Recent advances in the diagnosis and management of chronic pancreatitis

Novel therapeutics to treat chronic pancreatitis: targeting pancreatic stellate cells and macrophages

INTRODUCTION

Chronic pancreatitis (CP) is a persistent, recurrent, and progressive disorder that is characterized by chronic inflammation and irreversible fibrosis of the pancreas. It is associated with severe morbidity, resulting in intense abdominal pain, diabetes, exocrine and endocrine dysfunction, and an increased risk of pancreatic cancer. The etiological factors are diverse and the major risk factors include smoking, chronic alcoholism, as well as other environmental and genetic factors. The treatment and management of CP is challenging, and no definitive curative therapy is currently available.

AREAS COVERED

This review paper aims to provide an overview of the different cell types in the pancreas that is known to mediate disease progression and outline potential novel therapeutic approaches and drug targets that may be effective in treating and managing CP. The information presented in this review was obtained by conducting a NCBI PubMed database search, using relevant keywords.

EXPERT OPINION

In recent years, there has been an increased interest in the development of novel therapeutics for CP. A collaborative multi-disciplinary approach coupled with a consistent funding for research can expedite progress of translating the findings from bench to bedside.

Catechin hydrate ameliorates cerulein‑induced chronic pancreatitis via the inactivation of TGF‑β/Smad2 signaling

Chronic pancreatitis (CP) is a pancreatic inflammatory disease associated with histological changes, including fibrosis, acinar cell loss and immune cell infiltration, and leads to damage of the pancreas, which results in pain, weight loss and loss of pancreas function. Catechin or catechin hydrate (CH) has antioxidant, anticancer and immune‑regulatory effects. However, unlike other catechins, the antifibrotic effects of (+)‑CH have not been widely studied in many diseases, including CP. Therefore, the anti‑fibrotic effects of (+)‑CH against CP were evaluated in the present study. To assess the prophylactic effects of CH, (+)‑CH (1, 5 or 10 mg/kg) or ethanol was administered 1 h before first cerulein (50 µg/kg) injection. To assess the therapeutic effects, (+)‑CH (5 mg/kg) or ethanol was administered after cerulein injection for one or two weeks. In both methods, cerulein was injected intraperitoneally into mice once every hour, six times a day, four times a week, for a total of three weeks, to induce CP. The data showed that (+)‑CH markedly inhibited glandular destruction and inflammation during CP. Moreover, (+)‑CH prevented pancreatic stellate cell (PSC) activation and the production of extracellular matrix components, such as fibronectin 1 and collagens, which suggested that it may act as a novel therapeutic agent. Furthermore, the mechanism and effectiveness of (+)‑CH on pancreatic fibrosis were investigated in isolated PSCs. (+)‑CH suppressed the activation of Smad2 and fibrosis factors that act through transforming growth factor‑β (TGF‑β) or platelet‑derived growth factor. These findings suggest that (+)‑CH exhibits antifibrotic effects in cerulein‑induced CP by inactivating TGF‑β/Smad2 signaling.

Risk factors for pancreatitis occurrence after gallstone treatment using endoscopic retrograde cholangiopancreatography

Background

Patients with gallstones are prone to pancreatitis after treatment using endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to explore the risk factors for pancreatitis occurrence after gallstone treatment using ERCP.

Methods

A total of 193 patients treated from October 2017 to October 2020 were assigned into pancreatitis group (n=55) and non-pancreatitis group (n=138). Multivariate logistic regression analysis was utilized to analyse the risk factors for post-ERCP pancreatitis. The discrimination and accuracy of an established nomogram model were evaluated using receiver operating characteristic and calibration curves, respectively.

Results

The incidence rate of pancreatitis was 28.50% (55/193). Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, number of intubation ≥2 and absence of pancreatic duct stenting were risk factors for post-ERCP pancreatitis (P<0.05). The established model had high discrimination and accuracy. The incidence rates of pancreatitis in patients with and without pancreatic duct stenting were 11.84% (9/76) and 39.31% (46/117), respectively. The patients undergoing pancreatic duct stenting had lower serum amylase levels 6, 12 and 24 h after ERCP than those of patients who did not.

