ACG Clinical Guideline: Chronic Pancreatitis

Multiparametric MRI Scoring System of the Pancreas for the Diagnosis of Chronic Pancreatitis

BACKGROUND

Ductal features alone may not offer high diagnostic sensitivity or most accurate disease severity of chronic pancreatitis (CP).

PURPOSE

Diagnose CP based on multiparametric MRI and MRCP features.

STUDY TYPE

Prospective.

POPULATION

Between February 2019 and May 2021, 46 control (23 males, 49.3 ± 14.1 years), 45 suspected (20 males, 48.7 ± 12.5 years), and 46 definite (20 males, 53.7 ± 14.6 years) CP patients were enrolled at seven hospitals enrolled in the MINIMAP study. CP classification was based on imaging findings and clinical presentation.

FIELD STRENGTH AND SEQUENCES

1.5 T. T1-weighted (T1W) spoiled gradient echo, T1 map with variable flip angle, dual-echo Dixon, secretin-enhanced MRCP before and after secretin infusion.

ASSESSMENT

Dual-echo fat fraction (FF), T1 relaxation time, extracellular volume (ECV), T1 signal intensity ratio of the pancreas to the spleen (T1 score), arterial-to-venous enhancement ratio (AVR), pancreatic tail diameter (PTD), pancreas volume, late gadolinium enhancement, pancreatic ductal elasticity (PDE), and duodenal filling grade of secretin-enhanced MRCP were measured.

STATISTICAL TESTS

Logistic regression analysis generated CP-MRI and secretin-enhanced CP-SMRI scores. Receiver operating characteristics analysis was used to differentiate definite CP from control. Interobserver agreement was assessed using Lin's concordance correlation coefficient.

RESULTS

Compared to control, definite CP cohort showed significantly higher dual-echo FF (7% vs. 11%), lower AVR (1.35 vs. 0.85), smaller PTD (2.5 cm vs. 1.95 cm), higher ECV (28% vs. 38%), and higher incidence of PDE loss (6.5% vs. 50%). With the cut-off of >2.5 CP-MRI score (dual-echo FF, AVR, and PTD) and CP-SMRI score (dual-echo FF, AVR, PTD, and PDE) had cross-validated area under the curves of 0.84 (sensitivity 87%, specificity 68%) and 0.86 (sensitivity 89%, specificity 67%), respectively. Interobserver agreement for both CP-MRI and CP-SMRI scores was 0.74.

CONCLUSION

The CP-MRI and CP-SMRI scores yielded acceptable performance and interobserver agreement for the diagnosis of CP.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Risk of and factors influencing the progression from acute to recurrent acute to chronic pancreatitis

OBJECTIVES & AIMS

Acute pancreatitis (AP) recurrence rates range from 11 to 36 % yet accurately predicting recurrent acute pancreatitis (RAP) and its progression to chronic pancreatitis (CP) after an initial episode remains challenging. Thus, this study explored the risk factors contributing to RAP and its progression to CP.

METHODS

This retrospective study included patients with AP from three tertiary medical centers between January 2010 and December 2017. The patients were followed up for up to 60 months. The primary endpoint was the incidence of RAP and CP; risk factors influencing these outcomes were also identified.

RESULTS

Overall, 501 patients were included, of which 164 (32.7 %) experienced RAP, and 71 (14.2 %) progressed to CP. The leading causes of AP were alcohol consumption (43.1 %), gallstones (41.5 %) and hypertriglyceridemia (4.4 %). Multivariate Cox regression analysis revealed that smoking (HR, 4.09; 95 % CI, 2.752-6.078, p < 0.001), and organ failure after 48 h of hospitalization (HR, 3.52; 95 % CI, 1.22-10.19, p < 0.02) were significant risk factors for RAP. Significant risk factors for progression to CP included age over 60 years (HR, 5.29; 95 % CI, 1.25-22.47, p = 0.024), smoking (HR, 2.50; 95 % CI, 1.04-6.01, p = 0.04), alcohol consumption (HR, 8.79; 95 % CI, 2.06-37.43, p = 0.003), computed tomography severity index (CTSI) (HR, 1.22; 95 % CI, 1.04-1.44, p = 0.015), and recurrence of AP (HR, 70.69; 95 % CI, 2.61-1914.86, p = 0.011). In alcohol-induced RAP patients, ≥3 recurrences (HR, 4.18; 95 % CI, 1.75-9.98, p = 0.001) was significant risk factor for progression to CP.

CONCLUSIONS

Alcohol consumption was the predominant cause of AP and RAP. The severity of the initial AP episode was the key determinant for RAP, and RAP was the most significant risk factor for the progression to CP. Therefore, smoking and alcohol cessation are important to prevent the development of recurrent AP and CP during long-term follow-up.

Statin therapy associated Lactobacillus intestinalis attenuates pancreatic fibrosis through remodeling intestinal homeostasis

Chronic pancreatitis (CP) is characterized by irreversible fibrotic destruction and impaired pancreatic function. CP disrupts lipid metabolism and causes the imbalance of gut microbiota which in turn exacerbates pancreatic fibrosis. Statins alter gut microbiota and exert anti-inflammatory effects, but its role in CP has not been fully elucidated. Here, we found that statins-associated higher abundance of Lactobacillus intestinalis (L.intestinalis) maintained gut homeostasis that restrained bacteria translocation from gut to the pancreas, which eventually aggravated pancreatic fibrosis through inhibiting CD8+T cells-dependent immunity. Fecal microbiota transplantation (FMT) or L.intestinalis administration inhibited the infiltration of CD8+T cells and macrophages that delayed CP progression. L.intestinalis restrained the recruitment of M1 macrophages and limited the release of Ccl2/7 in the colon, which prevented epithelial damage and epithelial barrier dysfunction through blocking Ccl2/7-Ccr1 signaling. Our findings elucidate that the utilization of statin therapy or supplementation of L.intestinalis can be potential approach for the therapies of CP.

Contemporary Approach to Acute Pancreatitis in Emergency Medicine

Acute pancreatitis is a commonly encountered pathology in the emergency department. We presented a clinical review summarizing the contemporary emergency medicine approach to managing acute pancreatitis. Although the diagnostic criteria for acute pancreatitis are straightforward, it has many possible causes, several treatment options, and both short- and long-term sequelae. We discussed diagnostic, intervention, and disposition considerations relevant to emergency clinicians and considered risk assessment using available clinical decision tools. We also discussed changes to traditional treatments and ongoing investigational therapies, including steroids, monoclonal antibodies, and calcium release-activated calcium channel inhibitors.

