Value of genetic testing in the management of pancreatitis

Acute pancreatitis in childhood - a comparative international study and tale of two cities

BACKGROUNDS

To compare factor(s) contributing to aetiology, management and clinical outcome(s) of paediatric patients acquiring acute pancreatitis (AP) at two major university paediatric surgical centres in Liverpool and Bangkok.

METHODS

All patients (<18 years) with an index diagnosis of AP (ICD 10 coding) during 2006-2016 were studied.

RESULTS

121 patients included n = 79 (65.3%) in Thailand versus n = 42 (34.7%) in the UK centre with no difference(s) in age at diagnosis at 10.4 ± 4.5 and 11.7 ± 6 years. (P = 0.12). Major AP aetiology(s) in Thailand were medications (39.2%) and choledochal cysts (8.9%). In the UK-gallstone disease (21.4%), and medications (16.7%) were leading factors (P < 0.01). Ultrasonography was deployed more frequently in the UK versus Thai centre (74.3% vs. 49.1%; P < 0.01). Pancreatitis was confirmed by imaging in 67.9% (Thai) and 62.9% (UK) patients (P = 0.47). Most patients at both centres had a mild-grade pancreatitis illness (95% Thai vs. 90.5% UK; P = 0.28) while 12.7% of Thai and 19% of UK children developed pancreatitis-related complication (P = 0.37). Overall mortality rate (%) was significantly higher in the Thai versus UK centre (27.8% vs. 9.5%; P = 0.02).

CONCLUSIONS

Aetiology of acute pancreatitis appears to vary between UK and Thailand children. Timely early diagnosis and healthcare pathways may be driven by local patient-related factor(s). The higher mortality (%) observed in Thailand versus UK in this comparative study was linked to underlying co-existent chronic medical condition(s) in vulnerable patient cohorts.

Recurrence rates and risk factors for recurrence after first episode of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

There are a certain number of acute pancreatitis (AP) patients who may suffer from multiple episodes and develop recurrent acute pancreatitis (RAP), but recurrence rates and associated risk factors for RAP vary significantly in the published literature.

METHODS

We searched PubMed, Web of Science, Scopus, and Embase databases to identify all publications reporting AP recurrence until October 20th, 2022. Meta-analysis and meta-regression were performed to calculate the pooled estimates using the random-effects model.

RESULTS

A total of 36 studies met the inclusion criteria and all were used in pooled analyses. The overall rate of recurrence after first-time AP was 21% (95% CI, 18%- 24%), and pooled rates in biliary, alcoholic, idiopathic, and hypertriglyceridemia etiology patients were 12%, 30%, 25%, and 30%, respectively. After managing underlying causes post-discharge, the recurrence rate decreased (14% versus 4% for biliary, 30% versus 6% for alcoholic, and 30% versus 22% for hypertriglyceridemia AP). An increased risk of recurrence was reported in patients with a smoking history (odds ratio [OR] = 1.99), alcoholic etiology (OR = 1.72), male sex (hazard ratio [HR] = 1.63), and local complications (HR = 3.40), while biliary etiology was associated with lower recurrence rates (OR = 0.38).

CONCLUSION

More than one-fifth of AP patients experienced recurrence after discharge, with the highest recurrence rate in alcoholic and hypertriglyceridemia etiologies, and managing underlying causes post-discharge was related to decreased incidence. In addition, smoking history, alcoholic etiology, male gender, and presence of local complications were independent risks for the recurrence.

Clinical and genetic determinants of severe acute pancreatitis: A genetic association study in the UK Biobank

BACKGROUND AND AIM

The clinical severity of acute pancreatitis is unpredictable, ranging from self-limiting disease to life-threatening inflammation. The determinants of severe acute pancreatitis (SAP) are unclear. We aim to identify clinical variables and single nucleotide polymorphisms (SNP) associated with SAP.

METHODS

We used UK Biobank data to conduct a case-control clinical and genetic association study. Pancreatitis patients were identified through national hospital and mortality records across the United Kingdom. Clinical covariates and SAP were analyzed for associations. Genotyped data that included 35 SNPs were assessed for independent associations with SAP and SNP to SNP interaction.

RESULTS

A total of 665 patients with SAP and 3304 non-SAP patients were identified. Male sex and older age increased odds of developing SAP (odds ratio [OR] 1.48; 95% confiden interval [CI] 1.24-1.78, P < 0.0001) and (OR 1.23; 95% CI 1.17-1.29), P < 0.0001), respectively. SAP was associated with diabetes (OR 1.46; 95% CI 1.15-1.86, P = 0.002), chronic kidney disease (OR 1.74; 95% CI 1.26-2.42, P = 0.001), and cardiovascular disease (OR 2.00; 95% CI 1.54-2.61, P = 0.0001). A significant association was established between IL-10 rs3024498 and SAP (OR 1.24; 95% CI 1.09-1.41, P = 0.0014). Epistasis analysis revealed that the odds of SAP was greater by an interaction between TLR 5 rs5744174 and Factor V rs6025 (ORinteraction 7.53; P = 6.64 × 10-5 ).

CONCLUSION

This study reports clinical risk factors for SAP. We also show evidence for an interaction between rs5744174 and rs6025 as determinants for SAP in addition to rs3024498 independently altering the severity of acute pancreatitis.

Diagnosis and Management of Acute Pancreatitis in Pregnancy

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.

A Nano-Liposomal Formulation of Caffeic Acid Phenethyl Ester Modulates Nrf2 and NF-κβ Signaling and Alleviates Experimentally Induced Acute Pancreatitis in a Rat Model

The currently available management strategies for acute pancreatitis are inadequately effective which calls for exploration of new approaches to treat this condition. Caffeic acid phenethyl ester (CAPE) is a major bioactive constituent of honeybee propolis with promising therapeutic and preventive applications. However, its pharmaceutical potential and clinical use are hindered by its poor water solubility and limited plasma stability. In this study, we aimed to prepare, characterize and evaluate a CAPE-loaded nanoliposomal formulation to improve the efficacy of CAPE for the management of acute pancreatitis. The CAPE-loaded nanoliposomes (CAPE-loaded-NL) were prepared by a thin layer evaporation technique and were optimized using three edge activators. CAPE-loaded-NL were characterized for their vesicle size (VS), zeta potential (ZP), encapsulation efficiency (EE), polydispersity index (PDI), crystalline state and morphology. The protective effect of the optimal CAPE-loaded-NL was evaluated in a rat model of acute pancreatitis induced by administering a single intraperitoneal injection of L-ornithine. Oral pretreatment with CAPE-loaded-NL significantly counteracted ornithine-induced elevation in serum activities of pancreatic digestive enzymes and pancreatic levels of malondialdehyde, nuclear factor kappa B (NF-κB) p65, tumor necrosis factor-alpha, nitrite/nitrate, cleaved caspase-3 and myeloperoxidase activity. Moreover, pretreatment with CAPE-loaded-NL significantly reinstated the ornithine-lowered glutathione reductase activity, glutathione, nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 levels and ATP/ADP ratio, and potentiated the Bcl-2/Bax ratio in pancreatic tissue. CAPE-loaded-NL displayed superior antioxidant, anti-inflammatory and anti-apoptotic effects compared to free CAPE oral suspension and achieved a more potent correction of the derangements in serum amylase and pancreatic myeloperoxidase activities. The histological observations were in line with the biochemical findings. Our results suggest that CAPE-loaded-NL provide a promising interventional approach for acute pancreatitis mainly through the enhancement of the exerted antioxidant, anti-inflammatory and anti-apoptotic effects which may be mediated, at least in part, through modulation of Nrf2 and NF-κβ signaling.

Delayed presentation of cannabis induced pancreatitis

A thorough history and identifying risk factors are pivotal in establishing the cause of pancreatitis and preventing recurrences to curb the incidence of chronic pancreatitis and/or pancreatic cancer.

Genetic Evaluation of Pancreatitis

Hereditary pancreatitis (HP) is a rare inherited chronic pancreatitis (CP) with strong genetic associations, with estimated prevalence ranging from 0.3 to 0.57 per 100,000 across Europe, North America, and East Asia. Apart from the most well-described genetic variants are PRSS1, SPINK1, and CFTR, many other genes, such as CTRC, CPA1, and CLDN2 and CEL have been found to associate with HP, typically in one of the 3 main mechanisms such as altered trypsin activity, pancreatic ductal cell secretion, and calcium channel regulation. The current mainstay of management for patients with HP comprises genetic testing for eligible individuals and families, alcohol and tobacco cessation avoidance, pain control, and judicious screening for complications, including exocrine and endocrine insufficiency and pancreatic cancer.

