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Darden CM, Mohammed ARH, Kirkland J, Kuncha J, Lawrence MC, Danobeitia JS, Beecherl E, Lee SHS, Gupta A, Naziruddin B. Total pancreatectomy with islet autotransplantation outcomes in patients with pancreatitis of genetic etiology: A single-center experience with a large cohort of patients. J Gastrointest Surg 2024:S1091-255X(24)00481-5. [PMID: 38834105 DOI: 10.1016/j.gassur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/15/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment for patients with chronic pancreatitis (CP) when other interventions are unsuccessful. CP has many etiologies including heredity. Metabolic and pain relief outcomes after TPIAT are presented among patients with a genetic CP etiology compared with those with a nongenetic etiology in a large cohort of patients who underwent this procedure at our center. METHODS A retrospective analysis was performed of 237 patients undergoing TPIAT between 2006 and 2023. We analyzed the differences in patients with genetic (n = 56) vs nongenetic CP etiologies (n = 181) in terms of pre-TPIAT factors including patient characteristics and disease state, results from the isolation process, and outcomes such as long-term glycemic and pain control. RESULTS Patients with genetic CP underwent TPIAT at a significantly younger age (32.3 vs 41.3 years nongenetic; P < .0001) and endured symptoms for a significantly longer period (10 vs 6 years; P < .01). A significantly lower mass of islets was isolated from patients with genetic CP (P < .01), which increased with body mass index in both groups. Despite lower yields, patients with genetic CP maintained metabolic function similar to patients with nongenetic CP, as indicated by insulin independence and C-peptide, blood glucose, and hemoglobin A1C levels after TPIAT. Post-transplant narcotic usage and pain scores significantly decreased compared with those before TPIAT, and more patients with genetic CP were pain free and narcotic free after TPIAT. CONCLUSION Our data validate TPIAT as a beneficial procedure for patients enduring CP of genetic etiology. Pain that is inevitably recurrent after minor interventions owing to the nature of the disease and favorable TPIAT outcomes should be considered in the decision to perform early TPIAT in cases of genetic CP.
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Affiliation(s)
- Carly M Darden
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | | | - Jeffrey Kirkland
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Jayachandra Kuncha
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - Michael C Lawrence
- Islet Cell Laboratory, Baylor Scott & White Research Institute, Dallas, TX, United States
| | - J Sebastian Danobeitia
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Ernest Beecherl
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Seung Hee S Lee
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Amar Gupta
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States.
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Qiu M, Zhou X, Zippi M, Goyal H, Basharat Z, Jagielski M, Hong W. Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis. Ann Med 2023; 55:2265939. [PMID: 37813108 PMCID: PMC10563627 DOI: 10.1080/07853890.2023.2265939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/26/2023] [Indexed: 10/11/2023] Open
Abstract
It is well known, that the inflammatory process that characterizes acute pancreatitis (AP) can lead to both pancreatic damage and systemic inflammatory response syndrome (SIRS). During the last 20 years, there has been a growing incidence of episodes of acute pancreatitis associated with hypertriglyceridaemia (HTAP). This review provides an overview of triglyceride metabolism and the potential mechanisms that may contribute to developing or exacerbating HTAP. The article comprehensively discusses the various pathological roles of free fatty acid, inflammatory response mechanisms, the involvement of microcirculation, serum calcium overload, oxidative stress and the endoplasmic reticulum, genetic polymorphism, and gut microbiota, which are known to trigger or escalate this condition. Future perspectives on HTAP appear promising, with ongoing research focused on developing more specific and effective treatment strategies.
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Affiliation(s)
- Minhao Qiu
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Xiaoying Zhou
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Maddalena Zippi
- Unit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
| | - Hemant Goyal
- Department of Surgery, University of TX Health Sciences Center, Houston, TX, United States
| | | | - Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Nicolaus Copernicus University in Toruń, Poland
| | - Wandong Hong
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
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3
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Guan L, Ding L, Wan J, Xia L, He W, Xiong H, Luo L, Lu N, Zhu Y. Serum triglyceride levels are associated with recurrence in patients with acute hypertriglyceridemic pancreatitis. Front Med (Lausanne) 2023; 10:1079637. [PMID: 37007797 PMCID: PMC10050706 DOI: 10.3389/fmed.2023.1079637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/21/2023] [Indexed: 03/17/2023] Open
Abstract
AimTo analyze the clinical profile of patients with acute hypertriglyceridemic pancreatitis (HTGP) and explore risk factors for recurrence.MethodsA retrospective observational study was conducted in patients who experienced an attack of HTGP for the first time. Patients were followed until the recurrence of acute pancreatitis (AP) or 1 year. The detailed clinical profile was compared between patients with or without recurrence. Multivariate logistic regression analysis was conducted to explore independent risk factors for recurrence.ResultsA total of 108 HTGP patients were included in this study with 73.1% being male, and the median age being 37 (interquartile range, IQR, 30.3–44.8) years. Recurrence occurred in 70 patients (64.8%). Compared with the nonrecurrent group, serum triglyceride (TG) levels before discharge [4.1 (2.8,6.3) mmol/L vs. 2.9 (2.2,4.2) mmol/L; p = 0.002], at 1 month [3.7 (2.3,9.7) mmol/L vs. 2.0 (1.4,2.7) mmol/L; p = 0.001], at 6 months [6.1 (3.1,13.1) mmol/L vs. 2.5 (1.1,3.5) mmol/L; p = 0.003] and 12 months [9.6 (3.5,20.0) mmol/L vs. 2.7 (1.6,5.5) mmol/L; p = 0.001] after discharge were higher in the recurrent group. Poor control of TG levels (TG > 3.1 mmol/l) at the 1-month follow-up after discharge and a high Charlson’s Comorbidity Index score (≥ 2 points) increased the risk of recurrence of HTGP.ConclusionHigh TG levels during follow-up and Charlson’s Comorbidity Index score were independently associated with recurrence in patients with HTGP.
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Muacevic A, Adler JR, Brás C, Curto A, Silveira Ramos M, Madeira C. Plasmapheresis as an Alternative Treatment of Hypertriglyceridemia-Induced Pancreatitis: A Case Report. Cureus 2022; 14:e32000. [PMID: 36589169 PMCID: PMC9798146 DOI: 10.7759/cureus.32000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 11/30/2022] Open
Abstract
Hypertriglyceridemia-induced pancreatitis is a relatively common form of acute pancreatitis that may represent up to 10% of all etiologies of this condition. Due to its specific pathogenic mechanisms related to high serum triglyceride levels, different treatment options have been proposed, including insulin perfusion, heparin perfusion, and plasmapheresis. Although the superiority of plasmapheresis in this clinical setting has not been demonstrated in randomized clinical trials, many centers have reported its effectiveness and considered this as a possible alternative according to the current guidelines. We report a case of a young patient diagnosed with hypertriglyceridemia-induced pancreatitis that was successfully treated with plasmapheresis. Since complications associated with plasmapheresis are rare and other therapeutic options may not be so effective or safe, we believe that this should be a valid alternative treatment that may be offered to these patients. More studies are still needed to further evaluate its effectiveness and to elucidate if there is a subset of patients in whom treatment with plasmapheresis may be more beneficial.
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Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early. World J Surg 2022; 46:1758-1767. [PMID: 35355100 PMCID: PMC9174303 DOI: 10.1007/s00268-022-06533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/23/2022]
Abstract
Background The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP. Methods The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected. Results From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05). Conclusions In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06533-w.
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Xu F, Yang C, Tang M, Wang M, Cheng Z, Chen D, Chen X, Liu K. The Role of Gut Microbiota and Genetic Susceptibility in the Pathogenesis of Pancreatitis. Gut Liver 2021; 16:686-696. [PMID: 34911043 PMCID: PMC9474482 DOI: 10.5009/gnl210362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 11/22/2022] Open
Abstract
Pancreatitis is one of the most common inflammatory diseases of the pancreas caused by autodigestion induced by excessive premature protease activation. However, recognition of novel pathophysiological mechanisms remains a still challenge. Both genetic and environmental factors contribute to the pathogenesis of pancreatitis, and the gut microbiota is a potential source of an environmental effect. In recent years, several new frontiers in gut microbiota and genetic risk assessment research have emerged and improved the understanding of the disease. These investigations showed that the disease progression of pancreatitis could be regulated by the gut microbiome, either through a translocation influence or in a host immune response manner. Meanwhile, the onset of the disease is also associated with the heritage of a pathogenic mutation, and the disease progression could be modified by genetic risk factors. In this review, we focused on the recent advances in the role of gut microbiota in the pathogenesis of pancreatitis, and the genetic susceptibility in pancreatitis.