Metabolomics Approach Revealed Polyunsaturated Fatty Acid Disorders as Pathogenesis for Chronic Pancreatitis-Induced Osteoporosis in Mice

Background: Osteoporosis is frequently observed in patients with chronic pancreatitis, and both conditions are closely associated with systemic metabolic disorders. However, the underlying mechanisms linking chronic pancreatitis and osteoporosis remain unclear. Methods: In this study, we utilized high-performance liquid chromatography-mass spectrometry (HPLC-MS) to conduct metabolomics and lipidomics analyses on pancreatic, serum, and other tissues from a mouse model of chronic pancreatitis-induced osteoporosis (CP-OP), with the aim to elucidate the metabolism-related pathogenic mechanisms of CP-OP. Results: We identified over 405 metabolites and 445 lipids, and our findings revealed that several metabolites involving the tricarboxylic acid (TCA) cycle, as well as triacylglycerols and diacylglycerols with higher saturation, were significantly increased in the CP-OP model. In contrast, triglycerides with higher unsaturation were decreased. Differential pathways were enriched in n-3 long-chain polyunsaturated fatty acid metabolism in both pancreatic and bone tissues, and these pathways exhibited positive correlations with bone-related parameters. Furthermore, the modulation of these polyunsaturated fatty acids by Qingyi granules demonstrated significant therapeutic effects on CP-OP, as validated in mouse models. Conclusions: Through the metabolomics approach, we uncovered that disorders in polyunsaturated fatty acids play a critical role in the pathogenesis of CP-OP. This study not only enhances our understanding of the pathogenesis of CP-OP but also highlights the therapeutic potential of targeting polyunsaturated fatty acids as a future intervention strategy for osteoporosis treatment.

Updates in the Diagnosis of Chronic Pancreatitis: Current Approaches and New Possibilities

This review provides a comprehensive update on the diagnostic approaches to chronic pancreatitis (CP), emphasizing recent advancements in imaging techniques, biomarker research, and multivariable scoring systems. Despite substantial progress in these areas, current diagnostic algorithms have limitations, particularly for early and non-calcific CP. Traditional criteria have focused on classic diagnostic signs, but "minimal change" CP is increasingly recognized through advanced imaging and function tests. This article aims to guide clinicians in applying current methods and available strategies for CP diagnosis and outline research efforts in the field.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Treatment Strategies for Chronic Pancreatitis (CP)

Chronic pancreatitis (CP) and autoimmune pancreatitis (AIP) are diseases with overlapping features, both requiring complex management strategies. CP is characterized by pancreatic exocrine insufficiency (PEI) and pain, with treatment focused on symptom relief through pancreatic enzyme replacement therapy (PERT), pain control, and lifestyle and nutritional changes. However, the standard therapy does not address the underlying inflammation or fibrosis, which drives disease progression. AIP, on the other hand, presents with obstructive jaundice and fibrosis and is classified into two subtypes: Type 1 (AIP-1), linked to IgG4-related disease, and Type 2 (AIP-2), associated with inflammatory bowel disease. Treatment for AIP typically involves oral steroids. Immunomodulators and rituximab are used for recurrent or refractory cases. Novel therapies targeting the inflammation and fibrotic components of CP are being explored. A multidisciplinary approach is essential to optimize care and improve patients' outcomes.

Associations between ABO, FUT2 and chronic pancreatitis: A comprehensive meta-analysis of multiple cohorts and public biobanks

OBJECTIVES

Associations of ABO blood group specifying transferases A/B (ABO) and fucosyltransferase 2 (FUT2) with CP remain inconclusive. We aimed to comprehensively investigate the associations by Chinese sequencing cohorts and external cohorts.

METHODS

First, we analyzed the distributions of ABO blood groups and FUT2 status, along with lead single nucleotide polymorphisms (SNPs) at ABO (rs8176693 C/T) and FUT2 (rs632111 A/G) gene loci in Chinese low-coverage whole-genome sequencing discovery cohort. Subsequently, we investigated the associations of CP with ABO and FUT2 SNPs in Chinese whole-exome sequencing validation cohort and three public biobanks (FinnGen, UK Biobank, and BioBank Japan). Finally, comprehensive meta-analysis was performed by integrating data from two Chinese cohorts, reported cohorts and public biobanks.

RESULTS

Firstly, in Chinese discovery cohort, the distribution of blood types in CP patients showed no significant difference compared to healthy controls, and similar results were observed in subgroup analyses and in meta-analysis with the reported cohorts. Secondly, results indicated no association between rs8176693 or rs632111 and CP in Chinese cohorts and meta-analysis of three biobanks, though ABO SNP was found to be significantly associated with CP in UK Biobank (odds ratio [OR] = 1.27, P = 0.04). Finally, no association was observed between rs8176693 (OR = 1.03, P = 0.29) or rs632111 (OR = 1.04, P = 0.10) and CP in comprehensive meta-analysis.

CONCLUSIONS

No association was found between lead SNPs of ABO or FUT2 and CP in meta-analysis, nor was there an association between ABO blood group or FUT2 secretor status and CP in Chinese cohort. ABO and FUT2 might play limited role in CP development.

Incidence and Management of Splanchnic Vein Thrombosis in Pancreatic Diseases

Splanchnic vein thrombosis (SVT) in pancreatic disease has a 20%-30% incidence rate, leading to increased mortality and complication rates. Therefore, the aim of this review is to summarize recent evidence about the incidence, risk factors, and management of pancreatic cancer, pancreatic cystic neoplasm-, and pancreatitis-related SVT. Doppler ultrasound should be the first imaging choice, followed by contrast-enhanced computed tomography or magnetic resonance imaging. Data regarding SVT treatment in acute pancreatitis and pancreatic cancer are scarce; however, for venous thromboembolism treatment, direct oral anticoagulants and low molecular weight heparin have been effective. Further trials must investigate the length of anticoagulant treatment and the need for interventional radiological procedures.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Risk factors associated with pain and pain relief in patients with chronic pancreatitis

BACKGROUND

Abdominal pain is one of the most prominent symptoms in patients with chronic pancreatitis (CP) and can manifest intermittently or persistently. The mechanism of pain is not yet clear, and no effective treatment is currently available. This study aimed to explore the risk factors for pain in patients with CP, which may provide new insights for developing effective pain control modalities.

METHODS

This clinical study was based on a single-centre research database that included 570 patients with CP. We compared the differences in baseline data, clinical characteristics, and psychophysiology traits between patients with and without pain. Subsequently, patients will be followed up to assess changes in their risk factors and explore their relationship with pain.

RESULTS

In the final risk factor model, young age (P = .031; odds ratio [OR] = 0.986 [0.973, 0.999]), prolonged disease duration (P < .001; OR = 1.307 [1.127, 1.516]), heavy smoking (P = .014; OR = 1.331 [1.060, 1.617]), alcohol consumption (P = .003; OR = 1.419 [1.127, 1.788]), low body mass index (P < .001; OR = 0.786 [0.703, 0.879]), pancreatic exocrine insufficiency (P = .040; OR = 1.683 [1.024, 2.767]), acute pancreatitis attacks (P = .027; OR = 1.759 [1.067, 2.902]), anxiety, and depression (P = .016; OR = 1.047 [1.009, 1.088]; P = .014; OR = 1.068 [1.013, 1.126]) were associated with CP pain. Reducing tobacco and alcohol intake (P = .001; OR = 2.367 [1.525, 4.637]; P = .024; OR = 2.011 [1.085, 3.199]), increasing the body mass index (P = .005; OR = 1.968 [1.265, 3.805]), and improving anxiety (P = .001; OR = 1.164 [1.081, 1.340]) were identified to be beneficial for pain relief. Compared to the effects on persistent pain, pancreatic enzyme supplementation (P = .004; OR = 1.794 [1.186, 2.502]) had a clear effect on intermittent pain in patients with CP.

