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García-Compeán D, Jiménez-Rodríguez AR, Muñoz-Ayala JM, González-González JA, Maldonado-Garza HJ, Villarreal-Pérez JZ. Post-acute pancreatitis diabetes: A complication waiting for more recognition and understanding. World J Gastroenterol 2023; 29:4405-4415. [PMID: 37576704 PMCID: PMC10415972 DOI: 10.3748/wjg.v29.i28.4405] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/22/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023] Open
Abstract
Post-acute pancreatitis diabetes (PAPD) is the second most common type of diabetes below type 2 diabetes mellitus. Due to the boom in research on this entity carried out during the last decade, its recognition has increased. However, much of the medical community still does not recognize it as a medium and long-term complication of acute pancreatitis (AP). Recent prospective cohort studies show that its incidence is about 23% globally and 34.5% in patients with severe AP. With the overall increase in the incidence of AP this complication will be certainly seen more frequently. Due to its high morbidity, mortality and difficult control, early detection and treatment are essential. However, its risk factors and pathophysiological mechanisms are not clearly defined. Its diagnosis should be made excluding pre-existing diabetes and applying the criteria of the American Diabetes Association after 90 d of resolution of one or more AP episodes. This review will show the evidence published so far on the incidence and prevalence, risk factors, possible pathophysiological mechanisms, clinical outcomes, clinical characteristics and preventive and corrective management of PAPD. Some important gaps needing to be clarified in forthcoming studies will also be discussed.
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Affiliation(s)
- Diego García-Compeán
- Department of Gastroenterology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Department of Gastroenterology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Juan M Muñoz-Ayala
- Department of Gastroenterology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Department of Gastroenterology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Department of Gastroenterology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Jesús Z Villarreal-Pérez
- Department of Endocrinology, Autonomous University of Nuevo León, Monterrey 64700, Nuevo León, Mexico
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Akbar W, Unnisa M, Tandan M, Murthy HVV, Nabi Z, Basha J, Chavan R, Lakhtakia S, Ramchandani M, Kalapala R, Koutarapu C, Gangdany ZM, Reddy DN, Talukdar R. New-onset prediabetes, diabetes after acute pancreatitis: A prospective cohort study with 12-month follow-up. Indian J Gastroenterol 2022; 41:558-66. [PMID: 36580265 DOI: 10.1007/s12664-022-01288-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 07/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute pancreatitis (AP) is known to result in endocrine dysfunction (prediabetes, diabetes). The objective of this study was to determine the temporal incidence of endocrine dysfunction after onset of AP and determine the risk factors in Indian patients. METHODS In this prospective study, enrolled patients diagnosed with AP between February 2019 and May 2019 were followed at 3, 6, and 12 months until May 2020. Patients with recurrent AP, chronic pancreatitis, and pre-existing endocrine dysfunction were excluded. Demographic and disease severity (clinical, laboratory, and radiological) data were recorded. Mann-Whitney U and Chi-square tests were used to compare groups. Temporal trend for development of endocrine dysfunction was evaluated using the Extended Mantel Haenszel Chi-square test for trend. Logistic regression was used to identify independent risk factors. RESULTS Eighty-six patients (males 66, median [IQR] age 33.0 [26.0-44.2] years) who fulfilled enrolment criteria were finally analyzed. The most common etiology was alcohol (n=31 [36%]) followed by gallstones (n=17 [19.8%]). The proportion of patients with moderately severe acute pancreatitis and severe AP were 59.3% and 15.1%, respectively. Overall, the frequency of prediabetes and diabetes increased temporally across the follow-up period. These were 2 (2.33%) and 1 (1.16%) at 3 months, 11 (12.8%) and 5 (5.81%) at 6 months, and 20 (23.2%) and 9 (10.5%) at 1 year, respectively. On multivariable logistic regression, intervention for walled-off necrosis (WON) emerged as the single independent risk factor for endocrine dysfunction (odds ratio 9.01 [2.3-35.5]; p=0.002). CONCLUSIONS Endocrine dysfunction is frequent after an episode of AP. Intervention for WON is an independent risk factor for endocrine dysfunction.
