A prospective cohort study of smoking in acute pancreatitis

Early Hypophosphatemia as a Prognostic Marker in Acute Pancreatitis

OBJECTIVES

Acute pancreatitis (AP) is a complex disease representing a significant portion of gastrointestinal-related hospitalizations in the U.S. Understanding risk factors of AP might provide attractive therapeutic targets. We evaluated hypophosphatemia a prognostic marker in AP.

METHODS

We performed a retrospective review of electronic health records of patients with AP from 01/ 01/2012-12/31/2021 at Cedars-Sinai Medical Center with serum phosphate measured within 48 hours of admission. Multivariable logistic regression modeling was used to evaluate associations with ICU admission and AP severity. Multivariable log-linear modeling was employed to examine associations with length of stay (LOS).

RESULTS

Of 1526 patients admitted for AP, 33% (499) had a serum phosphate level measured within 48 hours. Patients with hypophosphatemia were more likely to have ICU admission (adjusted odds ratio (AOR) = 4.57; 95% confidence interval (CI): 2.75-7.62; P < 0.001), have a longer hospital stay (log-LOS = 0.34; SE; 0.09; 95% CI: 0.17-0.52; P < 0.001), and have moderate or severe AP (AOR = 1.80; 95% CI: 1.16-2.80; P < 0.001) compared with those without hypophosphatemia.

CONCLUSION

Serum phosphate is infrequently measured in patients with AP and shows promise as an early prognostic marker for outcomes of AP.

A dose-response correlation between smoking and severity of acute pancreatitis: a propensity score-matched study

Background

Acute pancreatitis, among the most prevalent gastrointestinal disorders, exhibits a continual rise in its incidence recent years. This study endeavor to explore the correlation between smoking exposure and the severity of acute pancreatitis (AP).

Methods

Five hundred and eight patients diagnosed as acute pancreatitis (AP) were included in our data analysis. Patients were categorized based on their smoking pack-years into four groups: light, moderate, heavy, and non-smokers. Outcomes were classified as two: "mild acute pancreatitis (MAP)" and "moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP)". We conducted propensity score matching (PSM) to adjust confounding factors and multivariable logistic regression analysis to determine adjusted odds ratios and 95% confidence intervals. Additionally, a dose-dependent association analysis between smoking exposure and the incidence rate of "MSAP or SAP" was performed.

Results

Smokers exhibited a higher risk of "MSAP or SAP" compared to non-smokers, both before (17.1 vs. 54.9%, p < 0.001) and after (9.4 vs. 24.7%, p < 0.001) PSM. With an area under the ROC curve of 0.708, smoking showed a moderate level of predictive ability. Furthermore, propensity score matching analysis showed that patients who smoked compared to non-smokers had significantly higher risks of "MSAP or SAP" for light smoking (OR 3.76, 95% CI 1.40-10.07, p = 0.008), moderate smoking (OR 4.94, 95% CI 2.23-10.92, p < 0.001), and heavy smoking (OR 8.08, 95% CI 3.39-19.25, p < 0.001).

Conclusion

Smoking is an independent risk factor that can raise the severity of pancreatitis. Moreover, the severity of acute pancreatitis escalates in tandem with the accumulation of pack-years of smoking.

Alcoholic Acute Pancreatitis, a Retrospective Study about Clinical Risk Factors and Outcomes-A Seven-Year Experience of a Large Tertiary Center

(1) Background: Alcohol consumption is one of the main causes of acute pancreatitis. (2) Material and Methods: In this unicentric retrospective cohort study, we selected 1855 patients from the Bucharest Acute Pancreatitis Index (BUC-API) who presented with acute pancreatitis. We investigated correlations between Alcoholic Acute Pancreatitis (AAP) and the rate of complications, cost, length of hospitalization and rate of recurrence. (3) Results: We found a moderately strong association between AAP and recurrence (p < 0.01) and observed that the disease is likelier to evolve with pseudocysts and walled-off necrosis than other forms of AP. Patients with AAP are less likely to have a morphologically normal pancreas than patients suffering from AP of other causes (p < 0.01), but a low probability of requiring intensive care unit admission (p < 0.01) significantly lowers daily cost (Md = 154.7 EUR compared to Md = 204.4 EUR) (p < 0.01). (4) Conclusions: This study's data show that patients with AAP have a greater rate of pseudocyst occurrence, lower intensive care unit admittance rate and lower cost of hospitalization than patients with AP of other causes. Typical Sketch: A middle-aged male tobacco smoker with recurrent AP, lower risk of in-hospital mortality and complications such as pseudocysts; treated in a gastroenterological ward and discharged at-will.

Incidence, implications and predictors of abdominal compartment syndrome in acute pancreatitis: A nationwide analysis

BACKGROUND

Acute pancreatitis (AP) often presents with varying severity, with a small fraction evolving into severe AP, and is associated with high mortality. Complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are intricately associated with AP.

OBJECTIVE

To assess the clinical implications and predictors of ACS in AP patients.

METHODS

We conducted a retrospective study using the National Inpatient Sample (NIS) database on adult AP patients, further stratified by the presence of concurrent ACS. The data extraction included demographics, underlying comorbidities, and clinical outcomes. Multivariate linear and logistic regression analyses were performed using STATA (v.14.2).

RESULTS

Of the 1,099,175 adult AP patients, only 1,090 (0.001%) exhibited ACS. AP patients with ACS had elevated inpatient mortality and all major complications, including septic shock, acute respiratory distress syndrome (ARDS), requirement for total parenteral nutrition (TPN), and intensive care unit (ICU) admission (P < 0.01). These patients also exhibited increased odds of requiring pancreatic drainage and necrosectomy (P < 0.01). Predictor analysis identified blood transfusion, obesity (BMI ≥30), and admission to large teaching hospitals as factors associated with the development of ACS in AP patients. Conversely, age, female gender, biliary etiology of AP, and smoking were found less frequently in patients with ACS.

CONCLUSION

Our study highlights the significant morbidity, mortality, and healthcare resource utilization associated with the concurrence of ACS in AP patients. We identified potential factors associated with ACS in AP patients. Significantly worse outcomes in ACS necessitate the need for early diagnosis, meticulous monitoring, and targeted therapeutic interventions for AP patients at risk of developing ACS.

Early evaluation of waist-to-height ratio for the prediction of worsening acute pancreatitis

The purpose of this study was to evaluate the association between the waist-to-height ratio (WHtR) and the aggravation of acute pancreatitis (AP). This prospective study included AP patients treated from May 2019 to December 2019 in the Department of Gastroenterology, the First Affiliated Hospital of Nanchang University. Receiver operating characteristic curves were constructed to determine the optimal threshold values for predicting the aggravation of AP. Risk factor analysis was performed via logistic regression analysis. Of 258 patients included in this study, 77 (29.84%) were diagnosed with mild acute pancreatitis, 120 (46.51%) with moderately severe acute pancreatitis, and 61 (23.64%) with severe acute pancreatitis (SAP). WHtR, waist circumference, weight, and body mass index were all associated with AP severity, and the highest area under the receiver operating characteristic value was observed for WHtR. The optimal threshold WHtR value for predicting SAP was 0.567. Multivariate logistic regression analysis identified WHtR ≥ 0.567 as independent risk factor for SAP. Moreover, the hospital stay was longer and intensive care unit admission rate was higher among AP patients with a WHtR ≥ 0.567. The WHtR was found to be closely related to the severity of AP and an independent risk factor for the aggravation of AP. This simple parameter can aid the early prediction of AP progression, thereby facilitating early intervention and improving patient outcomes.

