Micronutrient antioxidant status in tropical compared with temperate-zone chronic pancreatitis

Fibrocalculous pancreatic diabetes

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes reported from tropical countries, associated with both endocrine and exocrine disease of the pancreas. The pre-diabetic phase of the disease is called tropical chronic pancreatitis (TCP). Currently FCPD is classified as a secondary form of diabetes called pancreatic diabetes, because essentially the disease is caused by pancreatic damage. There is an overlap of these subjects with idiopathic, non-alcoholic pancreatitis. This review will cover the etiopathogenesis, diagnosis and management of this clinical condition. FCPD could lead to endocrine dysfunction (diabetes and its complications) as well as exocrine dysfunction, and is associated with a higher risk of pancreatic cancer, for which early detection is important.

Nutrition and Inflammatory Biomarkers in Chronic Pancreatitis Patients

BACKGROUND

Chronic pancreatitis (CP) patients frequently experience malabsorption and maldigestion, leading to micronutrient and macronutrient deficiencies. Comorbid diabetes and lifestyle habits, such as alcohol consumption, may impact nutrition status.

METHODS

We compared micronutrient antioxidant, bone metabolism, serum protein, and inflammatory marker levels in 301 CP patients and 266 controls with no known pancreatic disease. We analyzed serum prealbumin and retinol binding protein; vitamins A, D, E, and B12; osteocalcin; tumor necrosis factor-α; and C-reactive protein (CRP). We also evaluated biomarkers among subsets of patients, examining factors including time since diagnosis, body mass index, alcohol as primary etiology, diabetes mellitus, vitamin supplementation, and pancreatic enzyme replacement.

RESULTS

After correcting for multiple comparisons, CP patients had significantly lower levels than controls of the following: vitamin A (40.9 vs 45.4 μg/dL) and vitamin E (α-tocopherol [8.7 vs 10.3 mg/L] and γ-tocopherol [1.8 vs 2.2 mg/L]), as well as osteocalcin (7.9 vs 10 ng/mL) and serum prealbumin (23 vs 27 mg/dL). Both patients and controls who took vitamin supplements had higher serum levels of vitamins than those not taking supplements. Compared with controls, in controlled analyses, CP patients had significantly lower levels of vitamins A, D, and E (both α-tocopherol and γ-tocopherol). CP patients also had significantly lower levels of osteocalcin, serum prealbumin, and retinol binding protein, and higher CRP.

CONCLUSIONS

CP patients demonstrated lower levels of selected nutrition and bone metabolism biomarkers than controls. Diabetes and alcohol did not impact biomarkers. Vitamin supplements and pancreatic enzyme replacement therapy improved nutrition biomarkers in CP patients.

A comparative study of the clinical profile of fibrocalculous pancreatic diabetes and type 2 diabetes mellitus

AIMS

The present study aimed to compare the clinical characteristics of patients with fibrocalculous pancreatic diabetes (FCPD) and those with type 2 diabetes mellitus (T2DM) to identify the characteristics distinctive of FCPD.

METHODS

A total of 133 patients with FCPD were compared with 665 patients with T2DM matched for duration of diabetes. Biochemical parameters and microvascular and macrovascular complications were assessed in all patients. Multivariate regression analyses were performed to study the determinants of microvascular and macrovascular complications in both groups.

RESULTS

The mean duration of diabetes was 4.42 ± 5.65 years in the FCPD group and 4.51 ± 3.88 years in the T2DM group. FCPD participants were significantly younger at diagnosis and leaner than patients with T2DM. The FCPD group had higher fasting and postprandial glucose and HbA1c levels than the T2DM group. The FCPD group had significantly lower triglyceride, total cholesterol, low-density lipoprotein cholesterol, serum total calcium, hemoglobin, and serum creatinine values than the T2DM group. The prevalence of coronary artery disease, stroke, and retinopathy was significantly higher in the T2DM patients while the prevalence of distal symmetric polyneuropathy was significantly lower. On multivariate logistic regression analysis, duration of diabetes and HbA1c (OR = 1.17, P = 0 0.04) in FCPD patients and age (OR = 1.04, P < 0 0.001), duration of diabetes (OR = 1.17, P < 0 0.001) and HbA1c (OR = 1.28, P < 0.001) in T2DM patients were associated with microvascular complications.

CONCLUSIONS

There are several differences in the phenotype, biochemical parameters, and prevalence of diabetic complications between patients with FCPD and T2DM. Timely diagnosis may have implications in the follow-up and management of patients.

Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group

OBJECTIVES

Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed.

METHODS

This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified.

RESULTS AND DISCUSSION

The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies.

CONCLUSIONS

This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.

Guidelines for the understanding and management of pain in chronic pancreatitis

Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.

[Nutritional status in patients with chronic pancreatitis]

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas, accompanied by damage to the functioning parenchyma and ducts to develop irreversible structural changes (fibrosis, calcification) and irreparable loss of the endocrine and exocrine functions of this organ. Maldigestion is a typical outcome of CP of any etiology with a long-term history. Fat malabsorption is considered as a basis for malnutrition in patients with CP. The severity of malnutrition in patients with CP correlates with three major pathogenetic factors: primary nutrient deficiency, pancreatic maldigestion and secondary malabsorption syndrome (nutrient loss), hypermetabolism that is caused by an inflammatory process in the pancreas and that determines the severity of the disease. Malnutrition in patients with CP is not just a complication of this disease, but has an important impact on its course. Patients with severe malnutrition are noted to have the significantly lower activity of pancreatic enzymes in the duodenal contents, feces, and blood, which is correlated with the smaller blood amount of total protein and albumin.

Fibrocalculous pancreatic diabetes in adult

Fibrocalculous pancreatic diabetes has distinctive features like younger age at onset, presence of large intraductal calculi, aggressive course of the disease, and proneness for pancreatic cancer. Pancreatic calculi are the hallmark for the diagnosis. We report a 32-year-old male patient, a known case of diabetes since 2 years, presented with recurrent pain abdomen, malabsorption, and neuropathic symptoms. The diagnosis was established on the basis of clinical examination, biochemical and radiological investigations. He was prescribed two doses of premix insulin and pancreatic enzyme supplements for relief of abdominal pain and steatorrhea.

Emerging concepts in the pathogenesis of diabetes in fibrocalculous pancreatic diabetes

Fibrocalcific pancreatic diabetes (FCPD) is a rare form of diabetes affecting people in the tropics and presenting with unique clinical and radiological features. The onset of diabetes usually follows the first few episodes of abdominal pain and develops by the second or third decade of life. Endocrine and exocrine pancreatic insufficiency, brittle glycemic control, and insulin-requiring, ketosis-resistant diabetes are the novel characteristics of FCPD. The etiopathogenetic mechanisms leading to FCPD remain unknown. Although defects in insulin secretion are the major contributors, growing evidence towards a possible role for insulin resistance and body composition abnormalities have added a new dimension to the disease pathogenesis. Deciphering the key pathogenetic mechanisms may have a profound effect on therapeutic strategies in future studies on FCPD.

