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Phillips AE, Hughes SJ, Andersen DK, Bell A, Brand R, Coté GA, Cowdin A, Diazgranados N, Dudeja V, Duggan SN, Fogel E, Forsmark CE, Freeman AJ, Gittes G, Hart PA, Jeon C, Nealon W, Neoptolemos J, Palermo TM, Pandol S, Roberts KM, Rosenthal M, Singh VK, Yadav D, Whitcomb DC, Zyromski N. Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2024; 53:e368-e377. [PMID: 38518063 PMCID: PMC10963039 DOI: 10.1097/mpa.0000000000002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven J Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Adam Bell
- Translational Medicine and Regulatory Affairs, Theraly Fibrosis, Gaithersburg, MD
| | - Randall Brand
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | | | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Evan Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - A Jay Freeman
- Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - George Gittes
- Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christie Jeon
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William Nealon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Stephen Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kristen M Roberts
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | | | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nicholas Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Keaskin L, Egan SM, Almirall-Sanchez A, Tewatia V, Jorba R, Ferreres J, Memba R, Ridgway PF, O'Connor DB, Duggan SN, Conlon KC. Development of a clinical score to estimate pancreatitis-related hospital admissions in patients with a new diagnosis of chronic pancreatitis: the trinity score. HPB (Oxford) 2023:S1365-182X(23)00131-4. [PMID: 37183126 DOI: 10.1016/j.hpb.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/20/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND The clinical course of chronic pancreatitis is unpredictable and there is no globally accepted score to predict the disease course. We developed a clinical score to estimate pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis. METHODS We conducted a retrospective cohort study using two clinical chronic pancreatitis databases held in tertiary referral centres in Dublin, Ireland, and in Tarragona, Spain. Individuals diagnosed with chronic pancreatitis between 2007 and 2014 were eligible for inclusion. Candidate predictors included aetiology, body mass index, exocrine dysfunction, smoking and alcohol history. We used multivariable logistic regression to develop the model. RESULTS We analysed data from 154 patients with newly diagnosed chronic pancreatitis. Of these, 105 patients (68%) had at least one hospital admission for pancreatitis-related reasons in the 6 years following diagnosis. Aetiology of chronic pancreatitis, body mass index, use of pain medications and gender were found to be predictive of more pancreatic-related hospital admissions. These predictors were used to develop a clinical score which showed acceptable discrimination (area under the ROC curve = 0.70). DISCUSSION We developed a clinical score based on easily accessible clinical parameters to predict pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis.
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Affiliation(s)
- Laura Keaskin
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland
| | - Suzanne M Egan
- Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | | | - Vikram Tewatia
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Rosa Jorba
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Joan Ferreres
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Robert Memba
- Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Paul F Ridgway
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Donal B O'Connor
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland.
| | - Kevin C Conlon
- Department of Surgery, School of Medicine, Trinity College, Dublin, Ireland; Centre for Pancreatico-Biliary Diseases, Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
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Halle-Smith JM, Powell-Brett SF, Hall LA, Duggan SN, Griffin O, Phillips ME, Roberts KJ. Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients. Cancers (Basel) 2023; 15:cancers15092466. [PMID: 37173931 PMCID: PMC10177139 DOI: 10.3390/cancers15092466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sarah F Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Lewis A Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, University of Dublin, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Oonagh Griffin
- Department of Nutrition and Dietetics, St. Vincent's University Hospital, D04 T6F4 Dublin, Ireland
| | - Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital, Guildford GU2 7XX, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
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Monaghan B, Monaghan A, Ul Ain Q, Duggan SN, Conlon KC, Gormley J. Significantly lower physical activity participation in individuals with chronic pancreatitis compared to controls: An exploratory study of objectively assessed physical activity levels. Dig Surg 2023:000530543. [PMID: 37088072 DOI: 10.1159/000530543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/23/2023] [Indexed: 04/25/2023]
Abstract
Introduction The beneficial effects of exercise and physical activity (PA) have been demonstrated in many chronic inflammatory diseases. Knowledge on physical activity levels is unknown in the chronic pancreatitis population and there are currently no specific PA recommendations for this condition. Methods Physical activity was measured objectively over a 7- day period in 17 individuals with chronic pancreatitis using an accelerometer (Acti-graph) and in 15 controls, matched for age, sex, and body mass index. Results Participants with chronic pancreatitis spent a significantly lower amount of time in moderate, light, and moderate/vigorous activity compared to the healthy control group. Mean time in light activity in the chronic pancreatitis group 825.4 +- 972 (SD) compared to 1500 +- 958 (SD) in the healthy control group. Moderate activity mean mins was 61.6 +-85 in the chronic pancreatitis group compared to 161.4 +-131.2 in the healthy control group. Moderate /Vigorous mean minutes was 62.1+- 86 (SD) in the chronic pancreatitis group compared to 164.3 +-132 (SD) in the healthy control group. There was no significant difference found between the groups for either vigorous activity or time spent sedentary. Discussion/Conclusion This exploratory study offers early objective evidence that activity levels in the chronic pancreatic group are not meeting current international recommendations. Further investigation of this chronic illness population is strongly recommended.