CONCLUSION

We identified a multifactorial model of pain risk factors for CP and confirmed that modifying these risk factors could influence patient pain symptoms.

Comparative diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and Bayesian network meta-analysis

PURPOSE

We aimed to perform a Bayesian network meta-analysis to assess the comparative diagnostic performance of different imaging modalities in chronic pancreatitis(CP).

METHODS

The PubMed, Embase and Cochrane Library databases were searched for relevant publications until March 2024. All studies evaluating the head-to-head diagnostic performance of imaging modalities in CP were included. Bayesian network meta-analysis was performed to compare the sensitivity and specificity between the imaging modalities. The Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool was used to evaluate the quality of studies.

RESULTS

This meta-analysis incorporated 17 studies. Network meta-analytic results indicated that endoscopic ultrasonography (EUS) achieved the highest surface under the cumulative ranking (SUCRA) value at 0.86 for sensitivity. Conversely, magnetic resonance imaging (MRI) demonstrated best specificity, recording the highest SUCRA value at 0.99. Ultrasonography (US) displayed comparatively lower sensitivity than endoscopic retrograde cholangiopancreatography (ERCP) (relative risk[RR]: 0.83, 95% Confidence Interval[CI]: 0.69-0.99) and EUS (RR: 0.73, 95% CI: 0.57-0.91). MRI outperformed all other imaging modalities in terms of specificity.

CONCLUSIONS

It appears that EUS demonstrates higher sensitivity, while MRI exhibits higher specificity in patients with chronic pancreatitis. However, it is crucial to note that our analysis was limited to the diagnostic performance and did not evaluate the cost-effectiveness of these various imaging modalities. Consequently, further extensive studies are needed to assess the benefit-to-risk ratios comprehensively.

Chronic Pancreatitis: One Patient, Multiple Etiologies

Pancreatitis, by definition, is an acute inflammation of the pancreas. Acute and chronic pancreatitis can be seen as a spectrum of the same disease rather than two different entities. Here, the authors report the diagnostic and therapeutic approach to a case of a 44-year-old male patient with multiple episodes of acute pancreatitis, leading to the development of chronic pancreatitis. An extended study revealed multiple causes for chronic pancreatitis, such as tobacco, alcohol, and genetics. Pain management and risk factor control were challenging in this case.

Minimally invasive versus open lateral pancreaticojejunostomy in patients with painful chronic pancreatitis: systematic review

BACKGROUND

Patients with painful chronic pancreatitis combined with a dilated main pancreatic duct and a normal size pancreatic head are treated according to guidelines by lateral pancreaticojejunostomy (LPJ). This systematic review compared outcomes of minimally invasive LPJ and open LPJ.

METHODS

From 1 January 2000 until 13 November 2023, series reporting on minimally invasive LPJ and open LPJ in patients with symptomatic chronic pancreatitis were included. This study was structured in accordance with the PRISMA guidelines. The primary outcome was intraoperative and postoperative complications. Secondary outcomes included long-term clinical outcomes.

RESULTS

Overall, 19 retrospective studies were included. Morbidity rate ranged from 0% to 57% after minimally invasive LPJ versus 4% to 68% after open LPJ (median: 25, i.q.r.: 23). Length of hospital stay ranged from 5 to 7 days after minimally invasive LPJ and from 6 to 16 days after open LPJ. The rate of pain relief ranged from 62% to 91% after open LPJ (median: 78.5, i.q.r.: 23) and from 71% to 100% (median: 82.5, i.q.r.: 12.5) after minimally invasive LPJ respectively. New-onset endocrine insufficiency ranged from 21% to 22% in minimally invasive LPJ and 19% to 26% after open LPJ. New-onset exocrine insufficiency was shown in 11% to 27% in minimally invasive LPJ versus 8% to 26% after open LPJ. Weight gain ranged from 60% to 100% (median: 97, i.q.r.: 23) after minimally invasive LPJ.

DISCUSSION

This systematic review suggested that minimally invasive LPJ can be performed safely in selected patients with symptomatic chronic pancreatitis. Phase 2 randomized trials should assess potential short-term benefits such as postoperative pain and length of hospital stay after minimally invasive LPJ.

Comparison of the efficacy and safety of basket catheters and balloon catheters for endoscopic pancreatic duct stone clearance

BACKGROUND

The choice of a basket or a balloon catheter during endoscopic retrograde cholangiopancreatography (ERCP) for the clearance of pancreatic duct stones in patients with chronic pancreatitis (CP) remains controversial. This study compared the efficacy and safety of these two devices for pancreatic duct stone extractions.

METHODS

We compared the efficacy and safety of basket and balloon catheters for pancreatic stone extractions. We enrolled CP patients who underwent ERCP for the first time at Changhai Hospital, Naval Medical University between February 2012 and December 2021. After propensity score matching (1:1), 101 patients were included in each group. The primary outcome was the rate of pancreatic stone clearance. Secondary outcomes included the rate of adverse events during hospitalization, long-term pain relief, and quality of life after one year follow-up period.

RESULTS

The rate of complete clearance was comparable between the two groups (86.1 % vs. 84.2 %, P = 0.692). In patients with stones ≥ 2 cm before extracorporeal shock wave lithotripsy (ESWL), the rate of complete clearance was significantly higher in the balloon catheter group when compared to the basket catheter group [100 % (19/19) vs. 70.0 % (14/20), P = 0.031]. In the multivariate analysis, ESWL prior to stone extraction was the only independent predictor of complete clearance [with ESWL 58.4 % (264/452) vs. without ESWL 41.6 % (188/452), odds ratio = 2.3, 95 % confidence interval: 1.2-4.3; P = 0.013]. No significant differences between groups were found regarding the rates of adverse events during hospitalization, quality of life, and pain relief after one year of follow-up.

CONCLUSIONS

Basket and balloon catheters showed similar efficacy and safety for pancreatic stone extractions. However, the balloon catheter was superior to the basket catheter if the pancreatic stone size was ≥ 2 cm before ESWL.