Fibrocalculous pancreatic diabetes (FCPD)

Fibrocalculous pancreatic diabetes (FCPD) is an uncommon form of diabetes that occurs as a result of chronic calcific pancreatitis, in the absence of alcohol abuse. The disease is restricted to tropical regions of the world, and southern India has the highest known prevalence of FCPD. The typical patient with FCPD is a lean adolescent or young adult of either sex, presenting with history of recurrent bouts of abdominal pain and steatorrhea. Demonstration of large, discrete pancreatic calculi by plain radiographs or ultrasonography of the abdomen is diagnostic. While the exact etiology of FCPD is unknown, genetic, nutritional and inflammatory factors have been hypothesized to play a role. Diabetes in FCPD is often brittle and difficult to control; most patients require multiple doses of insulin for control of glycemia. However, in spite of high blood glucose levels, patients rarely develop ketosis. Malabsorption responds to pancreatic enzyme supplementation. Surgical removal of stones is indicated for symptomatic relief of intractable pain. While patients with FCPD develop microvascular complications as frequently as those with type 2 diabetes, macrovascular disease is uncommon. Development of pancreatic malignancy is the most dreaded complication and should be suspected in any patient who complains of weight loss, back pain or jaundice.

Genetic and phenotypic heterogeneity in tropical calcific pancreatitis

Tropical calcific pancreatitis (TCP) is a form of chronic non-alcoholic pancreatitis initially reported in the developing parts of the tropical world. The clinical phenotype of TCP has undergone marked changes since its first description in 1968. The disease is now seen in relatively older people with less severe symptoms. In addition, there are varying reports on the proportion of cases presenting with imaging abnormalities like calcification, ductal dilation, and glandular atrophy. Significant progress has also been made in understanding the etiopathology of TCP. The role of malnutrition and cassava toxicity in its pathogenesis is disproven and few studies have focused on the role of micronutrient deficiency and oxidative stress in the etiopathogenesis of TCP. Emerging evidence support an important role for genetic risk factors in TCP. Several studies have shown that, rather than mutations in trypsinogens, variants in serine protease inhibitor kazal type 1, cathepsin B, chymotrypsin C, cystic fibrosis transmembrane regulator, and carboxypeptidase A1, predict risk of TCP. These studies also provided evidence of mutational heterogeneity between TCP and chronic pancreatitis in Western populations. The current review summarizes recent advances that have implications in the understanding of the pathophysiology and thus, heterogeneity in genotype-phenotype correlations in TCP.

Oxidative stress in chronic pancreatitis: pathophysiological relevance and management

SIGNIFICANCE

Chronic pancreatitis (CP) is a progressive, inflammatory disease of the pancreas leading to slow destruction of pancreatic parenchyma and progressive fibrosis. The pathophysiological mechanism of CP is not well understood.

RECENT ADVANCES

A pathophysiologic role of oxidative stress in CP has, however, been suggested in recent years. Pancreatic acinar cells contain phase I cytochrome P450 (CYP 450) biotransforming enzymes and phase II conjugation reactions for the metabolism of xenobiotics. The oxidative stress in the acinar cell may result from generation of free radicals through CYP induction, concurrent exposure to a chemical that undergoes bioactivation, and insufficiency of micronutrients that are required to sustain antioxidant (AO) capacity.

CRITICAL ISSUES

Studies have shown that there is indeed a state of oxidative stress as evidenced by increased levels of products of oxidative stress and reduced AO capacity in patients with CP. A recent randomized, controlled trial has shown beneficial effect of AO therapy in CP; a combination of AOs (0.54 g ascorbic acid, 9000 IU β-carotene, 270 IU α-tocopherol, 600 μg organic selenium, and 2 g methionine per day in divided doses) led to significant reductions in pain and oxidative stress in patients with CP.

FUTURE DIRECTIONS

Similar studies from other centers and multicenter studies should confirm that oxidative stress plays an important role in the pathophysiology of CP and supplementation with AOs leads to significant pain relief in patients with this disease.

The complex exocrine-endocrine relationship and secondary diabetes in exocrine pancreatic disorders

The pancreas is a dual organ with exocrine and endocrine functions. The interrelationship of the endocrine-exocrine parts of the pancreas is a complex one, but recent clinical and experimental studies have expanded our knowledge. Many disorders primarily of the exocrine pancreas, often solely in the clinical realm of gastroenterologists are associated with diabetes mellitus (DM). Although, the DM becoming disorders are often grouped with type 2 diabetes, the pathogenesis, clinical manifestations and management differ. We review here data on the association of exocrine-endocrine pancreas, the many hormones of the pancreas and their possible effects on the exocrine functions followed by data on the epidemiology, pathogenesis, and management of DM in chronic pancreatitis, cystic fibrosis, pancreatic cancer, and clinical states after pancreatic surgery.

Inhibitory mechanism of lycopene on cytokine expression in experimental pancreatitis

Reactive oxygen species (ROS) are important mediators to induce pancreatitis. Serum levels of antioxidant enzymes and carotenoids including lycopene are lower in patients with pancreatitis than those of healthy subjects. The cholecystokinin (CCK) analog cerulein induces similar pathologic events as shown in human pancreatitis. Recent studies show that high doses of cerulein activate NF-κB and induce the expression of inflammatory cytokines, in pancreatic acinar cells, which is mediated by the activation of NADPH oxidase. Lycopene functions as a very potent antioxidant to suppress the induction of inflammatory cytokines, in pancreatic acinar cells stimulated with cerulein. In this review, the possible beneficial effect of lycopene on experimental pancreatitis shall be discussed based on its antioxidant activity.

Assessment of oxidative status in chronic pancreatitis and its relation with zinc status

BACKGROUND

Oxidative stress-induced free radicals have been implicated in the pathology of chronic pancreatitis (CP).

AIM

We aimed to estimate oxidative stress and antioxidant status in tropical chronic pancreatitis (TCP) and alcoholic chronic pancreatitis (ACP) and correlate with zinc status.

METHODS

One hundred and seventy-five CP patients (91 TCP, 84 ACP) and 113 healthy subjects were prospectively studied. Disease characteristics and imaging features were recorded. Erythrocyte reduced glutathione, glutathione peroxidase (GPx), superoxide dismutase (SOD), plasma vitamin C, and erythrocyte thiobarbituric acid reactive substance (TBARS) were estimated by spectrophotometry. Erythrocyte zinc was estimated by flame atomic absorption spectrophotometry.

RESULTS

Enhanced lipid peroxidation with concomitant decrease in antioxidant status was observed in both TCP and ACP patients (p < 0.05). The findings were comparable in both diabetic and non-diabetic CP patients. Significantly, lower plasma vitamin C and elevated levels of erythrocyte TBARS was noted in TCP as compared to ACP patients. The erythrocyte zinc significantly correlated with SOD activity (r = 0.450, p < 0.001).

CONCLUSIONS

Our study corroborates the role of oxidative stress in CP and suggests some differences in oxidative status in TCP and ACP patients. Zinc deficiency appears to affect oxidative status in CP patients.