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Affiliation(s)
- Fumin Xu
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chunmei Yang
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Mingcheng Tang
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ming Wang
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhenhao Cheng
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Dongfeng Chen
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiao Chen
- Department of Nuclear Medicine, Daping Hospital, Army Medical University, Chongqing, China
| | - Kaijun Liu
- Department of Gastroenterology, Daping Hospital, Army Medical University, Chongqing, China
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Yu XQ, Li WQ. Progress in research of hyperlipidemic acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2021; 29:804-808. [DOI: 10.11569/wcjd.v29.i14.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
With the continuous change of dietary structure and other factors, the incidence of hyperlipidemic acute pancreatitis (HLAP) has increased year by year. In particular, HLAP is different from other types of acute pancreatitis in its mechanism, so its clinical diagnosis and treatment have its own particularity. In this paper, we review the progress in the research of HLAP.
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Affiliation(s)
- Xian-Qiang Yu
- Medical College of Southeast University, Nanjing 210009, Jiangsu Province, China
| | - Wei-Qin Li
- Medical College of Southeast University, Nanjing 210009, Jiangsu Province, China,Department of Critical Care Medicine, Jinling Hospital, Affiliated to Southeast University, General Hospital of Eastern Theater Command, Nanjing 210002, Jiangsu Province, China
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Laufs U, Parhofer KG, Ginsberg HN, Hegele RA. Clinical review on triglycerides. Eur Heart J 2021; 41:99-109c. [PMID: 31764986 PMCID: PMC6938588 DOI: 10.1093/eurheartj/ehz785] [Citation(s) in RCA: 256] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/20/2019] [Accepted: 10/23/2019] [Indexed: 12/23/2022] Open
Abstract
Hypertriglyceridaemia is a common clinical problem. Epidemiologic and genetic studies have established that triglyceride-rich lipoproteins (TRL) and their remnants as important contributors to ASCVD while severe hypertriglyceridaemia raises risk of pancreatitis. While low-density lipoprotein is the primary treatment target for lipid lowering therapy, secondary targets that reflect the contribution of TRL such as apoB and non-HDL-C are recommended in the current guidelines. Reduction of severely elevated triglycerides is important to avert or reduce the risk of pancreatitis. Here we discuss interventions for hypertriglyceridaemia, including diet and lifestyle, established treatments such as fibrates and omega-3 fatty acid preparations and emerging therapies, including various biological agents. ![]()
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Affiliation(s)
- Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, Leipzig, Germany
| | - Klaus G Parhofer
- University Munich, Medical Department 4 - Grosshadern, Marchioninistr. 15, Munich, Germany
| | - Henry N Ginsberg
- Irving Institute for Clinical and Translational Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY, USA
| | - Robert A Hegele
- Department of Medicine, Robarts Research Institute, Western University, London, Ontario, Canada
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Susheela AT, Vadakapet P, Pillai L, Thampi S. Familial chylomicronemia syndrome: a case report. J Med Case Rep 2021; 15:5. [PMID: 33419463 PMCID: PMC7791813 DOI: 10.1186/s13256-020-02609-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 11/30/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Familial chylomicronemia is an extremely rare disease. Lipoprotein lipase deficiency, lipoprotein defect or lipoprotein receptor defect are the main genetic causes of familial chylomicronemia. CASE PRESENTATION We report a rare case of hypertriglyceridemia which was diagnosed at 24 days after birth. A newborn south east Asian baby born for G3P2A1 mother was presented with hematuria at 24 days at the hospital. The patient's family history is significant for pink blood in an elder sibling who died within a few months of birth without a proper diagnosis. Physical examination was not significant for any findings. Urinalysis revealed numerous RBC in the urine. Blood draw to perform renal function test revealed a characteristic pink blood. Baby's blood was normal and red in color at the time of birth. During the present visit, although most of the blood test were not able to be carried out by the regular laboratory instruments, the patient's lipid profile was alarmingly high with triglyceride levels over 4000 mg/dL. Due to a very high triglyceride level in a neonate and a significant familial history, a genetic cause of hypertriglyceridemia is suspected. Upon diagnosis, baby was discontinued of breast feeding completely and was given a special diet devoid of triglyceride and containing medium chain fatty acid diet and was also started with fenofibrate. After a month and a half, follow up tests were conducted which showed the triglyceride level was reduced to 1300 and a reversal of the blood color from pink to red. Since the imported diet was extremely expensive for the family, the patient was put on skimmed milk with medium-chain triglyceride (MCT) oil. With 6 weeks of treatment, baby's condition has improved and is thriving well. CONCLUSIONS Our case reports an extremely rare and fatal condition and illustrated the significance of timely diagnosis and intervention for saving the life of the baby.
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Affiliation(s)
- Ammu Thampi Susheela
- Loyola-MacNeal Hospital, 3249 S Oak Park Ave, Berwyn, IL, 60402, USA. .,Edward Hines, Jr. VA Hospital/Loyola University Medical Center, 5000 5th Ave, Hines, IL, 60141, USA.
| | - Padmesh Vadakapet
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
| | - Lekshmi Pillai
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
| | - Susheela Thampi
- Ahalia Women and Children's Hospital, P.O, Ahalia Double Rd, Ahalia Campus, Kanal Pirivu, Kerala, 678556, India
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Incidence and Management of Hypertriglyceridemia-Associated Acute Pancreatitis: A Prospective Case Series in a Single Australian Tertiary Centre. J Clin Med 2020; 9:jcm9123954. [PMID: 33291273 PMCID: PMC7762124 DOI: 10.3390/jcm9123954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hypertriglyceridemia-associated acute pancreatitis (HTGAP) has been linked with increased severity and morbidity. In this study, triglyceride levels were measured in all patients admitted with acute pancreatitis (AP) to establish the incidence of HTGAP in an Australian center. METHODS A prospective cohort with AP was collated over an 18-month period in a single tertiary referral hospital. HTGAP was defined as AP with triglycerides ≥ 11.2 mmol/L (1000 mg/dL). Incidence, clinical co-morbidities, severity and management strategies were recorded. RESULTS Of the 292 episodes of AP, 248 (85%) had triglycerides measured and were included. HTGAP was diagnosed in 10 of 248 (4%) AP cases. Type 2 diabetes, obesity, alcohol misuse and gallstones were common cofactors. The HTGAP group demonstrated severe hypertriglyceridemia compared to the non-HTGAP group (median 51 mmol/L vs. 1.3 mmol/L). Intensive care unit (ICU) admissions were significantly increased (odds ratio (OR) 16; 95% CI 4-62) in the HTGAP group (5/10 vs. 14/238 admissions, p < 0.001) and constituted 26% (5/19) of total ICU admissions for AP. Four patients received intravenous insulin with fasting and had a rapid reduction in triglyceride levels by 65-77% within 24 h; one patient had mild hypoglycemia secondary to therapy. CONCLUSION HTGAP occurred in 4% of AP cases and was associated with higher risk of ICU admission. Intravenous insulin and fasting appear safe and efficacious for acutely lowering triglyceride levels in HTGAP.
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Hypertriglyceridemia and acute pancreatitis. Pancreatology 2020; 20:795-800. [PMID: 32571534 DOI: 10.1016/j.pan.2020.06.005] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/21/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023]
Abstract
Hypertriglyceridemia is the third most common cause of acute pancreatitis. It typically occurs in patients with an underlying disorder of lipoprotein metabolism and in the presence of a secondary condition such as uncontrolled diabetes, alcohol abuse, or medication use. The presentation of hypertriglyceridemia-induced pancreatitis is similar to that of acute pancreatitis due to other causes; however, patients with hypertriglyceridemia-induced pancreatitis are more likely to have severe disease courses and have a higher likelihood of persistent organ failure. The initial treatment of hypertriglyceridemia-induced pancreatitis is also similar to acute pancreatitis from other causes and consists of aggressive fluid resuscitation, pain control, and nutritional support. Hypertriglyceridemia is specifically treated with apheresis or insulin therapy when necessary. The prompt recognition of hypertriglyceridemia in the setting of acute pancreatitis is essential in both the initial and long-term management of this disease and are essential to prevent recurrent acute pancreatitis. The review seeks to highlight the etiology, pathogenesis, and clinical course of hypertriglyceridemia-induced acute pancreatitis.