Pancreatitis and pancreatic cancer: A case of the chicken or the egg

Acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer are three distinct pancreatic diseases with different prognoses and treatment options. However, it may be difficult to differentiate between benign and malignant disease. AP may be a first symptom of pancreatic cancer, particularly in patients between the ages of 56 and 75 with presumed idiopathic AP who had a concomitant diagnosis of new-onset diabetes mellitus or patients who present with CP at diagnosis of AP. In these patients, additional imaging is warranted, preferably by endoscopic ultrasonography. CP may lead to pancreatic cancer through oncogenic mutations, mostly in patients with hereditary CP, and in patients in whom risk factors for pancreatic cancer (e.g., nicotine and alcohol abuse) are also present. Patients with PRSS1-mediated CP and patients with a history of autosomal dominant hereditary CP without known genetic mutations may be considered for surveillance for pancreatic cancer. Pancreatic inflammation may mimic pancreatic cancer by appearing as a focal mass-forming lesion on imaging. Differentiation between the above mentioned benign and malignant disease may be facilitated by specific features like the duct-penetrating sign and the duct-to-parenchyma ratio. Research efforts are aimed towards developing a superior discriminant between pancreatitis and pancreatic cancer in the form of imaging modalities or biomarkers. This may aid clinicians in timely diagnosing pancreatic cancer in a potentially curable stage.

The histopathology of SPINK1-associated chronic pancreatitis

BACKGROUND

The identification of genetic risk factors for chronic pancreatitis, such as PRSS1, CFTR and SPINK1, provides the opportunity to define key pathologic hallmarks and etiologic-specific changes. For example, pancreata from PRSS1 and CFTR patients exhibit progressive lipomatous atrophy without significant fibrosis. Considering the pathology of SPINK1-associated pancreatitis is ill-defined, we examined the pancreata of SPINK1 patients with chronic pancreatitis.

METHODS

Histologic sections after total pancreatectomy with islet autotransplantation and associated clinicopathologic data were collected from 28 patients with SPINK1 germline alterations. Clinical findings, germline data, anatomic anomalies and pathologic findings were descriptively evaluated.

RESULTS

Patients ranged in age from 5 to 48 years (median, 21.6 years) with abdominal pain between 2 and 25 years (median, 5.8 years). Most patients were SPINK1 heterozygous and 14 (50%) had co-occurring CFTR (n = 12) and CTRC (n = 2) mutations. Other pancreatitis risk factors included anatomic anomalies (n = 9) and tobacco use (n = 1). Overall, 24 (86%) patients had additional pancreatitis-associated germline alterations, SPINK1 homozygosity, anatomic anomalies or environmental factors. Examination of pancreata revealed a sequential pattern of exocrine parenchymal loss and replacement by prominent fibrosis, dependent on the duration of abdominal pain. No malignancies were identified, but low-grade pancreatic intraepithelial neoplasia was present for 2 cases.

CONCLUSIONS

Within this descriptive study, SPINK1-associated pancreatitis is characterized by parenchymal fibrosis and suggests divergent pathophysiologic mechanisms from PRSS1 and CFTR-associated pancreatitis. Moreover, SPINK1 patients frequently had additional etiologic factors that did not impact the development of pancreatic fibrosis and may implicate SPINK1 as a disease modifier gene.

Acute pancreatitis in children: Updates in epidemiology, diagnosis and management

Acute pancreatitis (AP), manifesting as acute onset of abdominal pain, vomiting, and nausea, is increasingly being recognized in children secondary to increased awareness, more identifiable etiologies as well as advances in diagnostic capabilities, like imaging. Despite this increased awareness and ability for more frequent diagnoses, the natural history of AP remains poorly understood leading to gaps in approach and management, especially in children. Coupled with poor epidemiologic and management awareness, there remains a lack of understanding of the long term implications of severe acute pancreatitis (SAP). Hence, the role of the primary care clinician in the early diagnosis, and management, remains critical and may affect the need for consultation with pediatric sub-specialists like gastroenterologists. This review provides guidelines regarding epidemiology, diagnosis, and management strategies to address some of these gaps.

The Impact of Cannabis Consumption on Mortality, Morbidity, and Cost in Acute Pancreatitis Patients in the United States: A 10-Year Analysis of the National Inpatient Sample

OBJECTIVES

The aim of this study was to identify the prevalence of cannabis use among all patients admitted with acute pancreatitis (AP) in the United States and to investigate the impact of cannabis use on AP mortality, morbidity, and cost of care.

METHODS

The National Inpatient Sample database from 2003 to 2013 was queried for all patients with AP and active exposure to cannabis. Outcomes included in-hospital mortality, length of stay, inflation adjusted charges, acute kidney injury, acute respiratory distress syndrome, and shock. Results were adjusted for age, sex, race, Charlson comorbidity index, median income quartile, and hospital characteristics.

RESULTS

More than 2.8 million patients with AP patients were analyzed. Cannabis-exposed (CE) patients' prevalence was 0.3%. Patients exposed to cannabis were younger and mostly males compared with non-cannabis-exposed patients. After adjusting for these factors, the CE group had significantly lower inpatient mortality compared with the noncannabis group (odds ratio, 0.17; 95% confidence interval, 0.06-0.53). Cannabis-exposed patients also had decreased length of stay, inflation-adjusted charges, acute kidney injury, ileus, shock, acute respiratory distress syndrome, and parenteral nutrition requirement.

CONCLUSIONS

Cannabis-exposed hospitalized patients with AP had lower age-adjusted, mortality, morbidity, and hospitalization-cost than non-cannabis-exposed patients.

The Role of Genetics in Pancreatitis

Individuals with acute recurrent and chronic pancreatitis may have an inherited predisposition to the development of the disease. Pancreatitis in the setting of a significant family history of the disease can be classified as hereditary or familial pancreatitis. In this article, the authors closely examine the specific genes implicated in pancreatitis, investigate the role of genetic testing for diagnosis, and describe the impact of genetic testing results on clinical management.

Is There an Effect of Cannabis Consumption on Acute Pancreatitis?

BACKGROUND AND AIM

Twenty-percentage of acute pancreatitis (AP) cases is labeled as idiopathic. Cannabis remains the most frequently used illicit drug in the world. The aim of this study was to identify the prevalence of cannabis use among all patients with a first episode of AP, particularly in those labeled as idiopathic etiology, and determine any effect on AP severity.

METHODS

Retrospective cohort of all consecutive patients admitted with a first episode of AP at a large tertiary referral hospital from 01/2013 through 12/2014. AP was identified by ICD9 code, or lipase ≥ 3 times the upper limit of normal and abdominal pain consistent with AP. Cannabis users (CU) were identified via history or urine toxicology.

RESULTS

Four hundred and sixty patients were included. 54% were men, with a mean age of 48 years (range 17-89 years). Forty-eight patients (10%) were identified as CU. After adjusting for admission SIRS, age, and gender, cannabis use was not found to be an independent risk factor for persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU admission, length of stay, in-hospital infections, nor recurrent AP. Of note, AKI was least common among non-CU compared to CU (OR 0.4; p = 0.02; CI 0.2-0.9) and non-CU had a higher admission BISAP score (≥ 2) compared to CU (OR 2.5; p = 0.009; CI 1.2-4.9).

CONCLUSION

This is the largest study to date examining cannabis use in AP. Cannabis use was found across almost all etiologies of AP with a prevalence of 10% (48 cases), and in 9% (9 cases) of so-called idiopathic AP cases in this cohort, which could account as an association for approximately 2% of all AP cases. Cannabis use did not independently impact AP severity or mortality.

Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management

PURPOSE OF REVIEW

There have been significant developments in the diagnosis, clinical approach, and management of patients with recurrent acute pancreatitis (RAP) in the last decade. This review systematically summarizes our current understanding of RAP.