Quality of life assessment in patients with chronic pancreatitis receiving antioxidant therapy

AIM: To undertake a baseline study comparing quality of life (QoL) in patients with chronic pancreatitis (CP) on Antox to those with CP, matched for disease duration, who were not on this medication.

METHODS: CP was defined according to the Zurich classification. Sixty eight consecutive patients with CP who were taking Antox (antioxidants) were compared with 69 consecutive control CP patients not on Antox. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core questions 30 and Pancreatic Modification (28 questions) were used to assess QoL. Out of a total of 137 patients 28 in each group were matched for disease duration (within 12 mo). Median disease duration was 8 (1-22) years in the Antox group and 7 (1-23) years in the Non-Antox cohort (P = NS, Mann-Whitney U-test). Other parameters (age, gender, etiology, endocrine and exocrine insufficiency) were similar between groups.

RESULTS: Median visual analogue pain score in the Antox group was 3 (0-8) compared with 6 (0-8) in the Non-Antox group (P < 0.01). Perceptions of cognitive, emotional, social, physical and role function were impaired in the Non-Antox group compared to Antox patients (P < 0.0001, P = 0.0007, P = 0.0032 and P < 0.005 and P < 0.001, respectively). Analgesics and opiate usage was significantly lower in the Antox group (P < 0.01). Overall physical health and global QoL was better in the Antox group (P < 0.0001, 95% CI: 1.5-3).

CONCLUSION: Contemporary quality of life assessments show that after correction for disease duration and cigarette smoking, patients with CP taking antox had better scores than non-antox controls.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the last year.

RECENT FINDINGS

Cholecystokinin-stimulated endoscopic pancreatic function testing has low specificity for diagnosis of early chronic pancreatitis, likely because of correctable technical limitations or failure to exclude confounding diseases. Fecal elastase 1 is a poor test for diagnosing pancreatic malabsorption. A 2-week trial of corticosteroids may differentiate autoimmune pancreatitis (AIP) from pancreatic cancer in select patients. A genetic screen may help to predict relapse of AIP. Repeated, 6-month visits to counsel against alcohol use may reduce recurrent attacks of alcoholic pancreatitis. A five-component antioxidant cocktail may reduce the frequency of pain in chronic pancreatitis by 1.5 days per month.

SUMMARY

Researchers this last year have further characterized clinical aspects of chronic pancreatitis that may lead to improved detection of early chronic pancreatitis and AIP, risk stratification and application of risk-lowering strategies to prevent relapses in AIP or the development of recurrent (and possibly chronic) alcoholic pancreatitis and new evidence that antioxidants may have a modest effect on reducing the dominant symptom in chronic pancreatitis, abdominal pain.

A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis

BACKGROUND & AIMS

Oxidative stress has been implicated in the pathophysiology of chronic pancreatitis (CP). We evaluated the effects of antioxidant supplementation on pain relief, oxidative stress, and antioxidant status in patients with CP.

METHODS

In a placebo-controlled double blind trial, consecutive patients with CP were randomized to groups that were given placebo or antioxidants for 6 months. The primary outcome measure was pain relief, and secondary outcome measures were analgesic requirements, hospitalization, and markers of oxidative stress (thiobarbituric acid-reactive substances [TBARS]) and antioxidant status (ferric-reducing ability of plasma [FRAP]).

RESULTS

Patients (age 30.5+/-10.5 years, 86 male, 35 alcoholic, and 92 with idiopathic CP) were assigned to the placebo (n=56) or antioxidant groups (n=71). After 6 months, the reduction in the number of painful days per month was significantly higher in the antioxidant group compared with the placebo group (7.4+/-6.8 vs 3.2+/-4, respectively; P< .001; 95% CI, 2.07, 6.23). The reduction in the number of analgesic tablets per month was also higher in the antioxidant group (10.5+/-11.8 vs 4.4+/-5.8 respectively; P= .001; 95% CI, 2.65, 9.65). Furthermore, 32% and 13% of patients became pain free in the antioxidant and placebo groups, respectively (P= .009). The reduction in the level of TBARS and increase in FRAP were significantly higher in the antioxidant group compared with the placebo group (TBARS: placebo 1.2+/-2.7 vs antioxidant 3.5+/-3.4 nmol/mL; P= .001; 95% CI 0.96, 3.55; FRAP: placebo -5.6+/-154.9 vs antioxidant 97.8+/-134.9 microMFe(+2) liberated, P= .001, 95% CI 44.98, 161.7).

CONCLUSIONS

Antioxidant supplementation was effective in relieving pain and reducing levels of oxidative stress in patients with CP.

Molecular mechanisms of pancreatitis: current opinion

Pancreatitis (necroinflammation of the pancreas) has both acute and chronic manifestations. Gallstones are the major cause of acute pancreatitis, whereas alcohol is associated with acute as well as chronic forms of the disease. Cases of true idiopathic pancreatitis are steadily diminishing as more genetic causes of the disease are discovered. The pathogenesis of acute pancreatitis has been extensively investigated over the past four decades; the general current consensus is that the injury is initiated within pancreatic acinar cells subsequent to premature intracellular activation of digestive enzymes. Repeated attacks of acute pancreatitis have the potential to evolve into chronic disease characterized by fibrosis and loss of pancreatic function. Our knowledge of the process of scarring has advanced considerably with the isolation and study of pancreatic stellate cells, now established as the key cells in pancreatic fibrogenesis. The present review summarizes recent developments in the field particularly with respect to the progress made in unraveling the molecular mechanisms of acute and chronic pancreatic injury secondary to gallstones, alcohol and genetic factors. It is anticipated that continued research in the area will lead to the identification and characterization of molecular pathways that may be therapeutically targeted to prevent/inhibit the initiation and progression of the disease.

Cause and effect relationship of malnutrition with idiopathic chronic pancreatitis: prospective case-control study

BACKGROUND AND AIM

Patients with chronic pancreatitis are often malnourished. The role of malnutrition in the pathogenesis of chronic pancreatitis is unclear. The aim of the present article was to study prospectively the cause and effect relationship of malnutrition with idiopathic chronic pancreatitis in a case-control study.

METHODS

Consecutive patients with chronic pancreatitis underwent anthropometry, nutritional and dietary assessments. For dietary assessment, food frequency questionnaire and 24-hour dietary recall methods were used. Primary outcome measure was cause and effect relationship of malnutrition with idiopathic chronic pancreatitis.

RESULTS

Of 201 patients with chronic pancreatitis, 120 had idiopathic chronic pancreatitis (mean age 29.60 years, 74 males) who formed the study group. None of the patients consumed cassava. The nutritional status and dietary intake of the patients before the onset of chronic pancreatitis were comparable with those of controls with 20.6% of patients and 22.5% of controls being malnourished (body mass index [BMI] < 18.5). After the onset of chronic pancreatitis, 56.5% of patients lost weight and significantly more patients became malnourished compared with controls (45.8% vs 22.5%; P < 0.001). The causes of weight loss were diabetes, higher calories from proteins, and pseudocyst.