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Brewer MJ, Doucette JT, Bar-Mashiah A, Glickman JW, Kessel E, Aronson A, Lucas AL. Glycemic Changes and Weight Loss Precede Pancreatic Ductal Adenocarcinoma by up to 3 Years in a Diverse Population. Clin Gastroenterol Hepatol 2022; 20:1105-1111.e2. [PMID: 34358720 DOI: 10.1016/j.cgh.2021.07.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/17/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Elevations in fasting blood glucose are observed prior to the development of pancreatic ductal adenocarcinoma (PDAC). Our aim was to describe glycemic and weight changes that occur prior to PDAC diagnosis in a diverse population. METHODS We conducted a case-control study comparing patients with PDAC with matched controls between January 2011 and November 2019 at a tertiary care institution. Normally distributed variables were compared using t tests, and the Wilcoxon rank sum test was used for non-normally distributed variables; logistic regression was used to estimate odds of PDAC based on changes over time in hemoglobin A1c (HbA1c) and body mass index (BMI), controlling for appropriate confounders. RESULTS A total of 4626 patients met inclusion criteria: 1542 cases and 3084 controls; the median age was 69.3 years, and 2487 (53.8%) were male; 751 cases (48.7%) were non-Hispanic white. In the 3 years prior to diagnosis, HbA1c was higher in patients with PDAC compared with controls (P ≤ .02 for all); a similar trend was seen for glucose values. BMI was greater for patients with PDAC for all study periods, except 0 to 6 months prior to cancer diagnosis when BMI was lower (P < .01 for all). The change in BMI (ΔBMI) of cases at 1 year and 6 months before diagnosis was -0.59 and -1.21 when compared with -0.08 and 0.03 for controls (P < .01 for both). Multivariable logistic regression demonstrated that HbA1c slope (adjusted odds ratio, 1.33; 95% confidence interval, 1.01-1.76) and BMI slope (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87) were predictors of PDAC. CONCLUSION Glycemic elevations and weight loss predate PDAC diagnosis. These metabolic changes may suggest an underlying PDAC.
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Affiliation(s)
- Marlon J Brewer
- Henry D. Janowitz Division of Gastroenterology, New York, New York
| | - John T Doucette
- Division of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ariel Bar-Mashiah
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jacob W Glickman
- Henry D. Janowitz Division of Gastroenterology, New York, New York
| | - Elizabeth Kessel
- Henry D. Janowitz Division of Gastroenterology, New York, New York
| | - Anne Aronson
- Henry D. Janowitz Division of Gastroenterology, New York, New York
| | - Aimee L Lucas
- Henry D. Janowitz Division of Gastroenterology, New York, New York.
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Bao J, Liu D, Sun J, Su X, Cheng H, Qi L, Zhang Y, Lv Y, Ye Z, Yu X, Wei Q, Qiu Y, Su J, Li L. Pancreatic cancer-associated diabetes mellitus is characterized by reduced β-cell secretory capacity, rather than insulin resistance. Diabetes Res Clin Pract 2022; 185:109223. [PMID: 35149166 DOI: 10.1016/j.diabres.2022.109223] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/19/2021] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
Abstract
AIMS The early distinction of pancreatic cancer associated diabetes (PaCDM) in patients with elderly diabetes is critical. However, PaCDM and type 2 diabetes mellitus (T2DM) remain indistinguishable. We aim to address the differences between the pancreatic and gut endocrine hormones of patients with PaCDM and T2DM. METHODS A total of 44 participants underwent mixed meal tolerance test (MMTT). Fasting and postprandial concentrations of insulin, C-peptide, glucagon, pancreatic polypeptide (PP), glucagon-like peptide-1 (GLP-1), and gastric inhibitory peptide (GIP) were measured. Insulin sensitivity and secretion indices were calculated. One-way ANOVA with post-hoc analysis was used for statistical analysis. RESULTS Insulin and C-peptide responses to MMTT were blunted in PaCDM patients compared with T2DM. Baseline concentrations and AUCs differed. PaCDM patients showed lower insulin secretion capacity but better insulin sensitivity than T2DM patients. The peak concentration and AUC of PP in T2DM group were higher than healthy controls, but in accordance with PaCDM. PaCDM patients presented lower baseline GLP-1 concentration than T2DM patients. No between-group differences were found for glucagon and GIP. CONCLUSIONS PaCDM patients had a lower baseline and postprandial insulin and C-peptide secretion than T2DM patients. Reduced insulin secretion and improved peripheral sensitivity were found in PaCDM patients compared with T2DM.