Adherence to the Mediterranean diet is associated with reduced chronic pancreatitis risk: a longitudinal cohort study

Background: The role of diet on the risk of chronic pancreatitis (CP) is understudied. The health benefits of the Mediterranean diet (MedDiet) pattern have long been recognized, but its association with CP risk is unclear. We aimed to investigate the association between adherence to MedDiet and the incidence of CP in a large-scale cohort. Methods: 190 790 participants from the UK Biobank were involved, all free of CP and with typical diet recall data at recruitment. The diagnosis of CP was ascertained by the combination of hospital inpatient data, primary care data, and death registry data. Multivariable Cox regression models were used to evaluate the associations between MedDiet adherence, measured by the Mediterranean Diet Adherence Screener (MEDAS) continuous score, and the incidence of CP. The mediating role of inflammation (assessed by C-reactive protein) and metabolic status between MedDiet adherence and CP risk was also investigated. Results: During a mean of 10.8 years of follow-up, 214 participants developed CP. Individuals with the highest adherence to MedDiet, defined by continuous MEDAS scores, exhibited significantly lower risk of developing CP (hazard ratio [HR] = 0.57, 95% confidence interval [CI]: 0.40-0.82; p = 0.002) compared to those in the lowest tertiles. Metabolic status mediated 4.74% of the association between MedDiet adherence and CP risk, while the mediating role of C-reactive protein was not significant. Conclusion: Greater Mediterranean diet adherence is associated with reduced chronic pancreatitis risk.

Wet-Cupping's Impact on Pancreatitis Induced by Hypertriglyceridemia: A case study and brief literature review

Familial hypertriglyceridemia is a genetic disorder marked by excessive production of very low-density lipoproteins, resulting in elevated serum triglyceride levels. This can lead to various medical conditions including acute pancreatitis. In cases of recurrence, it may progress to chronic pancreatitis. Cupping therapy, a traditional treatment practiced in numerous cultures worldwide, is utilised to address various medical conditions. We report a 34-year-old male patient who presented to a tertiary hospital, Muscat, Oman, in 2022. He was diagnosed with familial hypertriglyceridemia and subsequently developing chronic pancreatitis. During his last presentation with acute-on-chronic pancreatitis, his lipid profile revealed a notable reduction in serum triglycerides. This reduction coincided with the introduction of cupping therapy into his treatment regimen. Remarkably, following the initiation of cupping therapy, his hospital admissions for acute pancreatitis notably decreased. This case report highlights the potential impact of cupping therapy on familial hypertriglyceridemia, potentially mitigating the risk of acute pancreatitis.

Total Pancreatectomy With Percutaneous Islet Autotransplant After Remote Islet Processing: A Viable Paradigm?

OBJECTIVES

Total pancreatectomy with islet autotransplant (TPIAT) is important therapy for select chronic pancreatitis (CP) patients. The specialized technique of islet isolation limits widespread TPIAT use. We hypothesized that remote islet isolation provides satisfactory islet yield and perioperative outcomes.

METHODS

A retrospective review of TPIAT patients between 2020 and 2022 was conducted. Islet isolation was performed off-site, with percutaneous intraportal islet autotransplant (IAT) completed the morning following pancreatectomy. Demographics and perioperative outcomes were analyzed.

RESULTS

Fourteen patients underwent TPIAT; median age was 43 (interquartile range, 12.5) years. Operation occurred 7.5 (14.8) years after pancreatitis diagnosis. The most common pancreatitis etiology was genetic (50%). All patients underwent preoperative endoscopic therapy; three underwent prior pancreatectomy. Operative time was 236 (51) minutes; subsequent percutaneous IAT time was 87 (35) minutes. The islet equivalent (IEQ)/kilogram (kg) yield was 3456 (3815) IEQ/kg. Nine patients had positive islet cultures. Two thromboembolic events and one bacteremia occurred. One perihepatic hematoma occurred after percutaneous portal venous access. The median postoperative length of stay was 14.5 days, and five patients (36%) were readmitted within 90 days. All patients were discharged home on insulin. No mortality occurred.

CONCLUSIONS

Total pancreatectomy with remote islet isolation provides excellent islet yield for autotransplant and satisfactory perioperative outcomes.

Diagnostic Yield of Endoscopic Ultrasound in Common Bile Duct Dilation: A Real Breakthrough

BACKGROUND

Endoscopic ultrasound (EUS) is important for the evaluation of patients with common bile duct (CBD) dilation.

AIMS

The purpose of this study was to evaluate the diagnostic performance of EUS for CBD dilation in patients with negative initial studies.

METHODS

This was a retrospective cohort study that included patients who underwent EUS for CBD dilation (≥ 7 mm if intact anatomy or ≥ 10 mm if prior cholecystectomy) in the absence of pathology on previous ultrasonography (US), computed tomography (CT), and/or magnetic resonance cholangiopancreatography (MRCP).

RESULTS

A total of 109 patients were included, among whom 41 had a positive EUS: 33 choledocholithiasis (30.3%), 6 chronic pancreatitis (5.5%), and 2 ampullary cancer (1.8%). If the EUS was negative, no pathology was found during 1-year follow-up. Older age was associated with positive EUS (79 versus 71 years, p = 0.030). Patients with jaundice, cholelithiasis, and altered liver biochemistry were 16.2 (p = 0.002), 3.1 (p = 0.024), and 2.9 (p = 0.009) times more likely to have positive EUS, respectively. A total of 53 patients had a negative MRCP (48.6%); those with biliary abdominal pain and jaundice were 15.5 (p < 0.001) and 20.0 (p = 0.007) times more likely to have positive EUS, respectively. Considering asymptomatic patients with normal liver tests, CBD diameter ≥ 10 mm in US and ≥ 11 mm in CT can predict a positive EUS (AUC 0.754, p = 0.047 and AUC 0.734, p = 0.048).

CONCLUSIONS

EUS is a useful diagnostic method for patients with unexplained CBD dilation, even if negative MRCP, and especially in patients with older age, abdominal pain, jaundice, cholelithiasis, and/or altered liver biochemistry. CBD diameter in US and CT had a moderate discriminative ability in predicting positive EUS in asymptomatic patients without altered liver biochemistry.

Experience of endoscopy versus surgery as initial management of chronic pancreatitis

INTRODUCTION AND AIM

Chronic pancreatitis is a pathologic fibroinflammatory syndrome of the pancreas. Treatment includes medical management and endoscopic and/or surgical interventions. Our aim was to describe progression in patients with chronic pancreatitis whose initial management was either endoscopic or surgical.

MATERIAL AND METHODS

A retrospective, analytic, observational, and longitudinal study was conducted that included patients diagnosed with chronic pancreatitis treated at the Hospital de Especialidades of the Centro Médico Nacional Siglo XXI from 2015 to 2021.

RESULTS

Twenty-two patients were included in the study; 12 underwent endoscopy and 10 underwent surgery. The mean number of interventions performed was 3 in the endoscopic management group and 1.1 in the surgical management group (p = 0.001). Regarding pain remission (partial or total), results were statistically significant in favor of surgical management (p = 0.035). Of the 12 patients that initially underwent endoscopy, 7 (58.3%) eventually required surgery during follow-up. There were no statistically significant differences with respect to opioid and pancreatin use, readmissions, weight loss, steatorrhea, newly diagnosed diabetes, or deaths during follow-up.