A population-based cohort study on risk factors for acute pancreatitis: A comparison by age group

BACKGROUND

/objectives: Acute pancreatitis (AP) is an acute inflammatory disorder that can occur in all age groups. The risk of AP has been shown to increase with age. However, no study has compared risk factors for AP according to age group yet. Thus, the aim of this study was to perform such comparison.

METHODS

Clinical data from individuals 20 years of age and older who received a health examination arranged by the Korean national health insurance program in 2009 (n = 4,238,822) were used. First-attack AP was identified using claims data from baseline to December 2018. Incidence and risk factors of AP were analyzed for young (20-39 years old), middle-aged (40-64 years old), and old (over 65 years old) groups.

RESULTS

Incidences of AP in young, middle-aged, and old groups were 16.30, 27.85, and 57.19 per 100,000 person-years, respectively. Smoking, alcohol drinking, diabetes, gallstone, and chronic pancreatitis were associated with increased risk of AP in all age groups. Meanwhile, male, older age, and higher waist circumference were associated with increased risk of AP in middle-aged and old groups. In young and middle-aged groups, risk of AP was increased in the presence of hypertension and dyslipidemia. However, high income was associated with decreased risk of AP in these groups.

CONCLUSIONS

In this population-based cohort study, incidences and risk factors for AP differed according to age group. Thus, a tailored strategy might be needed to prevent AP according to age group.

The association between smoking, changes in smoking behavior, and acute pancreatitis: A population-based cohort study in Korea

BACKGROUND AND AIMS

In the Asian population, existing studies regarding the association between smoking and acute pancreatitis are few in number. The aim of this study was to investigate the incidence of acute pancreatitis according to smoking habits and smoking habit changes of the Korean population.

METHODS

We used clinical data from individuals (aged 20 years or older) who received health examinations arranged by the Korean National Health Insurance Service in 2009 (n = 4 238 822) or in 2009 and 2011 (n = 2 617 306). The incidence of acute pancreatitis was analyzed according to smoking status or smoking habit change reported by individuals during their health examination. Newly diagnosed acute pancreatitis was identified using claims data from baseline to the date of diagnosis or until December 31, 2018.

RESULTS

The risk of acute pancreatitis was significantly higher in current smokers compared with never-smokers regardless of age or sex. The adjusted hazard ratio (HR) of acute pancreatitis in current smokers increased according to the amount of smoking (HR 1.28; 95% confidence interval [CI], 1.12-1.45 in <10 cigarettes/day, HR 1.4; CI, 1.3-1.52 in 10-19 cigarettes/day, HR 1.66; CI, 1.55-1.78 in ≥20 cigarettes/day). The adjusted HR of acute pancreatitis in continuous smokers was 1.66 (CI, 1.53-1.8) compared with never-smokers and was higher than smokers who quit smoking (HR 1.34; CI, 1.17-1.54).

CONCLUSIONS

In this Korean population-based cohort study, smoking increased the incidence of acute pancreatitis in a dose-dependent manner, and smoking cessation helped decrease the incidence of acute pancreatitis.

ACUTE PANCREATITIS in HELSINKI in 2016-2018: INCIDENCE, ETIOLOGY and RISK FACTORS - analysis of 1378 acute pancreatitis episodes in a Finnish normal population

OBJECTIVES

Updated population-based studies on acute pancreatitis (AP) in Finland are lacking. Our aim was to evaluate the current data for AP in Helsinki.

MATERIALS AND METHODS

We performed an electronic health care records (EHRs) search on AP patients treated at Helsinki University Hospital between the years 2016 - 2018. Incidence was calculated, etiological and potential risk factors, as well as severity of AP were documented and analyzed.

RESULTS

Between 2016 and 2018 we found 1378 AP episodes on 1084 patients, 35% of the patients had several AP episodes, i.e., recurrent AP (RAP). The domicile-adjusted incidence was 42.2/100 000. 47% of the patients had alcohol etiology (59% men, 27% women) and 23% had biliary etiology, 21% were idiopathic and 2.9% were post-ERCP pancreatitis. 13.1% of the patients had passed at the end of September 2021. 45% of the patients were currently smoking, 11% were ex-smokers, and the highest percentage of smokers was in the group of alcohol-caused AP with 74% ever-smokers. Biliary AP had the highest amount of overweight patients. 24% of the patients used anticoagulation (AC) medication, and the percentage was significantly higher with idiopathic AP (48%). RAP, female sex and normal BMI associated with a mild form of AP.

CONCLUSIONS

Incidence of AP and the percentage of alcohol etiology are lower than earlier reported for Finland although still higher than in other Nordic countries. Smoking and the use of AC medication associate with AP.

Pancreatic Secretory Trypsin Inhibitor (SPINK1) Gene Mutation in Patients with Acute Alcohol Pancreatitis (AAP) Compared to Healthy Controls and Heavy Alcohol Users without Pancreatitis

Only 3-5% of heavy alcohol users develop acute alcohol pancreatitis (AAP). This suggests that additional triggers are required to initiate the inflammatory process. Genetic susceptibility contributes to the development of AAP, and SPINK1 mutation is a documented risk factor. We investigated the prevalence of the SPINK1(N34S) mutation in patients with AAP compared to heavy alcohol users who had never suffered an episode of pancreatitis. Blood samples for the mutational analysis from patients with first episode (n = 60) and recurrent AAP (n = 43) and from heavy alcohol users without a history of AAP (n = 98) as well as from a control population (n = 1914) were obtained. SPINK1 mutation was found in 8.7% of the patients with AAP. The prevalence was significantly lower in healthy controls (3.4%, OR 2.72; 1.32-5.64) and very low in alcoholics without pancreatitis (1.0%, OR 9.29; 1.15-74.74). In a comparison adjusted for potential cofounders between AAP patients and alcoholics, SPINK1 was found to be an independent marker for AAP. The prevalence of the SPINK1 mutation is overrepresented in AAP patients and very low in alcoholics without pancreatitis. This finding may play a role in understanding the variable susceptibility to AAP found in heavy alcohol users.

The Clinical Characteristics and Outcome of Elderly Patients With Acute Pancreatitis

OBJECTIVES

This study aimed to identify the risk factors for the progression of acute pancreatitis (AP) to severe acute pancreatitis (SAP) and death in elderly patients.

METHODS

This was a single-center retrospective study conducted in a tertiary teaching hospital. Data on patient demographics, comorbidities, duration of hospitalization, complications, interventions, and mortality rates were collected.

RESULTS

Between January 2010 and January 2021, 2084 elderly patients with AP were included in this study. The mean age of the patients was 70.0 years (standard deviation, 7.1 years). Among them, 324 (15.5%) had SAP and 105 died (5.0%). The 90-day mortality rate in the SAP group was significantly higher than that in the AP group (P < 0.0001). Multivariate regression analysis revealed that trauma, hypertension, and smoking were risk factors for SAP. After multivariate adjustment, acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage were associated with higher 90-day mortality.

CONCLUSIONS

Traumatic pancreatitis, hypertension, and smoking are independent risk factors for SAP in elderly patients. Acute respiratory distress syndrome, acute kidney injury, sepsis, organ perforation, and abdominal hemorrhage are independent risk factors for death in elderly patients with AP.