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Affiliation(s)
- Jiantong Bao
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Dechen Liu
- Department of Endocrinology, School of Medicine, and Department of Clinical Science and Research, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jinfang Sun
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China.
| | - Xianghui Su
- Department of Endocrinology, Changji Branch, First Affiliated Hospital of Xinjiang Medical University, Xinjiang 831100, China
| | - Hao Cheng
- Department of Hepatobiliary and Pancreatic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Qi
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yidi Zhang
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yingqi Lv
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zheng Ye
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xuebing Yu
- Department of Endocrinology, Changzhou Jintan District People's Hospital, School of Medicine in Jiangsu University, Changzhou, China
| | - Qiong Wei
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yudong Qiu
- Department of Hepatobiliary and Pancreatic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jianhua Su
- Changzhou Jintan District People's Hospital, School of Medicine in Jiangsu University, Changzhou, China
| | - Ling Li
- Department of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
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Shimizu K, Ito T, Irisawa A, Ohtsuka T, Ohara H, Kanno A, Kida M, Sakagami J, Sata N, Takeyama Y, Tahara J, Hirota M, Fujimori N, Masamune A, Mochida S, Enomoto N, Shimosegawa T, Koike K. Evidence-based clinical practice guidelines for chronic pancreatitis 2021. J Gastroenterol 2022; 57:709-24. [PMID: 35994093 DOI: 10.1007/s00535-022-01911-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress. METHODS The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions. RESULTS Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition. CONCLUSIONS These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.
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Kharoud HK, Mettler T, Freeman ML, Trikudanathan G, Beilman GJ, Chinnakotla S, Downs E, Schwarzenberg SJ, Bellin MD. Type 1 diabetes mellitus in patients with recurrent acute and chronic pancreatitis: A case series. Pancreatology 2021; 21:95-97. [PMID: 33309625 PMCID: PMC7856006 DOI: 10.1016/j.pan.2020.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/19/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatogenic diabetes mellitus has been assumed to result from non-immune beta cell destruction when the pancreas is replaced by fibrotic tissue secondary to acute and chronic pancreatitis. We hypothesize that recurrent episodes of pancreatic inflammation may increase the risk for developing β-cell autoimmunity in susceptible individuals. METHODS We describe 11 patients who had both recurrent acute and/or chronic pancreatitis and type 1 diabetes (T1D) requiring insulin therapy. RESULTS All 11 patients had positive autoantibodies and 8 patients tested had minimal to undetectable (7/8) or moderate (1/8) stimulated C-peptide at 12 months after T1D onset. Three had biopsy confirmation of insulitis. CONCLUSIONS These cases lend support to the theory that pancreatitis may increase risk for T1D. We postulate that the pro-inflammatory conditions of pancreatitis may increase posttranslational protein modifications of β-cell antigens and neoepitope generation, which are potential initiating events for loss of β-cell self-tolerance.
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Affiliation(s)
- Harmeet K. Kharoud
- Department of Epidemiology, School of Public Health, University of Minnesota Medical School, Minneapolis, MN
| | - Tetyana Mettler
- Department of Pathology, University of Minnesota Medical School, Minneapolis, MN
| | - Martin L. Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Elissa Downs
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - Melena D. Bellin
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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Aslam M, Vijayasarathy K, Talukdar R, Sasikala M, Nageshwar Reddy D. Reduced pancreatic polypeptide response is associated with early alteration of glycemic control in chronic pancreatitis. Diabetes Res Clin Pract 2020; 160:107993. [PMID: 31877344 DOI: 10.1016/j.diabres.2019.107993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/21/2019] [Revised: 11/25/2019] [Accepted: 12/20/2019] [Indexed: 01/24/2023]
Abstract
AIM To study the incidence of glucose intolerance in CP patients without diabetes by performing oral glucose tolerance test (OGTT). METHODS We screened consecutive Indian CP patients without diabetes over 6 months by performing OGTT and correlated with physical characteristics and glycated hemoglobin (HbA1c). We also compared c-peptide and pancreatic polypeptide response in different groups based on OGTT. Relevant statistical tests were performed. P < 0.05 was considered significant. RESULTS Total of 171 patients were screened. Mean duration of CP was 5.03 ± 4.32 years. 55 were detected to have prediabetes and 40 DM on OGTT. CP patients with diabetes and prediabetes had significantly dilated pancreatic duct compared to non-diabetic CP (4.2 ± 2.7 mm, 3.6 ± 2.7 mm, 2.84 ± 2.25 mm; p = 0.018). Fasting blood glucose (FBS) and 2-hour OGTT were 109.35 ± 19.06, 97.47 ± 11.94, 85.24 ± 9.95 and 236.13 ± 31.42, 154.65 ± 19.53, 112.89 ± 16.32 in patients with DM, prediabetes and CP patients without diabetes (p < 0.0001). There was a good c-peptide response (p = 0.001) and reduced pancreatic polypeptide response (p = 0.003) in CP patients compared to controls. CONCLUSION Early in the course of disease reduced pancreatic polypeptide response in the presence of good c-peptide response may result in development of DM.