Conclusion

Patients with gallstones have a higher risk of developing pancreatitis. Young age, long course of disease, gallbladder wall thickness >3 mm, sand-like stones, history of pancreatic disease, pancreatic duct visualization and number of intubation ≥2 are risk factors for post-ERCP pancreatitis.

[Clinical forms and surgical strategy for chronic pancreatitis]

OBJECTIVE

To analyze treatment outcomes in patients with various forms of chronic pancreatitis.

MATERIAL AND METHODS

We analyzed 434 patients with chronic pancreatitis. These ones underwent 2879 different examinations to determine morphological type of pancreatitis and dynamics of pathological process, as well as substantiate treatment strategy and functional monitoring of various organs and systems. Morphological type A (Buchler et al. 2002) was present in 51.6% of cases, type B - 40.0%, type C - 4.3%. Cystic lesions were detected in 41.7% of cases, pancreatic calculi - 45.7%, choledocholithiasis - 19.1%, tubular stricture of distal choledochus - 21.4%, pancreatic duct enlargement - 95.7%, narrowing or interruption of the duct - 93.5%, communication of the duct with the cyst - in 17.4% of patients. Induration of pancreatic parenchyma was noted in 97% of patients, heterogeneous structure - 94.4%, enlargement of the pancreas - 10.8%, shrinkage of the gland - in 49.5% of cases. Surgical treatment was performed in 186 patients: ERCP + EPST in 8 patients, ERCP + EPST + pancreatic duct stenting in 2 patients, ERCP + EPST + wirsungotomy with stenting in 2 patients, laparotomy with hepaticocholedochojejunostomy in 6 patients, laparotomy with gastropancreatoduodenal resection in 19 patients, laparotomy with Puestow I procedure in 18 patients, Puestow II procedure in 34 patients, laparotomy + pancreatic tail resection + Duval procedure in 3 patients, laparotomy with Frey surgery in 19 cases, laparotomy and Beger procedure in 2 patients, external drainage of pseudocyst in 21 patients, endoscopic internal drainage of pseudocyst in 9 patients, laparotomy with cystodigestive anastomosis in 34 patients, excision of fistula and distal pancreatectomy in 9 cases).

RESULTS

Postoperative complications developed in 22 (11.8%) patients. Mortality rate was 2.2%.

The Evaluation of Inflammatory Biomarkers in Predicting Progression of Acute Pancreatitis to Pancreatic Necrosis: A Diagnostic Test Accuracy Review

Acute pancreatitis is the acute inflammation of the pancreas; 30% of cases may progress to pancreatic necrosis. The aim of this study was to assess the diagnostic accuracy of inflammatory biomarkers (C-reactive protein (CRP), procalcitonin (PCT), and lactate dehydrogenase (LDH)) in detecting pancreatic necrosis in adults with confirmed acute pancreatitis within 14 days of symptom onset and without organ failure. A systematic search was conducted across the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane, Embase, PubMed, and Web of Science until May 30, 2022, with the following keywords: acute disease, biomarkers, C-reactive protein, calcitonin, differential, diagnosis, lactate dehydrogenase, pancreatitis, acute necrotizing, necrosis, sensitivity, specificity. Statistical analysis was conducted in RevMan 5.4.1 (Cochrane). Five studies pooling 645 participants were included of which 59.8% were males, with a mean age of 49 years. CRP was the best cutoff at 279 mg/L (χ2 = 47.43, p < 0.001), followed by 200 mg/L (χ2 = 36.54, p < 0.001). LDH was cut off at 290 units/L (χ2 = 51.6, p < 0.001), whereas PCT did not display the most reliable results at 0.05 ng/mL. Inflammatory biomarkers are scalable diagnostic tools that may confer clinical value by decreasing the mortality of acute pancreatitis sequelae.