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Takahashi T, Miao Y, Kang F, Dolai S, Gaisano HY. Susceptibility Factors and Cellular Mechanisms Underlying Alcoholic Pancreatitis. Alcohol Clin Exp Res 2020; 44:777-789. [PMID: 32056245 DOI: 10.1111/acer.14304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/03/2020] [Indexed: 12/16/2022]
Abstract
Alcohol is a major cause of acute and chronic pancreatitis. There have been some recent advances in the understanding of the mechanisms underlying alcoholic pancreatitis, which include perturbation in mitochondrial function and autophagy and ectopic exocytosis, with some of these cellular events involving membrane fusion soluble N-ethylmaleimide-sensitive factor receptor protein receptor proteins. Although new insights have been unraveled recently, the precise mechanisms remain complex, and their finer details have yet to be established. The overall pathophysiology of pancreatitis involves not only the pancreatic acinar cells but also the stellate cells and duct cells. Why only some are more susceptible to pancreatitis and with increased severity, while others are not, would suggest that there may be undefined protective factors or mechanisms that enhance recovery and regeneration after injury. Furthermore, there are confounding influences of lifestyle factors such as smoking and diet, and genetic background. Whereas alcohol and smoking cessation and a generally healthy lifestyle are intuitively the advice given to these patients afflicted with alcoholic pancreatitis in order to reduce disease recurrence and progression, there is as yet no specific treatment. A more complete understanding of the pathogenesis of pancreatitis from which novel therapeutic targets could be identified will have a great impact, particularly with the stubbornly high fatality (>30%) of severe pancreatitis. This review focuses on the susceptibility factors and underlying cellular mechanisms of alcohol injury on the exocrine pancreas.
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Affiliation(s)
- Toshimasa Takahashi
- From the, Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Yifan Miao
- From the, Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Fei Kang
- From the, Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Subhankar Dolai
- From the, Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Herbert Y Gaisano
- From the, Departments of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
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Relationships between Metabolic Comorbidities and Occurrence, Severity, and Outcomes in Patients with Acute Pancreatitis: A Narrative Review. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2645926. [PMID: 31687382 PMCID: PMC6800961 DOI: 10.1155/2019/2645926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 12/16/2022]
Abstract
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.
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Chatila AT, Bilal M, Guturu P. Evaluation and management of acute pancreatitis. World J Clin Cases 2019; 7:1006-1020. [PMID: 31123673 PMCID: PMC6511926 DOI: 10.12998/wjcc.v7.i9.1006] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/19/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023] Open
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal causes for hospi-talization in the United States. In 2015, AP accounted for approximately 390000 hospitalizations. The burden of AP is only expected to increase over time. Despite recent advances in medicine, pancreatitis continues to be associated with a substantial morbidity and mortality. The most common cause of AP is gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is established with any two of three following criteria: (1) Abdominal pain consistent with that of AP; (2) Serum amylase and/or lipase greater than three times the upper limit of normal; and (3) Characteristics findings seen in cross-sectional abdominal imaging. Multiple criteria and scoring systems have been established for assessing severity of AP. The cornerstones of management include aggressive intravenous hydration, appropriate nutrition and pain management. Endoscopic retrograde cholangiopancreatography and surgery are important aspects in management of acute gallstone pancreatitis. We provide a comprehensive review of evaluation and management of AP.
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Affiliation(s)
- Ahmed T Chatila
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Mohammad Bilal
- Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Praveen Guturu
- Division of Gastroenterology and Hepatology, the University of Texas Medical Branch, Galveston, TX 77555, United States
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Kim H, Kang JH, Heo TY, Kang BT, Kim G, Chang D, Na KJ, Yang MP. Evaluation of Hypertriglyceridemia as a Mediator Between Endocrine Diseases and Pancreatitis in Dogs. J Am Anim Hosp Assoc 2019; 55:92-100. [DOI: 10.5326/jaaha-ms-6791] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ABSTRACT
The role of hypertriglyceridemia (HTG) secondary to endocrine diseases in the occurrence of pancreatitis in dogs has not been fully investigated. The objective of the present study was to evaluate HTG as a mediator between endocrine diseases and pancreatitis in dogs. The study design was a retrospective case-control study. Medical records of dogs newly diagnosed with acutely presenting pancreatitis between 2012 and 2014 were reviewed for the presence or absence of hyperadrenocorticism (HAC), diabetes mellitus (DM), and hypothyroidism. A matched case-control analysis was performed, and the association between endocrine diseases and pancreatitis was evaluated using multiple logistic regression analysis. In dogs with pancreatitis, the odds of HAC (P < .001) and DM (P < .001) were 4.5 and 12.4 times that of dogs without pancreatitis, respectively. HTG significantly mediated the association between DM and pancreatitis but not between HAC and pancreatitis. Additional studies will be necessary to confirm these findings and to further elucidate the associations between endocrine diseases and pancreatitis.
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Affiliation(s)
- Hakhyun Kim
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Ji-Houn Kang
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Tae-Young Heo
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Byeong-Teck Kang
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Gonhyung Kim
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Dongwoo Chang
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Ki-Jeong Na
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
| | - Mhan-Pyo Yang
- Veterinary Medical Center, College of Veterinary Medicine (H.K., J-H.K., B-T.K., G.K., D.C., K-J.N., M-P.Y.), and Department of Information and Statistics, College of Natural Science (T-Y.H.), Chungbuk National University, Cheongju, South Korea
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Song YX, Zhu HY, Du YQ. Advances in research of pathogenesis and treatment of hyperlipidemic acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2019; 27:112-116. [DOI: 10.11569/wcjd.v27.i2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the incidence of hyperlipidemic acute pancreatitis has increased year by year. At present, the exact pathogenesis is still unclear. It may be related to the increase of free fatty acids due to increased triglyceride (TG), which leads to toxicity to the pancreas, pancreatic microcirculation disorder, and calcium overload. The key to treatment is to reduce TG rapidly. Lifestyle changes and weight loss are the key to preventing recurrence.
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Affiliation(s)
- Ying-Xiao Song
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
| | - Hui-Yun Zhu
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
| | - Yi-Qi Du
- Department of Gastroenterology, Changhai Hospital Affiliated to Naval Military Medical University, Shanghai 200433, China
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Adiamah A, Psaltis E, Crook M, Lobo DN. A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis. Clin Nutr 2018; 37:1810-1822. [PMID: 29056284 DOI: 10.1016/j.clnu.2017.09.028] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies. METHODS The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included. RESULTS Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis. CONCLUSION The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.
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Affiliation(s)
- Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Emmanouil Psaltis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Martin Crook
- Department of Clinical Biochemistry, Guy's and St. Thomas' Hospital NHS Trust, London SE1 9RT, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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Jagannath S, Garg PK. Recurrent Acute Pancreatitis: Current Concepts in the Diagnosis and Management. ACTA ACUST UNITED AC 2018; 16:449-465. [PMID: 30232693 DOI: 10.1007/s11938-018-0196-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Soumya Jagannath
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
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Li X, Ke L, Dong J, Ye B, Meng L, Mao W, Yang Q, Li W, Li J. Significantly different clinical features between hypertriglyceridemia and biliary acute pancreatitis: a retrospective study of 730 patients from a tertiary center. BMC Gastroenterol 2018; 18:89. [PMID: 29914404 PMCID: PMC6007076 DOI: 10.1186/s12876-018-0821-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 06/07/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Unlike western world, gallstones and hypertriglyceridemia (HTG) are among the first two etiologies of acute pancreatitis (AP) in China. But yet, detailed differences in clinical features and outcomes between hypertriglyceridemia and biliary acute pancreatitis have not been well described. METHODS This retrospective study enrolled 730 acute pancreatitis patients from July 1, 2013 to October 1, 2016 in Jinling Hospital. The causes of the study patients were defined according to specific diagnostic criteria. The clinical features and outcomes of patients with hypertriglyceridemia acute pancreatitis (HTG-AP) and biliary acute pancreatitis (BAP) were compared in terms of general information, disease severity, laboratory data, system complications, local complications, and clinical outcome. RESULTS In the enrolled 730 AP patients, 305 (41.8%) were HTG-AP, and 425 (58.2%) were BAP. Compared to BAP, the HTG-AP patients were found to be younger, with higher body mass Index (BMI), and much higher proportion of diabetes, fatty liver and high fat diet. Besides that, HTG-AP patients had significantly higher C-reactive protein (CRP) (p<0.01) and creatinine (p = 0.031), together with more acute respiratory distress syndrome (ARDS) (p = 0.039), acute kidney injury (AKI) (p<0.001), deep venous thrombosis (p = 0.008) and multiple organ dysfunction syndrome (MODS) (p = 0.032) in systematic complications. As for local complications, HTG-AP patients had significantly less infected pancreatitis necrosis (p = 0.005). However, there was no difference in mortality, hospital duration and costs between the groups. CONCLUSION HTG-AP patients were younger, more male, having high fat diet and with higher BMI compared to BAP patients. The prevalence of AKI/ARDS/DVT/MODS in HTG-AP patients was higher than BAP patients, while BAP patients had a greater possibility in development of infected pancreatitis necrosis (IPN). According to the multivariate analysis, only the complication of AKI was independently related with the etiology of HTG, however, BMI contributes to AKI, ARDS and DVT.