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Monaghan B, Monaghan A, Mockler D, Ul Ain Q, Duggan SN, Conlon KC, Gormley J. Physical activity for chronic pancreatitis: a systematic review. HPB (Oxford) 2022; 24:1217-1222. [PMID: 35289280 DOI: 10.1016/j.hpb.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/31/2022] [Accepted: 02/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic pancreatitis (CP) is a progressive inflammatory disorder of the pancreas. Sarcopenia is a degenerative loss of skeletal muscle mass, quality, and strength and is commonly associated with chronic pancreatitis. Regular physical activity and adequate functional fitness have been found to ameliorate the risk and effects of sarcopenia in other chronic diseases. The objective of this systematic review was to collate all the published evidence which has examined any type of physical activity as an intervention in the chronic pancreatitis patient population. METHODS This systematic review was conducted in accordance with the PRISMA guidelines. The search strategy was designed by the medical librarian (DM) for Embase and then modified for the other search platforms. Two of the researchers (BM) and (AM) then performed the literature search using the databases Embase, Medline, CINAHL, and Web of Science. RESULTS An electronic identified a total of 571 references imported to Covidence as 420 when the duplicates (151) were removed. 420 titles were screened and 390 were removed as not relevant from their titles. 30 full text papers were selected and from these, only one full text paper was deemed suitable for inclusion. CONCLUSIONS There is currently insufficient evidence to advise physical activity in the chronic pancreatitis population. However, given the evidence to support physical activity in many other chronic diseases this review highlights the need for urgent investigation of physical activity as an intervention on this specific patient population.
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Affiliation(s)
- Brenda Monaghan
- Discipline of Physiotherapy, School of Medicine, University of Dublin, Trinity College, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland.
| | - Ann Monaghan
- Discipline of Physiotherapy, School of Medicine, University of Dublin, Trinity College, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
| | - David Mockler
- John Stearne Library, University of Dublin, Trinity College, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
| | - Qurat Ul Ain
- Professional Surgical Unit, Department of Surgery, University of Dublin, Trinity College Tallaght Hospital, Dublin 24 D24NROA, Ireland
| | - Sinead N Duggan
- Professional Surgical Unit, Department of Surgery, University of Dublin, Trinity College Tallaght Hospital, Dublin 24 D24NROA, Ireland
| | - Kevin C Conlon
- Professional Surgical Unit, Department of Surgery, University of Dublin, Trinity College Tallaght Hospital, Dublin 24 D24NROA, Ireland
| | - John Gormley
- Discipline of Physiotherapy, School of Medicine, University of Dublin, Trinity College, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
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Phillips ME, McGeeney LM, Griffin O, Freeman K, Dann S, Duggan SN. Training 1,200 dietitians: An evaluation of a training course for non-specialist dietitians on the management of pancreatic exocrine insufficiency. Clinical Nutrition Open Science 2022. [DOI: 10.1016/j.nutos.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Ul Ain Q, Bashir Y, Kelleher L, Bourne DM, Egan SM, McMahon J, Keaskin L, Griffin OM, Conlon KC, Duggan SN. Dietary intake in patients with chronic pancreatitis: A systematic review and meta-analysis. World J Gastroenterol 2021; 27:5775-5792. [PMID: 34629801 PMCID: PMC8473599 DOI: 10.3748/wjg.v27.i34.5775] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/26/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A progressive reduction in the secretion of pancreatic enzymes in patients with chronic pancreatitis (CP) results in malabsorption and ultimate malnutrition. However, the pathogenesis of malnutrition is multifactorial and other factors such as chronic inflammation, alcohol excess and poor dietary intake all contribute. Patients may restrict their dietary intake due to poor appetite or to avoid gastrointestinal symptoms and abdominal pain. Whilst up to half of patients with chronic pancreatitis are reportedly malnourished, the dietary intake of patients with CP is relatively understudied and has not been systematically reviewed to date.