Bone Marrow Mesenchymal Stem Cells Modified with microRNA-216a-5p Enhance Proliferation of Acinar Cells in Severe Acute Pancreatitis

This study assesses the effect of bone marrow mesenchymal stem cells (BMSC) modified with miR-216a-5p on acinar cell proliferation in SAP. 40 rats were equally assigned into miR-NC set, miR-216a-5p set, BMSC set and anti-miR-216a-5p set randomly. The SAP model was prepared using AR42J cells which were disposed with CAE. Cells were transfected with lipidosome method to meaure miR-216-5p by RT-PCR, cell proliferation by CCK-8 along with analysis of cell clone formation and apoptosis. miR-216a-5p in modified BMSC was significantly upregulated compared with BMSC, indicating that BMSC was modified with miR-216a-5p successfully. BMSC modified with miR-216a-5p significantly promoted cell proliferation and clone formation and decreased apoptosis. The luciferase activity in wild type of miR-216a-5p was reduced, indicating that miR-216-5p could target Pak2 gene. In conclusion, proliferation of acinar cells in SAP is prompted and apoptosis ise reduced by BMSC modified with miR-216a-5p, which is possibly through targeting PAK2 gene.

[Surgical treatment of chronic pancreatitis: indications, timing, methods]

The review is devoted to complex treatment of chronic pancreatitis considering modern data on pathogenesis of this disease. The authors analyze various aspects of endoscopic and surgical interventions in refractory pain syndrome and complications of chronic pancreatitis, as well as positive and negative aspects of each method. Various surgical interventions and indications are analyzed in detail. One of the important points was analysis of the period between disease onset and surgical treatment that affects quality of life in patients with chronic pancreatitis in mid- and long-term period.

Comprehensive review of diagnostic modalities for early chronic pancreatitis

Chronic pancreatitis (CP) is a progressive condition caused by several factors and characterised by pancreatic fibrosis and dysfunction. However, CP is difficult to diagnose at an early stage. Various advanced methods including endoscopic ultrasound based elastography and confocal laser endomicroscopy have been used to diagnose early CP, although no unified diagnostic standards have been established. In the past, the diagnosis was mainly based on imaging, and no comprehensive evaluations were performed. This review describes and compares the advantages and limitations of the traditional and latest diagnostic modalities and suggests guidelines for the standardisation of the methods used to diagnose early CP.

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Robot-Assisted Total Pancreatectomy With Autologous Islet Cell Transplantation: Perioperative Nursing Considerations

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas that causes pain and gastrointestinal problems in patients. Robot-assisted total pancreatectomy with autologous islet cell transplantation (TPAIT) is a surgical procedure for treating patients with CP that has been unresponsive to other treatments. After performing a total pancreatectomy, the surgical team isolates islet cells and then infuses them into the patient's liver. To provide the best possible care for patients undergoing TPAIT, perioperative nurses should understand the physiological functions of the pancreas, the etiology of and treatment options for CP, and their role in coordinating care for this patient population. This article discusses the disease process for CP, reasons for choosing the robotic approach to TPAIT, preparation of the OR for the procedure, the role of the RN circulator during a robot-assisted TPAIT, and nursing management of the patient during the postoperative phase of care.

Endoscopic Ultrasound-Guided Management of Chronic Pancreatitis

PURPOSE OF REVIEW

The purpose of this review is to discuss the role of endoscopic ultrasound (EUS) in the diagnosis and treatment of chronic pancreatitis (CP).

RECENT FINDINGS

EUS has evolved and become invaluable in diagnosing early CP with the use of elastography and contrast enhancement. Lumen-apposing metal stents have allowed for easier transmural drainage and necrosectomy for pancreatic pseudocyst and walled of necrosis. EUS-guided pancreatic duct drainage is being utilized for pancreatic duct complications including stenosis, stones, and duct disruptions that are not amendable to endoscopic retrograde cholangiopancreatography. EUS is an effective tool that assists with the diagnosis and treatment of CP. The technology continues to evolve allowing for diagnosis of CP in earlier stages, which enables more effective therapy. The development of new EUS-guided tools and techniques has improved the treatment of complications from CP.