NEW FINDINGS

Gallstones and alcohol are common causes of RAP. Non-alcohol non-biliary RAP (nAnB RAP) is a difficult group of patients after excluding these two causes because extensive workup is required to elucidate the etiology. Idiopathic RAP is diagnosed after excluding all the known causes and recurrence is noted to be higher in such patients. Patients with non-biliary RAP are prone to develop chronic pancreatitis (CP) suggesting a continuum from acute to recurrent to chronic pancreatitis. Often, patients destined to develop CP present at an earlier stage with RAP. Endoscopic ultrasound and magnetic resonance cholangiopancreatography (MRCP) are the investigations of choice to detect microlithiasis, choledocholithiasis, ductal abnormalities, peri-ampullary malignancies, and early changes of chronic pancreatitis. The role of pancreas divisum, sphincter of Oddi dysfunction, and anomalous pancreatobiliary union in causing RAP is controversial. Genetic testing may be advisable in younger patients.

CONCLUSION

With a focused approach and appropriate investigations, the etiology of RAP can be identified in a significant proportion of patients. Therapeutic options are limited and future research is needed to improve understanding of the disease.

A case of chronic pancreatitis exacerbation associated with pancreatic arteriovenous malformation: a case report and literature review

A 60-year-old man with an unruptured cerebral aneurysm and family history of moyamoya disease was admitted to our hospital with epigastric pain since the previous day. Serum levels of pancreatic enzyme were elevated and abdominal contrast-enhanced computed tomography showed localized enlargement of the pancreatic tail in the arterial phase and revealed numerous areas of fine mesh-like vascular hyperplasia consistent with an enlarged pancreatic tail. We diagnosed pancreatic arteriovenous malformation (P-AVM) with acute pancreatitis. Furthermore, in the pancreatic body, endoscopic ultrasonography showed lobularity (honeycombing type) and hyperechoic foci (non-shadowing), which suggests chronic pancreatitis. Acute management was performed with conservative treatment including administration of replacement fluids and proteolytic enzyme inhibitor. Distal pancreatectomy for P-AVM was performed because P-AVM is associated with acute pancreatitis recurrence, development of portal hypertension, progression of chronic pancreatitis, and refractory duodenal bleeding. Histological findings on the resected specimens revealed the anastomosis of abnormal arteries and veins, which suggested P-AVM. In addition, inflammation accompanied by fat necrosis due to ischemic infarction in the pancreatic tail, which suggested acute pancreatitis, and mild fibrosis in the pancreatic body, which suggested chronic pancreatitis, were shown. Although P-AVM is associated with various complications, symptomatic P-AVM should be considered a chronic and progressive disease.

Differential susceptibility of mouse strains on pancreatic injury and regeneration in cerulein-induced pancreatitis

Acute pancreatitis (AP), a common disease, causes significant morbidity and mortality in clinical practice. Our objective of this study was to establish an experimental mouse AP model with cerulein treatment and to explore the susceptibility of mouse strains on the severity of pancreatic injury and the subsequent repair and regeneration. C57BL/6 and FVB/N mouse strains were used in this study. AP model was induced by six hourly intraperitoneal (i.p.) injections of cerulein dissolved in saline (100 μg/kg) administered on four consecutive days. Animals were sacrificed on 1, 3 and 7 days after last cerulein treatment, and then pancreas tissues were harvested and subjected to various histological, cellular and molecular analysis. Analyses of pancreatic injury and pancreatic amylase expression indicated that this cerulein-induced AP model was established successfully and that FVB/N mice showed more severe pancreatic injury and poor recovery compared to C57BL/6 strain. Analyses of myeloperoxidase (MPO), IL-1β and NF-κB showed that FVB/N strain exhibited more severe inflammation in the pancreas compared to C57BL/6 mice. Immunofluorescence analysis of activated caspase-3 and TUNEL assay indicated that the pancreas of FVB/N strain had more apoptosis compared to C57BL/6 mice. Analysis of Ki67 indicated FVB/N mice experienced more active proliferation compared to C57BL/6 strain. Collectively, these results demonstrated that there exists differential susceptibility on pancreatic injury and regeneration between FVB/N and C57BL/6 mice in the cerulein-induced AP.

Cannabis-Induced Acute Pancreatitis: A Systematic Review

OBJECTIVES

Cannabis is the most frequently consumed illicit drug in the world, with higher prevalence under the age of 35 years. Cannabis was first reported as a possible cause of acute pancreatitis (AP) in 2004. The aim of this systematic review is to examine cannabis use as an etiology of AP.

METHODS

A search using PubMed/Medline, Embase, Scopus, and Cochrane was performed without language or year limitations to May 1, 2016. Search terms were "Cannabis" and "Acute Pancreatitis" with all permutations. The search yielded 239 results. Acute pancreatitis was defined by meeting 2 of 3 Revised Atlanta Classification criteria. Cannabis-induced AP was defined by preceding use of cannabis and exclusion of common causes of AP when reported. Sixteen papers met inclusion criteria dating from 2004 to 2016.

RESULTS

There were 26 cases of cannabis-induced AP (23/26 men; 24/26 under the age of 35 y). Acute pancreatitis correlated with increased cannabis use in 18 patients. Recurrent AP related temporally to cannabis use was reported in 15 of 26. There are 13 reports of no further AP episodes after cannabis cessation.

CONCLUSIONS

Cannabis is a possible risk factor for AP and recurrent AP, occurring primarily in young patients under the age of 35 years. Toxicology screens should be considered in all patients with idiopathic AP.

The Impact of Risk Factors of Chronic Pancreatitis on Secretin Pancreatic Function Testing: Results of a 20-Year Study

OBJECTIVES

The aim of this study was to determine the effect of established risk factors on the outcome of secretin pancreatic function testing (sPFT) in patients undergoing work-up for suspected chronic pancreatitis.

METHODS

We completed a retrospective review of patients who underwent sPFT for suspected chronic pancreatitis over 20 years. We compared peak bicarbonate concentrations between groups and completed univariate and multivariate analyses to determine associations between risk factors and positive sPFT results (peak bicarbonate <80 mEq/L).

RESULTS

Forty-three of 162 patients had positive sPFT results. There were significant differences in peak bicarbonate concentrations in patients with and without recurrent acute pancreatitis (RAP) and with local complications from acute pancreatitis (AP) (P ≤ 0.05). The bicarbonate concentration in patients with and without other risk factors such as tobacco use, alcohol use, and family history of pancreatitis was not significantly different. Female sex, a history of AP, and a history of RAP were associated with positive sPFT results on univariate analysis (P ≤ 0.05). On multivariate analysis, sex and RAP remained significant.

CONCLUSIONS

Our study demonstrates that female sex, history of AP and RAP, and AP with local complications are associated with positive sPFT results or lower peak bicarbonate concentration. However, other risk factors do not impact the results of sPFT.

An Evaluation of Factors Associated With Pathogenic PRSS1, SPINK1, CTFR, and/or CTRC Genetic Variants in Patients With Idiopathic Pancreatitis

OBJECTIVES

We evaluated factors associated with pathogenic genetic variants in patients with idiopathic pancreatitis.

METHODS

Genetic testing (PRSS1, CFTR, SPINK1, and CTRC) was performed in all eligible patients with idiopathic pancreatitis between 2010 to 2015. Patients were classified into the following groups based on a review of medical records: (1) acute recurrent idiopathic pancreatitis (ARIP) with or without underlying chronic pancreatitis; (2) idiopathic chronic pancreatitis (ICP) without a history of ARP; (3) an unexplained first episode of acute pancreatitis (AP)<35 years of age; and (4) family history of pancreatitis. Logistic regression analysis was used to determine the factors associated with pathogenic genetic variants.

RESULTS

Among 197 ARIP and/or ICP patients evaluated from 2010 to 2015, 134 underwent genetic testing. A total of 88 pathogenic genetic variants were found in 64 (47.8%) patients. Pathogenic genetic variants were identified in 58, 63, and 27% of patients with ARIP, an unexplained first episode of AP <35 years of age, and ICP without ARP, respectively. ARIP (OR: 18.12; 95% CI: 2.16-151.87; P=0.008) and an unexplained first episode of AP<35 years of age (OR: 2.46; 95% CI: 1.18-5.15; P=0.017), but not ICP, were independently associated with pathogenic genetic variants in the adjusted analysis.