CONCLUSION

Malnutrition was not a cause of idiopathic chronic pancreatitis and weight loss occurred as an effect of chronic pancreatitis. Cassava was not found to be a cause of idiopathic chronic pancreatitis.

Dietary counseling versus dietary supplements for malnutrition in chronic pancreatitis: a randomized controlled trial

BACKGROUND & AIMS

Up to 50% of patients with chronic pancreatitis (CP) are malnourished. There are limited data on the role of dietary intervention in improving the nutritional status of such patients. The aim was to compare the efficacy of medium chain triglyceride (MCT)-enriched commercial dietary supplements with dietary counseling for homemade food in the management of malnutrition in patients with CP.

METHODS

In a randomized controlled trial, consecutive undernourished patients with CP (body mass index [BMI] <18.5 kg/m(2)) at a tertiary care hospital were randomized to receive either dietary counseling for regular homemade food or commercial MCT-enriched dietary supplements for a period of 3 months to compensate for the dietary calorie deficit. All patients received standard management for CP including pancreatic enzyme supplements. Primary outcome measure was improvement in BMI.

RESULTS

Sixty malnourished patients with CP were randomized to counseling group (n = 29; mean age, 32 +/- 10 years; male, 83%) and supplementation group (n = 31; mean age, 28 +/- 10 years; male, 84%). BMI increased in both the counseling group and supplementation group (17.2 +/- 1.7 vs 18.1 +/- 1.8 kg/m(2), P = .001; 16.7 +/- 1.6 vs 18.2 +/- 1.6 kg/m(2), P = .001). There were similar improvements in triceps skinfold thickness, dietary intake, fecal fat, and pain score during a period of 3 months in both groups. There was, however, no significant difference between the counseling and supplementation groups with regard to any of the outcome measures.

CONCLUSIONS

Dietary counseling for a balanced homemade diet is as good as commercial food supplements in improving malnutrition in patients with CP.

Hydrogen sulfide, nitric oxide and a molecular mass 66 u substance in the exhaled breath of chronic pancreatitis patients

BACKGROUND/AIMS

Human exhaled breath contains many molecules either present as gases or occurring in a soluble form in the vapor of the breath. This study was designed to evaluate the substances present in the exhaled breath of chronic pancreatitis (CP) patients.

SUBJECTS

Thirty-one consecutive CP patients (11 with exocrine insufficiency) and 31 healthy subjects (HS) were studied.

METHODS

Ninety-eight different substances were analyzed using a mass spectrometer on a breath sample from all subjects and on each respective ambient air sample.

RESULTS

H(2)S, NO and a substance having a molecular mass of 66 u (M66) were those which had significantly higher concentrations in CP patients than in HS after adjustment for the ambient air; the estimated increases attributable to the disease were 14% (p = 0.040) for H(2)S, 84% (p = 0.006) for M66 and 50% (p = 0.033) for NO, but the three volatile compounds showed poor diagnostic accuracy in differentiating CP patients from HS (AUC-ROC: 0.664, 0.715, and 0.602 for H(2)S, M66, and NO, respectively). Finally, no significant differences of H(2)S, M66, and NO were found between patients with and without alcoholic pancreatitis as well as between patients with and without pancreatic insufficiency.

CONCLUSIONS

Exhaled breath analysis can rapidly and easily assess the presence of volatile compounds (H(2)S, NO and a substance having a molecular mass of 66 u) which may have properties capable of explaining, at least in part, the pathogenesis of CP.

Pain in chronic pancreatitis and pancreatic cancer

Chronic, debilitating abdominal pain is arguably the most important component of chronic pancreatitis, leading to significant morbidity and disability. Attempting to treat this pain, which is too often unsuccessful, is a frustrating experience for physician and patient. Multiple studies to improve understanding of the pathophysiology that causes pain in some patients but not in others have been performed since the most recent reviews on this topic. In addition, new treatment modalities have been developed and evaluated in this population. This review discusses new advances in neuroscience and the study of visceral pain mechanisms, as well as genetic factors that may play a role. Updates of established therapies, as well as new techniques used in addressing pain from chronic pancreatitis, are reviewed. Lastly, outcome measures, which have been highly variable in this field over the years, are addressed.

Juvenile fibrocalculous pancreatopathy--a patient report

Fibrocalculous pancreatopathy (FCPP) is a secondary form of diabetes mellitus (DM) with obscure etiology. Recently various gene mutations have been reported in patients with FCPP from the Indian subcontinent. Initially termed tropical pancreatic diabetes, FCPP is uncommon and is characterized by pancreatic calcifications. The diagnosis is made in the third decade of life in most patients with the onset of abdominal pain and DM. We report a female child with DM diagnosed at the age of 3 years who had been managed with insulin but was ketosis resistant. The diagnosis of FCPP was made 3 years later. There were no mutations at N34S and P55S in the SPINK1 gene.

Tropical chronic pancreatitis

Tropical chronic pancreatitis (TCP) is a juvenile form of chronic calcific non-alcoholic pancreatitis, seen almost exclusively in the developing countries of the tropical world. The classical triad of TCP consists of abdominal pain, steatorrhoea, and diabetes. When diabetes is present, the condition is called fibrocalculous pancreatic diabetes (FCPD) which is thus a later stage of TCP. Some of the distinctive features of TCP are younger age at onset, presence of large intraductal calculi, more aggressive course of the disease, and a high susceptibility to pancreatic cancer. Pancreatic calculi are the hallmark for the diagnosis of TCP and in non-calcific cases ductal dilation on endoscopic retrograde cholangiopancreatography, computed tomography, or ultrasound helps to identify the disease. Diabetes is usually quite severe and of the insulin requiring type, but ketosis is rare. Microvascular complications of diabetes occur as frequently as in type 2 diabetes but macrovascular complications are uncommon. Pancreatic enzyme supplements are used for relief of abdominal pain and reducing the symptoms related to steatorrhoea. Early diagnosis and better control of the endocrine and exocrine dysfunction could help to ensure better survival and improve the prognosis and quality of life of TCP patients.

Comparison of histological features and inflammatory cell reaction in alcoholic, idiopathic and tropical chronic pancreatitis

BACKGROUND

There is increasing evidence that immune mechanisms may be crucial in the development of alcoholic chronic pancreatitis. However, it is not known whether differences in underlying aetiology influence the inflammatory reaction in patients with chronic pancreatitis. The histological features and the pattern of inflammatory cell infiltration were studied in three aetiological forms of chronic pancreatitis: alcoholic, idiopathic and tropical pancreatitis.

METHODS

Forty-three patients, ten with alcoholic, 12 with idiopathic and 21 with tropical chronic pancreatitis, were evaluated for the pattern of pancreatic inflammatory cell infiltration and histological features. Ten organ donors served as controls. Haematoxylin and eosin-stained tissue sections were used for histological evaluation. For immunohistochemical characterization of the inflammatory reaction, four antibodies-CD4, CD8, CD45 and CD68-were used. Quantitative evaluation of the various cell infiltrates was performed with computer-assisted image analysis. The inflammatory cell infiltration pattern was also evaluated.