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Affiliation(s)
- Mohsin Aslam
- Clinical Endocrinologist, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India.
| | | | - Rupjyothi Talukdar
- Clinical Pancreatologist, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India
| | - M Sasikala
- Director, Research, Institute of Basic Sciences and Translational Research, Asian Healthcare Foundation, Somajiguda, Hyderabad, India
| | - D Nageshwar Reddy
- Chairman and Chief of Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India
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Melki G, Laham L, Karim G, Komal F, Kumar V, Barham S, Grossman M, Kuru S, Mohamed H, Garris R, Baddoura W. Chronic Pancreatitis Leading to Pancreatogenic Diabetes Presenting in Diabetic Ketoacidosis: A Rare Entity. Gastroenterology Res 2019; 12:208-210. [PMID: 31523331 PMCID: PMC6731042 DOI: 10.14740/gr1203] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 01/24/2023] Open
Abstract
Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient's anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.
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Affiliation(s)
- Gabriel Melki
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Linda Laham
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Gres Karim
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Fnu Komal
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Vinod Kumar
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Shaker Barham
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Matthew Grossman
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Sugabramya Kuru
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Hadir Mohamed
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Rana Garris
- Department of Medicine, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Walid Baddoura
- Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA
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Kaser S, Winhofer-Stöckl Y, Kazemi-Shirazi L, Hofer SE, Brath H, Sourij H, Vila G, Abrahamian H, Riedl M, Weitgasser R, Resl M, Clodi M, Luger A. [Other specific types of diabetes and exocrine pancreatic insufficiency (Update 2019)]. Wien Klin Wochenschr 2019; 131:16-26. [PMID: 30980164 DOI: 10.1007/s00508-019-1454-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The heterogenous catagory "specific types of diabetes due to other causes" encompasses disturbances in glucose metabolism due to other endocrine disorders such as acromegaly or hypercortisolism, drug-induced diabetes (e. g. antipsychotic medications, glucocorticoids, immunosuppressive agents, highly active antiretroviral therapy (HAART)), genetic forms of diabetes (e. g. Maturity Onset Diabetes of the Young (MODY), neonatal diabetes, Down Syndrome, Klinefelter Syndrome, Turner Syndrome), pancreatogenic diabetes (e. g. postoperatively, pancreatitis, pancreatic cancer, haemochromatosis, cystic fibrosis), and some rare autoimmune or infectious forms of diabetes. Diagnosis of specific diabetes types might influence therapeutic considerations. Exocrine pancreatic insufficiency is not only found in patients with pancreatogenic diabetes but is also frequently seen in type 1 and long-standing type 2 diabetes.
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10
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Kumar KVSH, Manrai M, Sood AK, Sharma R. A clinical study of insulin resistance in patients with chronic pancreatitis. Diabetes Metab Syndr 2017; 11 Suppl 1:S283-S286. [PMID: 28284910 DOI: 10.1016/j.dsx.2017.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 12/14/2016] [Accepted: 03/03/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Insulin resistance (IR) and beta cell dysfunction are the pathophysiological determinants of the diabetes mellitus (DM). We investigated the presence of IR in patients with chronic pancreatitis (CP) and compared the same with the underlying etiology. METHODS In this cross-sectional, observational study, we included serial patients of CP presented to our hospital. The study population is in different stages of CP and are grouped as alcoholic CP (Group 1; N=67) and tropical CP (Group 2; N=35). IR was estimated by the homeostasis model assessment (HOMA) method. The results were analyzed by appropriate statistical methods. RESULTS The study participants (85M and 17F) had a mean age 40.8±12.6 yr, CP duration 3.7±4.7 yr and body mass index (BMI) of 22.5±3.2kg/m2. DM was seen in 54 patients with average glycosylated hemoglobin of 7.5±1.6%. A total of 9 patients had HOMA-IR more than 3 suggestive of IR with no significant difference between the two groups. The duration of the DM correlated negatively with glycemic parameters and BMI showed a positive correlation with the fasting insulin and HOMA-IR. CONCLUSION IR was seen in a minority of patients with CP and is not a significant contributor to the pancreatogenic diabetes.