AIM To perform a systematic review and meta-analysis of the dietary intakes of patients with CP compared to healthy controls, and to compare the dietary intake of patients with alcohol-related CP and non-alcohol-related CP.
METHODS A systematic literature search was performed using EMBASE, MEDLINE, and Cochrane review on studies published between 1946 and August 30th, 2019. Adult subjects with a diagnosis of CP who had undergone dietary assessment were included in the systematic review (qualitative analysis). Studies on patients with other pancreatic diseases or who had undergone pancreatic surgery were not included. Studies comparing the dietary intake of patients with CP to that of healthy controls were included in the meta-analysis (quantitative analysis). Meta-analysis was performed using Review Manager 5.3. Newcastle Ottawa Scale (NOS) was used to assess quality of studies.
RESULTS Of 6715 studies retrieved in the search, 23 were eligible for qualitative analysis while 12 were eligible for quantitative analysis. In the meta-analysis, the total energy (calorie) intake of patients with CP was similar to that of healthy controls [mean difference (MD): 171.3; 95% confidence interval (CI): -226.01, 568.5; P = 0.4], however patients with CP consumed significantly fewer non-alcohol calories than controls [MD: -694.1; 95%CI: -1256.1, (-132.1); P = 0.02]. CP patients consumed more protein, but carbohydrate and fat intakes did not differ significantly. Those with alcohol-related CP consumed more mean (standard deviation) calories than CP patients with a non-alcohol aetiology [2642 (1090) kcal and 1372 (394) kcal, respectively, P = 0.046], as well as more protein, fat, but not carbohydrate.
CONCLUSION Although patients with CP had similar calorie intake to controls, studies that analysed the contribution of alcohol to energy intake showed that patients with CP consumed fewer non-alcohol calories than healthy controls. A high calorie intake, made up to a large degree by alcohol, may in part contribute to poor nutritional status in CP.
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Affiliation(s)
- Qurat Ul Ain
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
| | - Yasir Bashir
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
| | - Linda Kelleher
- Department of Nutrition and Dietetics, Tallaght University Hospital, Dublin 24 D24 NR0A, Ireland
| | - David M Bourne
- Department of Newcastle Nutrition, Freeman Hospital, Newcastle Upon Tyne NE77DN, United Kingdom
| | - Suzanne M Egan
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
| | - Jean McMahon
- Library and Information Services Tallaght, Tallaght University Hospital, Dublin 24 D24 NR0A, Ireland
| | - Laura Keaskin
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
| | - Oonagh M Griffin
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
- Department of Nutrition and Dietetics, St. Vincent’s University Hospital, Dublin 4 D04 T6F4, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
| | - Sinead N Duggan
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Dublin 24 D24 NR0A, Ireland
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Phillips ME, Hopper AD, Leeds JS, Roberts KJ, McGeeney L, Duggan SN, Kumar R. Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000643. [PMID: 34140324 PMCID: PMC8212181 DOI: 10.1136/bmjgast-2021-000643] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency is a finding in many conditions, predominantly affecting those with chronic pancreatitis, pancreatic cancer and acute necrotising pancreatitis. Patients with pancreatic exocrine insufficiency can experience gastrointestinal symptoms, maldigestion, malnutrition and adverse effects on quality of life and even survival.There is a need for readily accessible, pragmatic advice for healthcare professionals on the management of pancreatic exocrine insufficiency. METHODS AND ANALYSIS A review of the literature was conducted by a multidisciplinary panel of experts in pancreatology, and recommendations for clinical practice were produced and the strength of the evidence graded. Consensus voting by 48 pancreatic specialists from across the UK took place at the 2019 Annual Meeting of the Pancreatic Society of Great Britain and Ireland annual scientific meeting. RESULTS Recommendations for clinical practice in the diagnosis, initial management, patient education and long term follow up were developed. All recommendations achieved over 85% consensus and are included within these comprehensive guidelines.
