Acute recurrent pancreatitis: An autoimmune disease?

The Diagnostic Usefulness of Serum Total Bile Acid Concentrations in the Early Phase of Acute Pancreatitis of Varied Etiologies

The most common causes of acute pancreatitis (AP) are biliary tract diseases with cholestasis and alcohol consumption. In 10%-15% of patients, etiology determination is difficult. Identification of the etiology allows for the implementation of adequate treatment. The aim of this study was to assess the utility of the serum concentrations of total bile acids (TBA) to diagnose AP etiology in the early phase of the disease. We included 66 patients with AP, admitted within the first 24 h from the onset of symptoms. TBA were measured in serum at 24, 48, and 72 h from the onset of AP, using an automated fifth generation assay. The bilirubin-to-TBA ratio (B/TBA) was calculated. TBA was highest on the first day of AP and decreased subsequently. In patients with biliary etiology, serum TBA was significantly higher compared to those with alcoholic and other etiologies. B/TBA was significantly higher in patients with alcoholic etiology. At admission, the cut-off values of 4.7 µmol/L for TBA and 4.22 for the B/TBA ratio allowed for a differentiation between biliary and other etiologies of AP with a diagnostic accuracy of 85 and 83%. Both TBA and B/TBA may help in the diagnosis of AP etiology in the early phase of AP.

Immunosuppressive drugs for the treatment of autoimmune pancreatitis

Autoimmune pancreatitis is one of the few diseases of the pancreas characterized by the possibility of curing the illness using immunosuppressant drugs. In this paper, the therapeutic approach used to treat autoimmune pancreatitis patients and the clinical outcome related to each treatment modality were reviewed. Steroids are useful in alleviating the symptoms of the acute presentation of autoimmune pancreatitis, but some questions remain open, such as a shared definition of the disease’s remission as well as autoimmune pancreatitis relapse, the dosage of steroids in the symptomatic phase of the disease and the duration of steroid therapy. Finally, it should be determined if other immunosuppressive nonsteroidal drugs could become first-line therapy in patients with autoimmune pancreatitis without jaundice and without atrophic pancreas.

Pathophysiology of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a recently discovered form of pancreatitis and represents one of the diseases of the pancreas which can be cured and healed medically. International consensus diagnostic criteria have been developed, and the clinical phenotypes associated with the histopathologic patterns of lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric pancreatitis should be referred to as type 1 and type 2 AIP, respectively. Most importantly, in type 1 AIP, the pancreatic manifestations are associated with other extrapancreatic disorders, resembling an immunoglobulin G4 (IgG4)-related disease. In addition, the pancreas of a patient with AIP is often infiltrated by various types of immune cells; the cluster of differentiation (CD) 4 or CD8 T lymphocytes and IgG4-bearing plasma cells have been found in the pancreatic parenchyma and other involved organs in AIP and factors regulating T-cell function may influence the development of AIP. From a genetic point of view, it has also been reported that DRB1*0405 and DQB1*0401 mutations are significantly more frequent in patients with AIP when compared to those with chronic calcifying pancreatitis, and that only DQB1*0302 had a significant association with the relapse of AIP. Finally, it has been found that the polymorphic genes encoding cytotoxic T lymphocyte-associated antigen 4, a key negative regulator of the T-cell immune response, are associated with AIP in a Chinese population. Even if these data are not concordant, it is possible that physiological IgG4 responses are induced by prolonged antigen exposure and controlled by type 2 helper T cells. We reviewed the current concepts regarding the pathophysiology of this intriguing disease, focusing on the importance of the humoral and cellular immune responses.

Therapeutic management and clinical outcome of autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis, in comparison to other benign chronic pancreatic diseases, is characterized by the possibility of curing the illness with immunosuppressant drugs. The open question is whether to differentiate autoimmune pancreatitis as a primary or secondary disease based on the presence or absence of other autoimmune diseases or whether to consider autoimmune pancreatitis a clinical and pathological systemic entity, called IgG4-related sclerosing disease, since this aspect is also very important from a therapeutic point of view.

METHODS

In this paper, we reviewed the conventional therapeutic approach used to treat autoimmune pancreatitis patients and the clinical outcome related to each treatment modality. We also reviewed some aspects which are important for the correct management of autoimmune pancreatitis, such as the surgical approach, the outcome of surgically treated autoimmune pancreatitis patients, whether medical treatment is always necessary, and, finally, when medical treatment should be initiated.

