The pathogenesis of chronic pancreatitis

Association of matrix metalloproteinase-7 (-181A/G) promoter polymorphism in chronic pancreatitis

BACKGROUND & OBJECTIVES

Chronic pancreatitis is progressive and irreversible destruction of the pancreas. Matrix metalloproteinase-7 (MMP-7) is a secreted matrilysin, which contributes to angiogenesis and breakdown of basement membranes of pancreatic tissues. The present study was aimed to investigate the association of MMP-7 -181A/G (rs11568818) gene promoter polymorphism in patients with chronic pancreatitis.

METHODS

A total of 100 chronic pancreatitis patients and 150 unrelated healthy individuals were included in this case control study. The genotyping of the MMP-7 gene (- 181 A/G) (rs11568818) was carried out based on PCR-RFLP. The serum levels of MMP-7 were determined by ELISA. Association between genotypes and chronic pancreatitis was examined by odds ratio (OR) with 95% confidence interval (CI).

RESULTS

The frequencies of the genotypes in promoter of MMP-7 were AA 49 per cent, AG 25 per cent and GG 26 per cent in chronic pancreatitis patients and AA 53 per cent, AG 38 per cent and GG 9 per cent in control subjects. Frequency of MMP-7 -181GG genotype and - 181G allele was significantly associated with chronic pancreatitis compared to healthy subjects [OR = 1.58 (95% CI: 1.06 -2.36), p =0.019]. There was no significant difference in the serum MMP-7 levels in the patients compared to control subjects.

INTERPRETATION & CONCLUSIONS

The present study revealed a significant association of MMP-7 -181A/G (rs11568818) GG genotype with chronic pancreatitis patients, indicating its possible association with the disease.

[Inflammatory pancreatic disease due to enzyme autodigestion: an exceptional model of glandular crinophagy]

The exocrine pancreas is a functionally dangerous structure since it is exposed to digestion by its most aggressive enzymes (proteases, etc) despite self-protective measures such as the synthesis of some of these enzymes in the form of inactive zymogens (trypsinogen, etc.). We review inflammatory pancreatic disease by separately analyzing its classical forms of onset: acute and chronic pancreatitis (AP and CP). There is general consensus that the initial pathogenic event in AP is intraacinar activation of trypsinogen into trypsin, followed by that of the remaining proenzymes, giving rise to an unusual model of autophagic inflammation. In contrast, consensus is lacking on the initial pathogenic event in CP (toxic-metabolic lesion, oxidative stress, ductal hypertension, etc.?), although in some cases a <<necrosis-fibrosis>> sequence due to recurrent episodes of AP seems evident. The pathogenic features shared by both forms of the disease and which justify some recent attempts to formulate an overall explanation of the pathogenesis of pancreatitis are discussed. Such an explanation would place both forms of pancreatitis within the conceptual framework of an <<inflammatory pancreatic disease due to enzyme autodigestion>>.

Pathogenesis of chronic pancreatitis: an evidence-based review of past theories and recent developments

In the past several decades, four prominent theories of chronic pancreatitis pathogenesis have emerged: the toxic-metabolic theory, the oxidative stress hypothesis, the stone and duct obstruction theory, and the necrosis-fibrosis hypothesis. Although these traditional theories are formulated based on compelling scientific observations, substantial contradictory data also exist for each. Furthermore, the basic premises of some of these theories are directly contradictory. Because of the recent scientific progress in the underlying genetic, cellular, and molecular pathophysiology, there have been substantial advances in the understanding of chronic pancreatitis pathogenesis. This paper will provide an evidence-based review and critique of the traditional pathogenic theories, followed by a discussion of the new advances in pancreatic fibrogenesis. Moreover, we will discuss plausible pathogenic sequences applied to each of the known etiologies.

Pancreatic acinar atrophy in German shepherd dogs and rough-coated collies. Etiopathogenesis, diagnosis and treatment. A review

In pancreatic acinar atrophy (PAA) a selective destruction of digestive enzyme-producing acinar cells leads to maldigestion signs typical of exocrine pancreatic insufficiency (EPI). Although the clinical disease is well-known, the etiopathogenesis of PAA has been long remained obscure. German shepherd dogs and rough-coated Collies with PAA show similar genetic, clinical and pathological findings indicating a similar etiopathogenesis of the disease in these two breeds. In this review article the etiopathogenesis of PAA is discussed, including the current suggestion of autoimmune nature of the disease. The diagnostic methods for detection both early and end-stage exocrine pancreatic dysfunction are described, as well as the treatment options and prognosis.

Major pancreatic resections for chronic pancreatitis

OBJECTIVE

Indications for major pancreatic resections have been expanded to include complicated chronic pancreatitis (CP). We assessed clinical findings and outcomes and evaluated histology in patients who had major pancreatic resections for CP. We also determined if histologic findings were associated with persistent postoperative pain.

DESIGN

We reviewed charts and slides from 44 patients who underwent major pancreatic resections for CP between 1989 and 1999.

RESULTS

The etiology for disease included alcohol (n = 15), hereditary (n = 5), idiopathic (n = 6), pancreas divisum (n = 3), stricture (n = 2), trauma (n = 2), systemic lupus erythematosus (n = 1), and unknown (n = 10). Patients included 20 men and 24 women; ages ranged from 22 to 76 years. Perioperative mortality and morbidity were 0% and 4.5%, respectively. Persistent pain was present in 25 (57%) of the 44 patients, and pain was encountered more frequently in patients with alcoholic pancreatitis (67%) versus other etiologies (52%), and in those who underwent Whipple/Beger or total resections (68%) versus distal or subtotal pancreatectomy (42%). Metaplastic changes were present in 14 cases, and ductal atypia was seen in 9 cases. No malignancies were found. Acinar necrosis and acute inflammation were seen more often in patients with persistent pain than in those who were pain free (P =.081).

CONCLUSION

Major pancreatic resection for CP can be performed with low morbidity and mortality. This procedure relieves pain in nearly half the patients. There is a wide spectrum of histopathologic changes seen in CP, including ductal atypia and metaplastic changes. Acute exacerbations of CP identified histologically at the time of surgery and alcohol as etiology for CP may be associated more frequently with intractable pain.

Molecular understanding of chronic pancreatitis: a perspective on the future

Despite the recent development of medical imaging technology, chronic pancreatitis can only be diagnosed when the disease is fully established. This is due to the lack of specific and sensitive markers for this disease. The discovery of mutations in the cationic trypsinogen gene in patients with hereditary pancreatitis and a high incidence of mutations in the cystic fibrosis transmembrane conductance regulator gene in patients with chronic pancreatitis might be important clues to understanding the molecular mechanisms of this disease. The interaction between ethanol and ion channels might be the missing link between alcohol ingestion and chronic pancreatitis.

Pancreatitis in ulcerative colitis: a case report of improved stricture of the main pancreatic duct

We present one case with pancreatitis that synchronized with manifestations of ulcerative colitis, in which an improvement of stricture of the main pancreatic duct was observed. A 27-year-old man, having a history of nonalcoholic acute pancreatitis, complained of anal bleeding and pain in the epigastric region. The treatment for pancreatitis relieved the pain and decreased the serum levels of pancreatic enzymes to within normal ranges. Colonoscopy and histopathologic examination revealed ulcerative colitis in the rectum, and treatment with steroid enema made proctitis quiescent. Endoscopic retrograde pancreatography demonstrated a remarkable and short stricture of the main pancreatic duct, which improved at follow-up pancreatography. In a 20-month follow-up period, active proctitis relapsed with a episode of recurrent pancreatitis once, and without pancreatitis once.