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Affiliation(s)
- Xiaoyao Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lu Ke
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Dong
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bo Ye
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lei Meng
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wenjian Mao
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qi Yang
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Weiqin Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Jieshou Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Donelli D, Morini L, Trenti C, Santi R, Arioli D, Negri EA. Plasma Exchange for the Treatment of Transient Extreme Hypertriglyceridemia Associated with Diabetic Ketoacidosis and Acute Pancreatitis. Eur J Case Rep Intern Med 2018; 5:000853. [PMID: 30756035 PMCID: PMC6346927 DOI: 10.12890/2018_000853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/16/2018] [Indexed: 12/28/2022] Open
Abstract
Diabetic ketoacidosis (DKA) can quite frequently present in association with acute pancreatitis (AP) caused by transient severe hypertriglyceridemia (HTG). Here we report the case of a patient presenting with DKA, severe HTG and AP who received urgent plasma exchange for HTG control, and who reached adequate serum triglyceride levels only after appropriate DKA management. The treatment of patients presenting with DKA and coexistent AP associated with severe HTG should focus first on appropriate DKA management. Plasma exchange as a treatment for severe HTG in patients with DKA and AP should be evaluated carefully. LEARNING POINTS The treatment of patients presenting with diabetic ketoacidosis, acute pancreatitis and severe hypertriglyceridemia should focus first on diabetic ketoacidosis management.Plasma exchange as a treatment for severe hypertriglyceridemia in patients with diabetic ketoacidosis and acute pancreatitis should be evaluated carefully.Triglyceride concentrations should always be measured in case of diabetic ketoacidosis.
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Affiliation(s)
- Davide Donelli
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Lorenzo Morini
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Chiara Trenti
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Rosaria Santi
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Dimitriy Arioli
- Medicina II Cardiovascolare, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
| | - Emanuele Alberto Negri
- Alta Intensità Medica, Department of Internal Medicine, Arcispedale Santa Maria Nuova - IRCCS, Reggio Emilia, Italy
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de Pretis N, Amodio A, Frulloni L. Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical management. United European Gastroenterol J 2018; 6:649-655. [PMID: 30083325 DOI: 10.1177/2050640618755002] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/26/2017] [Indexed: 12/12/2022] Open
Abstract
Hypertriglyceridemic pancreatitis (HTGP) typically occurs in patients with an underlying dyslipidemia (such as type I, IV or V dyslipidemia) and in the presence of a secondary condition, such as inadequately controlled diabetes, excess alcohol consumption or medication use. Although the symptoms of HTGP are similar to those of acute pancreatitis from other etiologies, HTGP is often associated with greater clinical severity and rate of complications. Therefore, accurate diagnosis of HTGP is essential so that patients receive the appropriate treatment. Novel therapies that aim to reduce the incidence of pancreatitis in this patient population are now available or in development. Understanding the etiology, pathophysiology and clinical characteristics of HTGP will enable future development of therapeutic agents to treat HTGP.
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Affiliation(s)
| | - Antonio Amodio
- Department of Medicine, University of Verona, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
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Abstract
Recently, many studies have focused on the relationship between hyperlipidemia (HL) and acute pancreatitis (AP). HL is a significant cause of AP, but it may also be secondary to AP. Hypertriglyceridemia (HTG) and hypercholesterolemia (HTC) are two types of HL. It is generally believed that HTG may induce AP and AP could increase the incidence of HTG. However, the relationship between HTC and AP has not yet confirmed. The diagnosis of hyperlipidemic acute pancreatitis (HLAP) needs not only the evidence of AP, but also an elevated level of serum lipids. Nevertheless, there still exist some divergent opinions regarding the level of serum lipids. Since the diagnosis of HLAP is critical for the therapy and prognosis, the lack of unified diagnostic criteria poses a great challenge for clinicians.
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Niu L, Ge CL. Acute recurrent pancreatitis and hyperlipidemia: Reciprocal causal relationship and clinical features. Shijie Huaren Xiaohua Zazhi 2016; 24:4205-4210. [DOI: 10.11569/wcjd.v24.i30.4205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To investigate the influence of serum levels of lipids on the occurrence, development and prognosis of acute recurrent pancreatitis (ARP) to discuss the reciprocal causal relationship between ARP and hyperlipidemia (HL) and their clinical features.
METHODS Clinical data and follow-up information for 121 patients with ARP who were treated at the First Hospital of China Medical University from January 2013 to December 2015 were retrospectively analyzed. All these patients were divided into a hyperlipidemia group (HL group) and a non-hyperlipidemia group (non-HL group) according to the serum lipid levels within 24 h after admission. General data, severity, recrudescence, complications, operation rate, and mortality were compared between the two groups.
RESULTS The average age was significantly lower in the HL group than in the non-HL group (38.5 ± 8.9 vs 49.8 ± 13.2, P < 0.01). The operation rate was significantly lower (11.3% vs 21.9%, P < 0.05) and the proportion of male patients was significantly higher (41/53 vs 40/68, P < 0.05) in the HL group. BMI (28.2 ± 6.0 vs 22.5 ± 5.2, P < 0.01), serum levels of glucose (9.65 ± 6.00 vs 6.88 ± 3.26, P < 0.01) and lipids (13.94 ± 8.91 vs 3.22 ± 1.47, P < 0.01) were significantly higher in the HL group than in the non-HL group, while serum amylase was significantly lower in the HL group (332.02 ± 246.71 vs 490.79 ± 417.11, P < 0.05). The HL group was more frequently complicated with diabetes (34.0% vs 13.2%, P < 0.01) and fatty liver (22.6% vs 7.4%, P < 0.05). For the causes of ARP, elevated serum lipid levels in the observation group were mainly caused by primary HL itself (62.3%, P < 0.01), and HL appeared as a concomitant symptom in other ARP patients induced by other factors. In the non-HL group, ARP was predominantly caused by gallstones (66.1%, P < 0.01). There was no statistical difference about alcoholic pathogenesis, severity or prognosis of disease between the two groups.
CONCLUSION There is a reciprocal causal relationship between HL and ARP. High serum lipid levels in the observation group are mainly related to the primary HL itself. The ARP patients with concomitant HL tend to be younger, be male, have lower surgical intervention rate, and be easily complicated with diabetes or fatty liver.
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Nawaz H, Koutroumpakis E, Easler J, Slivka A, Whitcomb DC, Singh VP, Yadav D, Papachristou GI. Elevated serum triglycerides are independently associated with persistent organ failure in acute pancreatitis. Am J Gastroenterol 2015; 110:1497-503. [PMID: 26323188 DOI: 10.1038/ajg.2015.261] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 07/05/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Hypertriglyceridemia (HTG) represents a major health problem with prevalence exceeding 30% in the U.S. The present study aims to assess the effect of elevated serum triglyceride (TG) levels on the severity of acute pancreatitis (AP). METHODS Prospectively enrolled AP patients were categorized into normal, mild, moderate, and severe/very severe categories based on their TG levels and compared in respect to demographics, comorbidities, and clinical outcomes. Multivariate analysis determined whether elevated TG levels were independently associated with persistent organ failure. RESULTS Two hundred and one out of 400 AP patients had serum TGs measured within 72 h of presentation, of which 115 had normal TG levels and 86 HTG (20 mild, 41 moderate, and 25 severe/very severe). Patients with HTG were of younger age (44 vs. 52 years), predominantly male (65% vs. 45%), obese (57% vs. 34%), diabetic (38% vs. 17%), and developed more frequently persistent organ failure (40% vs. 17%) compared with those with normal TGs (P<0.02). The rate of persistent organ failure increased proportionally with HTG severity grades (17% when normal TGs, 30% in mild, 39% in moderate, and 48% in severe/very severe HTG, Ptrend<0.001). On multivariate analysis controlling for age, gender, body mass index, diabetes, and alcohol etiology, moderate HTG (odds ratio (OR), 2.6; P=0.04) and severe/very severe HTG (OR, 4.9; P=0.009) were independently associated with persistent organ failure. CONCLUSIONS Elevated serum TGs in AP patients are independently and proportionally correlated with persistent organ failure regardless of etiology. TG-mediated lipotoxicity may be an attractive target to design novel interventions for severe AP.