Underweight Is Associated with a Higher Risk of Acute Pancreatitis in Type 2 Diabetes: A Nationwide Cohort Study

Type 2 diabetes is known as a risk factor for acute pancreatitis, but the risk of acute pancreatitis according to glycemic status and body mass index (BMI) has remained unknown. Therefore, we aim to investigate the risk of acute pancreatitis according to BMI and glycemic status. We included 3,912,496 subjects from the Korean National Health Insurance System cohort who underwent the National Health Screening program in 2009. Each subject’s clinical course was examined through follow-ups until December 2018. BMI and glycemic status were each categorized into five groups. Hazard ratios (HRs) of acute pancreatitis according to BMI and glycemic status were calculated. The adjusted HRs of acute pancreatitis were the highest in the underweight group (BMI < 18.5) in all five glycemic status categories. The HR of acute pancreatitis in the underweight group increased as the glycemic status worsened, excluding the category of diabetes for more than five years (HR 1.381 for normal fasting glucose; 1.805 for impaired fasting glucose; 2.332 for new-onset diabetes; 4.51 for diabetes duration <5 years; 4.135 for diabetes duration ≥5 years). We found that the risk of acute pancreatitis was further increased in the underweight group, depending on the status and duration of type 2 diabetes.

Frequency, Predisposing Factors, and Clinical Outcome of Azathioprine-Induced Pancreatitis Among Patients With Inflammatory Bowel Disease: Results From a Tertiary Referral Center

OBJECTIVE

The aim of the study was to identify the frequency of azathioprine-induced acute pancreatitis (AZA-AP) and related factors.

METHODS

Seven hundred eighty-seven inflammatory bowel disease (IBD) patients on AZA therapy were retrospectively analyzed. Azathioprine-induced AP was diagnosed with positive imaging and/or an at least 3-fold increased amylase level, in presence of typical abdominal pain. The AZA-AP group was compared with patients on AZA therapy with no history of pancreatitis and 4 numerical adjacent cases with the same diagnosis were selected (group B).

RESULTS

Fifty-four patients developed gastrointestinal symptoms (6.9%); however, only half of them (26 of 54) had pancreatitis, except 1, all within the first 2 months under AZA. When the AZA-AP group was compared with group B, only budesonide usage and active smoking were significantly more common in group A (46.2% vs 25%, P = 0.034, and 77% vs 51%, P = 0.017, respectively). Active smoking was the only independent risk factor for AZA-AP development (odds ratio, 3.208 [95% confidence interval, 1.192-8.632]).

CONCLUSIONS

All IBD patients developed AZA-AP nearly all within the first 2 months. Azathioprine intolerance may be a hidden diagnosis in at least half of the patients with AZA-AP symptoms. All smoker IBD patients should be monitored closely for AZA-AP development.

Excess Body Weight and Pancreatic Disease

Background

Excess body weight (EBW) is a risk factor for various acute and chronic conditions. Conversely, the "obesity paradox" suggests a protective effect of higher body weight on some disease outcomes. This article discusses the role of EBW along the disease continuum of pancreatitis and pancreatic cancer (PC) in terms of incidence and outcome.

Summary

Comparison of findings is hampered by the use of different methods to assess EBW. Nevertheless, in acute pancreatitis (AP) and PC, EBW, especially visceral obesity, presents a distinct risk factor and predictor of a negative outcome. Findings of a protective effect likely result from nonconsideration of fat distribution or other confounders. Regarding chronic pancreatitis (CP), few studies indicate lower incidence and a better outcome with higher body mass. However, there is insufficient evidence to confirm the existence of an obesity paradox. The precise mechanisms of how EBW affects the disease continuum require further elucidation but both common and disease-specific effects seem involved.

Key Messages

EBW is associated with higher incidence and a negative outcome in AP and PC. The association with CP is less conclusive. Thus, maintaining normal weight is advisable at any stage of the disease continuum.

High Body Mass Index and Central Adiposity Is Associated with Increased Risk of Acute Pancreatitis: A Meta-Analysis

BACKGROUND

Higher body mass index and waist circumference have been associated with increased risk of pancreatitis in several prospective studies; however, the results have not been entirely consistent.

AIMS

We conducted a systematic review and dose-response meta-analysis of prospective studies on adiposity and risk of pancreatitis to clarify this association.

METHODS

PubMed and Embase databases were searched for studies on adiposity and pancreatitis up to January 27, 2020. Prospective studies reporting adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) for the association between adiposity and risk of pancreatitis were included, and summary RRs (95% CIs) were calculated using a random effects model.

RESULTS

Ten prospective studies with 5129 cases and 1,693,657 participants were included. The summary RR (95% CI) of acute pancreatitis was 1.18 (95% CI: 1.03-1.35, I² = 91%, n = 10 studies) per 5 kg/m² increase in BMI and 1.36 (95% CI: 1.29-1.43, I² = 0%, n = 3) per 10 cm increase in waist circumference. There was evidence of a nonlinear association between BMI and acute pancreatitis, p_nonlinearity < 0.0001, with a steeper association at higher levels of BMI, but not for waist circumference, p_nonlinearity = 0.19. Comparing a BMI of 35 with a BMI of 22, there was a 58% increase in the RR and there was a fourfold increase in the RR comparing a waist circumference of 110 cm with 69 cm. There was no evidence of publication bias.

CONCLUSIONS

This meta-analysis suggests that both increasing BMI and waist circumference are associated with a dose-response-related increase in the risk of acute pancreatitis.

Body Mass Index, Triglycerides, and Risk of Acute Pancreatitis: A Population-Based Study of 118 000 Individuals

OBJECTIVE

The incidence of acute pancreatitis is rising worldwide and currently no curative treatment exists. Clarification of preventable risk factors is important for the reduction of morbidity and mortality from acute pancreatitis. In this study, we tested the hypothesis that the risk of acute pancreatitis associated with body mass index (BMI) is partly mediated through elevated triglycerides.

DESIGN

We included 118 085 individuals from 2 prospective cohort studies, the Copenhagen City Heart Study and the Copenhagen General Population Study, with BMI measured at baseline. Diagnosis of acute pancreatitis was assessed from the national Danish registries, as hospitalization or death due to acute pancreatitis.

RESULTS

Higher BMI was associated with higher risk of acute pancreatitis with a multivariable-adjusted hazard ratio of 1.4 (95% CI, 1.1-1.8) for BMI of 25-29.9, 2.1 (1.6-2.9) for BMI of 30-34.9, and 2.8 (1.8-4.3) for BMI > 35, compared with individuals with BMI of 18.5-24.9. Triglycerides mediated 29% (95% CI, 12%-46%; P = 0.001) of the association between BMI and risk of acute pancreatitis in the age- and sex-adjusted model and 22% (6%-39%; P = 0.008) in the multivariable-adjusted model.

CONCLUSION

Higher BMI is associated with higher risk of acute pancreatitis in individuals from the general population, partly mediated through higher triglycerides. This indicates a potential for preventing acute pancreatitis by reducing BMI and triglycerides in individuals with high values.

Tobacco smoking and the risk of pancreatitis: A systematic review and meta-analysis of prospective studies

BACKGROUND

Tobacco smoking has been associated with increased risk of pancreatitis in several studies, however, not all studies have found an association and it is unclear whether there is a dose-response relationship between increasing amount of tobacco smoked and pancreatitis risk. We conducted a systematic review and meta-analysis of prospective studies on tobacco smoking and pancreatitis to clarify the association.

METHODS

PubMed and Embase databases were searched for relevant studies up to April 13th^, 2019. Prospective studies that reported adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) for the association between tobacco smoking and pancreatitis were included and summary RRs were calculated using a random effects model.