RESULTS

The degree of endophlebitis and the overall density of plasma cells were greater in tropical than in alcoholic chronic pancreatitis. The grade of intralobular fibrosis was significantly higher in tropical chronic pancreatitis compared with the idiopathic form. No significant quantitative differences in the specific cellular infiltrates (CD4, CD8, CD45, CD68) were observed in the three different groups. However, the perivascular inflammation number score was significantly higher in alcoholic compared with idiopathic pancreatitis (P = 0.037), and the perivascular inflammation area score was significantly lower in idiopathic than in alcoholic (P = 0.024) or tropical (P = 0.020) pancreatitis.

CONCLUSION

Different aetiological forms of chronic pancreatitis result in similar histological features and a comparable inflammatory cell reaction, indicating that the disease, independent of the underlying aetiology, reaches a common immunological stage beyond which it appears to progress as a single distinctive entity.

Tropical pancreatitis

Tropical pancreatitis is a special type of chronic pancreatitis that is seen mainly in tropical countries. The prevalence of tropical pancreatitis is about 126/100,000 population in southern India. It occurs usually in young people, involves the main pancreatic duct and results in large ductal calculi. The etiology is not known, but genetic mutations such as the SPINK1 gene mutation and environmental factors are likely causes. Clinically, >90% of patients present with abdominal pain. About 25% of patients develop diabetes which generally requires insulin for its control but is ketosis-resistant. Painless diabetes is another clinical presentation in some patients. Most patients develop malnutrition during the course of the disease. Steatorrhea is less common. Patients with tropical pancreatitis may develop pancreatic cancer as a long-term complication. The diagnosis can be established by plain radiography of the abdomen, ultrasonography, computerized tomography scan of the abdomen or endoscopic retrograde cholangiopancreatography. Management is directed towards relief from pain and control of diabetes and steatorrhea. Pain relief can be obtained by analgesics and enzyme supplementation with preparations rich in proteases. Endotherapy coupled with stone fragmentation by extracorporeal shock wave lithotripsy is an effective therapy for those who fail to respond to medical therapy. Surgical decompression of the main pancreatic duct by lateral pancreato-jejunostomy is reserved for patients with severe pain non-responsive to other forms of therapy.

Liver, pancreas and biliary tract enhanced lipoperoxidation products in pure pancreatic juice: evidence for organ-specific oxidative stress in chronic pancreatitis

BACKGROUND

Oxygen-free radicalscan play a role in the development of chronic pancreatitis, altering the redox state with damage of cell constituents and decrease in antioxidant defences.

AIMS

To measure levels of lipoperoxidation products, conjugated dienes and lipid hydroperoxides, in pure pancreatic juice and serum of chronic pancreatitis patients and compare them to that in controls. To investigate a possible correlation with serum indexes of pancreatic inflammation (amylase and lipase).

PATIENTS

Pancreatic juice was collected during ERCP, after secretin stimulation, in 20 patients with chronic pancreatitis and 11 controls with biliary diseases.

METHODS

Lipid hydroperoxide levels were determined with FOX2 method and measured as absorbance at 560 nm. Conjugated diene levels were measured using second-derivative spectroscopy.

RESULTS

No substantial difference was present in serum levels of lipid hydroperoxides, conjugated dienes (in both isomeric forms) and isomer-ratio values between those of patients with chronic pancreatitis and controls. In pancreatic juice, there was a significant increase in lipid hydroperoxides and conjugated dienes levels (especially trans-trans isomers) in chronic pancreatitis patients compared with controls, with a decrease in cis-trans isomers and a significant difference in isomer-ratio values.

CONCLUSIONS

Increased levels of lipid hydroperoxides and conjugated dienes in the pancreatic juice of chronic pancreatitis patients is indicative of an enhanced lipoperoxidation and antioxidants consumption in pancreatic tissue, confirmed by the decreased isomer-ratio values as an indirect index of decreased antioxidant capacity. The lack of significant difference in conjugated diene and lipid hydroperoxide levels in the serum of chronic pancreatitis patients versus that of controls suggests an oxidative stress limited to pancreatic tissue and indicative of an organ-specific pathology, confirmed by the parallel behaviour of oxidative parameters (lipid hydroperoxides and conjugated dienes) and indexes of pancreatic inflammation (amylase and lipase).

Tropical chronic pancreatitis: an update

Tropical chronic pancreatitis represents a juvenile nonalcoholic form of chronic pancreatitis prevalent in many tropical developing countries. Tropical chronic pancreatitis differs from temperate zone pancreatitis in its younger age of onset, more accelerated course, higher prevalence of pancreatic calculi and diabetes, and greater propensity to pancreatic malignancy. The diabetic stage of the disease is referred to as fibrocalculous pancreatic diabetes. The diabetes is severe and insulin requiring although ketosis resistant. Diabetic complications occur in fibrocalculous pancreatic diabetes just like in other primary forms of diabetes. The etiology of tropical chronic pancreatitis remains unclear, although malnutrition along with dietary cyanogen toxicity, antioxidant deficiency, and a genetic predisposition have been proposed. In the last few decades, the prognosis has markedly improved as a result of better management of diabetes. Yet a better understanding of the pathogenesis of tropical chronic pancreatitis could further improve treatment options and offer an opportunity for prevention of this disorder, which leads to severe morbidity in a large proportion of affected patients.

Detection of oncogenes in chronic pancreatitis

BACKGROUND

The pathogenesis of chronic pancreatitis (CP) remains poorly understood. Recently, molecular biology has identified the genetic background for many patients with hereditary CP. In addition, a number of studies have focused on the detection of proto-oncogenes and tumour suppressor gene mutations in the pathogenesis of CP. So far, the use of these mutations (with the exception of mutations causing hereditary CP), as diagnostic and prognostic markers is still controversial.

DISCUSSION

It is well known that the risk of pancreatic cancer in patients with CP, especially the hereditary form, is high. At present, there is insufficient evidence to show a clear relationship between the development of pancreatic cancer and certain mutations. New biotechnological methods, such as DNA array expression analysis, expand our knowledge of the molecular pathogenesis of this disease and may help to develop specific diagnostic, prognostic and therapeutic tools. However, until long-term studies examine the safety and efficacy of certain genetic markers, long-term follow-up of patients with CP who harbour mutations is needed.

Tropical pancreatitis

Tropical pancreatitis is an uncommon cause of acute, and often chronic, relapsing pancreatitis. Patients present with abdominal pain, weight loss, pancreatic calcifications, and glucose intolerance or diabetes mellitus. Etiologies include a protein-calorie malnourished state, a variety of exogenous food toxins, pancreatic duct anomalies, and a possible genetic predisposition. Chronic cyanide exposure from the diet may contribute to this disease, seen often in India, Asia, and Africa. The pancreatic duct of these patients often is markedly dilated, and may contain stones, with or without strictures. The risk of ductal carcinoma with this disease is accentuated. Treatment may be frustrating, and may include pancreatic enzymes, duct manipulations at endoscopic retrograde cholangiopancreatography, octreotide, celiac axis blocks for pain control, or surgery via drainage and/or resection.

