smoking and all event related to AIP was searched for. RESULTS 96 patients with type 1 (73%) or type 2 (27%) AIP were included; 76% of patients were low smokers (never, ex- or smokers <10 p.y.) and 24% were high smokers (≥10 p.y.). The mean follow-up was 60 months [5-188]. AIP relapse was observed in 26% of patients. At the end-point, smokers ≥10 p.y. presented more frequently diabetes (50% vs 27%, p = 0.04) and imaging pancreatic damages (59% vs 34%, p = 0.02) than low smokers. There was also a non significant tendency to observe more frequently exocrine insufficiency and relapse in smokers ≥10 pack-year. No protective effect of smoking was observed in the subgroup of patients with type 2 AIP and ulcerative colitis. CONCLUSIONS In patients with AIP, high tobacco intake is associated with the risk of imaging pancreatic damages and with the occurrence of diabetes. Smoking cessation should be recommended.
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Affiliation(s)
- Frédérique Maire
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France.
| | - Vinciane Rebours
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Marie Pierre Vullierme
- Department of Radiology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Anne Couvelard
- Department of Pathology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Philippe Lévy
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Olivia Hentic
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Maxime Palazzo
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Pascal Hammel
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
| | - Philippe Ruszniewski
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, and Paris-Diderot University, Paris, France
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Fisetin attenuates cerulein-induced acute pancreatitis through down regulation of JNK and NF-κB signaling pathways. Eur J Pharmacol 2014; 737:149-58. [PMID: 24861022 DOI: 10.1016/j.ejphar.2014.05.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/15/2014] [Accepted: 05/16/2014] [Indexed: 11/24/2022]
Abstract
Acute pancreatitis (AP) is a complicated disease which is largely undiscovered. Fisetin, a natural flavonoid from fruits and vegetables, has been shown to have anti-inflammatory, antioxidant, and anti-cancer activities in various disease models. However, the effects of fisetin on AP have not been determined. Pre- and post- treatment of mice with fisetin reduced the severity of AP and pancreatitis-associated lung injury and inhibited several biochemical parameters (pancreatic weight to body weight ratio, amylase, lipase, and myeloperoxidase activity) and production of inflammatory cytokines. In pancreatic acinar cells, fisetin also inhibited cell death and production of inflammatory cytokines. In addition, fisetin inhibited activation of c-Jun NH2-terminal kinase (JNK) and nuclear factor (NF)-κB in vivo and in vitro. In conclusion, these results suggest that fisetin exhibits anti-inflammatory effect on AP and could be a beneficial agent in the treatment of AP and its pulmonary complications.
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Brock C, Nielsen LM, Lelic D, Drewes AM. Pathophysiology of chronic pancreatitis. World J Gastroenterol 2013; 19:7231-7240. [PMID: 24259953 PMCID: PMC3831204 DOI: 10.3748/wjg.v19.i42.7231] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 07/09/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis (CP) is an inflammatory disease of the pancreas characterized by progressive fibrotic destruction of the pancreatic secretory parenchyma. Despite the heterogeneity in pathogenesis and involved risk factors, processes such as necrosis/apoptosis, inflammation or duct obstruction are involved. This fibrosing process ultimately leads to progressive loss of the lobular morphology and structure of the pancreas, deformation of the large ducts and severe changes in the arrangement and composition of the islets. These conditions lead to irreversible morphological and structural changes resulting in impairment of both exocrine and endocrine functions. The prevalence of the disease is largely dependent on culture and geography. The etiological risk-factors associated with CP are multiple and involve both genetic and environmental factors. Throughout this review the M-ANNHEIM classification system will be used, comprising a detailed description of risk factors such as: alcohol-consumption, nicotine-consumption, nutritional factors, hereditary factors, efferent duct factors, immunological factors and miscellaneous and rare metabolic factors. Increased knowledge of the different etiological factors may encourage the use of further advanced diagnostic tools, which potentially will help clinicians to diagnose CP at an earlier stage. However, in view of the multi factorial disease and the complex clinical picture, it is not surprising that treatment of patients with CP is challenging and often unsuccessful.
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American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400-15; 1416. [PMID: 23896955 DOI: 10.1038/ajg.2013.218] [Citation(s) in RCA: 1301] [Impact Index Per Article: 118.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 06/18/2013] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.
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