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Affiliation(s)
- Mary E Phillips
- Nutrition and Dietetics, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Keith J Roberts
- HPB Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Laura McGeeney
- Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Rajesh Kumar
- HPB Surgery, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
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Duggan SN, O'Connor DB, Antanaitis A, Campion JR, Lawal O, Ahmed M, Tisdall AR, Sherlock M, Boran G, le Roux C, Gibney J, Conlon KC. Metabolic dysfunction and diabetes mellitus during long-term follow-up of severe acute pancreatitis: A case-matched study. Pancreatology 2020; 20:813-821. [PMID: 32522508 DOI: 10.1016/j.pan.2020.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/07/2020] [Accepted: 03/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Endocrine insufficiency following severe acute pancreatitis (SAP) leads to diabetes of the exocrine pancreas, (type 3c diabetes mellitus), however it is not known how this metabolic phenotype differs from that of type 2 diabetes, or how the two subtypes can be differentiated. We sought to determine the prevalence of diabetes following SAP, and to analyse the behaviour of glucose and pancreatic hormones across a 2-h oral glucose tolerance test (OGTT). METHODS Twenty-six patients following SAP (mean (range) duration of first SAP episode to study time of 119.3 (14.8-208.9) months) along with 26 matched controls underwent an OGTT with measurement of glucose, insulin, c-peptide, glucagon and pancreatic polypeptide (PP) at fasting/15/90/120min. Beta-cell area was estimated using the 15min c-peptide/glucose ratio, and insulin resistance (IR) using homeostasis model assessment (HOMA) and oral glucose insulin sensitivity (OGIS) models. RESULTS The prevalence of diabetes/prediabetes was 54% following SAP (38.5% newly-diagnosed compared to 19.2% newly-diagnosed controls). Estimated beta-cell area and IR did not differ between groups. AUC c-peptide was lower in SAP versus controls. AUC insulin and AUC c-peptide were lower in SAP patients with diabetes versus controls with diabetes; between-group differences were observed at the 90 and 120 min time-points only. Half of new diabetes cases in SAP patients were only identified at the 120min timepoint. CONCLUSIONS Diabetes and pre-diabetes occur frequently following SAP and are difficult to distinguish from type 2 diabetes in controls but are characterised by reduced insulin and c-peptide at later stages of an OGTT. Consistent with this observation, most new post SAP diabetes cases were diagnosed by 2-h glucose levels only.
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Affiliation(s)
- Sinead N Duggan
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland.
| | - Donal B O'Connor
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
| | - Andrius Antanaitis
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - John R Campion
- Department of Gastroenterology, Tallaght University Hospital, Dublin 24, Ireland
| | - Oladapo Lawal
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
| | - Mohamed Ahmed
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland
| | - Ana Rakovac Tisdall
- Department of Clinical Chemistry, Tallaght University Hospital, Dublin 24, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland; Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons, Ireland
| | - Gerard Boran
- Department of Clinical Chemistry, Tallaght University Hospital, Dublin 24, Ireland
| | - Carel le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - James Gibney
- Department of Endocrinology, Tallaght University Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Department of Surgery, Trinity College Dublin, The University of Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin 24, Ireland
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Griffin OM, Duggan SN, Ryan R, McDermott R, Geoghegan J, Conlon KC. Characterising the impact of body composition change during neoadjuvant chemotherapy for pancreatic cancer. Pancreatology 2019; 19:850-857. [PMID: 31362865 DOI: 10.1016/j.pan.2019.07.039] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/07/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic Cancer remains a lethal disease for the majority of patients. New chemotherapy agents such as Folfirinox offer therapeutic potential for patients who present with Borderline Resectable disease (BRPC). However, results to date are inconsistent, with factors such as malnutrition limiting successful drug delivery. We sought to determine the prevalence of sarcopenia in BRPC patients at diagnosis, and to quantify body composition change during chemotherapy. METHODS The diagnostic/restaging CT scans of BRPC patients were analysed. Body composition was measured at L3 using Tomovision Slice-O-Matic™. Total muscle and adipose tissue mass were estimated using validated regression equations. Sarcopenia was defined as per gender- and body mass index (BMI)-specific lumbar skeletal muscle index (LSMI) and muscle attenuation reference values. RESULTS Seventy-eight patients received neo-adjuvant chemotherapy, and 67 patients underwent restaging CT, at which point a third were deemed resectable. Half were sarcopenic at diagnosis, and sarcopenia was equally prevalent across all BMI categories.. Skeletal muscle and adipose tissue (intra-muscular, visceral and sub-cutaneous) area decreased during chemotherapy (p < 0.0001). Low muscle attenuation was observed in half of patients at diagnosis, and was associated with increased mortality risk. Loss of lean tissue parameters during chemotherapy was associated with an increased mortality risk; specifically fat-free mass, HR 1.1 (95% CI 1.03-1.17, p = 0.003) and skeletal muscle mass, HR 1.21 (95%CI 1.08-1.35, p = 0.001). CONCLUSIONS Sarcopenia was prevalent in half of patients at the time of diagnosis with BRPC. Low muscle attenuation at diagnosis, coupled with lean tissue loss during chemotherapy, independently increased mortality risk.