CONCLUSION

Pain is the main indication for invasive treatment, whether endoscopic or surgical, in patients with chronic pancreatitis. Slightly more than half of the patients that were initially managed endoscopically required surgery during follow-up. Management decisions should be multidisciplinary and individualized for each patient.

Pancreatic cancer screening in high-risk individuals

The incidence of pancreatic cancer is increasing, although globally it represents less than 3% of all cancers. Despite advances in medical and surgical management, survival rates have not significantly improved in recent years. Consequently, pancreatic cancer, though relatively uncommon, is the third leading cause of cancer-related deaths. This is primarily due to the disease´s late detection. Symptoms appear late and are nonspecific, and over 80% of cases are diagnosed at an advanced stage and unsuitable for curative surgery, resulting in a five-year survival rate below 10%. However, the exceptional cases that are diagnosed early show five-year survival rates exceeding 80%. Therefore, one of the keys to improving pancreatic cancer prognosis lies in early detection, making screening in high-risk individuals a potentially crucial strategy.

Beta-cell function and glucose metabolism in patients with chronic pancreatitis

AIMS

Chronic pancreatitis (CP) is - along with acute pancreatitis - the most frequent cause of diabetes of the exocrine pancreas (DEP). Although insulin deficiency is widely accepted as the major feature of DEP, it is still unclear whether diabetes associated with CP is characterized by additional or different functional defects of the insulin secretory machinery. To identify possible functional defects specifically induced by CP, we performed a cross-sectional study in individuals with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) and diabetes mellitus (DM) comparing patients with and without CP (CP vs. NCP).

METHODS

We administered an oral glucose tolerance test (OGTT) to all participants and, according to their glucose tolerance, classified them as NGT, IGT and DM. Insulin sensitivity and beta-cell functional parameters were derived from OGTT, hyperglycemic clamp and hyperinsulinemic euglycemic clamp.

RESULTS

Studying 146 subjects, we found that beta-cell function and insulin secretion were significantly lower in CP compared to NCP patients. However, when we classified the subjects according to OGTT-derived glucose tolerance, we found no differences in beta-cell function or in insulin sensitivity between CP and NCP with the same glucose tolerance status. Of note, we found that arginine-stimulated insulin secretion is reduced only in subjects with CP and DM compared to NCP subjects with DM.

CONCLUSIONS

Patients with CP had no specific alterations in insulin secretion and beta-cell function. However, in patients diagnosed with diabetes, we found a lower arginine-stimulated insulin secretion, a marker of reduced functional mass.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis

BACKGROUND AND AIMS

Extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred therapeutic approaches for painful chronic pancreatitis (CP) with pancreatic stones. This study aimed to report the short- and long-term outcomes following P-ESWL and ERCP in a large cohort with CP.

METHODS

Patients with painful CP and pancreatic stones >5 mm in size, who underwent P-ESWL and subsequent ERCP between March 2011 and June 2018, were included in this retrospective-prospective mixed observational study. The total stone clearance rates were recorded. All patients were followed up until the end of March 2024, with the visual analogue scale (VAS) for pain, pain type, quality-of-life scores and other relevant information recorded.

RESULTS

A total of 2071 patients underwent P-ESWL, and 93.1% of them subsequently underwent ERCP during the study period. Patients were followed up for an average of 11.8 years from the onset of CP and 6.7 years from the first P-ESWL procedure. Complete stone clearance was achieved in 73.7% of the patients. At the end of the follow-up period, 70.1% of the patients achieved complete pain remission. Significant pain type conversion and lower VAS scores were observed in the patients after treatment. Quality-of-life scores and body mass indices increased after P-ESWL and ERCP.

CONCLUSIONS

P-ESWL and ERCP are effective and minimally invasive treatments for pancreatic stones in patients with painful CP. Most patients achieved complete pain relief, and pain-type conversion was common after treatment. (ClinicalTrials.gov: NCT05916547).

Progress in treatment of chronic pancreatitis: A review based on the ClinicalTrials.gov database

Chronic pancreatitis (CP) is a chronic progressive fibro-inflammatory disease of the pancreas caused by various etiologies, characterized by recurrent upper abdominal pain and pancreatic exocrine dysfunction. ClinicalTrials.gov is the most commonly used clinical trial database, including information of clinical trials which have been completed or are ongoing, or upcoming. Based on the ClinicalTrials.gov database, we retrieved all clinical studies registered before June 30, 2024, screened out recent clinical studies related to CP, and summarized and integrated highlights and directions of these studies from the perspectives of nutritional support, medication, endoscopy, etc., aiming to provide new ideas for the design of CP clinical studies in the future.

The Clinical Significance of Pancreatic Steatosis in Pancreatic Cancer: A Hospital-Based Study

Background/Objectives: Pancreatic cancer remains one of the deadliest malignancies worldwide with a pressing need for early detection and intervention strategies. Emerging evidence has suggested a potential link between pancreas steatosis, characterized by excessive pancreatic fat accumulation, and an increased risk of pancreatic cancer development. This retrospective imaging study aims to elucidate the association between pancreatic steatosis and the subsequent development of pancreatic cancer. In the study, we aimed to determine the characteristics of pancreatic cancer with pancreatic steatosis. Methods: During the period of January 2022 to December 2022, we conducted a retrospective study, collecting 101 newly diagnosed pancreas cancer cases from the available image datasets. A comprehensive database of retrospective abdominal imaging studies, comprising computed tomography (CT) and magnetic resonance imaging (MRI), was established from a diverse patient population and subsequently analyzed. Inclusion criteria encompassed patients having available baseline imaging data, allowing for the assessment of pancreatic fat content. Pancreatic fat content was quantified using validated radiological techniques, while demographic, clinical, and histopathological data were all collected. The clinical data and patient characteristics were collected from medical records and analyzed. Results: Preliminary analysis revealed a significant correlation between elevated pancreatic fat content and an increased incidence of subsequent pancreatic cancer. Moreover, subgroup analysis based on age, gender, and comorbidities provided valuable insight into potential risk factors associated with this progression. Additionally, the study identified novel radiological markers that may serve as early indicators of pancreatic cancer development in individuals with pancreatic steatosis. Conclusions: In the imaging study, approximately 30% (30/101) of pancreatic cancer patients presented with pancreatic steatosis. Chronic pancreatitis emerged as the primary factor contributing to pancreatic steatosis in these patients. Importantly, pancreatic steatosis did not significantly impact the prognosis of pancreatic cancer. Follow-up data revealed no significant differences in survival duration between patients with or without pancreatic steatosis. Additionally, no association was found between pancreatic steatosis and hepatic steatosis.

Quality of Life Following Total Pancreatectomy With Islet Autotransplantation: A Patient Experience Survey

OBJECTIVES

Total pancreatectomy with islet autotransplantation (TPIAT) is performed to improve the quality of life (QOL) of patients with chronic pancreatitis. Few reports have documented QOL following TPIAT, with none using the pancreatitis-specific Pancreatitis Quality of Life Instrument (PANQOLI). We surveyed patients at our center who underwent TPIAT to document postoperative QOL.