RESULTS

Ten prospective studies were included. The summary RR for acute pancreatitis was 1.49 (95% CI: 1.29-1.72, I² = 68%, n = 7) for current smokers, 1.24 (95% CI: 1.15-1.34, I² = 0%, n = 7) for former smokers, and 1.39 (95% CI: 1.25-1.54, I² = 69%, n = 7) for ever smokers compared to never smokers. Similar results were observed for chronic pancreatitis and acute/chronic pancreatitis combined. The summary RR per 10 cigarettes per day was 1.30 (95% CI: 1.18-1.42, I² = 42%, n = 3) and per 10 pack-years in current smokers was 1.13 (95% CI: 1.08-1.17, I² = 14%, n = 4) for acute pancreatitis and results were similar for chronic pancreatitis and acute/chronic pancreatitis combined.

CONCLUSIONS

These results suggest that tobacco smoking increases the risk of acute and chronic pancreatitis and acute and chronic pancreatitis combined and that there is a dose-response relationship between increasing number of cigarettes and pack-years and pancreatitis risk.

Relationships between Metabolic Comorbidities and Occurrence, Severity, and Outcomes in Patients with Acute Pancreatitis: A Narrative Review

Background. The population of patients with acute pancreatitis treated by the staff at our department of gastroenterology includes those with mild and self-limited disease ranging to those with severe and fatal disease. Early diagnosis and accurate prediction of the severity and outcome of this disease, which is commonly seen by our department, is important for a successful outcome. Metabolic comorbidities (e.g., diabetes mellitus, fatty liver, obesity, and metabolic syndrome) are relevant to the severity and progression of many diseases. The objective of this review was to examine clinical relationships between metabolic comorbidities and occurrence, severity, and outcome of acute pancreatitis.

Lifestyle and cancer incidence and mortality risk depending on family history of cancer in two prospective cohorts

The extent to which a favorable lifestyle may lower cancer risk in subjects with a family history of cancer is unknown. We conducted a prospective study in two Swedish cohorts, the Malmö Diet and Cancer Study (MDCS; n = 25,604) and the Malmö Preventive Project (MPP; n = 16,216). The association between a favorable lifestyle (based on nonsmoking, normal weight, absence of excessive drinking, regular physical activity and healthy diet) and cancer incidence and mortality risk was assessed using Cox regression stratified by family history of cancer (all types). A favorable lifestyle was associated with a 22% (95% confidence interval [CI]: 18-26%) and 40% (95% CI: 36-44%) lower risk of cancer incidence and mortality, respectively, compared to an unfavorable lifestyle. No significant effect modification by family history was observed but there was a null association between lifestyle and cancer incidence among subjects with two or more affected first-degree relatives. The observed relative risk estimates comparing an unfavorable with a favorable lifestyle corresponded to standardized 10-year cancer incidence rates of 11.2 vs. 9.5% in the MDCS, and 4.4 vs. 3.2% in the MPP, and a reduction in 20-year cancer mortality rate from 11.7% to 7.4% in the MDCS and 6.7% to 3.9% in the MPP. Improved adherence to cancer prevention recommendations may reduce cancer incidence and mortality risk in the general population, however, further studies are needed to assess the impact of lifestyle on cancer incidence among subjects with strong familial or polygenic risk for specific cancers.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Ethnic differences in risk factors of acute pancreatitis

OBJECTIVE

The ethnic difference in the risk factors of acute pancreatitis remains unknown. The objective of this study is to investigate the differences in the risk factors of acute pancreatitis between Taiwanese aborigines and nonaborigines.

DESIGN

A retrospective study of 622 patients with acute pancreatitis admitted to our hospital (Puli Christian Hospital) from 2006 to 2014. The risk factors and biochemical properties of acute pancreatitis were comapred between aborgines and nonaborgines.

RESULTS

The first episode of acute pancreatitis amongst the aboriginal group was commonly observed in young age groups (39.3 versus 47.8 years, p < 0.05), female patients (0.61 versus 0.27, p < 0.05), and patients with a habit of drinking alcohol (84% versus 65%, p < 0.05). Analysis of the biochemical properties and risk factors demonstrated siginifcantly high uric acid levels (7.63 versus 6.56 mg/dL, p < 0.05), and an increased prevalence of alcohol-related pancreatitis (60.0% versus 49.6%, p < 0.05) in the aboriginal group.

CONCLUSIONS

Taiwanese aborigines were reported to be more susceptible to alcohol-related pancreatitis than nonaborigines. The decreasing levels of excessive alcohol consumption may reduce the disease burden of acute pancreatitis.

Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel

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.

Impact of cigarette smoking on recurrence of hyperlipidemic acute pancreatitis

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.

Alcohol, smoking and benign hepato-biliary disease

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

Angiotensin II receptor blockers and risk of acute pancreatitis - a population based case-control study in Sweden

Background

Acute pancreatitis is a potentially lethal disease, with a rising incidence in the Western world. Yet, no pharmacological prevention or specific treatment for acute pancreatitis exists. Also, the connection with severity of acute pancreatitis is unknown. Experimental and epidemiological research suggests a protective effect of angiotensin II receptor blockers.

Methods

During 2006 to 2008, we performed a nationwide case–control study on Swedish residents aged 40–84 years. First-time cases with acute pancreatitis were identified in the National Patient Register and data on dispensed prescriptions was retrieved from the Prescribed Drug Register. Controls were randomly selected from the general population in Sweden frequency-matched on sex, age, and calendar year. To estimate relative risk of acute pancreatitis, by degree of severity, among users of angiotensin II receptor blockers, as compared to non-users, we used multivariable logistic regression analysis to calculate odds ratios (OR) with 95% confidence interval (CI).

Results

Among 6,161 cases of acute pancreatitis and 61,637 controls, current use of angiotensin II receptor blockers was followed by a decreased risk of acute pancreatitis, compared to non-users, adjusted OR 0 · 77 (95% CI 0 · 69–0 · 86). No protective association, but an increased risk was found for users of angiotensin-converting enzyme inhibitors (adjusted OR 1 · 11, 95% CI: 1 · 01–1 · 21), analysed for comparison reasons. There was a significant decreased risk associated with both severe acute pancreatitis, (OR 0 · 71 (0 · 59–0 · 85), and mild acute pancreatitis; adjusted OR 0 · 81 (0 · 70–0 · 94).

Conclusion

This population-based case–control study indicates that use of angiotensin II receptor blockers might be associated with a lesser risk of acute pancreatitis, and that the protective association was significant among cases of both severe and mild acute pancreatitis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-017-0595-8) contains supplementary material, which is available to authorized users.

Patients With Sentinel Acute Pancreatitis of Alcoholic Etiology Are at Risk for Organ Failure and Pancreatic Necrosis: A Dual-Center Experience

OBJECTIVES

To assess the relationship between alcoholic etiology, tobacco use, and severe acute pancreatitis (AP).

METHODS

Smoking and alcohol exposure were recorded upon admission in a cohort of patients with AP within the United States. Patients with first, "sentinel" attack of AP were identified for analysis.Associations between alcohol, smoking, and severe AP were validated in an independent cohort of patients from Spain.