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Affiliation(s)
- Haq Nawaz
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Efstratios Koutroumpakis
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Easler
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David C Whitcomb
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vijay P Singh
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Georgios I Papachristou
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Division of Gastroenterology, Department of Medicine, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
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Wu L, Kong XX, Zheng YP. Alprostadil combined with peritoneal lavage therapy for treatment of hyperlipidemic severe acute pancreatitis. Shijie Huaren Xiaohua Zazhi 2015; 23:3624-3628. [DOI: 10.11569/wcjd.v23.i22.3624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical effects of alprostadil combined with peritoneal lavage therapy in the treatment of hyperlipidemic severe acute pancreatitis (HSAP).
METHODS: Twenty-seven patients with HSAP were randomly divided into two groups: a control group (13 patients) and a treatment group (14 patients). Both groups received the same conventional medical therapy, and the treatment group additionally received alprostadil and peritoneal lavage therapy (14 d as a cycle). Curative effects were compared between the two groups.
RESULTS: Compared with the control group, the time to patient's condition improvement (5.55 d ± 3.12 d vs 8.18 d ± 4.09 d, 4.14 d ± 2.94 d vs 6.75 d ± 3.58 d), the time to improvement of triacylglycerol (5.42 d ± 2.06 d vs 8.28 d ± 3.55 d), total response rate (85.71% vs 61.54%), rates of complications (21.6% vs 38.5%) and mortality (7.14% vs 15.38%), average hospital stay (23.84 d ± 7.54 d vs 31.98 d ± 12.18 d), and total expenses of the medical treatment (34.56 ± 13.44 vs 41.29 ± 18.81) were significantly better in the treatment group (P < 0.05 or P < 0.01).
CONCLUSION: Alprostadil combined with peritoneal lavage therapy is a safe and effective therapy for HSAP. It may become a basic choice for treating HSAP.
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Zhang XL, Li F, Zhen YM, Li A, Fang Y. Clinical Study of 224 Patients with Hypertriglyceridemia Pancreatitis. Chin Med J (Engl) 2015; 128:2045-9. [PMID: 26228216 PMCID: PMC4717952 DOI: 10.4103/0366-6999.161361] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Hypertriglyceridemia (HTG) is the most common etiology of acute pancreatitis (AP) after alcohol and gallstone-induced disease. Elevation of serum triglyceride (TG) levels to ≥ 1000 mg/dl in a patient with AP strongly indicates HTG as the cause. The absolute risk of pancreatitis based on serum TG ≤ 1000 mg/dl has not been clearly defined. The aims of this study were to address the role of elevated TG levels between 500 and 1000 mg/dl in the clinical course of HTG pancreatitis (HTGP); and assess the relationship between the level of serum TG and disease severity. METHODS A total of 224 HTGP patients between 2007 and 2011 were divided into two subgroups. Totally, 122 patients in Group A had serum TG >1000 mg/dl; 102 patients in Group B had maximal TG levels between 500 and 1000 mg/dl accompanied by lactescent serum; 100 patients with biliary AP and 99 patients with alcoholic AP hospitalized during the study period were enrolled as controls. The clinical and biochemical data were analyzed. RESULTS The clinical presentation of HTG-induced pancreatitis was similar to other causes. Severe form of AP in Group A was higher than Group B (χ2 = 4.002, P = 0.045). The severity with HTGP was significantly higher as compared to biliary AP (χ2 = 33.533, P = 0.000) and alcoholic AP (χ2 = 7.179, P = 0.007). Systemic complications with HTGP were significantly higher than biliary AP (χ2 = 58.763, P = 0.000). CONCLUSIONS The study demonstrated that TG level ≥ 500 mg/dl should raise a high degree of suspicion, especially if no other etiology of AP is apparent. The severity of HTGP seems to correlate directly with TG level. HTGP seems be more severe than other causes of AP.
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Affiliation(s)
- Xiao-Li Zhang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ya-Min Zhen
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Yu Fang
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Cystic fibrosis transmembrane conductance regulator gene variants are associated with autoimmune pancreatitis and slow response to steroid treatment. J Cyst Fibros 2015; 14:661-7. [PMID: 25869325 DOI: 10.1016/j.jcf.2015.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/22/2015] [Accepted: 03/22/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is a distinct type of chronic pancreatitis. To date, the association of CFTR gene variants with AIP has not been studied. METHODS The entire coding and intronic regions of the CFTR gene were examined using next-generation sequencing in 89 AIP patients. Clinical features, including imaging, histology, serology, steroid treatment response and extra-pancreatic involvement, were compared between AIP patients with and without CFTR gene variants. RESULTS A total of 28.1% (25/89) of the AIP patients carried 26 CFTR variants, including nine with I556V, seven with 5T, four with S42F, two with I125T, and one each with R31C, R553X, S895N, and G1069R. The presence of CFTR variants and age was independent predictors of the response to steroid treatment, as shown by multivariate analysis. CONCLUSIONS CFTR variants are associated with AIP. Because AIP patients with CFTR variants show slower and reduced steroid treatment responses, different treatments should be considered in AIP patients with CFTR variants.
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Abstract
BACKGROUND Hypertriglyceridemia (HTG) is a well-recognized cause of acute pancreatitis (AP). However, the role of HTG in modulating disease course remains to be cleared. We aimed to explore the impact of HTG on the outcome of acute biliary pancreatitis (ABP). METHODS A total of 90 ABP patients with HTG were enrolled in this study and were divided into 3 groups based on ABP severity: mild AP, moderately severe AP (MSAP) and severe AP (SAP), according to the modified Atlanta classification. Besides, patients were divided into type I, II and III HTG groups based on the triglyceride (TG) level, according to the national cholesterol education program (NCEP). Disease severity, Ranson score and complications were recorded and analyzed. Logistic regression analysis was performed to screen predictive risk factors of severe outcomes. RESULTS There were 23 patients with SAP, 41 with MSAP and 26 with mild AP among the ABP patients with HTG. Significant differences were observed in the obesity, plasma TG level and Ranson score among groups. The risk of developing MSAP in ABP patients with type II and III HTG was increased. Similarly, the risk of developing SAP in ABP patients with type III HTG was also enhanced. The incidence of systemic, especially respiratory failure, and local complications in type III HTG group were significantly higher than normal lipid group. CONCLUSIONS High TG level (≥2.26 mmol/L or 200.11 mg/mL) may be a risk factor for severe ABP and the development of systemic and local complications in ABP.
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Valdivielso P, Ramírez-Bueno A, Ewald N. Current knowledge of hypertriglyceridemic pancreatitis. Eur J Intern Med 2014; 25:689-94. [PMID: 25269432 DOI: 10.1016/j.ejim.2014.08.008] [Citation(s) in RCA: 249] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/19/2014] [Accepted: 08/20/2014] [Indexed: 12/21/2022]
Abstract
Severe hypertriglyceridemia (HTG) is a well established and the most common cause of acute pancreatitis (AP) after alcohol and gall stone disease. It is alleged to account for up to 10% of all pancreatitis episodes. Studies suggest that in patients with triglyceride (TG) levels>1000 mg/dL (>11.3 mmol/L), hypertriglyceridemia-induced acute pancreatitis (HTGP-AP) occurs in approximately 15-20% of all subjects referred to Lipid Clinics. Until now, there is no clear evidence which patients with severe HTG will develop pancreatitis and which will not. Underlying pathophysiological concepts include hydrolysis of TG by pancreatic lipase and excessive formation of free fatty acids with inflammatory changes and capillary injury. Additionally hyperviscosity and ischemia may play a decisive role. The clinical features of HTG-AP patients are supposed to be no different from patients with AP of other etiologies. Yet, there are well-conducted studies suggesting that HTG-AP is associated with a higher severity and complication rate. Therapeutic measurements in HTG-AP include dietary modifications, different antihyperlipidemic agents, insulin and/or heparin treatment. The beneficial use of plasmapheresis is repeatedly reported and suggested in many studies. Yet, due to the lack of randomized and controlled trials, it is currently unknown if plasmapheresis may improve morbidity and mortality in the clinical setting of HTG-AP. Since there are no commonly accepted clinical guidelines in the management of HTG-AP, there is a definite need for an international, multicenter approach to this important subject.