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Affiliation(s)
- Oonagh M Griffin
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland; National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland.
| | - Sinead N Duggan
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland
| | - Ronan Ryan
- Department of Radiology, St Vincent's University Hospital, Dublin 24, Ireland
| | - Raymond McDermott
- Department of Medical Oncology, St Vincent's University Hospital, Dublin 24, Ireland
| | - Justin Geoghegan
- National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Trinity College Dublin, Trinity Centre for Health Science, Tallaght, Dublin 24, Ireland; National Surgical Centre for Pancreatic Cancer, St Vincent's University Hospital, Dublin 24, Ireland
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Rahman A, O'Connor DB, Gather F, Koscic S, Gilgan J, Mockler D, Bashir Y, Memba R, Duggan SN, Conlon KC. Clinical Classification and Severity Scoring Systems in Chronic Pancreatitis: A Systematic Review. Dig Surg 2019; 37:181-191. [PMID: 31269496 DOI: 10.1159/000501429] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/10/2019] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Chronic pancreatitis (CP) is characterised by pain, functional deficits, nutritional and mechanical complications. Frequently managed in out-patient settings, the clinical course is unpredictable and requires multi-disciplinary care. There remains substantial variation in management. In contrast to acute pancreatitis, there are no globally accepted classification or severity scores to predict the disease course or compare interventions. We conducted a systematic review to determine the scope and clinical use of existing scoring systems. METHODS A systematic search was developed with a medical librarian using the Embase, Medline and Cochrane databases. Original articles and conference abstracts describing an original or modified classification or scoring system in CP that stratified patients into clinical and/or severity categories were included. To assess clinical application/validation, studies using all or part of a score as a stratification tool to measure another parameter or outcome were selected. Studies reporting on diagnosis or aetiology only were excluded. Four authors performed the search in independent pairs and conflicts were resolved by a fifth author using CovidenceTM systematic review software. RESULTS Following screening 6,652 titles and 235 full-text reviews, 48 papers were analysed. Eleven described original scores and 6 described modifications of published scores. Many were comprehensive but limited in capturing the full spectrum of disease. In 31 studies, a score was used to categorise patients to compare or correlate various outcome measures. Exocrine and endocrine dysfunction and pain were included in 6, 5, and 4 scoring systems, respectively. No score included other nutrition parameters, such as bone health, malnutrition, or nutrient deficiency. Only one score has been objectively validated prospectively and independently for monitoring clinical progression and prognosis, but this had been applied to an in-patient population. CONCLUSION Available systems and scores do not reflect recent advances and guidelines in CP and are not commonly used. A practical clinical classification and scoring system, validated prospectively for prognostication would be useful for the meaningful analysis in observational and interventional studies in CP.
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Affiliation(s)
- Abidur Rahman
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Donal B O'Connor
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland,
| | - Felix Gather
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Sarah Koscic
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Joshua Gilgan
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - David Mockler
- Medical Library, Trinity College Dublin, Dublin, Ireland
| | - Yasir Bashir
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Robert Memba
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland.,Department of HPB Surgery, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain
| | - Sinead N Duggan
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Kevin C Conlon
- Department of Surgery, Tallaght University Hospital, Trinity College Dublin, Dublin, Ireland
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Bashir Y, Chonchubhair HN, Duggan SN, Memba R, Ain QU, Murphy A, McMahon J, Ridgway PF, Conlon KC. Systematic review and meta-analysis on the effect of obesity on recurrence after laparoscopic anti-reflux surgery. Surgeon 2019; 17:107-118. [DOI: 10.1016/j.surge.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/31/2018] [Accepted: 05/04/2018] [Indexed: 01/11/2023]