CONCLUSIONS

Pathogenic genetic variants are most likely to be identified in patients with ARIP and an unexplained first episode of AP<35 years of age. Genetic testing in these patient populations may delineate an etiology and prevent unnecessary diagnostic testing and procedures.

Is acute recurrent pancreatitis in children a precursor of chronic pancreatitis? A long-term follow-up study of 93 cases

BACKGROUND/AIMS

In view of paucity of literature we analyzed our experience of acute recurrent pancreatitis (ARP) to study clinical profile and long-term outcome.

METHODS

Over 13 years, 93 consecutive children (≤18 years) diagnosed to have ARP were included in this study. Magnetic resonance cholangiopancreatography was done at baseline and on follow-up. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease inhibitor (PRSS1 R122S) and cystic fibrosis transmembrane conductance regulator (CFTR deltaF508, 5T) were studied in 22 idiopathic cases.

RESULTS

The median age of the children with ARP was 13 (10-14.5) years, 53 were males. Etiology included biliary in 14 (15%), pancreas divisum in 6 (7%), others in 3 (3.5%) and idiopathic in the remaining 70 (75%). SPINK1 mutation was found in 10/22 (45%) cases. Over a median follow-up of 25.5 (8.25-48) months, 37 (42%) of 88 (5 lost to follow-up) developed chronic pancreatitis (CP). On multivariate analysis idiopathic etiology (p<0.03), presence of SPINK1 mutation (p=0.01), longer follow-up (p<0.001) were associated with progression to CP.

CONCLUSIONS

Biliopancreatic structural/obstructive causes should always be looked for. It seems ARP is a precursor of CP and progression is associated with idiopathic etiology and presence of genetic mutations. Hence, patients with ARP should be kept on regular follow-up to detect CP.

An Update on Pediatric Pancreatitis

There has been a rise in the incidence and number of admissions of children with pancreatitis over the past 20 years. Current management practices for pancreatitis in children are adapted from standards of care for adults, and there are a lack of multicenter, prospective research studies on pancreatitis in children. There are inherent differences in the clinical presentation and natural course of pancreatitis between adults and children. This review focuses on the current understanding of the epidemiology, etiologies, evaluation, and management of children with pancreatitis. [Pediatr Ann. 2017;46(5):e207-e211.].

Genetic Susceptibility in Acute Pancreatitis: Genotyping of GSTM1, GSTT1, GSTP1, CASP7, CASP8, CASP9, CASP10, LTA, TNFRSF1B, and TP53 Gene Variants

OBJECTIVES

Genetic testing could play a critical role in diagnosis and prognosis of acute pancreatitis (AP) and guide effective therapeutic interventions. We hypothesized that genetic polymorphisms in apoptosis and oxidative stress genes could determine incidence or severity in AP.

METHODS

We conducted a hospital-based case-control study in a white Portuguese population (133 AP patients and 232 age- and sex-matched healthy controls) to evaluate the role of 15 gene polymorphisms (2 deletions and 13 single nucleotide polymorphisms [SNPs]) in oxidative stress (GSTM1, GSTT1, GSTP1) and apoptosis genes (CASP7, CASP8, CASP9, CASP10, LTA, TNFRSF1B, TP53) in AP. Criteria for AP were abdominal pain, hyperamylasemia, and contrast-enhanced computed tomography.

RESULTS

The presence of GSTM1 is associated with increased susceptibility for AP, and the GSTP1 Val105Ile SNP is associated with an increased risk for AP in men. CASP9 Phe136Leu/Phe136Phe SNPs (heterozygotes) increases the risk for mild AP (odds ratio, 3.616; 95% confidence interval, 1.151-11.364; P < 0.05), whereas the homozygotic genotype of CASP9 Ala28Val decreases risk for mild AP (odds ratio, 0.296; 95% confidence interval, 0.091-0.963; P < 0.05).

CONCLUSIONS

Our results suggest that variations in GSTM1, GSTP1, and CASP9 may influence risk for AP.

A Report of 320 Cases of Childhood Pancreatitis: Increasing Incidence, Etiologic Categorization, Dynamics, Severity Assessment, and Outcome

OBJECTIVES

Because there is paucity of data on natural history of pediatric pancreatitis, we studied prevalence, etiology, severity, and outcome of pancreatitis.

METHODS

Over 12 years consecutive children with pancreatitis were included. Pancreatitis was classified as acute (AP), acute recurrent (ARP), and chronic pancreatitis (CP) as per standard definitions.

RESULTS

The study group comprised of 320 children (age, 11.4 ± 3.5 years, 201 males); AP, 160 (50%); ARP, 67 (21%); and CP, 93 (29%). The number of cases increased progressively from 28 to 157 between first and last quarter, and there was a significant increase (r = 0.92, P < 0.001) in AP-related hospitalizations over the years. Half of AP were idiopathic, 69% had severe pancreatitis (6 died) and on follow-up (21.1 ± 20.9 months) 21.5% progressed to either ARP (n = 8) or CP (n = 24). Progression was significantly associated with idiopathic etiology. The majority of ARP (70%) and CP (88%) were idiopathic and on follow-up (23.2 ± 28.9 months) 22% of ARP developed CP.

CONCLUSIONS

There was 7-fold increase in number of hospitalization due to pancreatitis over the years. Progression of AP to ARP/CP was noted in 21.5% and ARP to CP in 22%. Thus, a subset of pancreatitis seems to be a continuum of acute to ARP and CP.

Novel method to rescue a lethal phenotype through integration of target gene onto the X-chromosome

The loss-of-function mutations of serine protease inhibitor, Kazal type 1 (SPINK1) gene are associated with human chronic pancreatitis, but the underlying mechanisms remain unknown. We previously reported that mice lacking Spink3, the murine homologue of human SPINK1, die perinatally due to massive pancreatic acinar cell death, precluding investigation of the effects of SPINK1 deficiency. To circumvent perinatal lethality, we have developed a novel method to integrate human SPINK1 gene on the X chromosome using Cre-loxP technology and thus generated transgenic mice termed “X-SPINK1“. Consistent with the fact that one of the two X chromosomes is randomly inactivated, X-SPINK1 mice exhibit mosaic pattern of SPINK1 expression. Crossing of X-SPINK1 mice with Spink3^+/− mice rescued perinatal lethality, but the resulting Spink3^−/−;XX^SPINK1 mice developed spontaneous pancreatitis characterized by chronic inflammation and fibrosis. The results show that mice lacking a gene essential for cell survival can be rescued by expressing this gene on the X chromosome. The Spink3^−/−;XX^SPINK1 mice, in which this method has been applied to partially restore SPINK1 function, present a novel genetic model of chronic pancreatitis.

Progression of recurrent acute and chronic pancreatitis: A short-term follow up study from a southern Indian centre

BACKGROUND

Little data exist on the progression of recurrent acute (RAP) and chronic pancreatitis (CP) from regions from where the entity of tropical chronic pancreatitis was originally described. The study aimed to follow up patients with RAP and CP seen at a southern Indian centre for progression of disease over time.

METHODS

Prospectively enrolled patients with RAP and CP were followed up, and the alcoholic and idiopathic subgroups were assessed for progression of structural and functional changes in the organ.

RESULTS

One hundred and forty patients (RAP = 44; 31.4 %, CP = 96; 68.5 %) were followed up over a median 12.2 (interquartile range 12.0-16.8) months. The cause was alcohol in 31 (22.1 %) and not evident in 109 (77.8 %). The disease progressed from RAP to CP in 7 (15.9 %), 6 (16.2 %) out of 37 in the idiopathic and 1 (14.2 %; p = 1.00) out of 7 in the alcoholic subgroups. Three (42.8 %) and 1 (14.2 %) developed steatorrhea and diabetes mellitus (DM), respectively, and 2 (4.5 %) developed calcification. Established CP progressed in 19 (19.7 %), 1 (1.0 %), 5 (5.2 %), 2 (2.0 %) and 11 (11.4 %) newly developed DM, steatorrhea, calcification and duct dilation during follow up. Among the idiopathic and alcoholic CP, disease progression was seen in 15 (20.8 %) out of 72 and 4 (16.6 %) out of 24 respectively.

CONCLUSIONS

Idiopathic RAP and CP progressed during the short-term follow up. This is similar to other etiological forms of pancreatitis, as described from elsewhere in the world.