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Affiliation(s)
- K V S Hari Kumar
- Departments of Endocrinology & Gastroenterology, Army Hospital (R&R), Delhi 110010, India.
| | - Manish Manrai
- Departments of Endocrinology & Gastroenterology, Army Hospital (R&R), Delhi 110010, India
| | - A K Sood
- Departments of Endocrinology & Gastroenterology, Army Hospital (R&R), Delhi 110010, India
| | - Rahul Sharma
- Departments of Endocrinology & Gastroenterology, Army Hospital (R&R), Delhi 110010, India
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11
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Roeyen G, Jansen M, Hartman V, Chapelle T, Bracke B, Ysebaert D, De Block C. The impact of pancreaticoduodenectomy on endocrine and exocrine pancreatic function: A prospective cohort study based on pre- and postoperative function tests. Pancreatology 2017; 17:974-982. [PMID: 28958898 DOI: 10.1016/j.pan.2017.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 05/08/2017] [Revised: 07/07/2017] [Accepted: 09/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Studies reporting on function after pancreatic surgery are frequently based on diabetes history, fasting glycemia or random glycemia. The aim of this study was to investigate prospectively the evolution of pancreatic function in patients undergoing pancreaticoduodenectomy based on proper pre- and postoperative function tests. It was hypothesised that pancreatic function deteriorates after pancreaticoduodenectomy. METHODS Between 2013 and 2016, 78 patients undergoing pancreaticoduodenectomy for oncologic indications had a prospective evaluation of their endocrine and exocrine pancreatic function. Endocrine function was evaluated with the 75 g oral glucose tolerance test (OGTT) and the 1 mg intravenous glucagon test. Exocrine function was evaluated with a 13C-labelled mixed-triglyceride breath test. Tests were performed pre- and postoperatively. RESULTS In 90.5% (19/21) of patients with preoperatively known diabetes, no change in endocrine function was observed. In contrast, endocrine function improved in 68.1% (15/22) of patients with newly diagnosed diabetes. 40% (14/35) of patients with a preoperative normal OGTT or prediabetes experienced deterioration in function. In multivariate analysis, improvement of newly diagnosed diabetes was correlated with preoperative bilirubin levels (p = 0.045), while progression towards diabetes was correlated with preoperative C-peptidogenic index T30 (p = 0.037). A total of 20.5% (16/78) of patients had pancreatic exocrine insufficiency preoperatively. Another 51.3% (40/78) of patients deteriorated on exocrine level. In total, 64.1% (50/78) of patients required pancreatic enzyme-replacement therapy postoperatively. CONCLUSIONS Although deterioration of endocrine function was expected after pancreatic resection, improvement is frequently observed in patients with newly diagnosed diabetes. Exocrine function deteriorates after pancreaticoduodenectomy.
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Affiliation(s)
- Geert Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium.
| | - Miet Jansen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Belgium
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Maker AV, Sheikh R, Bhagia V. Perioperative management of endocrine insufficiency after total pancreatectomy for neoplasia. Langenbecks Arch Surg 2017; 402:873-883. [PMID: 28733926 DOI: 10.1007/s00423-017-1603-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 07/07/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Indications for total pancreatectomy (TP) have increased, including for diffuse main duct intrapapillary mucinous neoplasms of the pancreas and malignancy; therefore, the need persists for surgeons to develop appropriate endocrine post-operative management strategies. The brittle diabetes after TP differs from type 1/2 diabetes in that patients have absolute deficiency of insulin and functional glucagon. This makes glucose management challenging, complicates recovery, and predisposes to hospital readmissions. This article aims to define the disease, describe the cause for its occurrence, review the anatomy of the endocrine pancreas, and explain how this condition differs from diabetes mellitus in the setting of post-operative management. The morbidity and mortality of post-TP endocrine insufficiency and practical treatment strategies are systematically reviewed from the literature. Finally, an evidence-based treatment algorithm is created for the practicing pancreatic surgeon and their care team of endocrinologists to aid in managing these complex patients. METHODS A PubMed, Science Citation Index/Social sciences Citation Index, and Cochrane Evidence-Based Medicine database search was undertaken along with extensive backward search of the references of published articles to identify studies evaluating endocrine morbidity and treatment after TP and to establish an evidence-based treatment strategy. RESULTS Indications for TP and the etiology of pancreatogenic diabetes are reviewed. After TP, ~80% patients develop hypoglycemic episodes and 40% experience severe hypoglycemia, resulting in 0-8% mortality and 25-45% morbidity. Referral to a nutritionist and endocrinologist for patient education before surgery followed by surgical reevaluation to determine if the patient has the appropriate understanding, support, and resources preoperatively has significantly reduced morbidity and mortality. The use of modern recombinant long-acting insulin analogues, continuous subcutaneous insulin infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed. CONCLUSION Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.
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Affiliation(s)
- Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott Ave. MC790, Chicago, IL, 60612, USA.