RESULTS

US cohort (n = 222): Thirty-five percent developed organ failure (OF), 35% pancreatic necrosis (PNec), and 7% died. OF (54% vs 33%, P = 0.03), PNec (62% vs 31%, P = 0.006), intensive care unit admission (58% vs 36%, P = 0.03), and length of stay (LOS) (20 vs 8 days, P = 0.007) were greater in alcoholic when compared to other etiologies.Spanish cohort (n = 366): Similar differences in outcomes were also found with between alcoholic and nonalcoholic etiologies: OF (24% vs 8%, P = 0.001), PNec (38% vs 14%, P < 0.001), intensive care unit admission (20% vs 3%, P < 0.001), and LOS (17 vs 11 days, P = 0.04).Multivariable analysis confirmed alcoholic etiology to be independently associated with OF and PNec in both cohorts.

CONCLUSIONS

Alcoholic etiology is independently associated with OF and PNec in patients with sentinel AP and is important when evaluating risk for severe disease in AP.

Prospective Study of Alcohol Drinking, Smoking, and Pancreatitis: The Multiethnic Cohort

OBJECTIVES

We conducted a prospective analysis of 145,886 participants in the multiethnic cohort to examine the relationship of alcohol drinking and smoking with pancreatitis.

METHODS

Pancreatitis cases were categorized as gallstone-related acute pancreatitis (GSAP) (N = 1,065), non-GSAP (N = 1,222), and recurrent acute (RAP)/chronic pancreatitis (CP) (N = 523). We used the baseline questionnaire to identify alcohol intake and smoking history. Associations were estimated by hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox models.

RESULTS

Cigarette smoking was associated with non-GSAP and RAP/CP. Moderate alcohol intake was inversely associated with all types of pancreatitis in women (HRs, 0.66 to 0.81 for <1 drink per day), and with RAP/CP in men (HR, 0.57; 95% CI, 0.41-0.79 for <2 drinks per day). The risk of non-GS pancreatitis associated with current smoking was highest among men who consumed more than 4 drinks per day (HR, 2.06; 95% CI, 1.28-3.30), whereas among never smokers, moderate drinking was associated with a reduced risk (HR, 0.70; 95% CI, 0.51-0.96). In women, drinking less than 2 drinks per day was associated with a reduced risk of GSAP among never smokers (HR, 0.61; 95% CI, 0.46-0.80).

CONCLUSIONS

Smoking is a risk factor for non-GS pancreatitis. Moderate alcohol intake is protective against all types of pancreatitis in women and against RAP/CP in men.

Relationship Between Acute Benzodiazepine Poisoning and Acute Pancreatitis Risk: A Population-Based Cohort Study

We designed a population-based retrospective cohort study to investigate the association between the event of benzodiazepine (BZD) poisoning and the risk of acute pancreatitis.In the present study, 12,893 patients with BZD poisoning during 2000 to 2011 were enrolled and matched with 4 comparison patients according to mean age and sex. We determined the cumulative incidences and adjusted hazard ratios of acute pancreatitis.A significant association was observed between BZD poisoning and acute pancreatitis. After adjustment for potential risk factors, the patients with BZD poisoning had a 5.33-fold increased risk of acute pancreatitis compared with the controls without BZD poisoning (HR = 5.33, 95% CI = 2.26-12.60). The results revealed that acute pancreatitis in patients with BZD poisoning occurred in a follow-up time of ≤1 month (HR = 50.0, P < .001), and the risk of acute pancreatitis was no different between the patients with and without BZD poisoning when the follow-up time was >1 month (HR = 1.07, P > .05).This population-based study revealed the positive correlation between the event of BZD poisoning and an increased risk of acute pancreatitis. The findings warrant further large-scale and in-depth investigation.

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.

Factors That Affect Disease Progression After First Attack of Acute Pancreatitis

BACKGROUND & AIMS

Little is known about recurrence of pancreatitis after an initial episode, and little is known about how the disease progresses or what factors affect progression. We performed a population-based study of patients with acute pancreatitis (AP) to determine their outcomes and associated factors.

METHODS

We performed a retrospective study of patients with first-time AP from 2003 through 2012 in a well-defined area of Sweden. Data were collected from medical records on disease etiology, severity (according to the Atlanta classification), recurrence of AP, subsequent chronic pancreatitis, and mortality. Patients were followed up for a median time of 4.6 years, until death or the end of 2013.

RESULTS

We identified 1457 patients with first-time AP (48% biliary disease, 17% alcohol-associated, 9.9% severe); 23% of patients had 1 or more recurrences. Risk for recurrence was significantly higher among smokers (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.03-1.95; P = .03), patients with alcohol-associated AP (HR, 1.58; 95% CI, 1.25-2.23; P < .01), after organ failure (HR, 1.46; 95% CI 1.05-2.03; P = .02), and in patients with systemic complications (HR, 1.88; 95% CI, 1.27-2.79; P < .01) or local complications (HR, 1.66; 95% CI, 1.22-2.27; P < .01). AP of all etiologies progressed to chronic pancreatitis, although alcohol-associated AP progressed most frequently (2.8/100 patient-years). Patients with recurrent AP were at the highest risk for chronic pancreatitis (HR, 6.74; 95% CI, 4.02-11.3; P < .01), followed by alcohol-associated AP (HR, 3.10; 95% CI, 2.05-5.87; P < .01), smoking (HR, 2.26; 95% CI, 1.12-4.58; P = .02), systemic complications (HR, 1.37; 95% CI, 1.06-4.62; P = .03), and peripancreatic necrosis (HR, 2.74; 95% CI, 1.7-4.43; P < .01). In-hospital mortality was 2.8%, and independently associated only with organ failure (odds ratio, 71.17; 95% CI, 21.14-239.60; P < .01). Fifty-three percent of patients who died during disease recurrence had biliary AP; a higher percentage of these patients died upon first recurrence (5.9%) than upon first attack of AP (2%; P = .01).

CONCLUSIONS

The severity of first-time AP, smoking, and alcohol abuse are related to recurrence and subsequent chronic pancreatitis. Recurrence increases the risk for progression to chronic pancreatitis. Most patients who die upon disease recurrence have biliary AP.

Impact of a clinical pathway on treatment outcome in patients with acute pancreatitis

AIM: To determine the impact of a clinical pathway (CP) on acute pancreatitis (AP) treatment outcome.

METHODS: A retrospective analysis of medical records was performed. We compared the results of AP treatment outcome over two time periods in our centre, before (2006-2007) and after (2010-2012) the implementation of a CP. The CP comprised the following indicators of quality: performance of all laboratory tests on admission (including lipids and carbohydrate deficient transferrin), determination of AP aetiology, abdomen ultrasound (US) within the first 24 h after admission, contrast-enhanced computed tomography of the abdomen in all cases of suspected pancreatic necrosis, appropriately selected and sufficiently used antibiotic therapy (if necessary), pain control, adequate hydration, control of haemodynamic parameters and transfer to the Intensive Care Unit (ICU) (if necessary), endoscopic retrograde cholangiopancreatography (ERCP) in biliary AP, surgical treatment (if necessary), and advice on outpatient follow-up after discharge. A comparison of the length of stay with that in other Slovenian hospitals was also performed.

RESULTS: There were 139 patients treated in the three-year period after the introduction of a CP, of which 81 (58.3%) were male and 58 (41.7%) female. The patients’ mean age was 59.6 ± 17.3 years. The most common aetiologies were alcoholism and gallstones (38.8% each), followed by unexplained (11.5%), drug-induced, hypertriglyceridemia, post ERCP (2.9% each) and tumours (2.2%). Antibiotic therapy was prescribed in 72 (51.8%) patients. Abdominal US was performed in all patients within the first 24 h after admission. Thirty-two (23.0%) patients were treated in the ICU. Four patients died (2.9%). In comparison to 2006-2007, we found an increased number of alcoholic and biliary AP and an associated decrease in the number of unexplained aetiology cases. The use of antibiotics also significantly decreased after the implementation of a CP (from 70.3% to 51.8%; P = 0.003). There was no statistically significant difference in mortality (1.8% vs 2.9%). The length of stay was significantly shorter when compared to the Slovenian average (P = 0.018).