Yin-Chen-Hao Tang Attenuates Severe Acute Pancreatitis in Rat: An Experimental Verification of In silico Network Target Prediction

Yin-Chen-Hao Tang (YCHT) is a classical Chinese medicine compound that has a long history of clinical use in China for the treatment of inflammatory diseases. However, the efficacy and mechanisms of YCHT for the treatment of severe acute pancreatitis (SAP) are not known. The current study investigated the pharmacological properties of YCHT against SAP and its underlying mechanisms. A computational prediction of potential targets of YCHT was initially established based on a network pharmacology simulation. The model suggested that YCHT attenuated SAP progress by apoptosis inducement, anti-inflammation, anti-oxidation and blood lipid regulation. These effects were validated in SAP rats. YCHT administration produced the following results: (1) significantly inhibited the secretion of pancreatic enzymes and protected pancreatic tissue; (2) obviously increased the number of in situ terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive cells and induced apoptosis; (3) markedly inhibited neutrophil infiltration to the impaired pancreas and reduced the inflammatory reaction; (4) notably enhanced the activities of antioxidant enzymes and decreased the nitric oxide synthase levels; (5) significantly reduced the levels of triglycerides, total cholesterol and low-density lipoprotein and increased high-density lipoprotein; and (6) significantly up-regulated peroxisome proliferator-activated receptor-γ (PPARγ) and down-regulated nuclear factor-kappa B (NF-κB). In summary, these results demonstrated that YCHT attenuated SAP progress by inducing apoptosis, repressing inflammation, alleviating oxidative stress and regulating lipid metabolism partially via regulation of the NF-κB/PPARγ signal pathway.

Frequency of progression from acute to chronic pancreatitis and risk factors: a meta-analysis

BACKGROUND & AIM

Acute pancreatitis (AP) and chronic pancreatitis (CP) traditionally have been thought to be distinct diseases, but there is evidence that AP can progress to CP. Little is known about the mechanisms of pancreatitis progression. We performed a meta-analysis to quantify the frequency of transition of AP to CP and identify risk factors for progression.

METHODS

We searched PubMed, Scopus, and Embase for studies of patients with AP who developed CP, published from 1966 through November 2014. Pooled prevalence and 95% confidence intervals (CIs) were calculated for these outcomes, and sensitivity, subgroup, and meta-regression analyses were conducted.

RESULTS

We analyzed 14 studies, which included a total of 8492 patients. The pooled prevalence of recurrent AP was 22% (95% CI, 18%-26%), and the pooled prevalence of CP was 10% (95% CI, 6%-15%). Sensitivity analyses yielded a pooled prevalence of CP of 10% (95% CI, 4%-19%) and 36% (95% CI, 20%-53%) in patients after the first occurrence and recurrent AP, respectively. Subgroup analyses found alcohol use and smoking to be the largest risk factors for the development of CP, with pooled prevalence values of 65% (95% CI, 48%-56%) and 61% (95% CI, 47%-73%), respectively. Meta-regression analysis found that men were more likely than women to transition from AP to CP.

CONCLUSIONS

Ten percent of patients with a first episode of AP and 36% of patients with recurrent AP develop CP; the risk is higher among smokers, alcoholics, and men. Prospective clinical studies are needed to study pancreatitis progression.

Abnormalities of the Exocrine Pancreas in Type 1 Diabetes

Type 1 diabetes (T1D) is considered a pancreatic beta cell-specific disease that results in absolute insulin deficiency. Nevertheless, clinical studies from 1940 onwards showed that patients with T1D had an abnormal exocrine pancreas due to the presence of subclinical exocrine insufficiency and acinar atrophy. Exocrine abnormalities are an important, and mostly neglected, characteristic associated with T1D. It is however still unclear whether the exocrine dysfunction in T1D is a primary damage caused by the same pathogenic event that led to beta cell destruction or secondary to beta cell loss. In this review, we collect evidence supporting the hypothesis that T1D is a combined endocrine-exocrine disease in which the loss of functional beta cell mass is most clinically apparent.

How does cigarette smoking cause acute pancreatitis?

INTRODUCTION

Acute Pancreatitis (AP) is an emerging health problem world-wide and it is a major cause of admissions for gastrointestinal disease in many countries. Amongst the more common causes (alcohol and gallstones), recent evidence has emerged indicating that smoking is an independent risk factor for AP. However, the mechanisms involved in smoking-induced AP have not been completely elucidated. This review puts together all the published evidence in literature to present the clinical and laboratory evidence relating smoking to the causation of AP.

DISCUSSION

The two main metabolites from cigarette smoke, namely nicotine and NNK are able to induce functional and histological changes within the pancreas consistent with AP. The major mechanisms involved include their action on acinar cells and zymogen secretion through pathways involving CCK and the nicotinic preganglionic receptors. Effects on the pancreatic microvasculature may be mediated through the nitric oxide pathway. There is indirect evidence to suggest that nicotine and acrolein may lead to CFTR dysfunction thereby influencing ductal secretion. However, direct evidence for this effect is needed. The effect of cigarette smoke metabolites on stellate cells and the islets warrants further investigation in the context of pathogenesis of AP.

CONCLUSION

Using a step-wise approach, the review revisits the effects of the various metabolites of cigarette smoke on the constituents of the pancreas (exocrine, endocrine, neurohormonal, stellate cells, ductal system) and highlights their proven, and potential, mechanisms in triggering off an attack of AP.

Genetic predisposition and its impact on natural history of idiopathic acute and acute recurrent pancreatitis in children

BACKGROUND

Genetic predisposition in paediatric idiopathic acute, acute recurrent pancreatitis and its consequences are unknown. We studied frequency of genetic markers in acute, acute recurrent, chronic pancreatitis and their impact on natural history.

METHODS

Over a period of 2 years 68 consecutive children with pancreatitis (35.3% acute, 32.3% acute recurrent, 32.3% chronic) and 25 controls were recruited in a single centre. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease-inhibitor (PRSS1 R122H) and cystic fibrosis transmembrane conductance regulator (CFTR DeltaF508, 5T) were analysed.

RESULTS

Mean age was 13.4±2.5 years. Overall, 30 cases (SPINK1 N34S n=26, CFTR 5T n=4) and 1 control (SPINK1 N34S) had mutations (p=0.0001). The prevalence of SPINK1 N34S mutation was similar in chronic and acute recurrent pancreatitis (45%). Six children with severe acute pancreatitis had SPINK1 N34S mutations (25%, p<0.05), and 4 were homozygous. On follow-up 5 acute pancreatitis patients with mutations and 1 without mutations developed chronic pancreatitis (p=0.004); 8 cases of acute recurrent pancreatitis progressed to chronic pancreatitis (38%); of these 66.7% had mutations vs. 16.7% who did not (p=0.03).

CONCLUSIONS

Almost 50% of idiopathic chronic, acute recurrent and 33% of acute pancreatitis in children are genetically predisposed. Presence of genetic mutations in acute and recurrent acute pancreatitis increases the risk of developing chronic pancreatitis.

Genetics of acute and chronic pancreatitis: An update

Progress made in identifying the genetic susceptibility underlying acute and chronic pancreatitis has benefitted the clinicians in understanding the pathogenesis of the disease in a better way. The identification of mutations in cationic trypsinogen gene (PRSS1 gene; functional gain mutations) and serine protease inhibitor kazal type 1 (SPINK1 gene; functional loss mutations) and other potential susceptibility factors in genes that play an important role in the pancreatic secretory functions or response to inflammation during pancreatic injury has changed the current concepts and understanding of a complex multifactorial disease like pancreatitis. An individual’s susceptibility to the disease is governed by genetic factors in combination with environmental factors. Candidate gene and genetic linkage studies have identified polymorphisms in cationic trypsinogen (PRSS1), SPINK1, cystic fibrosis trans-membrane conductance regulator (CFTR), Chymotrypsinogen C (CTRC), Cathepsin B (CTSB) and calcium sensing receptor (CASR). Individuals with polymorphisms in the mentioned genes and other as yet identified genes are at an enhanced risk for the disease. Recently, polymorphisms in genes other than those involved in “intra-pancreatic trypsin regulatory mechanism” namely Claudin-2 (CLDN2) and Carboxypeptidase A1 (CPA1) gene have also been identified for their association with pancreatitis. With ever growing number of studies trying to identify the genetic susceptibility in the form of single nucleotide polymorphisms, this review is an attempt to compile the available information on the topic.