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Ní Chonchubhair HM, Bashir Y, Dobson M, Ryan BM, Duggan SN, Conlon KC. The prevalence of small intestinal bacterial overgrowth in non-surgical patients with chronic pancreatitis and pancreatic exocrine insufficiency (PEI). Pancreatology 2018; 18:379-385. [PMID: 29502987 DOI: 10.1016/j.pan.2018.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/13/2018] [Accepted: 02/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) is a condition characterised by symptoms similar to pancreatic exocrine insufficiency (PEI) in chronic pancreatitis patients. SIBO is thought to complicate chronic pancreatitis in up to 92% of cases; however, studies are heterogeneous and protocols non-standardised. SIBO may be determined by measuring lung air-expiration of either hydrogen or methane which are by-products of small bowel bacterial fermentation of intraluminal substrates such as carbohydrates. We evaluated the prevalence of SIBO among a defined cohort of non-surgical chronic pancreatitics with mild to severe PEI compared with matched healthy controls. METHODS Thirty-five patients and 31 age-, gender- and smoking status-matched healthy controls were evaluated for SIBO by means of a fasting glucose hydrogen breath test (GHBT). The relationship between SIBO and clinical symptoms in chronic pancreatitis was evaluated. RESULTS SIBO was present in 15% of chronic pancreatitis patients, while no healthy controls tested positive (P = 0.029). SIBO was more prevalent in those taking pancreatic enzyme replacement therapy (PERT) (P = 0.016), with proton pump inhibitor use (PPI) (P = 0.022) and in those with alcohol aetiology (P = 0.023). Patients with concurrent diabetes were more often SIBO-positive and this was statistically significant (P = 0.009). There were no statistically significant differences in reported symptoms between patients with and without SIBO, with the exception of 'weight loss', with patients reporting weight loss more likely to have SIBO (P = 0.047). CONCLUSION The prevalence of SIBO in this study was almost 15% and consistent with other studies of SIBO in non-surgical chronic pancreatitis patients. These data support the testing of patients with clinically-relevant PEI unresolved by adequate doses of PERT, particularly in those patients with concurrent diabetes. SIBO can be easily diagnosed therefore allowing more specific and more targeted symptom treatment.
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Affiliation(s)
- Hazel M Ní Chonchubhair
- Professorial Surgical Unit, Department of Surgery, The University of Dublin Trinity College, Tallaght Hospital, Dublin 24, Ireland.
| | - Yasir Bashir
- Professorial Surgical Unit, Department of Surgery, The University of Dublin Trinity College, Tallaght Hospital, Dublin 24, Ireland
| | - Mark Dobson
- Department of Gastroenterology, Tallaght Hospital, Dublin 24, Ireland
| | - Barbara M Ryan
- Department of Gastroenterology, Tallaght Hospital, Dublin 24, Ireland
| | - Sinead N Duggan
- Professorial Surgical Unit, Department of Surgery, The University of Dublin Trinity College, Tallaght Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Department of Surgery, The University of Dublin Trinity College, Tallaght Hospital, Dublin 24, Ireland
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Memba R, Duggan SN, Ni Chonchubhair HM, Griffin OM, Bashir Y, O'Connor DB, Murphy A, McMahon J, Volcov Y, Ryan BM, Conlon KC. The potential role of gut microbiota in pancreatic disease: A systematic review. Pancreatology 2017; 17:867-874. [PMID: 28935288 DOI: 10.1016/j.pan.2017.09.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several studies have suggested a link between microbiota imbalance and some gastrointestinal, inflammatory and neoplastic diseases. However, the role in pancreatic diseases remain unclear. To evaluate the available evidence for pancreatic diseases, we undertook a systematic review. METHODS OVID Medline (1946-2017), EMBASE (1980-2017) and the Cochrane Central Register of Controlled Trials (CENTRAL Issue 3, 2017) were searched for studies on microbiota in pancreatic disease. We also searched the reference lists of retrieved papers, and conference proceedings. We excluded animal studies, reviews, and case reports. RESULTS A total of 2833 articles were retrieved. After screening and applying the exclusion criteria, 10 studies were included. Three studies showed lower levels of Bifidobacterium or Lactobacillus and higher levels of Enterobacteriaceae in chronic pancreatitis. Two of these studies were uncontrolled, and the third (controlled) study which compared patients with endocrine and exocrine insufficiency, reported that Bacteroidetes levels were lower in those patients without diabetes, while Bifidobacteria levels were higher in those without exocrine insufficiency. Only one study investigated acute pancreatitis, showing higher levels of Enterococcus and lower levels of Bifidobacterium versus healthy participants. There was an overall association between pancreatic cancer and lower levels of Neisseria elongate, Streptococcus mitis and higher levels of Porphyromonas gingivalis and Granulicatella adiacens. CONCLUSIONS Current evidence suggests a possible link between microbiota imbalance and pancreatic cancer. Regarding acute and chronic pancreatitis, data are scarce, dysbiosis appears to be present in both conditions. However, further investigation is required to confirm these findings and to explore therapeutic possibilities.