[Tropical chronic pancreatitis in a young patient]

Tropical chronic pancreatitis is a form of idiopathic chronic pancreatitis that has not previously been described in Spain. Typically it is related to dietary factors and malnutrition, although genetic factors may also play a significant role in the development of the disease. We report a case of chronic tropical pancreatitis in a 27-year-old woman from the Dominican Republic domiciled in Spain since 1992. The patient was admitted to our hospital for acute pancreatitis that fulfilled the diagnostic criteria (clinical and radiological) for chronic tropical pancreatitis. This case has led us to review this uncommon entity. Because of the increasing number of immigrants from tropical countries, chronic tropical pancreatitis will probably need to be taken into account in the differential diagnosis of chronic pancreatitis in our patients.

Increased expression of glutathione S-transferase-pi in the islets of patients with primary chronic pancreatitis but not secondary chronic pancreatitis

The mechanism of tissue alteration in chronic pancreatitis (CP) is still unclear. Different hypotheses have been discussed, including increasing oxidant stress in the acinar cells, often as a result of exposure to xenobiotics. To evaluate the role of oxidative stress in CP, the authors investigated the expression of the drug-metabolizing phase II enzyme, glutathione S-transferase-pi (GST-pi), in the pancreatic tissue of patients with CP and compared it with the healthy pancreatic tissue from age-matched donors. Pancreatic tissue from patients with secondary CP resulting from ductal obstruction by pancreatic cancer (PC) was also examined. The percentage of cells immunoreacting with anti-GST-pi was counted within 15 randomly selected islets in each slide of the three groups. In all specimens, ductal and ductular cells, and in PC, cancer cells, expressed GST-pi in a moderate intensity. Acinar cells did not stain. Various numbers of islet cells in each of the three groups were stained strongly. More islet cells expressed GST-pi in CP (42%) than in healthy pancreatic tissue (16%, p < 0.001) or PC (17%, p < 0.001). Our results imply an important role of islet cells in the metabolism of substances, which are the substrate for GST-pi, and lend support to the hypothesis of oxidative stress as the cause of CP.

Evidence that diabetes mellitus favors impaired metabolism of zinc, copper, and selenium in chronic pancreatitis

Diabetes mellitus, a common complication of chronic pancreatitis, can disturb the metabolism of zinc, copper, and selenium. We analyzed the effects of hyperglycemia, malabsorption, and dietary intake on these factors in 35 men with alcohol-induced chronic pancreatitis complicated by insulin-treated diabetes mellitus (CP-D), 12 men with chronic pancreatitis but no diabetes (nondiabetic CP), 25 men with type 1 diabetes mellitus (type 1 DM), and 20 control subjects. Diabetes due to chronic pancreatitis was associated with decreased plasma zinc and selenium concentrations and with increased urinary copper excretion. Of the chronic pancreatitis patients, 17% had low plasma zinc, and 41% of them had low plasma selenium. None of the type 1 diabetic patients had low plasma concentrations of zinc, but 12% of them had a low selenium concentration. Hyperglycemia, as assessed by fasting plasma glucose and by plasma HbAlc, was responsible for the increased zinc excretion and the decreased superoxide dismutase activity. The perturbations of the copper, selenium, and zinc metabolism were particularly pronounced in subjects with chronic pancreatitis plus diabetes mellitus. We have yet to determine whether the differences in trace-element status contribute to the clinical expression of the disease.

The antioxidant profiles of patients with recurrent acute and chronic pancreatitis

OBJECTIVE

It has been suggested that patients with chronic pancreatitis have antioxidant deficiencies. It is unclear whether these antioxidant deficiencies also occur in patients with recurrent acute pancreatitis and whether this condition represents an intermediate state between normality and chronic pancreatitis. The aim of this study was to determine the antioxidant profiles of patients with pancreatitis (recurrent acute and chronic) and to compare their profiles with a control population.

METHODS

The antioxidant profiles of patients with chronic pancreatitis (n = 27) and recurrent acute pancreatitis (n = 11) were determined and compared with the antioxidant profiles of control subjects (n = 19). The following parameters were measured in blood: trace elements (selenium, copper, zinc), vitamins A and E, and carotenoids (alpha-carotene, beta-carotene, xanthine, beta-cryptoxanthine, lycopene).

RESULTS

Patients with chronic pancreatitis had significantly lower plasma concentrations of selenium, vitamin A, vitamin E, beta-carotene, xanthine, beta-cryptoxanthine, and lycopene compared with both control subjects and patients with recurrent acute pancreatitis (p < 0.05). There were no significant differences between the antioxidant profiles of patients with chronic pancreatitis due to alcohol excess and patients with idiopathic chronic pancreatitis, or between the antioxidant profiles of patients with recurrent acute pancreatitis and control subjects.

CONCLUSIONS

Patients with chronic pancreatitis had evidence of multiple antioxidant deficiencies. The antioxidant profiles of patients with recurrent acute pancreatitis did not differ from those of control subjects, discounting the hypothesis that recurrent acute pancreatitis represents an intermediate state between normality and chronic pancreatitis.

Tropical calcific pancreatitis

Tropical calcific pancreatitis is a special type of chronic pancreatitis that has features quite different from those of alcoholic pancreatitis and is seen almost exclusively in tropical countries. It is characterized by recurrent severe pain in the abdomen, insulin-requiring but ketosis-resistant diabetes and large pancreatic calculi in malnourished male adolescents. The clinical course of tropical calcific pancreatitis is protracted with malnutrition, recurrent infections and poorly controlled diabetes. Pancreatic cancer may complicate the natural course in up to 10% of cases. However, in the community a much milder form of the disease occurs with a female preponderance and a prevalence of 0.13% or one in 793. Malnutrition with deficiency of proteins and micronutrients with antioxidant properties and food-based toxins, such as cassava, which contain cyanogenic glycosides have been suspected as possible aetiological factors. Impaired immune response, a presumed infection (possibly viral) and genetic susceptibility are some of the other factors suspected in the aetiopathogenesis of this disease. Besides controlling diabetes with insulin, relief from pain is obtained by the administration of analgesics and pancreatic enzymes and, in severe cases, by performing endoscopic or surgical decompression of dilated pancreatic ducts with removal of pancreatic calculi.

Nutrient antioxidants in gastrointestinal diseases

Oxidative stress appears to play a role in the pathogenesis of a number of gastrointestinal disease states, including pancreatitis; gastric and duodenal ulcer disease; IBD; gastric, esophageal, and colon cancers; and hepatic injury secondary to alcohol, metal storage disorders, hepatitis, and ischemia/reperfusion injury. The nutritional antioxidants are attractive potential therapeutic and chemopreventive agents because they are inexpensive and have a relatively low toxicity profile. A word of caution should be noted: Some antioxidants, such as vitamin C, can be prooxidant under certain conditions, and systemically altering the redox state may have untoward effects on the inflammatory response in certain disease states. Thus, at the current time, antioxidant therapy should be restricted to randomized, controlled clinical trials, in which treatment effects can be closely monitored, and therapeutic efficacy can be determined with scientific accuracy.