Association analysis of genetic variants in the myosin IXB gene in acute pancreatitis

INTRODUCTION

Impairment of the mucosal barrier plays an important role in the pathophysiology of acute pancreatitis. The myosin IXB (MYO9B) gene and the two tight-junction adaptor genes, PARD3 and MAGI2, have been linked to gastrointestinal permeability. Common variants of these genes are associated with celiac disease and inflammatory bowel disease, two other conditions in which intestinal permeability plays a role. We investigated genetic variation in MYO9B, PARD3 and MAGI2 for association with acute pancreatitis.

METHODS

Five single nucleotide polymorphisms (SNPs) in MYO9B, two SNPs in PARD3, and three SNPs in MAGI2 were studied in a Dutch cohort of 387 patients with acute pancreatitis and over 800 controls, and in a German cohort of 235 patients and 250 controls.

RESULTS

Association to MYO9B and PARD3 was observed in the Dutch cohort, but only one SNP in MYO9B and one in MAGI2 showed association in the German cohort (p < 0.05). Joint analysis of the combined cohorts showed that, after correcting for multiple testing, only two SNPs in MYO9B remained associated (rs7259292, p = 0.0031, odds ratio (OR) 1.94, 95% confidence interval (95% CI) 1.35-2.78; rs1545620, p = 0.0006, OR 1.33, 95% CI 1.16-1.53). SNP rs1545620 is a non-synonymous SNP previously suspected to impact on ulcerative colitis. None of the SNPs showed association to disease severity or etiology.

CONCLUSION

Variants in MYO9B may be involved in acute pancreatitis, but we found no evidence for involvement of PARD3 or MAGI2.

Parenteral nutrition combined with enteral nutrition for severe acute pancreatitis

Background and Aims. Nutritional support in severe acute pancreatitis (SAP) is controversial concerning the merits of enteral or parenteral nutrition in the management of patients with severe acute pancreatitis. Here, we assess the therapeutic efficacy of gradually combined treatment of parenteral nutrition (PN) with enteral nutrition (EN) for SAP. Methods. The clinical data of 130 cases of SAP were analyzed retrospectively. Of them, 59 cases were treated by general method of nutritional support (Group I) and the other 71 cases were treated by PN gradually combined with EN (Group II). Results. The APACHE II score and the level of IL-6 in Group II were significantly lower than Group I (P < 0.05). Complications, mortality, mean hospital stay, and the cost of hospitalization in Group II were 39.4 percent, 12.7 percent, 32 ± 9 days, and 30869.4 ± 12794.6 Chinese Yuan, respectively, which were significantly lower than those in Group I. The cure rate of Group II was 81.7 percent which is obviously higher than that of 59.3% in Group I (P < 0.05). Conclusions. This study indicates that the combination of PN with EN not only can improve the natural history of pancreatitis but also can reduce the incidence of complication and mortality.

L-asparaginase-induced pancreatic injury is associated with an imbalance in plasma amino acid levels

BACKGROUND

The use of L-asparaginase (ASNase) to modify amino acid metabolism is one of the most effective chemotherapeutic means of inducing remission in acute lymphoblastic leukemia (ALL). However, severe pancreatitis sometimes occurs in patients receiving ASNase, because of an unknown mechanism.

OBJECTIVE

The purpose of the present study was to evaluate the relationship between ASNase-induced pancreatic injury and plasma amino acid levels in patients undergoing ASNase therapy.

METHODS

A total of 29 children aged 1-13.25 years (median age 4 years; male : female ratio 19 : 10) with ALL, who received induction therapy according to the Tokyo Children's Cancer Study Group L04-16 protocol, were studied. Levels of plasma amino acids and serum rapid turnover proteins (RTPs), pancreatic enzymes, and pancreatic protease inhibitors were measured before and 1, 2, 3, 4, 5, and 7 weeks after the first administration of ASNase.

RESULTS

Plasma asparagine levels were significantly lower after the first injection of ASNase (p < 0.01) and had almost recovered 2 weeks after the last ASNase injection. At 4 weeks after the first ASNase injection, serum aspartic acid, trypsin, and pancreatic secretory trypsin inhibitor (PSTI) levels remained significantly higher than those before the first ASNase injection (p < 0.01), and serum levels of prealbumin and transferrin remained significantly lower than those before the first ASNase injection (p < 0.01). Plasma amino acid and serum RTP levels gradually normalized after the last ASNase injection.

CONCLUSIONS

Levels of serum trypsin and PSTI were elevated during the 2 weeks after administration of ASNase, which suggested the presence of subclinical pancreatitis. This period is similar to the time period in the present study when the levels of plasma amino acids changed, thus suggesting that ASNase-induced pancreatic injury could be caused by the imbalance of plasma amino acid levels.

Screening of R122H and N29I mutations in the PRSS1 gene and N34S mutation in the SPINK1 gene in Mexican pediatric patients with acute and recurrent pancreatitis

OBJECTIVES

The study's objective was to assess the association between the PRSS1 R122H and N29I and the SPINK1 N34S mutations and acute pancreatitis (AP) and recurrent pancreatitis in Mexican pediatric patients.

METHODS

The N34S and R122H mutations were detected using polymerase chain reaction-restriction fragment length polymorphism, and the N29I mutation was detected using allele-specific polymerase chain reaction in 92 pancreatitis patients (58 AP and 34 recurrent pancreatitis patients) and 144 controls.

RESULTS

We found 1 mutated allele in 4 (4.3%) of 92 pancreatitis patients and none in the controls. All 4 patients bearing mutations had AP, with a frequency of 6.8% (4/58). Three (5.2%) of 58 patients were heterozygous for the N34S mutation, and 1 (1.7%) of 58 patients was heterozygous for the N29I mutation. The comparison between the AP and control groups revealed both a significant number of patients carrying any mutations in the screened genes (P = 0.008) and bearing the N34S mutation (P = 0.023). Moreover, we found that the N34S G allele increased the risk of developing AP (odds ratio, 10.3; confidence interval, 1.1-248.8).

CONCLUSIONS

Patients bearing the N34S G allele exhibited a 10-fold increased risk of developing AP compared with controls, suggesting that the SPINK1 N34S mutation represents an etiologic risk factor for AP in our Mexican pediatric patients.

Cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations in pancreatitis

BACKGROUND

The pancreas is one of the primary organs affected by dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. While exocrine pancreatic insufficiency is a well-recognized complication of cystic fibrosis (CF), symptomatic pancreatitis is often under-recognized.

RESULTS

The aim of this review is to provide a general overview of CFTR mutation-associated pancreatitis, which affects patients with pancreatic sufficient CF, CFTR-related pancreatitis, and idiopathic pancreatitis. The current hypothesis regarding the role of CFTR dysfunction in the pathogenesis of pancreatitis, and concepts on genotype-phenotype correlations between CFTR and symptomatic pancreatitis will be reviewed. Symptomatic pancreatitis occurs in 20% of pancreatic sufficient CF patients. In order to evaluate genotype-phenotype correlations, the Pancreatic Insufficiency Prevalence (PIP) score was developed and validated to determine severity in a large number of CFTR mutations. Specific CFTR genotypes are significantly associated with pancreatitis. Patients who carry genotypes with mild phenotypic effects have a greater risk of developing pancreatitis than patients carrying genotypes with moderate-severe phenotypic consequences at any given time.

CONCLUSIONS

The genotype-phenotype correlation in pancreatitis is unique compared to other organ manifestations but still consistent with the complex monogenic nature of CF. Paradoxically, genotypes associated with otherwise mild phenotypic effects have a greater risk for causing pancreatitis; compared with genotypes associated with moderate to severe disease phenotypes. Greater understanding into the underlying mechanisms of disease is much needed. The emergence of CFTR-assist therapies may potentially play a future role in the treatment of CFTR-mutation associated pancreatitis.