MATERIALS AND METHODS

We collected survey data from 18 adult patients who underwent TPIAT at our medical center from 2012 to 2020. Patients were asked questions assessing QOL following TPIAT and completed the Short-Form Health Survey and PANQOLI instruments.

RESULTS

Forty-three patients who underwent TPIAT were mailed surveys, and 18 were returned. The mean age was 45 years, and 67% of respondents were female. Almost half (44%) had hereditary pancreatitis. Sixty-seven percent believed that their overall QOL had improved after surgery. The mean postoperative Short-Form Health Survey physical score was 38.9 and mean mental score was 44. The mean PANQOLI score was 66 (physical function 20, role function 16, emotional function 14, self-worth 15). Following surgery, 33% were using opiate medications and 67% were using antihyperglycemic medications.

CONCLUSIONS

TPIAT resulted in improved self-reported QOL in most patients, although postoperative physical and mental QOL are less compared to the average healthy United States adult.

Germline multigene panel testing in acute and chronic pancreatitis

BACKGROUND/OBJECTIVES

Germline genetic testing is recommended for younger patients with idiopathic pancreatitis but there has been a lack of consensus in recommendations for those over age 35. We aimed to analyze the results of genetic testing among subjects of varying ages.

METHODS

Individuals who underwent germline multigene testing for pancreatitis susceptibility genes (CASR, CFTR, CPA1, CTRC, PRSS1, SPINK1) through a large commercial laboratory between 2017 and 2022 were included. Test results and information collected from test requisition forms were evaluated. Multivariable logistic regression models were performed to identify factors associated with a positive pancreatitis panel (pathogenic, likely pathogenic, and/or increased risk variants) in pancreatitis-related genes.

RESULTS

Overall, 2,468 subjects with primary indication of acute pancreatitis (AP) (n = 401), chronic pancreatitis (CP) (n = 631), pancreatic cancer (n = 128), or other indications (n = 1,308) completed germline testing. Among patients with AP or CP, the prevalence of any positive result for those <35 versus ≥35 years of age was 32.1% and 24.5% (p = 0.007), and the prevalence of a clinically meaningful result was 10.8% and 5.4%, respectively (p = 0.001). Positive family history of pancreatitis was associated with increased odds ratio (OR) of 8.59 (95% confidence interval (CI) 2.92-25.25) for a clinically significant panel result while each 5-year increase in age at test completion had lower odds (OR 0.89, 95% CI 0.83-0.95).

CONCLUSIONS

The highest prevalence of pathogenic variants is seen in younger individuals with a positive family history of pancreatitis. However, clinically meaningful results are identified in older subjects, suggesting that genetic counseling and testing should be considered for all age groups.

The causality between use of glucocorticoids and risk of pancreatitis: a Mendelian randomization study

BACKGROUND AND AIM

To date, the association between glucocorticoid use and the risk of pancreatitis remains controversial. The aim of this study was the investigation of this possible relationship.

METHODS

We carried out a two-sample Mendelian randomization (MR) analysis using GWAS data from European ancestry, East Asian descendants and the FinnGen Biobank Consortium to evaluate this potential causal relationship. Genetic variants associated with glucocorticoid use were selected based on genome-wide significance (p < 5×10-8).

RESULTS

Our MR analysis of European ancestry data revealed no significant causal relationship between glucocorticoid use and AP (IVW: OR=1.084, 95% CI= 0.945-1.242, P=0.249; MR-Egger: OR=1.049, 95% CI= 0.686-1.603, P=0.828; weighted median: OR=1.026, 95% CI= 0.863-1.219, P=0.775) or CP (IVW: OR=1.027, 95% CI= 0.850-1.240, P=0.785; MR-Egger: OR= 1.625, 95% CI= 0.913-2.890, P= 0.111; weighted median: OR= 1.176, 95% CI= 0.909-1.523, P= 0.218). Sensitivity analyses, including MR-Egger and MR-PRESSO, indicated no evidence of pleiotropy or heterogeneity, confirming the robustness of our findings. Multivariable MR analysis adjusted for alcohol consumption, BMI, cholelithiasis and C-reactive protein levels supported these findings. Replicated analysis was performed on datasets from the FinnGen Biobank Consortium and East Asian descendants, and similar results were obtained.

CONCLUSIONS

This MR analysis suggests that there is no causal association between glucocorticoid use and the risk of pancreatitis.

Chronic Pancreatitis in a Large Developing Country: Temporal Trends of Over 64,000 Hospitalizations from 2009 to 2019

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a progressive inflammatory disorder associated with marked morbidity and mortality and frequently requires hospitalization. This study aimed to investigate the time trends and geographical distribution of hospital admissions, the lethality rate of CP across Brazil, and the potential relationship with social indicators and associated risk factors.

METHODS

Data were retrospectively obtained from the Brazilian Public Health System Registry between January 2009 and December 2019. The prevalence and lethality rates of CP per 100,000 inhabitants in each municipality were estimated from hospitalizations to in-hospital deaths and classified by age, sex, and demographic features.

RESULTS

During the study period, 64,609 admissions were retrieved, and most of the patients were males (63.54%). Hospitalization decreased by nearly half (-54.68%) in both sexes. CP rates in males were higher in all age groups. The greatest reduction in admissions (- 64%) was also noted in patients ≥ 70y. CP In-hospital lethality remained stable (5-6%) and similar for males and females. Patients ≥ 70y showed the highest lethality. The greatest increase in CP lethality rates (+ 10%) was observed in municipalities integrated into metropolises, which was mainly driven by small-sized municipalities (+ 124%).

CONCLUSIONS

CP hospitalizations decrease in both urban and rural areas, particularly in the North, Northeast, and Central-West regions, and in those above 70 years of age, but are not correlated with lethality rates in the South. This suggests ongoing changes in the environmental and socioeconomic factors in Brazil.

Canadian Association of Radiologists Gastrointestinal Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion.

Diagnosis and Management of Pancreatic Cysts

As pancreatic cyst incidence rises, likely due to the ubiquitous increase in cross-sectional imaging, their management presents multiple challenges for both the practitioner and patient. It is critical that all pancreatic cysts are appropriately characterized, as treatment decisions depend on an accurate diagnosis. Diagnostic modalities such as cytology, biopsy, and cyst fluid biomarkers allow for definitive diagnosis of virtually all lesions. Some cysts, such as intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and cystic pancreatic endocrine neoplasms, have malignant potential and must be surveyed. Other cysts, such as serous cystadenomas and pancreatic fluid collections, do not have malignant potential. Surveillance strategies vary widely depending on cyst type and size and while multiple medical societies advocate surveillance, their published surveillance guidelines are heterogenous. Cysts with high-risk stigmata or worrisome features are usually resected, depending on the patient's surgical fitness. In patients unfit for resection, newer endoscopic ablative techniques are advocated. Controversial aspects regarding cyst management include whether surveillance can be stopped, how surveillance should be performed, and the extensive financial burden cyst management places on the health care system. Further study into the natural history of cystic lesions, including definitive determination of the rate of malignant transformation for each cyst type, is essential.