Chronic ethanol administration causes oxidative stress in the rat pancreas

There is increasing evidence implicating oxidative stress in the pathogenesis of both acute and chronic pancreatitis. Because ethanol is a major cause of pancreatitis in Western society, the aim of this study was to determine whether chronic ethanol administration results in oxidative stress in the pancreas. Twelve pairs of rats were fed a diet containing ethanol as 36% of calories or an isocaloric control diet for 4 weeks. Ethanol feeding resulted in a 46% increase in pancreatic malondialdehyde (p=0.006). In addition, total pancreatic glutathione was increased by 22% (p=0.005). These biochemical changes occurred in the absence of histologic evidence of inflammation or necrosis, implying that the observed oxidative stress is a primary phenomenon rather than part of an inflammatory response.

Alcohol and the pancreas

Alcoholic pancreatitis is a major, often lethal complication of alcohol abuse. Until recently it was generally accepted that alcoholic pancreatitis was a chronic disease from the outset. However, there is now emerging evidence in favour of the necrosis-fibrosis hypothesis that alcoholic pancreatitis begins as an acute process and that repeated acute attacks lead to chronic pancreatitis, resulting in exocrine and endocrine failure. Over the past 10-15 years, the focus of research into the pathogenesis of alcoholic pancreatitis has shifted from possible sphincteric and ductular abnormalities to the acinar cell itself which has increasingly been implicated as the initial site of injury. Recent studies have shown that the acinar cell can metabolize alcohol at rates comparable to those observed in hepatocytes. In addition, it has been demonstrated that alcohol and its metabolites exert direct effects on the pancreatic acinar cell which may promote premature digestive enzyme activation and oxidant stress. The challenge remains to identify predisposing and triggering factors in this disease.

A pilot study of antioxidant intake in patients with cholesterol gallstones

Whereas macronutrient intake has been extensively investigated in an attempt to unravel the pathogenesis of human cholesterol gallstones, theoretical considerations and animal models suggest that deficits in micronutrient antioxidants may be more relevant. We report a pilot study of this aspect. The plan was to obtain 7-d weighed food inventories over a 6-mo period from equal numbers of patients who had not consciously changed their diets, patients who were on low-fat diets and age- and gender-matched controls. Food tables would be used to derive daily intakes of 16 known antioxidants, essential amino acids, and essential fatty acids. Under-reporting of food intake, a recognized drawback of this dietary method, would be sought retrospectively by reference to a key publication giving minimum cut-off limits for ratios of energy intakes to basal metabolic rates. There were 18 pairs for study. Analysis of data for the 9 pairs involving patients on their normal diets showed no differences in the intakes of energy macronutrients, and cholesterol, but the patients ingested lower amounts of 10 among 16 antioxidants (P < 0.05 for methionine, alpha-tocopherol, manganese, and vitamin D; 0.05 < P < 0.10 for cysteine, beta-carotene, vitamin C, selenium, zinc, and phosphorus). Both subsets of patients ingested lower amounts of linoleic acid (diet unchanged P = 0.009, changed P = 0.026) and several essential amino acids than did matched controls. Institution of a low-fat diet caused the expected fall in intakes of energy and saturated fatty acids such that the deficit in alpha-tocopherol was amplified, but substitution of fruit and vegetables by the patients resulted in a fortuitous increase in vitamin C, beta-carotene, and manganese intake. Retrospective analysis confirmed under-reporting of food intake by all four subsets of subjects but there was no significant difference in the mean ratio of energy intake to estimated basal metabolic rate in the subset of patients who had not consciously altered their diets and the subset of matched controls. Furthermore, the lower daily intake of alpha-tocopherol and linoleic acid by these patients persisted when results were expressed relative to total fat consumption. The results support the hypothesis that insufficiency of dietary antioxidants, particularly alpha-tocopherol, may be germane to human gallstone disease; they also suggest that low intakes of linoleic acid and essential amino acids may be relevant. Because of the small sample sizes, however, these deductions should be regarded as tentative, pending confirmation by biochemical analysis of blood and especially of hepatic bile.

Deficiency in antioxidant factors in patients with alcohol-related chronic pancreatitis

Free radicals have been suspected to play a role in the pathogenicity of alcohol-related chronic pancreatitis. The aim of this study was to determine the status of several antioxidant parameters in these patients and examine the factors that are likely to influence them. Thirty-five subjects (23 males and 12 females, mean age 48 +/- 8 years) with disease proven by endoscopic pancreatography and 14 healthy controls (6 males and 8 females, mean age 44 +/- 7 years) were included in the study. Biochemical antioxidant parameters included: selenium, zinc, and copper levels in plasma; glutathione peroxidase in plasma and erythrocytes; plasma malondialdehyde concentrations assessed by thiobarbituric acid reactants; and serum vitamin E and A levels. Selenium and vitamin E oral intake was assessed by a five-day diet analysis. Hemoglobin (130 +/- 16 vs 143 +/- 15 g/liter), vitamin E (8 +/- 5 vs 16 +/- 9 mg/liter), vitamin A (30 +/- 11 vs 49 +/- 12 micrograms/dl), selenium (54 +/- 20 vs 87 +/- 11 micrograms/liter), and plasma glutathione peroxidase (903 +/- 313 vs 1326 +/- 168 units/liter) were significantly lower in patients than in controls (P < 0.05). In contrast, white blood cell count, C-reactive protein, and plasma copper levels were significantly higher in patients than in controls. Cholesterol, triglycerides, iron, ferritin, total proteins, zinc, and malondialdehyde were not different. Vitamin E was lower in patients with steatorrhea, while vitamin A was lower in patients with concomitant diabetes mellitus. Dietary intakes were not different between patients and controls. In conclusion, patients with alcohol-related chronic pancreatitis have low blood levels in many antioxidant factors. Dietary intakes of some of them (selenium and vitamin E) are adequate, however. Such deficiencies are secondary to pancreatic insufficiency and probably to increased requirements related to enhanced oxidative stress.

A radical view of gallstone aetiogenesis

It is proposed that gallstones stem from insufficiency of micronutrient antioxidants relative to the load of oxidants and/or oxidation-prone substrates within hepatocytes in such a way that ancillary hepatobiliary resources, including bilirubin with lactoferrin and mucin, are mobilized to combat oxidative stress but inadvertently promote lithogenesis. Aberrant activities of hepatic cytochrome P450 mono-oxygenases and of haem oxygenase are integral to this template, because differential inhibition or activation of these enzymes would help to rationalize the spectrum of human gallstone composition and also the different outcomes when animals are fed the same lithogenic diets. The hypothesis is based on a decade of work on another lithogenic disease, chronic pancreatitis. It accommodates observations on human and experimental gallstones, it is testable and, as shown by studies of chronic pancreatitis, has implications for primary disease prevention.