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Affiliation(s)
- Pedro Valdivielso
- Department of Medicine and Dermatology, University of Malaga, Spain; Servicio de Medicina Interna, Hospital Virgen de la Victoria, Malaga, Spain
| | - Alba Ramírez-Bueno
- Servicio de Medicina Interna, Hospital Virgen de la Victoria, Malaga, Spain
| | - Nils Ewald
- Justus-Liebig-University Giessen, 35392 Giessen, Germany; General Hospital Luebbecke-Rahden, Department of Internal Medicine, 32312 Luebbecke, Germany.
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Huang XL, Wang GP, Wang P, Yu CG. Severity, complications and mortality of acute pancreatitis of different etiology: A comparative analysis. Shijie Huaren Xiaohua Zazhi 2014; 22:4172-4176. [DOI: 10.11569/wcjd.v22.i27.4172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To compare the severity and clinical characteristics of hyperlipidemic acute pancreatitis (HLAP) and biliary acute pancreatitis (ABP).
METHODS: Clinical data for 23 patients with HLAP (HLAP group) and 84 patients with ABP (ABP group) treated at our hospital from January 2012 to December 2013 were retrospectively analyzed, and the general data, severity, complications and mortality were compared.
RESULTS: Body mass index (BMI) and time of hospitalization in the HLAP group were significantly higher than those in the ABP group (24.3 kg/m2 ± 2.15 kg/m2vs 22 kg/m2 ± 2.84 kg/m2, 14.30 d ± 5.77 d vs 10.32 d ± 3.91 d, P < 0.01). Serum AMS levels were significantly lower in the HLAP group than in the ABP group (598.04 U/L ± 857.40 U/L vs 1200.86 U/L ± 833.64 U/L, P < 0.05). C-reactive protein (CRP) values, acute physiology and chronic health evaluation scoring system (APACHEⅡ) scores, and bedside index for severity in acute pancreatitis (BISAP) scores at admission and 48 h after admission were significantly higher in the HLAP group than in the ABP group (P < 0.05 or P < 0.01). The modified CT severity index (MCTSI) score had no significant difference between the two groups at admission, but was significantly higher 48 h after admission in the HLAP group (5.91 ± 1.41 vs 4.98 ± 1.77, P < 0.01). The incidence of intestinal paralysis and acute respiratory distress syndrome (ARDS) in the two groups had no significant difference, but that of diabetes and pancreatic cysts was significantly higher in the HLAP group (13% vs 2.4%, 21.7% vs 6%, P < 0.05). There were 1 case of pancreatic encephalopathy and 2 deaths in the HLAP group, while there was no death in the ABP group.
CONCLUSION: HLAP is characterized by serious illness and high incidence of complications and mortality, and attention should be paid to this condition.
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Amin T, Poon LCY, Teoh TG, Moorthy K, Robinson S, Neary N, Valabhji J. Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy. J Matern Fetal Neonatal Med 2014; 28:954-8. [PMID: 25072837 DOI: 10.3109/14767058.2014.939064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acute pancreatitis is a recognised rare complication in pregnancy. The reported incidence varies between 3 and 7 in 10 000 pregnancies and is higher in the third trimester. The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia. Non-gallstone pancreatitis is associated with more complications and poorer outcome with hypertriglyceridaemia-induced acute pancreatitis having mortality rates ranging from 7.5 to 9.0% and 10.0 to 17.5% for mother and foetus, respectively. CASE HISTORY A 40-year-old para 4 woman, who presented at 15(+4) weeks' gestation, was diagnosed with acute pancreatitis. Past medical history included Graves' disease and hypertriglyceridaemia. Fenofibrate was discontinued immediately after discovery of the pregnancy. Initial investigations showed elevated amylase (475.0 µ/L) and triglycerides (46.6 mmol/L). Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced acute pancreatitis. Laboratory tests gradually improved (triglyceride 5.2 mmol/L on day 17). On day 18, ultrasound confirmed foetal demise (18(+1) weeks) and a hysterotomy was performed as she had had four previous caesarean sections. CONCLUSION Management of acute pancreatitis in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced acute pancreatitis has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre-pregnancy and antenatally can allow close monitoring through pregnancy to optimise care.
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Affiliation(s)
- Tejal Amin
- Department of Obstetrics and Gynaecology
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Acute Relapsing Pancreatitis with Pseudocyst Formation due to Sporadic Hypertriglyceridemic Pancreatitis: A Case Report. Indian J Surg 2014; 75:340-4. [PMID: 24426610 DOI: 10.1007/s12262-012-0701-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 06/28/2012] [Indexed: 01/18/2023] Open
Abstract
Acute pancreatitis is one of the common causes of the acute abdomen that should be included in any differential diagnosis for acute abdominal pain; it is also well known with its variant causes, of which most common is biliary tree stones, alcoholic pancreatitis, followed by a long list of other less common causes. We have reported a rare case of relapsing acute pancreatitis due to atypical sporadic hypertriglyceridemia (Frederickson's type IV) in a young male patient who was seen in the accident and emergency department presenting with severe agonizing abdominal pain, with history of recurrent similar attacks, which were unfortunately misdiagnosed elsewhere.
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Ahmed A, Gurjar M, Poddar B, Azim A. Undiagnosed diabetes presenting as hypertriglyceridemia-induced pancreatitis. Int J Crit Illn Inj Sci 2014; 3:225-6. [PMID: 24404464 PMCID: PMC3883205 DOI: 10.4103/2229-5151.119204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Armin Ahmed
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
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Pujar AK, Kumar V R A, M S, S V K. An interesting case of hypertriglyceridaemic pancreatitis. J Clin Diagn Res 2013; 7:1169-71. [PMID: 23905131 DOI: 10.7860/jcdr/2013/5500.3080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 03/24/2013] [Indexed: 11/24/2022]
Abstract
Hypertriglyceridaemia is a well-known but uncommon cause of acute pancreatitis. A serum triglyceride level of more than 1000mg/dl is needed to precipitate the pancreatitis. A 35 year male patient, who was a known diabetic who was on oral hypoglycaemics, presented to us with pain in the abdomen and vomiting of one day's duration. His serum amylase was normal. The serum was highly lactescent. The triglycerides were 1901mg/dl. CECT of the abdomen showed features which were suggestive of pancreatitis. The patient was managed just as the pancreatitis of any other eitiology. He was started on fibrates, atorvastatin, and antioxidants to prevent a relapse. His diabetes was controlled by insulin. He recovered well.
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Whitcomb DC, Lowry LW. Genetic risk factors for pancreatic disorders. Gastroenterology 2013; 144:1292-302. [PMID: 23622139 PMCID: PMC3684061 DOI: 10.1053/j.gastro.2013.01.069] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/15/2013] [Accepted: 01/17/2013] [Indexed: 02/06/2023]
Abstract
A combination of genetic, environmental, and metabolic factors contribute to the development and recurrence of acute and chronic pancreatitis; information on all of these is required to manage patients effectively. For example, variants that affect regulation of the protease, serine (PRSS)1-PRSS2, and claudin (CLDN)2 loci, rather than their coding sequences, interact with other genetic and environmental factors to affect disease development. New strategies are needed to use these data and determine their contribution to pathogenesis, because these variants differ from previously studied, rare variants in exons (coding regions) of genes such as PRSS1, SPINK1, cystic fibrosis transmembrane conductance regulator (CFTR), chymotrypsin (CTR)C, and calcium-sensing receptor (CASR). Learning how various genetic factors affect pancreatic cells and systems could lead to etiology-based therapies rather than treatment of symptoms.
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Affiliation(s)
- David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Abstract
Environmental and lifestyle changes have led to an increasing incidence of primary or secondary high triglycerides. As elevated triglycerides are an important risk factor for acute pancreatitis (AP), the incidence of AP of this cause has also been gradually increasing. Patients with hyperlipidemic AP often suffer severely and develop more complications. Crucial therapy is to lower serum triglyceride levels. In this article, we will summarize the recent progress in the treatment of hyperlipidemic pancreatitis.