The role of EUS in the diagnosis of early chronic pancreatitis

The diagnosis of early chronic pancreatitis (ECP) is challenging due to the lack of standardized diagnostic criteria. EUS has been considered a sensitive diagnostic modality for chronic pancreatitis (CP), with advancements in technique such as EUS-guided fine needle aspiration and biopsy (EUS-FNA/FNB) being developed. However, their role in the diagnosis of ECP remains unelucidated. This review thereby aimed to provide an overview of the clinical landscape of EUS in the field of ECP.

Endoscopic Management of Pain due to Chronic Pancreatitis

Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.

Pancreas-directed AAV8-hSPINK1 gene therapy safely and effectively protects against pancreatitis in mice

OBJECTIVE

Currently, there is no cure for chronic pancreatitis (CP). Germline loss-of-function variants in SPINK1 (encoding trypsin inhibitor) are common in patients with CP and are associated with acute attacks and progression of the disease. This preclinical study was conducted to explore the potential of adeno-associated virus type 8 (AAV8)-mediated overexpression of human SPINK1 (hSPINK1) for pancreatitis therapy in mice.

DESIGN

A capsid-optimised AAV8-mediated hSPINK1 expression vector (AAV8-hSPINK1) to target the pancreas was constructed. Mice were treated with AAV8-hSPINK1 by intraperitoneal injection. Pancreatic transduction efficiency and safety of AAV8-hSPINK1 were dynamically evaluated in infected mice. The effectiveness of AAV8-hSPINK1 on pancreatitis prevention and treatment was studied in three mouse models (caerulein-induced pancreatitis, pancreatic duct ligation and Spink1 c.194+2T>C mouse models).

RESULTS

The constructed AAV8-hSPINK1 vector specifically and safely targeted the pancreas, had low organ tropism for the heart, lungs, spleen, liver and kidneys and had a high transduction efficiency (the optimal expression dose was 2×1011 vg/animal). The expression and efficacy of hSPINK1 peaked at 4 weeks after injection and remained at significant level for up to at least 8 weeks. In all three mouse models, a single dose of AAV8-hSPINK1 before disease onset significantly alleviated the severity of pancreatitis, reduced the progression of fibrosis, decreased the levels of apoptosis and autophagy in the pancreas and accelerated the pancreatitis recovery process.

CONCLUSION

One-time injection of AAV8-hSPINK1 safely targets the pancreas with high transduction efficiency and effectively ameliorates pancreatitis phenotypes in mice. This approach is promising for the prevention and treatment of CP.

Revolutionizing the Pancreatic Tumor Diagnosis: Emerging Trends in Imaging Technologies: A Systematic Review

Background and Objectives: The pancreas, ensconced within the abdominal cavity, requires a plethora of sophisticated imaging modalities for its comprehensive evaluation, with ultrasonography serving as a primary investigative technique. A myriad of pancreatic pathologies, encompassing pancreatic neoplasia and a spectrum of inflammatory diseases, are detectable through these imaging strategies. Nevertheless, the intricate anatomical confluence and the pancreas's deep-seated topography render the visualization and accurate diagnosis of its pathologies a formidable endeavor. The objective of our paper is to review the best diagnostic imagistic tools for the pancreas. Materials and Methods: we have gathered several articles using Prisma guidelines to determine the best imagistic methods. The imperative of pancreatic scanning transcends its diagnostic utility, proving to be a pivotal element in a multitude of clinical specialties, notably surgical oncology. Within this domain, multidetector computed tomography (MDCT) of the pancreas holds the distinction of being the paramount imaging modality, endorsed for its unrivaled capacity to delineate the staging and progression of pancreatic carcinoma. In synergy with MDCT, there has been a notable advent of avant-garde imaging techniques in recent years. These advanced methodologies, including ultrasonography, endoscopic ultrasonography, contrast-enhanced ultrasonography, and magnetic resonance imaging (MRI) conjoined with magnetic resonance cholangiopancreatography (MRCP), have broadened the horizon of tumor characterization, offering unparalleled depth and precision in oncological assessment. Other emerging diagnostic techniques, such as elastography, also hold a lot of potential and promise for the future of pancreatic imaging. Fine needle aspiration (FNA) is a quick, minimally invasive procedure to evaluate lumps using a thin needle to extract tissue for analysis. It is less invasive than surgical biopsies and usually performed as an outpatient with quick recovery. Its accuracy depends on sample quality, and the risks include minimal bleeding or discomfort. Results, guiding further treatment, are typically available within a week. Elastography is a non-invasive medical imaging technique that maps the elastic properties and stiffness of soft tissue. This method, often used in conjunction with ultrasound or MRI, helps differentiate between hard and soft areas in tissue, providing valuable diagnostic information. It is particularly useful for assessing liver fibrosis, thyroid nodules, breast lumps, and musculoskeletal conditions. The technique is painless and involves applying gentle pressure to the area being examined. The resulting images show tissue stiffness, indicating potential abnormalities. Elastography is advantageous for its ability to detect diseases in early stages and monitor treatment effectiveness. The procedure is quick, safe, and requires no special preparation, with results typically available immediately. Results: The assembled and gathered data shows the efficacy of various techniques in discerning the nature and extent of neoplastic lesions within the pancreas. Conclusions: The most common imaging modalities currently used in diagnosing pancreatic neoplasms are multidetector computed tomography (MDCT), endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI), alongside new technologies, such as elastography.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Methods of pancreatic fibrosis assessment

Objective. This review provides an in-depth analysis of the current landscape in assessing pancreatic fibrosis. Key points. Pancreatic fibrosis is a common feature in various diseases, including inflammatory and neoplastic conditions, exacerbating their progression. Timely identification of fibrotic changes in pancreatic tissue plays a crucial role in halting or slowing down the advancement of glandular damage. Evaluation methods for fibrosis encompass both invasive and non-invasive approaches. Histological assessment remains the most dependable method for gauging the extent of pancreatic fibrosis. Among the numerous scales for the morphological assessment of pancreatic fibrosis, the system proposed by G. Kloppel, B. Maillet, which evaluates peri- and intralobular fibrosis along with an integrative index, currently stands out as the most applicable for research purposes. In the pursuit of novel non-invasive diagnostic methods for pancreatic tissue fibrosis, researchers are actively developing laboratory biomarkers such as matrix metalloproteinases and specific blood cytokines, as well as instrumental techniques like ultrasound, computed tomography, and magnetic resonance imaging. Conclusion. Each method possesses unique capabilities and limitations associated with the patient’s condition, the prevalence of the fibrotic process, and the presence of comorbidities. The most effective approach involves the integrated use of data obtained from an objective assessment of pancreatic tissue fibrosis. Notably, there is a current lack of standardized scales for the reproducibility of laboratory, instrumental and histological systems in assessing pancreatic fibrosis.