Drivers of oxidative stress in acute pancreatitis: the role of nutrition therapy

Severe acute pancreatitis is a disease process distinguished by increasing oxidative stress and potential destruction of the pancreatic gland. An initial injury to the acinar cell initiates a sentinel event, which leads to a vicious cycle of inflammation and cell death by either apoptosis or necrosis. Whether the acute inflammation resolves or goes on to a pattern of chronicity may be related to genetic predisposition, failure to remove injurious agents, and innate systems for antioxidant defense. The degree to which nutrition therapy can modulate oxidative stress, maintain intestinal function, and preserve the structure of the acinar cell is truly amazing. Understanding the mechanisms involved in this complex disease process and the manner in which these mechanisms are influenced by dietary agents affords new and exciting therapeutic options for the future.

Pancreas divisum is not a cause of pancreatitis by itself but acts as a partner of genetic mutations

OBJECTIVES

The role of pancreas divisum (PD) as a cause of acute recurrent or chronic pancreatitis (AR/CP) is still a matter of debate.

METHODS

The aims of this study were to evaluate the frequency of PD diagnosed using magnetic resonance cholangiopancreatography (MRCP) in patients with AR/CP of unknown origin (n=40) after careful exclusion of all known causes and to test the hypothesis of an interaction between anatomical (PD) and functional genetic anomalies (SPINK1, PRSS1, or CFTR gene mutations or polymorphisms (n=19, 25, and 30, respectively)) that could result in AR/CP. Patients with alcohol-induced pancreatitis (n=29) and subjects who had MRCP for a nonpancreatic disease (n=45) served as controls.

RESULTS

PD frequency was 7% in subjects without pancreatic disease, 7% in patients with alcohol-induced pancreatitis, and 5, 16, 16, and 47% in those with idiopathic, and PRSS1-, SPINK1-, and CFTR-associated pancreatitis, respectively (P<0.0001). There was no significant difference between idiopathic pancreatitis and the two control groups. The frequency of PD was higher in patients with CFTR gene-associated pancreatitis as compared with those with idiopathic and alcoholic pancreatitis (P<0.0001) and with those with SPINK1 and PRSS1 gene-associated pancreatitis (P<0.02).

CONCLUSIONS

The frequency of PD was not different in patients with idiopathic pancreatitis as compared with controls, demonstrating that PD by itself is not a cause of pancreatitis. PD frequency was higher in patients with genetic pancreatitis, especially in those with CFTR mutations or polymorphisms, suggesting a cumulative effect of these two cofactors.

Recurrent and relapsing pancreatitis

Recurrent acute pancreatitis is a common clinical problem. Most cases of pancreatitis are identified by a careful history and physical examination. Despite advanced evaluation, the cause is not apparent in about 10% of cases. The etiology of recurrent acute pancreatitis appears to be multifactorial, with genetic and environmental influences playing a significant role. The strength of evidence for certain etiologies is highly variable, and natural history data are limited. Controversy exists regarding the most appropriate diagnostic and therapeutic approach. Recurrent acute pancreatitis often represents a continuum with chronic pancreatitis.

Practical guidelines for acute pancreatitis

INTRODUCTION

The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis.

STATEMENTS

Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48-72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B).

CONCLUSIONS

The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.

CFTR gene mutation in patients with apparently idiopathic pancreatitis: lack of phenotype-genotype correlation

BACKGROUND AND AIMS

Despite an extensive search, no cause is found for recurrent acute/chronic pancreatitis (idiopathic pancreatitis (IP)) in about 20% of patients. In these patients, CFTR gene mutations may be identified. The aims of this study were (1) to describe the natural history of pancreatitis associated with the CFTR mutation, (2) to look for genotype-phenotype correlations, and (3) to examine the frequency of CFTR mutations in a population of patients with IP.

RESULTS

100 consecutive patients with IP were included between 1998 and 2005. 50% had one of the 33 most frequent CFTR gene mutations (common CF mutations, uncommon mutations causing variable phenotypes and variants of unknown significance in 28, 44 and 28%, respectively). Patients with a CFTR gene mutation were significantly younger than those without (34 vs. 40 years, p = 0.03). Duration of follow-up (3.5 vs. 3 years), proportion of patients with acute pancreatitis as first symptom (76 vs. 74%) were not significantly different. Signs of chronic pancreatitis (ductal changes and pancreatic calcifications), pseudocysts, common bile duct stenosis, exocrine or endocrine insufficiency occurred in 36, 26, 4, 10 and 12% of patients with CFTR gene mutations respectively, which was not different from patients without mutations. No phenotype-genotype correlation was observed.

CONCLUSIONS

In patients with IP, clinical and radiological manifestations are not related to the presence of a CFTR gene mutation or to the type of mutation.

CFTR polymorphisms in patients with alcoholic chronic pancreatitis

INTRODUCTION

Pancreas susceptibility to alcohol is variable and only 5-10% of chronic alcohol abusers develop chronic pancreatitis; the role of genetic factors in this process is unknown. The CFTR gene encodes a protein that acts on epithelial cells and plays a key role in normal exocrine pancreatic function.

METHODS

This study investigated the frequency of polymorphisms in intron 8 of the CFTR gene in patients with alcoholic chronic pancreatitis. Three groups of patients were studied: group A - 68 adult alcoholics with a diagnosis of chronic pancreatitis; group B - 68 adult alcoholics without pancreatic disease or liver cirrhosis and group C - 104 healthy nonalcoholic adults.

RESULTS

T5/T7 genotype was more frequent in group A (11.8%) than in group B (2.9%) (p = 0.0481), and there was no statistical difference when groups A and C (5.8%) were compared (p = 0.1317). The haplotype combination (TG)10-T7/(TG)11-T7 was more frequent in groups B (23.5%) and C (20.2%) than in group A (7.3%) (p = 0.0080 and 0.0162).

CONCLUSION

There are differences when these three groups are compared and individuals with T5/T7 genotype might have a greater risk of developing chronic pancreatitis when they become chronic alcoholics.

Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2)

BACKGROUND

Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) are complex syndromes associated with numerous etiologies, clinical variables and complications. We developed the North American Pancreatitis Study 2 (NAPS2) to be sufficiently powered to understand the complex environmental, metabolic and genetic mechanisms underlying RAP and CP.

METHODS

Between August 2000 and September 2006, a consortium of 20 expert academic and private sites prospectively ascertained 1,000 human subjects with RAP or CP, plus 695 controls (spouse, family, friend or unrelated). Standardized questionnaires were completed by both the physicians and study subjects and blood was drawn for genomic DNA and biomarker studies. All data were double-entered into a database and systematically reviewed to minimize errors and include missing data.

RESULTS

A total of 1,000 subjects (460 RAP, 540 CP) and 695 controls who completed consent forms and questionnaires and donated blood samples comprised the final dataset. Data were organized according to diagnosis, supporting documentation, etiological classification, clinical signs and symptoms (including pain patterns and duration, and quality of life), past medical history, family history, environmental exposures (including alcohol and tobacco use), medication use and therapeutic interventions. Upon achieving the target enrollment, data were organized and classified to facilitate future analysis. The approaches, rationale and datasets are described, along with final demographic results.

CONCLUSION

The NAPS2 consortium has successfully completed a prospective ascertainment of 1,000 subjects with RAP and CP from the USA. These data will be useful in elucidating the environmental, metabolic and genetic conditions, and to investigate the complex interactions that underlie RAP and CP.

SPINK1 and PRSS1 mutations in benign pancreatic hyperenzymemia

The aim of this study was to determine whether mutations in SPINK1/PRSS1 genes are associated with benign pancreatic hyperenzymemia (BPH).

METHODS

Sixty-eight subjects with BPH (including 13 familial cases) were studied. In all, we sequenced germline DNA for all the exons and intro-exon boundaries of PRSS1 and SPINK1.

RESULTS

Nine (13.2%) of the 68 subjects harbored PRSS1 or SPINK1 mutations. As to PRSS1, no hereditary pancreatitis-associated variant was detected, whereas previously undescribed mutations (p.Ala148Val and c.40+1G>A) were respectively found in 2 subjects (2.9%). SPINK1 mutations were detected in 7 subjects (10.3%). Five of them exhibited known mutations (3 p.Asn34Ser, 1 p.Pro55Ser, and 1 c.88-23A>T), whereas 2 had a newly found variant (p.Arg67Gly and c.*32C>T, respectively). Only 2 familial BPH, belonging to 2 different families, were found to carry a mutation (1 with p.Ala148Val for PRSS1 and 1 with p.Asn34Ser for SPINK1).