CONCLUSION: The introduction of a CP has improved the treatment of patients with AP, as assessed by all of the observed parameters.

Heavy Smoking Is Associated With Lower Age at First Episode of Acute Pancreatitis and a Higher Risk of Recurrence

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.

Epidemiologic and Mechanistic Associations Between Smoking and Pancreatitis

OPINION STATEMENT

Alcohol has long been associated with pancreatitis. Although first described more than three decades ago, smoking has been widely accepted as an important risk factor for all forms of pancreatitis only in the past few years. Empiric data has confirmed smoking as an independent and dose-dependent risk for both acute and chronic pancreatitis. Smoking also increases the risk of recurrences and progression of established chronic pancreatitis. The effects of smoking are enhanced in the presence of alcohol consumption. Indirect evidence suggests that smoking cessation may be beneficial in preventing disease progression. Smoking cessation can therefore be an important strategy for primary as well as secondary prevention of pancreatitis. Therefore, in addition to alcohol, physicians should routinely counsel patients for the benefits of smoking cessation. The mechanisms through which cigarette smoke triggers pathological cellular events, resulting in pancreatitis, are unresolved. Although cigarette smoke contains greater than 4000 compounds, principally nicotine and the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) have been broadly studied with regard to pancreatic diseases. Both nicotine and NNK have been shown to induce morphological changes in the pancreas consistent with those seen in pancreatitis. Furthermore, nicotine affects pancreatic secretion and NNK induces premature zymogen activation, two well-known features of pancreatitis. These cigarette toxins may mediate both pro- and anti-inflammatory pathways and can induce changes in pancreatic acinar cell function at the level of transcription, leading to conditions such as thiamin deficiency and mitochondrial dysfunction. Such circumstances could leave the pancreas prone to the development of pancreatitis. This review summarizes relevant research findings and focuses on the epidemiologic links between smoking and pancreatitis, and the cellular pathways that may be significant in induction and evolution of smoking-related pancreatitis.

Acute pancreatitis

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.

Treating acute pancreatitis: what's new?

The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.

Acute pancreatitis gravity predictive factors: which and when to use them?

INTRODUCTION

Acute pancreatitis has as its main causes lithiasic biliary disease and alcohol abuse. Most of the time, the disease shows a self-limiting course, with a rapid recovery, only with supportive treatment. However, in a significant percentage of cases, it runs with important local and systemic complications associated with high mortality rates.

AIM

To present the current state of the use of these prognostic factors (predictive scores) of gravity, as the time of application, complexity and specificity.

METHOD

A non-systematic literature review through 28 papers, with emphasis on 13 articles published in indexed journals between 2008 and 2013 using Lilacs, Medline, Pubmed.

RESULTS

Several clinical, laboratory analysis, molecular and image variables can predict the development of severe acute pancreatitis. Some of them by themselves can be determinant to the progression of the disease to a more severe form, such as obesity, hematocrit, age and smoking. Hematocrit with a value lower than 44% and serum urea lower than 20 mg/dl, both at admission, appear as risk factors for pancreatic necrosis. But the PCR differentiates mild cases of serious ones in the first 24 h. Multifactorial scores measured on admission and during the first 48 h of hospitalization have been used in intensive care units, being the most ones used: Ranson, Apache II, Glasgow, Iget and Saps II.

CONCLUSION

Acute pancreatitis is a disease in which several prognostic factors are employed being useful in predicting mortality and on the development of the severe form. It is suggested that the association of a multifactorial score, especially the Saps II associated with Iget, may increase the prognosis accuracy. However, the professional's preferences, the experience on the service as well as the available tools, are factors that have determined the choice of the most suitable predictive score.

The association of smoking and acute pancreatitis: a systematic review and meta-analysis

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.

Pathologic cellular events in smoking-related pancreatitis

Pancreatitis, a debilitating inflammatory disorder, results from pancreatic injury. Alcohol abuse is the foremost cause, although cigarette smoking has recently surfaced as a distinct risk factor. The mechanisms by which cigarette smoke and its toxins initiate pathological cellular events leading to pancreatitis, have not been clearly defined. Although cigarette smoke is composed of more than 4000 compounds, it is mainly nicotine and the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), which have been extensively studied with respect to pancreatic diseases. This review summarizes these research findings and highlights cellular pathways which may be of relevance in initiation and progression of smoking-related pancreatitis.

Impact of smoking on the risk of pancreatitis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Cigarette smoking may increase the risk of developing pancreatic cancer, although its impact on pancreatitis has only been discerned in recent years. However, the results of previous studies differ. We performed a meta-analysis to provide a quantitative pooled risk estimate of the association of cigarette smoking with pancreatitis.

METHOD

A literature search of the MEDLINE and Embase databases was conducted, and studies were selected that investigated the association of cigarette smoking with pancreatitis. Summary relative risks (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model.

RESULTS

Twenty-two studies were included. The summary RRs (95% CI) associated with ever, current and former smokers for acute and chronic pancreatitis (AP/CP) were as follows: 1.51 (1.10, 2.07)/3.00 (1.46, 6.17), 1.42 (1.08, 1.87)/2.72 (1.74, 4.24), and 1.22 (0.99, 1.52)/1.27 (1.00, 1.62), respectively. Moreover, studies that analyzed both AP and CP were also summarized: 1.73 (1.18, 2.54) for ever smokers, 1.67 (1.03, 2.68) for current smokers and 1.56 (1.16, 2.11) for former smokers, respectively. There was no evidence of publication bias across the studies.

CONCLUSION

The evidence suggests a positive association of cigarette smoking with the development of pancreatitis. It is possible that smoking cessation may be a useful strategy for the management of pancreatitis.

Meta-analysis: Tobacco smoking may enhance the risk of acute pancreatitis

BACKGROUND AND AIM

Questions remain unclear about the association of smoking status and the development of acute pancreatitis (AP). We performed a meta-analysis of observational studies explore this association.

METHODS

A computerized literature search was performed in MEDLINE and EMBASE through November 30, 2014. We also searched the reference lists of pertinent articles. We used a random-effects model to calculate the summary relative risks (SRRs) and their corresponding 95% confidence intervals (CIs).

RESULTS

A total of 3690 incident cases of AP included 12 observational studies (6 case-control and 6 prospective cohort/nested case-control studies) were identified. Compared with never smokers, the summary RR estimates were 1.54 (95% CI, 1.31-1.80) for ever smokers, 1.71 (95% CI, 1.37-2.14) for current smokers, and 1.21 (95% CI, 1.02-1.43) for former smokers. Smoking is found to be a potential risk factor for alcohol use, idiopathic factors and drugs related AP, but not for gallstone related AP, in the ever and current smokers. A dose-response effect of tobacco use on the risk was ascertained: current smokers had a 40% (95% CI, 30%-51%) increased risk of AP for every additional 10 cigarettes per day.

CONCLUSION

The present analysis suggests that smokers have an elevated risk of AP development. Further studies, however, are warranted before definitive conclusions can be drawn.