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Raja RA, Schmiegelow K, Frandsen TL. Asparaginase-associated pancreatitis in children. Br J Haematol 2012; 159:18-27. [PMID: 22909259 DOI: 10.1111/bjh.12016] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
l-asparaginase has been an element in the treatment for acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma since the late 1960s and remains an essential component of their combination chemotherapy. Among the major toxicities associated with l-asparaginase therapy are pancreatitis, allergic reactions, thrombotic events, hepatotoxicity and hyperlipidaemia. Acute pancreatitis is one of the most common reasons for stopping treatment with l-asparaginase. Short-term complications of asparaginase-associated pancreatitis include development of pseudocysts and pancreatic necrosis. Long-term complications include chronic pancreatitis and diabetes. The pathophysiology of asparaginase-associated pancreatitis remains to be uncovered. Individual clinical and genetic risk factors have been identified, but they are only weak predictors of pancreatitis. This review explores the definition, possible risk factors, treatment and complications of asparaginase-associated pancreatitis.
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Affiliation(s)
- Raheel Altaf Raja
- The Department of Paediatrics and Adolescent Medicine, the University Hospital Rigshospitalet, Copenhagen, Denmark
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A prospective cohort study on risk of acute pancreatitis related to serum triglycerides, cholesterol and fasting glucose. Pancreatology 2012; 12:317-24. [PMID: 22898632 DOI: 10.1016/j.pan.2012.05.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 04/25/2012] [Accepted: 05/03/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES To investigate risk for acute pancreatitis related to moderately elevated triglycerides, cholesterol and fasting glucose. METHODS This was a prospective cohort study in Malmö, Sweden of 33,346 subjects investigated 1974-1992 and followed until December 31, 2006. Baseline investigation included a self-administered questionnaire and analysis of serum triglycerides, cholesterol and fasting glucose. Cases of acute pancreatitis (n = 277, median time since baseline investigation 15.6 years) were identified in diagnosis registries and validated retrospectively. Attacks were classified as obstructive or non obstructive (alcohol or non alcohol related). Cox proportional hazards analysis was used to calculate hazard ratios (HR) for acute pancreatitis related to relevant risk factors, adjusting for age, sex, smoking habits and alcohol consumption. RESULTS Triglycerides were associated with overall, non obstructive and non obstructive non alcohol related acute pancreatitis with adjusted HRs of 1.21 (95% confidence interval (CI), 1.07-1.36), 1.23 (95% CI, 1.06-2.43) and 1.34 (95% CI, 1.11-1.62) per 1 mmol/l increment, respectively. Corresponding HRs for forth versus first quartile of triglycerides were 1.55 (95% CI, 1.09-2.21), 1.60 (95% CI, 1.60-1.01-1.35) and 2.07 (95% CI, 1.13-3.79). Triglycerides were not associated with obstructive acute pancreatitis and there were no associations between glucose or cholesterol and the risk of acute pancreatitis. CONCLUSIONS We found an association between prediagnostic levels of triglycerides and risk for acute pancreatitis. This association was most pronounced in the non obstructive non alcohol related group. Our findings suggest that triglycerides may be a more important risk factor for acute pancreatitis than what has previously been estimated.
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Huang P, Wang CY, Wu HS, Wu GJ, Li JJ. Treatment of hyperlipidemic acute pancreatitis by continuous venovenous hemofiltration: an analysis of 24 cases. Shijie Huaren Xiaohua Zazhi 2012; 20:964-968. [DOI: 10.11569/wcjd.v20.i11.964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To observe the treatment effect of continuous veno-venous hemofiltration (CVVH) in patients with hyperlipidemic acute pancreatitis (HLP).
METHODS: Forty-nine HLP patients were randomly divided into two groups: CVVH group (A, n = 24) and control group (B, n = 25). Both groups underwent conventional therapy, and patients in group A additionally underwent CVVH. Heart rate (HR), respiration, PO2/FiO2, SaO2, triglyceride (TG), IL-6 and TNF-α were monitored. APACHE Ⅱ score was used to evaluate patients' condition. The incidences of acute complications and survival rate were compared between the two groups.
RESULTS: After treatment by CVVH, HR, respiration, APACHE Ⅱ (10.8 ± 5.1 vs 15.5 ± 6.9, P < 0.05) as well as serum levels of TG, IL-6 and TNF-α (6.8 ± 3.7 vs 18.5 ± 6.3, 39.8 ± 16.7 vs 72.4 ± 25.1, 37.5 ± 14.1 vs 61.2 ± 16.1, all P < 0.05) decreased significantly. Seven days later, shock was corrected in both groups (P < 0.05). In group A, the incidences of acute renal failure (ARF) and acute respiratory distress syndrome (ARDS) were significantly decreased (5.0% vs 37.5%, 5.0% vs 25%, both P < 0.05). Compared to group B, group A had a higher survival rate (8.3% vs 20%).
CONCLUSION: CVVH is effective in treating HLP and is associated with a lower case fatality rate.
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Bishehsari F, Sharma A, Stello K, Toth C, O’Connell MR, Evans AC, LaRusch J, Muddana V, Papachristou GI, Whitcomb DC. TNF-alpha gene (TNFA) variants increase risk for multi-organ dysfunction syndrome (MODS) in acute pancreatitis. Pancreatology 2012; 12:113-8. [PMID: 22487520 PMCID: PMC4350817 DOI: 10.1016/j.pan.2012.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/20/2012] [Accepted: 02/20/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis (AP) is a complex inflammatory syndrome with unpredictable progression to systemic inflammation and multi-organ dysfunction syndrome (MODS). Tumor necrosis factor alpha (TNF-α) is a cytokine that may link inflammation to the systemic inflammatory response syndrome (SIRS), which usually precedes MODS. Small genetic cohort studies of the TNFA promoter in AP produced ambiguous results. We performed a comprehensive evaluation of TNFA promoter variants to assess both susceptibility to AP and risk of progression to MODS. METHODS We prospectively ascertained 401 controls and 211 patients with AP that were assessed for persistent SIRS (>48 h) and MODS. MODS was defined as failure of ≥2 organ systems (cardiovascular, pulmonary, and/or renal) persisting more than 48 h. Subjects were genotyped by DNA sequencing and analyzed for SNPs at -1031 C/T (rs1799964), -863 A/C (rs1800630), -857 C/T (rs1799724), -308 A/G (rs1800629), and -238 A/G (rs361525). RESULTS Twenty-three of 211 AP patients (11%) developed MODS. TNFA promoter variants were not associated with susceptibility to AP, but progression to MODS was associated with the minor allele at -1031C (56.5% vs. 32.4% P = 0.022, OR: 2.7; 95%CI: 1.12-6.51) and -863A (43.5% vs. 21.8% P = 0.022, OR: 2.76; 95%CI: 1.12-6.74). CONCLUSION TNFA promoter variants do not alter susceptibility to AP, but rather the TNF-α expression-enhancing -1031C and -863A alleles significantly increased the risk of AP progression to MODS. These data, within the context of previous studies, clarify the risk of specific genetic variants in TNFA and therefore the role of TNF-α in the overall AP syndrome.
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Affiliation(s)
- Faraz Bishehsari
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Arun Sharma
- Universtity of Pittsburgh School of Medicine, Pittsburgh, PA USA 15213
| | - Kimberly Stello
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Chad Toth
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Michael Richard O’Connell
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Anna C Evans
- Universtity of Pittsburgh School of Medicine, Pittsburgh, PA USA 15213
| | - Jessica LaRusch
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Venkata Muddana
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
| | - Georgios I Papachristou
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213,VA Pittsburgh Health Care System, Pittsburgh, PA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213,Department of Cell Biology & Physiology, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213,Department of Human Genetics, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA USA 15213
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Shah U, Shenoy-Bhangle AS. Case records of the Massachusetts General Hospital. Case 32-2011. A 19-year-old man with recurrent pancreatitis. N Engl J Med 2011; 365:1528-36. [PMID: 22010920 DOI: 10.1056/nejmcpc1100920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Uzma Shah
- Department of Pediatric Gastroenterology, Massachusetts General Hospital, and Harvard Medical School, Boston, USA
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A novel exon duplication of the cystic fibrosis transmembrane conductance regulator in a patient presenting with adult-onset recurrent pancreatitis. Pancreas 2011; 40:773-7. [PMID: 21673536 DOI: 10.1097/mpa.0b013e3182156e47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pancreatitis is a rare occurrence in patients with cystic fibrosis (CF) affecting 1.2% of all patients, but it can be the first presenting sign in approximately 15% of adults with pancreatic sufficiency and a milder CF phenotype. We report a case of a woman with recurrent pancreatitis who has one cystic fibrosis-causing mutation (G551D) and the first known description of a pathologic duplication of exon 19 of the CF transmembrane conductance regulator (CFTR). A 30-year-old white woman with 30 attacks of pancreatitis over a 5-year period starting at age 25 presented to the genetics department. She was found to have a mutation in the SPINK1 gene, IVS3+184T>A, and one cystic fibrosis-causing mutation (G551D) prompting full gene sequencing of the CFTR, revealing an additional duplication of exon 19. Sweat chloride testing was elevated at 97 and 106 mmol/L. Despite normal growth parameters and lung function, it is important to be aware of recurrent pancreatitis as a presenting sign of CF. Comprehensive CF gene analysis is necessary to detect a second CF-causing mutation that may put patients at risk for more severe symptoms of pancreatitis. There is a significant difference in the prevalence of heterozygote mutations between available testing methods.