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Affiliation(s)
- Robert Memba
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland.
| | - Sinead N Duggan
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
| | - Hazel M Ni Chonchubhair
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
| | - Oonagh M Griffin
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
| | - Yasir Bashir
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
| | - Donal B O'Connor
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
| | - Anne Murphy
- Tallaght Hospital Library, Tallaght Hospital, Dublin, Ireland
| | - Jean McMahon
- Tallaght Hospital Library, Tallaght Hospital, Dublin, Ireland
| | - Yuri Volcov
- Department of Molecular and Translational Medicine, Trinity College Dublin, St James Hospital, Dublin 8, Ireland
| | - Barbara M Ryan
- Department of Gastroenterology, Tallaght Hospital, Dublin 24, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin 24, Ireland
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Ní Chonchubhair HM, Bashir Y, McNaughton D, Barry JM, Duggan SN, Conlon KC. Hospital discharges and patient activity associated with chronic pancreatitis in Ireland 2009-2013. Pancreatology 2016; 17:56-62. [PMID: 27916415 DOI: 10.1016/j.pan.2016.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/21/2016] [Accepted: 11/25/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate trends in acute public hospital patient discharges in Ireland, to analyse hospital discharge activity for geographical variations, aetiological differences, and to estimate a national prevalence for chronic pancreatitis. METHOD We performed a nationwide retrospective study of all in-patient discharges from acute public hospitals in Ireland, participating in the Hospital In-Patient Enquiry (HIPE) reporting system. We searched for International Classification of Disease, Tenth Revision, Australian Modification (ICD-10-AM) codes K86.0 alcohol-induced chronic pancreatitis, and K86.1 other chronic pancreatitis, and data were extracted for the years 2009-2013. RESULTS There were 4098 emergency admissions for any aetiology chronic pancreatitis during the 5 year study period. Total discharges ranged from 753 in 2009 to 999 in 2013. Total patients ranged from 530 in 2009 to 601 in 2013. Prevalence of chronic pancreatitis is estimated at 11.6 per 100,000 to 13.0 per 100,000 over the five years. 'Other aetiology chronic pancreatitis' discharges were almost double that of 'alcohol chronic pancreatitis'. We found notable geographical variation in hospital discharge activity for chronic pancreatitis. CONCLUSIONS We report a prevalence which is similar to those worldwide studies who adopted a similar methodology utilising exact counts of patients. Our data are an underestimated as they are based on in-patient discharges only, excluding those attending primary care, outpatient or emergency room visits without admission. Despite studying this disease in a population with high per capita alcohol consumption, we report almost twice as many discharges for non-alcohol aetiology chronic pancreatitis.
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Affiliation(s)
- Hazel M Ní Chonchubhair
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Ireland.
| | - Yasir Bashir
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Ireland
| | - David McNaughton
- Hamilton Library, The University of Dublin Trinity College, Trinity College Dublin, Ireland
| | - Joseph M Barry
- Department of Public Health and Primary Care, The University of Dublin, Trinity College Dublin, Ireland
| | - Sinead N Duggan
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Ireland
| | - Kevin C Conlon
- Professorial Surgical Unit, Department of Surgery, Trinity College Dublin, Tallaght Hospital, Ireland
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Duggan SN, Ewald N, Kelleher L, Griffin O, Gibney J, Conlon KC. The nutritional management of type 3c (pancreatogenic) diabetes in chronic pancreatitis. Eur J Clin Nutr 2016; 71:3-8. [PMID: 27406162 DOI: 10.1038/ejcn.2016.127] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/02/2016] [Accepted: 06/10/2016] [Indexed: 12/19/2022]
Abstract
Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic diabetes, refers to diabetes caused by disease of the exocrine pancreas. T3cDM is not commonly recognised by clinicians and frequently it is misclassified as T1DM, or more commonly, T2DM. T3cDM can be difficult to distinguish from T1DM and T2DM, and it often co-exists with the latter. The aim of this review is to describe T3cDM, along with its complications, diagnosis and management. We focus on the nutritional implications of T3cDM for those with chronic pancreatitis, and provide a practical guide to the nutritional management of this condition.