Smoking and risk for acute pancreatitis: a systematic review and meta-analysis

We aimed to better understand the relationship between smoking and a risk for acute pancreatitis (AP) in existing observational studies. We identified studies by searching the PubMed, Scopus, and Web of Science databases (from inception through August 31, 2013) and by searching bibliographies of relevant articles. Summary relative risks (RRs) with 95% confidence intervals (CIs) were calculated with fixed-effects and random-effects models. A total of 5 studies met inclusion criteria for analysis. Both current smoking (summary RR, 1.74; 95% CI, 1.39-2.17; n = 5 studies) and former smoking (summary RR, 1.32; 95% CI, 1.03-1.71; n = 4 studies) were associated with an increased risk for AP. The positive association of current smoking and risk for AP remained when we limited the meta-analysis to studies that controlled for alcohol intake and body mass index (summary RR, 1.76; 95% CI, 1.31-2.36; n = 4 studies). Both current and former smoking are associated with increased risk for AP. Further investigations, both epidemiological and mechanistic, are needed to establish the extent to which the association can be explained by a causal link and whether smoking cessation can prevent the occurrence and development of AP.

Smoking, drinking, and pancreatitis: a population-based cohort study in Taiwan

OBJECTIVES

In Western population, smoking is a dose-dependent risk factor for pancreatitis, whereas a threshold of 5 drinks per day may exist for alcohol to increase pancreatitis risk. Given ethnic differences in tobacco and alcohol metabolism, we examined the associations between smoking, alcohol, and pancreatitis in Asians.

METHODS

A population-based cohort was assembled using participants of the National Health Interview Survey in Taiwan. Information on drinking and smoking was collected by in-person interview at baseline. Incident cases of pancreatitis were identified through data linkage with National Health Insurance claims database.

RESULTS

During 94,601 person-years of follow-up, 66 incident cases of pancreatitis occurred. Neither current nor ever smoking was associated with the incidence of pancreatitis (adjusted hazard ratio [aHR] 1.13; 95% confidence interval [CI], 0.62-2.06; and aHR, 1.14; 95% CI, 0.63-2.06, respectively). Dose-response analysis also showed no association between smoking and pancreatitis. By contrast, regular (aHR, 3.09; 95% CI, 1.51-6.30) and heavy alcohol drinking (aHR, 6.46; 95% CI, 3.07-13.60) were associated with an increased incidence of pancreatitis compared with abstinence.

CONCLUSIONS

In this Asian population-based cohort, alcohol was associated with pancreatitis in a dose-dependent way, but smoking was not associated with pancreatitis. These results support for ethnic differences in susceptibility to smoking- and alcohol-related pancreatitis.

Factors that affect risk for pancreatic disease in the general population: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND & AIMS

Pancreatic diseases place significant burdens on health care systems worldwide. However, there is lack of agreement about which factors increase or reduce risk for pancreatic disease. We reviewed high-quality studies of factors that affect risk for pancreatic diseases in the general population.

METHODS

We searched 3 databases (Medline, Embase, and Scopus) for prospective cohort studies of modifiable risk and/or protective factors for acute pancreatitis, chronic pancreatitis, and pancreatic cancer in adult populations. Factors that were investigated in 2 or more studies were assessed by meta-analysis if the required data were available. Subgroup analyses were performed when appropriate. Outcome measures were relative risk (RR) and 95% confidence interval (CI).

RESULTS

Our analysis included 51 population-based studies with more than 3 million individuals and nearly 11,000 patients with pancreatic diseases. A total of 31 different factors were investigated. Current tobacco use was the single most important risk factor for pancreatic diseases (RR, 1.87; 95% CI, 1.54-2.27), followed by obesity (RR, 1.48; 95% CI, 1.15-1.92) and heavy use of alcohol (RR, 1.37; 95% CI, 1.19-1.58). Tobacco and heavy use of alcohol had bigger effects on risk of acute pancreatitis and chronic pancreatitis than pancreatic cancer. Vegetable consumption (RR, 0.71; 95% CI, 0.57-0.88) and fruit consumption (RR, 0.73; 95% CI, 0.60-0.90) provided the greatest degree of protection against pancreatic diseases on the basis of meta-analyses. Vegetable consumption had stronger association with protection against acute pancreatitis and fruit consumption with protection against pancreatic cancer.

CONCLUSIONS

On the basis of systematic review and meta-analysis, current tobacco use, obesity, and heavy use of alcohol are associated with significant increases in risk for pancreatic diseases. Vegetables and fruit consumption are associated with reduced risk for pancreatic diseases. Prevention strategies for acute pancreatitis, chronic pancreatitis, and pancreatic cancer should consider these factors.

Risk factors of acute pancreatitis in the elderly Chinese population: a population-based cross-sectional study

OBJECTIVE

Lifestyle changes have led to an increasing incidence of acute pancreatitis (AP) in China. The aims of this study were to evaluate the association between lifestyle as well as medical history and AP in the elderly population and to provide evidence towards the prevention against AP.

METHODS

A population-based cross-sectional study was conducted in Daqing, Heilongjiang Province, China. A total of 23 294 residents aged ≥55 years were enrolled in the study. A questionnaire survey was conducted to collect data on participants' characteristics, lifestyle and medical history via a face-to-face interview, and compared these data with the medical chart.

RESULTS

In total, 45 participants had been diagnosed with AP, that is, a prevalence of 0.19%. No significant differences were observed with respect to their age, gender, marital status or body mass index (BMI) in participants with and without AP. However, those were better educated were more likely to develop AP (P = 0.005). The univariate analysis showed that a high meat intake, smoking, alcohol consumption and a medical history of gallstones were associated with a significant increase in the risk of developing AP (P < 0.05). Furthermore, smoking or alcohol consumption was dose-dependently associated with the risk of AP, particularly in those who smoked at least 15 pack-years or consumed ≥56.2 drinks per year. Multivariable logistics analysis suggested that the level of education, smoking and medical history of gallstone are independent risk factors for AP.

CONCLUSIONS

Our study indicated that a higher education level, smoking, alcohol consumption and history of gallstones may be potential risk factors for AP in the elderly in northeast China.

Does the presence of obesity and/or metabolic syndrome affect the course of acute pancreatitis?: A prospective study

OBJECTIVE

The incidence of acute pancreatitis (AP) is rising with increased prevalence of obesity, which exacerbates pancreatic injury. Metabolic syndrome (MS) is defined as a cluster condition of cardiovascular risk factors, including hyperglycemia, dyslipidemia, hypertension, and central obesity. We analyze if the presence of obesity and/or MS affects the course of pancreatitis.

METHODS

Data were collected from 140 patients with AP between January 2010 and February 2013. Anthropometric data, including body mass index and waist circumference, were measured. Biochemical tests were used including fasting glucose, triglyceride, low- and high-density lipoprotein cholesterol levels, and total cholesterol level. Atlanta criteria, Acute Physiology and Chronic Health Evaluation II, and Ranson scoring system were used to define severe AP. Patients were classified as having MS based on the International Diabetic Federation criteria.

RESULTS

The mean body mass index was 30.15 kg/m(2). Sixteen (11.4%) patients had severe AP, whereas 124 (88.6%) patients had mild AP. We found that 62.8% of patients with AP fulfilled the criteria of MS (P = 0.000). Body weight can be used to predict clinical severity of AP with significant P value (P = 0.009).

CONCLUSIONS

The presence of MS in patients with pancreatitis is noticeable, but it does not affect the course of disease severity, whereas obesity correlates with pancreatitis severity.