- Creticos Cancer Center, Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency Program in General Surgery, Chicago, IL, USA.
| | - Raashid Sheikh
- Creticos Cancer Center, Advocate Illinois Masonic Medical Center, University of Illinois Metropolitan Group Hospitals Residency Program in General Surgery, Chicago, IL, USA
| | - Vinita Bhagia
- Department of Medicine, Division of Endocrinology, University of Illinois at Chicago and Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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Abstract
Chronic pancreatitis is a disease that leads to irreversible changes in the pancreatic morphology and function. The loss of function can lead to diabetes mellitus and exocrine pancreatic insufficiency. The inflammation and fibrosis can also lead to other complications including a chronic abdominal pain syndrome, metabolic bone disease, and pancretic cancer. This article reviews our current understanding of the mechanisms and management of these complications of chronic pancreatitis.
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Dytz MG, Marcelino PAH, de Castro Santos O, Zajdenverg L, Conceição FL, Ortiga-Carvalho TM, Rodacki M. Clinical aspects of pancreatogenic diabetes secondary to hereditary pancreatitis. Diabetol Metab Syndr 2017; 9:4. [PMID: 28101143 PMCID: PMC5237278 DOI: 10.1186/s13098-017-0203-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 01/07/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Hereditary pancreatitis is a rare inherited form of pancreatitis, characterized by recurrent episodes of acute pancreatitis with early onset and/or chronic pancreatitis, and presenting brittle diabetes, composed of episodes of nonketotic hyperglycemia and severe hypoglycemia. The existing literature regarding this form of diabetes is scarce. In this report, clinical features of pancreatogenic diabetes secondary to hereditary pancreatitis are presented along with recommendations for appropriate medical treatment. RESULTS Clinical data from five patients of a family with pancreatogenic diabetes secondary to hereditary pancreatitis were analyzed. The average time between hereditary pancreatitis and diabetes diagnosis was 80 ± 24 months (range: 60-180 months) with a mean age of 25.6 ± 14.7 years (range: 8-42 years), four patients used antidiabetic agents for 46 ± 45 months and all progressed to insulin therapy with a mean dose of 0.71 ± 0.63 IU/kg (range: 0.3-1.76 IU/kg). The glycemic control had a high variability with average capillary blood glucose of 217.00 ± 69.44 mg/dl (range: 145-306 mg/dl) and the average HbA1c was 9.9 ± 1.9% (range: 7.6-11.6%). No ketoacidosis episodes occurred and there were several episodes of hospitalization for severe hypoglycemia. CONCLUSIONS Diabetes mellitus secondary to hereditary pancreatitis presents with early onset, diverse clinical presentation and with extremely labile glycemic control. Diabetes treatment varies according to the presentation and insulin is frequently necessary for glycemic control.
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Affiliation(s)
- Marcio Garrison Dytz
- Endocrinology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- Laboratory of Translational Endocrinology, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- Diabetes and Nutrology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- Endocrinology Section, Hospital Universitário Clementino Fraga Filho, Rua Rodolpho Paulo Rocco 255, Ilha do Fundão, Rio de Janeiro, RJ 21941-913 Brazil
| | - Pedro Arthur Hamamoto Marcelino
- Diabetes and Nutrology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Olga de Castro Santos
- Endocrinology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Lenita Zajdenverg
- Diabetes and Nutrology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Flavia Lucia Conceição
- Endocrinology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Tânia Maria Ortiga-Carvalho
- Laboratory of Translational Endocrinology, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Melanie Rodacki
- Diabetes and Nutrology Section, Department of Internal Medicine, Medical School, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Roeyen G, Jansen M, Chapelle T, Bracke B, Hartman V, Ysebaert D, De Block C. Diabetes mellitus and pre-diabetes are frequently undiagnosed and underreported in patients referred for pancreatic surgery. A prospective observational study. Pancreatology 2016; 16:671-6. [PMID: 27216012 DOI: 10.1016/j.pan.2016.04.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 12/28/2015] [Revised: 02/29/2016] [Accepted: 04/26/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previous reports on the prevalence of diabetes in pancreatic cancer and chronic pancreatitis patients are based on inconsistent and equivocal criteria. The objective of this study is to prospectively assess with conclusive methods the preoperative glycaemic status of patients undergoing pancreatic surgery. We hypothesise that most of those patients are unaware of these disturbances in glycaemic status and that the prevalence is underestimated. METHODS During the last 2 years, patients referred for pancreatic surgery and without history of diabetes underwent a prospective preoperative screening with an oral glucose tolerance test (OGTT) and determination of the glycated haemoglobin level (HbA1c). The American Diabetes Association's criteria for diabetes and pre-diabetes were used. Beta-cell function and insulin sensitivity were calculated using HOMA2 indices. Impact on surgical policy has been scored. RESULTS 99 patients were screened, 25 had a history of diabetes. The other 74 underwent an OGTT and HbA1c determination. Only 29.7% (22/74) had a normal glucose metabolism, while 8.1% (6/74) had impaired fasting glucose, 21.6% (16/74) had impaired glucose tolerance, 6.7% (5/74) had a combination of both, and 33.8% (25/74) had undiagnosed diabetes. In 15.2% (15/99) of the patients, this preoperative assessment had an impact on surgical policy. CONCLUSIONS 77.7% of patients referred for pancreatic surgery had some degree of (pre-)diabetes. In 70.3% of patients without a history of diabetes, these disturbances in glucose metabolism are a new finding. Physicians involved in pancreatic surgery should be aware of the frequently undiagnosed (pre-)diabetes and actively check for it. This prevalence is underestimated.