Toward an animal model of chronic pancreatitis. Pancreatobiliary secretion in hamsters on long-term treatment with chemical inducers of cytochromes P450

There is currently no reproducible model of the painful and lithogenic disease, chronic pancreatitis. Its biphasic evolution, from acinar cell hyperplasia and hyperactivity toward effacement of enzyme as well as bicarbonate secretory parenchyma, would be rationalized if it was linked to induction of cytochrome P450 mono-oxygenases (CYP): the increased oxidant load from long-term CYP induction eventually erodes micronutrient antioxidant defenses to injure cells. This philosophy would also rationalize the reported hepatobiliary aberrations associated with the human disease, including increases in free radical oxidation products in bile. Accordingly, pancreatic and biliary secretions were studied in Syrian golden hamsters that were reared for 6 mo on low or high (16% corn oil) fat diets that were supplemented with a prototype inducer of CYP2 (200 ppm phenobarbitone) or CYP1 (100 ppm beta naphthoflavone) enzyme families, with or without a putative enzyme inhibitor (400 ppm cimetidine). The drugs did not alter the reduction in flow rate or bicarbonate concentration of pancreatic juice caused by the high fat diet alone, but, in contrast, evoked pancreatic protein hypersecretion in a number of animals. beta naphthoflavone, but not phenobarbitone, augmented the output of biliary lipid peroxidation products irrespective of dietary fat content, and cimetidine cotreatment with either inducer did the same. We conclude: (1) that drug modifiers of CYP magnify the deleterious pancreatobiliary effects of corn oil-enriched diets and draw them closer to those found in human chronic pancreatitis; (2) that these functional derangements are accompanied by pancreatic lipoatrophy; and (3) that long-term CYP induction does not, of its own, cause fibrosis or the ductal abnormalities that generally accompany loss of pancreatic acinar cells in the human disease and, also in contrast, the changes that are caused appear to be painless.

Micronutrient antioxidant status in black South Africans with chronic pancreatitis: opportunity for prophylaxis

Biochemical assessments of micronutrient antioxidant status were done in 14 consecutive black patients with calcific chronic pancreatitis and 15 controls at Soweto, near Johannesburg in southern Africa. The patients showed subnormal levels of vitamin C in plasma; selenium, beta-carotene and alpha-tocopherol in serum; and inorganic sulphate (as an index of long-term sulphur amino acid intake) in urine (P < 0.001 for each): furthermore, among the patients ascorbate constituted a lower fraction of vitamin C (P < 0.002), indicating heightened oxidation of the bioactive form. By comparing the results in Sowetan controls with reference ranges from Manchester, UK, the markedly lower vitamin C and, hence, ascorbate levels in the Sowetans was underlined (P < 0.001) and their selenium levels were also lower (P < 0.001), but beta-carotene, alpha-tocopherol and inorganic sulphate levels were comparable. The very low bioavailability of ascorbate among Sowetan controls is reminiscent of our previous finding in outwardly healthy people at Madras in southern India: in both these areas chronic pancreatitis is currently endemic, has a propensity to pancreatic calculi and runs a virulent course towards premature death from diabetes, malnutrition or pancreatic cancer. Considering that low ascorbate levels are a feature in patients with chronic pancreatitis who develop pancreatic calculi at Manchester and that antioxidant supplements ameliorate painful symptoms, we suggest that poor antioxidant intake may predispose underprivileged tropical communities to the disease. If so, there could be an opportunity for prophylaxis through a daily tablet containing vitamin C, perhaps along with selenium at Soweto and beta-carotene at Madras.

Evidence of toxic metabolite stress in black South Africans with chronic pancreatitis

We report the results of a further study to test our hypothesis that toxic metabolite stress is germane to heightened free radical activity and hence to the genesis of chronic pancreatitis. Consecutive black South African patients with clinically quiescent chronic pancreatitis were studied, provided that the diagnosis had been made within the previous 2 years and that they did not have overt liver disease. All of them had been advised to stop drinking alcohol. Analysis of an early morning sample of urine showed a lower ratio of inorganic to ester sulphate (P < 0.001) and a higher ratio of D-glucaric acid to creatinine (P < 0.02) in the group of 14 patients than in 15 local controls, while plasma analysis showed a lower concentration of glutathione (GSH) in the patients (P < 0.001). This evidence of increased utilisation of phase II conjugative pathways of xenobiotic disposal was in keeping with on-going toxic metabolite stress from heightened phase I oxidative metabolism in the group of patients. Parallel studies of theophylline pharmacokinetics showed heightened drug clearance compatible with induced cytochrome P-4501A2 in two patients, whereas increased activity of gamma-glutamyl transferase in serum suggested persisting induction of P-4502E1, as by ethanol, in several others. The contemporaneous increases in free radical activity and utilisation of xenobiotic disposal pathways in Sowetan Africans with chronic pancreatitis is in line with the toxic metabolite concept of disease pathogenesis.

A preliminary report on urinary BT-PABA/PAS excretion index, serum pancreatic isoamylase and faecal chymotrypsin tests of pancreatic dysfunction in Sowetan Africans

The steady increase in chronic pancreatitis among black Africans at Soweto, RSA, in the past 40 years necessitates an objective and non-invasive test to detect the disease at an early stage. Given the biphasic nature of the disease--secretory hyperfunction with periodic active inflammatory episodes followed by steady exocrine impairment--we assessed three potential aids. Urinary BT-PABA/PAS excretion index (PEI), serum pancreatic isoamylase (PIA) and faecal chymotrypsin activity (FCA) were measured in the following groups: 16 outwardly healthy hospital workers, 16 consecutive patients with calcifying chronic pancreatitis and 19 with abdominal pain ascribed to other conditions (disease controls). (1) Healthy controls had lower PEI than those at Manchester, UK, or Madras, India, from subclinical acinar loss--as shown by lower PABA recovery whereas intestinal absorptive capacity was maintained, as shown by recovery of PAS. (2) Using the popular cut-off for PEI (0.75) only 9 of 14 patients with chronic pancreatitis were identified (sensitivity 64%, 2 tests unsatisfactory), while a value of less than 0.54, the mean -2 S.D. in local controls, yielded sensitivity of 50%. (3) If PEI of less than 0.75 or PIA outside the reference range was taken to indicate the disease, 5 of 9 disease controls would have been classed as chronic pancreatitis (among those with both tests satisfactory): retrospective ultrasound scans did not identify these. (4) Although FCA was less than the preselected cut-off, 5 units/g, in every patient with chronic pancreatitis (100% sensitivity) its poor predictive value was indicated by low specificity: subnormal levels in 4 of 14 and 6 of 16 healthy controls or disease controls, respectively, most of whom had near-normal values of PEI, PIA or both. (5) Collectively, these results suggest a high frequency of subclinical chronic pancreatitis at Soweto, but also that the combination of tests required to identify it may prove impractical--whether in field surveys or hospital practice.