Smoking as a risk factor for complications in chronic pancreatitis

OBJECTIVES

Several recent studies have demonstrated the association between smoking and chronic pancreatitis (CP). However, less is known about the role of smoking in the development of CP-related complications. Our aim was to investigate the impact of smoking and alcohol consumption on age of onset and complications at CP diagnosis.

METHODS

A cross-sectional case-case study was performed within a prospectively collected cohort of patients with CP. Alcohol consumption and smoking habits were assessed using a standardized questionnaire. Morphologic severity was defined based on endoscopic ultrasound criteria for CP and classified as mild (3-4 criteria), moderate (5-6 criteria), and severe (≥7 criteria or calcifications). Pancreatic exocrine insufficiency (PEI) was diagnosed using the C-mixed triglyceride breath test. Odds ratios (OR) with 95% confidence intervals (CI) for CP-related complications were calculated using a case-case design.

RESULTS

A total of 241 patients were included. Smoking was associated with PEI (OR [95% CI], 2.4 [1.17-5.16]), calcifications (OR [95% CI], 2.33 [1.10-4.95]), and severe morphologic changes (OR [95% CI], 3.41 [1.31-8.85]) but not with pseudocysts or diabetes. Neither smoking nor alcohol consumption was associated with age of onset.

CONCLUSIONS

Tobacco, but not alcohol, is associated with PEI, calcifications, and severe morphologic (≥7 criteria or calcifications) CP at diagnosis. Smoking cessation should be encouraged in patients with CP.

Drug-induced acute pancreatitis: results from the hospital-based Berlin case-control surveillance study of 102 cases

BACKGROUND

Drug toxicity is a well-known cause of acute pancreatitis (AP). Although many drugs have been associated with AP, the magnitude of the risk of most of them remains largely unknown.

AIM

To determine the pancreatotoxic risk of a wide range of drugs.

METHODS

The hospital-based Berlin case-control surveillance study, including all 51 Berlin hospitals in a hospital network, ascertained 102 cases with idiopathic AP (IAP) and 750 controls between 2002 and 2011. Patients with IAP were thoroughly validated using anamnestic, clinical or laboratory data. Drug exposure was obtained in a face-to-face interview. Possible drug aetiology was assessed in individual patients through a standardised causality assessment applying the criteria of the World Health Organization. Drug risks were further quantified [odds ratios (OR) with 95% confidence intervals (CI)] in a case-control design with unconditional logistic regression analysis.

RESULTS

The pancreatotoxic risk of several drugs, including azathioprine (OR 5.1; 95% CI 1.9-13.5), fenofibrate (OR 12.2; 95% CI 2.3-69.1), mesalazine (OR 3.3; 95% CI 1.1-9.5) or angiotensin-converting enzyme inhibitors, was corroborated by case-control analysis and causality assessment. Causality assessment suggested a pancreatotoxic potential, among others, for mercaptopurine or the seldom reported leflunomide, and alluded to a novel risk for tocilizumab. Case-control analysis showed an increased risk for two phytotherapeutics: harpagophytum and valerian radix.

CONCLUSIONS

Our study quantified the pancreatotoxic risk of different drugs and phytotherapeutics. The findings corroborate previous results from the literature but also indicate risks for substances not previously reported, highlighting the need for further controlled studies on pancreatic toxicity.

Clinical predictors of severe acute pancreatitis: value-adding the view from the end of the bed

BACKGROUND

Research into clinical determinants of severe acute pancreatitis remains important for therapeutic and preventive purposes. To contribute to prognostication, this study aimed to define clinical risk factors for the development of severe acute pancreatitis.

METHODS

Study design was a prospective cohort study, using multiple logistic regression. From March 2004 to July 2007, 153 cases of acute pancreatitis were recruited in a regional Australian hospital. Data were collected regarding demographic and clinical characteristics. The outcome measure was severe acute pancreatitis, as defined by composite consensus criteria.

RESULTS

After adjustment for potential confounders, there was a significant positive association with waist circumference and a negative association with current smoking status.

CONCLUSION

The study confirms other work suggesting central adiposity as a risk factor for severe acute pancreatitis. The finding of a possible protective effect for smoking may be physiologically plausible but merits further confirmatory research.

Application of biochemical markers CA 19-9, CEA and C-reactive protein in diagnosis of malicious and benign pancreatic tumors

INTRODUCTION

We would save many lives and spare a lot of suffering if we could only detect and accurately determine the character and TMN staging of pancreatic tumors (PTs). With improved diagnosis, we could offer specific treatment that would result in better treatment outcome. The aim of study was to determine the significance of neoplastic markers CA 19-9 and CEA for prognosis in inflammatory and carcinomatous PTs.

MATERIAL AND METHODS

We based our research upon a group of 170 patients. The patients were treated in our Oncologic Surgery Department from January 2007 to December 2010 for PTs. The patients were divided into four groups depending on the character of the tumor and underwent the following treatments: group 1 - 34 patients with carcinoma of the ampulla of Vater, group 2 - 64 patients with PTs at different stages (1, 2, 3) according to TMN classification, group 3 - 62 patients with PTs at stage 4 on the TMN scale (unresectable tumors), group 4 - 28 patients with inflammatory PTs.

RESULTS

The results of Ca 19-9 in group 2 were 736.00 (25-75% 220.40-4285.00) ng/ml before surgery, 53.00 (25-75% 12.60-84.00) ng/ml in the 7 days after surgery, 29.4 (25-75% 7.90-113.00) ng/ml at day 30, and 119.00 (25-75% 96.30-621.00) ng/ml 3 months after the operation. These results were significantly higher than the control group but were significantly lower than the results for group 3 (unresectable tumors). The highest average concentration and median for CA 19-9 and CEA were noted in patients with unresectable PTs (the 3(rd) group). The average concentration for CEA was lowest in group 4, but much higher than the lab limits.

CONCLUSIONS

The sensitivity of the CA 19-9 marker may be as high as 88%. Values of CA 19-9 above 852 U/ml may indicate TNM stage 4, consistent with an unresectable PT. In the cases where CA 19-9 is within normal limits but C-reactive protein is above normal limits (often thirty times the upper limit), in comparison to the control group and to patients with pancreatic neoplasms, strong consideration should be given towards the inflammatory characteristics of the pancreatic changes and conservative treatment should be applied.

Risk models for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP): smoking and chronic liver disease are predictors of protection against PEP

OBJECTIVES

We investigated which variables independently associated with protection against or development of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and severity of PEP. Subsequently, we derived predictive risk models for PEP.

METHODS

In a case-control design, 6505 patients had 8264 ERCPs, 211 patients had PEP, and 22 patients had severe PEP. We randomly selected 348 non-PEP controls. We examined 7 established- and 9 investigational variables.

RESULTS

In univariate analysis, 7 variables predicted PEP: younger age, female sex, suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate-difficult cannulation (MDC), pancreatic stent placement, and lower Charlson score. Protective variables were current smoking, former drinking, diabetes, and chronic liver disease (CLD, biliary/transplant complications). Multivariate analysis identified seven independent variables for PEP, three protective (current smoking, CLD-biliary, CLD-transplant/hepatectomy complications) and 4 predictive (younger age, suspected SOD, pancreatic sphincterotomy, MDC). Pre- and post-ERCP risk models of 7 variables have a C-statistic of 0.74. Removing age (seventh variable) did not significantly affect the predictive value (C-statistic of 0.73) and reduced model complexity. Severity of PEP did not associate with any variables by multivariate analysis.

CONCLUSIONS

By using the newly identified protective variables with 3 predictive variables, we derived 2 risk models with a higher predictive value for PEP compared to prior studies.