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Steiner B, Rosendahl J, Witt H, Teich N, Keim V, Schulz HU, Pfützer R, Löhr M, Gress TM, Nickel R, Landt O, Koudova M, Macek M, Farre A, Casals T, Desax MC, Gallati S, Gomez-Lira M, Audrezet MP, Férec C, des Georges M, Claustres M, Truninger K. Common CFTR haplotypes and susceptibility to chronic pancreatitis and congenital bilateral absence of the vas deferens. Hum Mutat 2011; 32:912-20. [PMID: 21520337 DOI: 10.1002/humu.21511] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Accepted: 04/04/2011] [Indexed: 12/19/2022]
Abstract
CFTR mutations enhance susceptibility for idiopathic chronic pancreatitis (ICP) and congenital bilateral absence of the vas deferens (CBAVD); however, it is unknown why CFTR heterozygotes are at increased disease risk. We recently showed that common CFTR variants are associated with aberrantly spliced transcripts. Here, we genotyped for common CFTR variants and tested for associations in two ICP (ICP-A: 126 patients, 319 controls; ICP-B: 666 patients, 1,181 controls) and a CBAVD population (305 patients, 319 controls). Haplotype H10 (TG11-T7-470V) conferred protection (ICP-A: OR 0.19, P<0.0001; ICP-B: OR 0.78, P = 0.06; CBAVD OR 0.08, P<0.001), whereas haplotype H3 (TG10-T7-470M) increased disease risk (ICP-A: OR 8.34, P = 0.003; ICP-B: OR 1.88, P = 0.007; CBAVD: OR 5.67, P = 0.01). The risk of heterozygous CFTR mutations carriers for ICP (OR 2.44, P<0.001) and CBAVD (OR 14.73, P<0.001) was fully abrogated by the H10/H10 genotype. Similarly, ICP risk of heterozygous p.Asn34Ser SPINK1 mutation carriers (OR 10.34, P<0.001) was compensated by H10/H10. Thus, common CFTR haplotypes modulate ICP and CBAVD susceptibility alone and in heterozygous CFTR and p.Asn34Ser mutation carriers. Determination of these haplotypes helps to stratify carriers into high- and low-risk subjects, providing helpful information for genetic counseling.
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Affiliation(s)
- Bernhard Steiner
- Institute of Medical Genetics, University of Zurich, Schwerzenbach and Children's Hospital, Cantonal Hospital Lucerne, Lucerne, Switzerland
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Abstract
Acute pancreatitis and chronic pancreatitis are complex inflammatory disorders of the pancreas with unpredictable severity, complications, and clinical courses. Growing evidence for genetic risk and modifying factors, plus strong evidence that only a minority of patients with these disorders are heavy alcohol drinkers, has revolutionized our concept of these diseases. Once considered a self-inflicted injury, pancreatitis is now recognized as a complex inflammatory condition like inflammatory bowel disease. Genetic linkage and candidate gene studies have identified six pancreas-targeting factors that are associated with changes in susceptibility to acute and/or chronic pancreatitis, including cationic trypsinogen (PRSS1), anionic trypsinogen (PRSS2), serine protease inhibitor Kazal 1 (SPINK1), cystic fibrosis transmembrane conductance regulator (CFTR), chymotrypsinogen C (CTRC) and calcium-sensing receptor (CASR). Patients with mutations in these genes are at increased risk of pancreatitis caused by a variety of stresses including hyperlipidemia and hypercalcemia. Multiple studies are reporting new polymorphisms, as well as complex gene x gene and gene x environmental interactions.
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Affiliation(s)
- David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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47
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Polymorphisms in tumour necrosis factor alpha (TNFalpha) gene in patients with acute pancreatitis. Mediators Inflamm 2010; 2010:482950. [PMID: 20396411 PMCID: PMC2855055 DOI: 10.1155/2010/482950] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Revised: 12/13/2009] [Accepted: 02/25/2010] [Indexed: 12/31/2022] Open
Abstract
Proinflammatory cytokines, such as tumour necrosis factor α (TNFα), play fundamental roles in the pathogenesis of acute pancreatitis (AP). The aim of this study was to determine if polymorphisms in the TNFα gene are associated with AP. Two polymorphisms located in the promoter region (positions −308 and −238) in TNFα gene were determined using polymerase chain reaction- (PCR-) restriction fragment length polymorphism (RFLP) methods in 103 patients with AP and 92 healthy controls. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression analysis adjusted for age, sex, BMI and smoking. The frequencies of TNFα polymorphisms were both similar in patients with mild or severe pancreatitis, so were in pancreatitis patients and in controls. We suggest that both SNPs of TNFα are not genetic risk factor for AP susceptibility (OR = 1.63; 95% CI: 1.13−4.01 for TNFα−308 and OR = 0.86; 95% CI: 0.75−1.77 for TNFα−238).
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48
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Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG) is a well recognized cause of acute pancreatitis accounting for approximately up to 10% of all cases and even up to 50% of all cases in pregnancy. Both primary and secondary disorders of lipoprotein metabolism may be associated with hypertriglyceridemic pancreatitis (HTGP). The purpose of this review is to provide an overview of the current studies on presentation and management of HTGP. RECENT FINDINGS/CONCLUSION Hydrolysis of triglycerides by pancreatic lipase and formation of free fatty acids that induce inflammatory changes are postulated to account for the development of HTGP, yet the exact pathophysiology remains unclear. The clinical features of patients with HTGP are generally not different from patients with acute pancreatitis of other causes, and there is some evidence that HTGP is associated with a higher severity or a higher complication rate. There is no clear evidence as to which HTG patients will develop pancreatitis. Several studies have evaluated the effect of apheresis, the benefit of insulin and/or heparin treatment and the use of different antihyperlipidemic agents in HTGP. Dietary modifications resemble the key features in the long-term management of HTG. Whether HTG may cause chronic pancreatitis in the long-term follow-up remains controversial.
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Affiliation(s)
- Nils Ewald
- Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Rodthohl 6, Giessen, Germany.
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49
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Current world literature. Curr Opin Lipidol 2009; 20:512-9. [PMID: 19935200 DOI: 10.1097/mol.0b013e328334096a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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50
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Lipoprotein lipase mutation S447X associated with pancreatic calcification and steatorrhea in hyperlipidemic pancreatitis. J Clin Gastroenterol 2009; 43:591-6. [PMID: 19034041 DOI: 10.1097/mcg.0b013e3181734a30] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The factors that whether and how genes involving lipid metabolism including lipoprotein lipase (LPL) and apolipoprotein CII (apo CII) influence occurrence of acute attack of pancreatitis and chronic pancreatitis is not clear. GOALS The aim of this study was to determine the association of LPL and apo CII genes with acute attack of pancreatitis and chronic pancreatitis in patients with hyperlipidemic pancreatitis (HLP) and hypertriglyceridemia (HTG). STUDY We performed genetic analysis of 134 patients in Taiwan with HTG (53 with HLP and 81 without HLP). The entire coding and intronic regions of the LPL and apo CII genes were identified with heteroduplex analytical techniques or high resolution melting analysis. All mutations were confirmed by sequencing analysis. Correlation of phenotype and genotype was also analyzed. RESULTS The frequency of LPL gene mutation rates in HLP patients (17.0%, 9 of 53) was significantly higher than that without HLP attack (4.9%, 4 of 81) (P<0.0001). A total of 10.4% (14 of 134) of our HTG patients carried LPL or apo CII mutation. The most common LPL gene mutation was S447X. There is a high prevalence (77.8%) of HLP attack in HTG patients carrying S447X mutation. Multivariate analysis in HLP patients indicated that the presence of LPL mutation and episode of acute attack were independent risks for pancreatic calcification and steatorrhea. CONCLUSIONS This is the first complete genetic study analyzing the association of LPL and apo CII mutation in a HLP population. LPL S447X mutation is associated with a higher risk of pancreatic calcification and steatorrhea than those previously known factors in HLP patients.
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