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Affiliation(s)
- Geert Roeyen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium.
| | - Miet Jansen
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary, Endocrine and Transplantation Surgery, Antwerp University Hospital, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Belgium
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Chaux F, Franco M, Varela JE. Metabolic surgery provides remission of pancreatogenic diabetes in a non-obese patient. Surg Obes Relat Dis 2016; 12:e25-6. [PMID: 26686307 DOI: 10.1016/j.soard.2015.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 09/15/2015] [Accepted: 09/17/2015] [Indexed: 11/21/2022]
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Hart PA, Baichoo E, Bi Y, Hinton A, Kudva YC, Chari ST. Pancreatic polypeptide response to a mixed meal is blunted in pancreatic head cancer associated with diabetes mellitus. Pancreatology 2015; 15:162-6. [PMID: 25766398 DOI: 10.1016/j.pan.2015.02.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [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: 12/10/2014] [Revised: 02/03/2015] [Accepted: 02/12/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pancreatic polypeptide (PP) is a hormone secreted by islet cells of the ventral pancreas. It has been proposed that a blunted PP response to a mixed meal can distinguish diabetes mellitus (DM) secondary to pancreatic disease from other types of DM. We performed a proof of concept study to determine if PP response to a mixed meal discriminates DM secondary to pancreatic cancer (PaCDM) from type 2 DM (T2DM). METHODS We studied 18 subjects with new onset DM (PaCDM (n = 9) and T2DM (n = 9); matched for age and gender). Serum PP levels were measured at 0, 30, and 60 min following a mixed meal. Increases in PP levels from baseline were compared using the Wilcoxon test. RESULTS In PaCDM the PP increase following a mixed meal was less than T2DM at 30 min (median 60.0%, IQR, 33.0-119.8 vs. 134.5%, IQR, 117.5-265.9; p = 0.03), but statistically similar at 60 min (median 55.8%, interquartile range (IQR) 23.7-121.5 vs. 100.0%, IQR, 47.7-202.5; p = 0.17). In PaCDM subjects, the PP increase over baseline was smaller in those with a tumor located in the pancreatic head (n = 6) compared to the body/tail (n = 3) at 30 min (41.3% vs. 158.7%, p = 0.02) and at 60 min (37.4% vs. 167.4%,p = 0.04). CONCLUSIONS Subjects with PaCDM have a blunted PP response to a mixed meal compared to T2DM. However, the blunted PP response is only observed in those PaC subjects with a tumor located in the head of the pancreas. Confirmation in larger studies may suggest this could be used to aid screening for sporadic PaC.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA; Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, OH, USA
| | - Esha Baichoo
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Yogish C Kudva
- Division of Endocrinology, Mayo Clinic Rochester, MN, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA.
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Das SLM, Kennedy JIC, Murphy R, Phillips ARJ, Windsor JA, Petrov MS. Relationship between the exocrine and endocrine pancreas after acute pancreatitis. World J Gastroenterol 2014; 20:17196-17205. [PMID: 25493036 PMCID: PMC4258592 DOI: 10.3748/wjg.v20.i45.17196] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [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: 03/19/2014] [Revised: 07/09/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the prevalence and time course of pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis.