Exocrine pancreatic insufficiency and pancreatic exocrine replacement therapy in clinical practice

Exocrine pancreatic insufficiency (EPI) is a complex condition that disrupts normal digestion and absorption. Patients with EPI may suffer from mild to debilitating malabsorption with a constellation of symptoms that can have a significant effect on quality of life and nutrition status. Pancreatic enzyme replacement therapy (PERT) is effective and safe to treat EPI and is the standard of care for this condition. A wide variety and various forms of these products exist, as well as numerous guidelines and recommendations. Obtaining PERT for patients can oftentimes be cost prohibitive. Determining the presence and extent of EPI can be challenging and patient specific, making it difficult for practitioners. This narrative review will explore these issues, as well as several disease states potentially affected by EPI, and review current management strategies.

Chronic pancreatitis: Pain and computed tomography/magnetic resonance imaging findings

Chronic pancreatitis (CP) is a fibroinflammatory disease characterized by irreversible destruction of pancreatic tissue. With the development of the disease, it may lead to exocrine and/or endocrine insufficiency. CP is one of the common diseases that cause abdominal pain, which will not get permanent spontaneous relief as the disease evolves. The American College of Gastroenterology clinical guidelines recommend computed tomography or magnetic resonance imaging as the first-line examination for the diagnosis of CP. CP common imaging findings include pancreatic atrophy, irregular dilatation of the pancreatic duct, calcification of pancreatic parenchyma, pancreatic duct stones, etc. In clinical practice, whether any correlations between CP-induced abdominal pain patterns (no pain/constant/intermittent pain) and corresponding imaging findings present are not well known. Therefore, this review aims to comprehensively sort out and analyze the relevant information by collecting lots of literature on this field, so as to construct a cross-bridge between the clinical manifestations and imaging manifestations of CP patients. Also, it provides an imaging basis and foundation for the classification and diagnosis of abdominal pain types in clinical CP patients.

EVALUATING LACTOFERRIN AND CALPROTECTIN AS MARKERS OF INTESTINAL INFLAMMATION INCHRONIC PANCREATITIS

BACKGROUND

The treatment of chronic pancreatitis does not consistently solve intestinal abnormalities, and despite the implementation of various therapeutic measures, patients often continue to experience persistent diarrhea. Therefore, it is imperative to recognize that diarrhea may stem from factors beyond pancreatic insufficiency, and intestinal inflammation emerges as a potential contributing factor.

OBJECTIVE

The aim of this study was to assess fecal lactoferrin and calprotectin levels as indicators of intestinal inflammation in patients with chronic pancreatitis experiencing persistent diarrhea.

METHODS

In this study, 23 male patients with chronic pancreatitis primarily attributed to alcohol consumption and presenting with diarrhea (classified as Bristol stool scale type 6 or 7), underwent a comprehensive evaluation of their clinical and nutritional status. Fecal lactoferrin and calprotectin levels were mea-sured utilizing immunoassay techniques.

RESULTS

The average age of the participants was 54.8 years, 43.5% had diabetes, and 73.9% were smokers. Despite receiving enzyme replacement therapy and refraining from alcohol for over 4 years, all participants exhibited persistent diarrhea, accompanied by elevated calprotectin and lactoferrin levels indicative of ongoing intestinal inflammation.

CONCLUSION

The findings of this study underscore that intestinal inflammation, as evidenced by elevated fecal biomarkers calprotectin and lactoferrin, may contribute to explaining the persistence of diarrhea in patients with chronic pancreatitis.

BACKGROUND

• Exploration of intestinal inflammation in chronic pancreatitis patients with altered bowel habits.

BACKGROUND

• Assessment of 23 patients using lactoferrin and calprotectin as intestinal inflammation biomarkers.

BACKGROUND

• Intestinal inflammation was detected in all patients; positive correlation between both biomarkers.

BACKGROUND

• Established connection between altered bowel habits and intestinal inflammation in chronic pancreatitis.

Management of chronic pancreatitis

Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.

Management of chronic pancreatitis: recent advances and future prospects

As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.

Does Chronic Pancreatitis in Growing Pigs Lead to Articular Cartilage Degradation and Alterations in Subchondral Bone?

Chronic pancreatitis (CP), a progressive inflammatory disease, poses diagnostic challenges due to its initially asymptomatic nature. While CP's impact on exocrine and endocrine functions is well-recognized, its potential influence on other body systems, particularly in young individuals, remains underexplored. This study investigates the hypothesis that CP in growing pigs leads to alterations in articular cartilage and subchondral bone, potentially contributing to osteoarthritis (OA) development. Utilizing a pig model of cerulein-induced CP, we examined the structural and compositional changes in subchondral bone, articular cartilage, and synovial fluid. Histological analyses, including Picrosirius Red and Safranin-O staining, were employed alongside immuno-histochemistry and Western blotting techniques. Our findings reveal significant changes in the subchondral bone, including reduced bone volume and alterations in collagen fiber composition. Articular cartilage in CP pigs exhibited decreased proteoglycan content and alterations in key proteins such as MMP-13 and TGF-β1, indicative of early cartilage degradation. These changes suggest a link between CP and musculoskeletal alterations, underscoring the need for further research into CP's systemic effects. Our study provides foundational insights into the relationship between CP and skeletal health, potentially guiding future pediatric healthcare strategies for early CP diagnosis and management.

Opportunistic screening for osteopathy with routine abdominal computed tomography scan in chronic pancreatitis

BACKGROUND AND AIMS

Lumbar vertebral bone attenuation, measured in Hounsfield units (HU) can indirectly indicate the bone mineral density (BMD). The aim of this study is to determine the optimal HU threshold on abdominal computed tomography (CT) scans to detect osteopathy in patients with chronic pancreatitis (CP).

METHODS

This cross-sectional study included patients with CP who underwent CT scans to measure HU at L1 to L4 vertebrae. The mean lumbar vertebral attenuation of female renal transplant donors, aged 20-30 years was utilized to calculate the T-scoreHU of all patients at each vertebral level. Receiver operator characteristic analysis was used to determine the HU and T-scoreHU for diagnosis of osteopathy in patients with CP. Dual-energy X-ray absorptiometry value was used to categorize osteopenia and osteoporosis.

RESULTS

A total of 175 patients (mean age, 34.5 ± 10.9 years; 72 % males) and 33 female renal transplant donors (mean age, 28 ± 2.4 years) were included. A threshold HU value 212 or T scoreHU of -1.80 at L1 vertebra was found to have a 78 % sensitivity and 70 % specificity for differentiating between osteoporosis and non-osteoporosis (osteopenia and normal BMD). Similarly, a threshold HU value of 254 or a T-scoreHU of -0.46 at L1 vertebra had 78 % sensitivity and 71 % specificity for distinguishing between normal and low BMD (osteoporosis and osteopenia).

CONCLUSION

Abdominal CT images, which are routinely performed in chronic pancreatitis, can be used for opportunistic screening of osteoporosis and osteopenia without additional cost or radiation exposure.