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Affiliation(s)
- S N Duggan
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - N Ewald
- Third Medical Department, University Hospital Giessen and Marburg, Giessen Site, Giessen, Germany
| | - L Kelleher
- Department of Clinical Nutrition and Dietetics, Tallaght Hospital, Dublin, Ireland
| | - O Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - J Gibney
- Department of Endocrinology, Tallaght Hospital, Dublin, Ireland
| | - K C Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
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Duggan SN, Ní Chonchubhair HM, Lawal O, O’Connor DB, Conlon KC. Chronic pancreatitis: A diagnostic dilemma. World J Gastroenterol 2016; 22:2304-2313. [PMID: 26900292 PMCID: PMC4735004 DOI: 10.3748/wjg.v22.i7.2304] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/23/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
Typical clinical symptoms of chronic pancreatitis are vague and non-specific and therefore diagnostic tests are required, none of which provide absolute diagnostic certainly, especially in the early stages of disease. Recently-published guidelines bring much needed structure to the diagnostic work-up of patients with suspected chronic pancreatitis. In addition, novel diagnostic modalities bring promise for the future. The assessment and diagnosis of pancreatic exocrine insufficiency remains challenging and this review contests the accepted perspective that steatorrhea only occurs with > 90% destruction of the gland.
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Duggan SN, Smyth ND, O'Sullivan M, Feehan S, Ridgway PF, Conlon KC. The prevalence of malnutrition and fat-soluble vitamin deficiencies in chronic pancreatitis. Nutr Clin Pract 2014; 29:348-54. [PMID: 24727205 DOI: 10.1177/0884533614528361] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with chronic pancreatitis are at risk of malnutrition and nutrient deficiency due to malabsorption, pain, and poor diet. We sought to examine fat-soluble vitamin levels and malnutrition parameters in patients with chronic pancreatitis. MATERIALS AND METHODS In a prospective controlled cohort study, 128 subjects (62 chronic pancreatitis patients and 66 age-/sex-matched controls) were recruited. Body mass index (BMI), handgrip strength (measure of functional capacity), fat stores (triceps skin fold), muscle stores (mid-arm muscle circumference), exocrine function, and serum levels of fat-soluble vitamins (A, D, E) were measured. RESULTS Half of patients in the chronic pancreatitis group were overweight or obese, although the mean BMI was lower in patients than in controls (P = .007). Handgrip strength (P = .048), fat stores (P = .000), and muscle stores (P = .001) were lower in patients than in controls. Of the patients, 14.5% and 24.2% were deficient in vitamins A and E, respectively. Nineteen percent of patients had excess serum vitamin A levels. CONCLUSIONS Despite the prevalence of overweight and obesity, patients had lower muscle stores, strength, and abnormal vitamin levels. Detailed nutrition assessment including anthropometry and vitamin status is warranted in chronic pancreatitis.
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Affiliation(s)
- Sinead N Duggan
- Centre for Pancreatico-Biliary Diseases, Department of Surgery, Trinity College Dublin, Dublin, Ireland
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Smyth ND, Neary E, Power S, Feehan S, Duggan SN. Assessing Appropriateness of Parenteral Nutrition Usage in an Acute Hospital. Nutr Clin Pract 2012; 28:232-6. [DOI: 10.1177/0884533612469988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | | | | | - Sinead N. Duggan
- Trinity Centre for Health Sciences, Trinity College, Dublin, Ireland
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Abstract
BACKGROUND Many guidelines exist for the nutritional management of acute pancreatitis; however, little is known regarding current practice. We aimed to investigate feeding practices, including the use of parenteral/enteral nutrition. METHODS The study design was a cross-sectional, descriptive survey. Electronic surveys were sent to dietitians in the UK, the Republic of Ireland and Canada. Of 253 dietitians surveyed, 204 saw patients with acute pancreatitis regularly or occasionally and were included in the analyses. RESULTS Most dietitians (92.8%) considered early feeding to mean <48 h after presentation. Over half (54.2%) favoured early feeding in severe disease, less in obesity (42%) and more with pre-existing malnutrition (81.9%). There was a tendency to feed earlier in university hospitals (P = 0.015), especially in obesity (P = 0.011). There was a tendency towards enteral (versus parenteral) nutrition in university hospitals (P = 0.000). The majority preferred the jejunal route (64.2%), although this was lower in the UK (43.8%) than in Canada (77.8%) or Ireland (54.2%). Under one-quarter of UK dietitians (23.2%) reported the existence of a pancreatic multidisciplinary team in their institutions, although this was lower in Ireland and Canada. CONCLUSIONS Despite guidelines, there are gaps in the nutritional management of acute pancreatitis, including a continued reliance on parenteral feeding.
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Affiliation(s)
- S N Duggan
- Department of Surgery, Trinity College Dublin, Dublin, Ireland.
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Duggan SN, Smyth ND, Egan SM, Roddy M, Conlon KC. An assessment of the validity of enteral aspirate pH measurements made with commercial pH strips. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.eclnm.2008.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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