CONCLUSIONS

No known mutations of PRSS1 have been found in BPH, whereas the frequency of known SPINK1 variants is similar to that reported in the general population. No segregation of PRSS1/SPINK1 variants occurs in BPH families. Benign pancreatic hyperenzymemia cannot be explained by mutations in genes whose variants are known to be associated with pancreatitis or by mutations in other PRSS1/SPINK1 genes.

Pathways to injury in chronic pancreatitis: decoding the role of the high-risk SPINK1 N34S haplotype using meta-analysis

Background

The complex interactions between recurrent trypsin-mediated pancreatic injury, alcohol-associated pancreatic injury and SPINK1 polymorphisms in chronic pancreatitis (CP) are undefined. We hypothesize that CP occurs as a result of multiple pathological mechanisms (pathways) that are initiated by different metabolic or environmental factors (etiologies) and may be influenced differentially by downstream genetic risk factors. We tested this hypothesis by evaluating the differences in effect size of the high risk SPINK1 N34S haplotype on CP from multiple etiologies after combining clinical reports of SPINK1 N34S frequency using meta-analysis.

Methods and Findings

The Pubmed and the Embase databases were reviewed. We studied 24 reports of SPINK1 N34S in CP (2,421 cases, 4,857 controls) using reported etiological factors as surrogates for pathways and multiple meta-analyses to determine the differential effects of SPINK1 N34S between alcoholic and non-alcoholic etiologies. Using estimates of between-study heterogeneity, we sub-classified our 24 studies into four specific clusters. We found that SPINK1 N34S is strongly associated with CP overall (OR 11.00; 95% CI: 7.59–15.93), but the effect of SPINK1 N34S in alcoholic CP (OR 4.98, 95% CI: 3.16–7.85) was significantly smaller than in idiopathic CP (OR 14.97, 95% C.I. = 9.09–24.67) or tropical CP (OR 19.15, 95% C.I. = 8.83–41.56). Studies analyzing familial CP showed very high heterogeneity suggestive of a complex etiology with an I² = 80.95%.

Conclusion

The small effect of SPINK1 N34S in alcoholic subjects suggests that CP is driven through a different pathway that is largely trypsin-independent. The results also suggest that large effect sizes of SPINK1 N34S in small candidate gene studies in CP may be related to a mixture of multiple etiologic pathways leading to the same clinical endpoint.

Pancreatic ductal system obstruction and acute recurrent pancreatitis

Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.

Hereditary pancreatitis amlodipine trial: a pilot study of a calcium-channel blocker in hereditary pancreatitis

OBJECTIVES

Hereditary pancreatitis (HP) is a form of recurrent acute pancreatitis (AP) mediated by mutations in cationic trypsinogen (PRSS1). Mutations cluster in the calcium-associated regulator regions of PRSS1. In rats, calcium-channel blockers (CCB) prevent hyperstimulation-associated AP. Because of the potential importance of hyperstimulation in triggering episodes of AP in HP, we designed a pilot study to evaluate the safety and potential benefit of CCB use in HP.

METHODS

Subjects 6 years or older had a PRSS1 mutation, recurrent AP, and pain. Total study duration was 16 weeks. Amlodipine was given during weeks 0 to 11. Dose (2.5, 5, or 10 mg) was based on weight (range, 0.08-0.17 mg x kg(-1) x d(-1)). Subjects filled a daily diary including pain (0-10 scale) and blood pressure reading. Clinical assessments occurred at weeks -4, 0, 1, 2, 6, 10, 11, and 12. Subjects filled a Medical Outcomes Study Short-Form Survey version 2 (SF-10 for children <14 years old) at weeks -4, 0, 6, and 10. Data were compared for weeks -4 to 0 and 6 to 10.

RESULTS

Nine subjects signed informed consent (4 males; 12-52 years old). Four were excluded during the screening phase. Drug was discontinued in one due to development of unilateral lower-extremity numbness. Four subjects (12-31 years old) completed the study. Mean blood pressure, laboratory tests, physical findings, and daily pain scores did not clinically significantly differ before and during drug therapy, but all reported reduced symptoms. Three reduced analgesic use. Three had improved scores on the Medical Outcomes Study Short-Form Survey version 2.

CONCLUSIONS

Amlodipine is generally safe in subjects with HP and does not increase pain or episodes of AP. Further research into the mechanism of CCB on pancreatitis would be important to provide a pathophysiologic basis to support further trials in HP.

Operative management of chronic pancreatitis: longterm results in 372 patients

BACKGROUND

Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or for the presence of complications of the disease. This study evaluates a single-center experience with operative management of chronic pancreatitis.

STUDY DESIGN

The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (n = 184), pancreaticoduodenectomy (n = 97), or distal pancreatectomy (n = 91) for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Longterm outcomes were assessed by patient survey, with a median followup of 5.5 +/- 0.2 years.

RESULTS

Primary indication for operative treatment included intractable pain (n = 215), pancreatic duct disruption (n = 109), inflammatory mass (n = 42), or biliary obstruction (n = 6). Perioperative morbidity was 22%, 51%, and 29% after lateral pancreaticojejunostomy, pancreaticoduodenectomy, and distal pancreatectomy, respectively, with a perioperative mortality rate of 1%. Two hundred twenty-eight patients were available for longterm followup. Fifty-eight patients (25%) died in the followup period. Twenty-four percent of the remaining 170 patients were pain free, and 25% had good pain control after the procedure. On multivariate analysis, risk factors for poor pain control were pancreaticoduodenectomy (p < 0.01), preoperative narcotic dependence (p < 0.02), earlier abdominal operations (p < 0.02), and an absent history of gallstone pancreatitis (p < 0.05). Sixty-two percent returned to work. Quality of life assessed by SF-36 version 2 questionnaire showed norm-based scores between the 35th and 46th percentile and slightly below, but not substantially different from, a general population. New onset of endocrine and exocrine insufficiency was present in 35% and 29% of patients, respectively.

CONCLUSIONS

Operative management of chronic pancreatitis can be performed with low mortality and acceptable morbidity. Surgical treatment can provide good pain control, return patients to work, and achieve a satisfactory quality of life in the majority of patients. Longterm mortality is high in a subset of patients.

Functional polymorphisms of the GSTT-1 gene do not predict the severity of acute pancreatitis in the United States

BACKGROUND/AIM

Acute pancreatitis (AP) is an inflammatory response to pancreatic injury that is clinically classified as mild AP or severe AP, depending on specific criteria. Rahman and colleagues [Gastroenterology 2004;126:1312-1322] reported that genetic variation in the glutathione S-transferase theta-1 gene (GSTT-1) is associated with susceptibility and severity of AP in England. Our aim was to determine whether the same GSTT-1 polymorphism affects the severity of AP in a population from Pittsburgh, Pa., USA.

METHODS

Ninety-one consecutive patients with AP (19 severe) were prospectively evaluated. The GSTT-1 haplotypes were determined by PCR amplification in all patients and 268 controls. The resulting genotypes were classified as functional (GSTT-1*A/*A or *A/null) and nonfunctional (GSTT-1 null/null) phenotypes.

RESULTS

The relative frequencies of functional GSTT-1 phenotypes were similar in subjects with severe AP (15 of 19, 78.9%) and mild AP (61 of 72, 84.7%; p = 0.54) and in the controls (228 of 268, 85.1%; p = 0.66). Furthermore, the GSTT-1 functional and nonfunctional phenotypes were not associated with serum C-reactive protein levels (11.9 vs. 7.3 mg/dl; p = 0.19), interleukin-6 levels (74 vs. 60 pg/ml; p = 0.9), APACHE II scores (7 vs. 9; p = 0.26), or 48-hour Ranson scores (1 vs. 1; p = 0.63).

CONCLUSION

Functional GSTT-1 phenotypes do not correlate with susceptibility to AP or severity of AP in our patient population.

Alcohol-associated pancreatitis

Only a small proportion of heavy drinking individuals develop pancreatitis. The environmental and host cofactors shown to have an association with alcoholic pancreatitis are smoking and race. The known genetic variations and polymorphisms do not seem to play an important role in alcoholic pancreatitis. Newer developments in the understanding of complex disorders allow clinicians to understand better the role of cofactors and interactions between known and yet unknown environmental and genetic factors in causing alcoholic pancreatitis.