CONCLUSIONS

Steroids are useful in alleviating the symptoms of the acute presentation of autoimmune pancreatitis, but some questions remain open such as the dosage of steroids in the acute phase and the duration of steroid therapy; finally, it should be assessed if other immunosuppressive non-steroidal drugs may become the first-line therapy in patients with AIP without jaundice and without atrophic pancreas.

Drug-induced acute pancreatitis related to medications commonly used in gastroenterology

BACKGROUND

With the growing number of pharmacological agents available nowadays, the gastrointestinal drug-induced side effects become more common than ever. However, drug-induced pancreatitis belongs to rather seldom reported adverse drug reactions, probably because of the difficulty in proving the relationship between an inflammation of the pancreas and the pharmacotherapy with a certain drug.

AIM

The aim of this review is to draw attention to an infrequent but real problem of drug-induced acute pancreatitis associated with medications commonly used in the treatment of gastrointestinal disorders.

METHODOLOGY

For the purpose of that the PubMed database was searched using the keywords "drug-induced pancreatitis", "drug-associated pancreatitis", "acute pancreatitis", "pancreatitis" in various combinations and relevant literature was reviewed.

RESULTS

A substantial number of drugs commonly prescribed for gastrointestinal disorders are known to cause acute pancreatitis. Case reports and review articles published so far draw attention to medications already known to cause drug-induced pancreatic damage as well as implicate new drugs. Generally, the etiopathological mechanisms involved in drug-induced pancreatitis remain unclear. It is difficult to establish or rule out definitely such unwanted event, especially in patients taking numerous medications prescribed for multiple comorbidities.

CONCLUSION

Pharmacological agents are among etiologic factors that should be considered in all patients presenting with signs and symptoms consistent with acute pancreatitis. The diagnosis of drug-induced AP is often difficult to established. Therefore a high index of suspicion and thorough drug history are crucial for making the final diagnosis.

Practical guidelines for acute pancreatitis

INTRODUCTION

The following is a summary of the official guidelines of the Italian Association for the Study of the Pancreas regarding the medical, endoscopic and surgical management of acute pancreatitis.

STATEMENTS

Clinical features together with elevation of the plasma concentrations of pancreatic enzymes are the cornerstones of diagnosis (recommendation A). Contrast-enhanced computed tomography (CT) provides good evidence for the presence of pancreatitis (recommendation C) and it should be carried out 48-72 h after the onset of symptoms in patients with predicted severe pancreatitis. Severity assessment is essential for the selection of the proper initial treatment in the management of acute pancreatitis (recommendation A) and should be done using the APACHE II score, serum C-reactive protein and CT assessment (recommendation C). The etiology of acute pancreatitis should be able to be determined in at least 80% of cases (recommendation B). An adequate volume of intravenous fluid should be administered promptly to correct the volume deficit and maintain basal fluid requirements (recommendation A); analgesia is crucial for the correct treatment of the disease (recommendation A). Enteral feeding is indicated in severe necrotizing pancreatitis and it is better than total parenteral nutrition (recommendation A). The use of prophylactic broad-spectrum antibiotics reduces infection rates in CT-proven necrotizing pancreatitis (recommendation A). Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention, including surgery and radiological drainage (recommendation B).

CONCLUSIONS

The participants agreed to revise the guidelines every 3 years in order to re-evaluate each question on the management of acute pancreatitis patients according to the most recent literature.

Serum leptin, but not adiponectin and receptor for advanced glycation end products, is able to distinguish autoimmune pancreatitis from both chronic pancreatitis and pancreatic neoplasms

OBJECTIVE

Serum leptin and adiponectin determinations have been proposed as markers for distinguishing pancreatic cancer and chronic pancreatitis from autoimmune pancreatitis; however, no studies exist in patients with autoimmune pancreatitis and in those with intraductal papillary mucinous tumors of the pancreas. The aim of this paper was to evaluate the circulating concentrations of receptor for advanced glycation end products (RAGE), leptin and adiponectin in patients with chronic pancreatic diseases.

MATERIAL AND METHODS

Seventy-five consecutive patients with chronic pancreatic diseases (47 males, 28 females; mean age 67.0 +/- 13.2 years; range 37-97 years) were studied: six (8.0%) had autoimmune pancreatitis, 23 (30.7%) had chronic pancreatitis, 34 (45.3%) had pancreatic cancer and the remaining 12 (16.0%) had intraductal papillary mutinous tumors of the pancreas. Leptin, adiponectin and RAGE were determined in serum using commercially available kits. The leptin concentrations were normalized to the lower and upper reference limits because of the different gender reference ranges.

RESULTS

Normalized leptin concentrations were significantly lower in chronic pancreatitis patients (0.53 +/- 1.28; p = 0.008) and in those with pancreatic cancer (0.12 +/- 0.33; p < 0.001) compared to the overall population (0.58 +/- 1.23), whereas autoimmune pancreatitis patients had significantly higher concentrations of this protein (2.18 +/- 2.56; p = 0.004) compared to the overall population. RAGE and adiponectin concentrations were similar among the four groups of patients studied. Among the clinical variables considered, only pain was significantly related to leptin concentrations (patients with pain 0.18 +/- 0.54, patients without pain 1.07 +/- 1.64; p = 0.001).

CONCLUSION

Serum leptin seems to be a good serum marker for differentiating autoimmune pancreatitis patients from those with chronic pancreatitis and pancreatic cancer.

Prevalence, diagnosis, and profile of autoimmune pancreatitis presenting with features of acute or chronic pancreatitis

BACKGROUND & AIMS

Little is known about how many patients with features of acute pancreatitis (AP) or chronic pancreatitis (CP) have autoimmune pancreatitis (AIP); most information comes from case reports. We explored the clinical profiles and relationship between these diseases.

METHODS

We evaluated 178 patients presenting to our Pancreas Clinic between January 2005 and June 2006 for evaluation of the etiology of their suspected pancreatitis; AIP was diagnosed when patients met HISORt (Histology, Imaging features, Serology, Other organ involvement and Response to steroid treatment) criteria. In a separate cohort of patients with AIP from our database, we identified patients who presented with features of AP (>/=2 of abdominal pain, increased pancreatic enzymes, pancreatic inflammation determined by imaging analyses) or CP (>/=1 of pancreatic calcification, irregular main pancreatic duct dilation, or marked atrophy) and determined their clinical profile.

RESULTS

Only 7/178 (3.9%) patients evaluated for etiology of suspected pancreatitis had AIP. Among 63 AIP patients in our database, 22 (34.9%) had features of AP (n = 15) or CP (n = 7) at presentation (average age 53.4 +/- 19.0 years, all males). Patients with AIP and pancreatitis were characterized by presence of obstructive jaundice (59.1%), increased levels of liver enzymes (81.8%), increased levels of serum immunoglobulin G4 (80.9%), and other organ involvement (69.1%). All 19 patients presenting with pancreatitis who were treated with steroids responded to treatment.

CONCLUSIONS

While AIP is an uncommon etiology for acute or chronic pancreatitis, >33% of AIP have features of acute or chronic pancreatitis at presentation.

Rational diagnosis and therapy for recurrent acute pancreatitis: a clinical analysis of 84 cases

AIM: To investigate the characteristics of etiology, clinical features and endoscopic manifestations and prevention methods of recurrent acute pancreatitis.

METHODS: The clinical data of 84 patients with recurrent acute pancreatitis (recurrence group) and 67 patients with incipient acute pancreatitis (control group) at our hospital from September 2001 to December 2007 were retrospectively analyzed; the results of imaging changes and endoscopy therapy were reviewed as well.

RESULTS: Incidence rate of biliary tract diseases was significantly higher in relapse group than in the control group (60.7% vs 38.8%, P < 0.01). Radiation pain, jaundice, intestinal obstruction were increased in the relapse group than in the control group, but there was no marked difference. Crude echo (38.3%), pancreatic duct dilation (21.3%), cholecystitis, the common bile duct stone were also significantly higher in relapse group than in control group. ERCP showed that stones and common bile duct dilation were significantly higher in relapse group than in control group (35.8% vs 11.6%, 32.1% vs9.3%, P < 0.05). Of 84 RAP cases, 20 underwent surgical treatment, 48 conservative treatment, and 16 endoscopy therapy. Three died in each surgery group and conservative treatment group, and none in endoscopy therapy group.

CONCLUSION: Recurrent acute pancreatitis often results from biliary tract diseases including cholelithiasis, chronic cholecystitis, inappropriate eating habit and alcohol use. Rational diagnosis and therapy is important measure to prevent relapse. Endoscopy therapy for RAP is safe, minimally invasive and effective, and is recommended for wide use.