METHODS: Relevant literature cited in three major biomedical journal databases (EMBASE, MEDLINE, and Scopus) was reviewed independently by two authors. There were no language constraints but the search was limited to human studies. Studies included were cohort studies of adult patients who were discharged after an attack of acute pancreatitis. Patients were excluded if they were under 18 years of age or had a previous diagnosis of prediabetes or diabetes mellitus, pancreatic exocrine insufficiency, or chronic pancreatitis. The main outcome measure was the prevalence of concomitant pancreatic exocrine insufficiency in patients who were diagnosed with prediabetes and diabetes mellitus after an attack of acute pancreatitis. Subgroup analysis was conducted for patients who were diagnosed with prediabetes only and those who were diagnosed with diabetes mellitus only. Subgroup analysis looking at the time course of concomitant pancreatic exocrine and endocrine insufficiency was also conducted. Pooled prevalence and corresponding 95% confidence intervals were calculated for all outcome measures and P-values < 0.05 were deemed statistically significant.
RESULTS: Eight clinical studies comprising of 234 patients met all eligibility criteria. The pooled prevalence of newly diagnosed prediabetes or diabetes in individuals after acute pancreatitis was 43% (95%CI: 30%-56%). The pooled prevalence of pancreatic exocrine insufficiency in individuals after acute pancreatitis was 29% (95%CI: 19%-39%). The prevalence of concomitant pancreatic exocrine insufficiency in individuals with newly diagnosed prediabetes or diabetes was 40% (95%CI: 25%-55%). The prevalence of concomitant pancreatic exocrine insufficiency among individuals with prediabetes alone and diabetes mellitus alone was 41% (95%CI: 12%-75%) and 39% (95%CI: 28%-51%), respectively. Further analysis showed that the prevalence of concomitant pancreatic exocrine insufficiency in individuals with prediabetes or diabetes decreases over time after an attack of acute pancreatitis.
CONCLUSION: Pancreatic exocrine insufficiency occurs in 40% of individuals with newly diagnosed prediabetes or diabetes mellitus after acute pancreatitis. Further studies are needed to investigate the pathogenesis of diabetes in this setting.
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Balzano G, Carvello M, Piemonti L, Nano R, Ariotti R, Mercalli A, Melzi R, Maffi P, Braga M, Staudacher C. Combined laparoscopic spleen-preserving distal pancreatectomy and islet autotransplantation for benign pancreatic neoplasm. World J Gastroenterol 2014; 20:4030-4036. [PMID: 24744593 PMCID: PMC3983459 DOI: 10.3748/wjg.v20.i14.4030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 11/24/2012] [Revised: 02/05/2013] [Accepted: 03/07/2013] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the safety and feasibility of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with autologous islet transplantation (AIT) for benign tumors of the pancreatic body-neck.
METHODS: Three non-diabetic, female patients (age 37, 44 and 35 years, respectively) were declared candidates for surgery, between May and September 2011, because of pancreatic body/neck cystic lesions. The planned operation was an LSPDP associated with AIT from the normal pancreas distal to the neoplasm. Islets isolation was performed on the residual pancreatic parenchyma after frozen section examination of the margin. Purified autologous islets were infused into the portal vein by a percutaneous transhepatic approach the day after surgery.
RESULTS: The procedure was performed successfully in all the three cases, and the spleen was preserved along with its vessels. Mean operation time was 283 ± 52 min and average blood loss was 133 ± 57 mL. Residual pancreas weights were 33, 22 and 30 g, and 105.200, 40.390 and 94.790 islet equivalents were isolated, respectively. Surgical complications occurred in one patient (grade A pancreatic fistula). Postoperative stays were 6, 6 and 7 d, respectively. Histopathological evaluation revealed mucinous cystic neoplasm in cases 1 and 3, and serous cystic neoplasm in patient 2. No postoperative insulin administration was required. One patient developed a transient partial portal thrombosis 2 mo after islet infusion. Patients are insulin independent at a mean follow up of 8 ± 2 mo.
CONCLUSION: Combination of LSPDP and AIT is feasible and could be effective to minimize the surgical impact for benign neoplasm of pancreatic body-neck.
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Ewald N, Hardt PD. Diagnosis and treatment of diabetes mellitus in chronic pancreatitis. World J Gastroenterol 2013; 19:7276-7281. [PMID: 24259958 PMCID: PMC3831209 DOI: 10.3748/wjg.v19.i42.7276] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [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: 06/10/2013] [Revised: 08/13/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
Diabetes secondary to pancreatic diseases is commonly referred to as pancreatogenic diabetes or type 3c diabetes mellitus. It is a clinically relevant condition with a prevalence of 5%-10% among all diabetic subjects in Western populations. In nearly 80% of all type 3c diabetes mellitus cases, chronic pancreatitis seems to be the underlying disease. The prevalence and clinical importance of diabetes secondary to chronic pancreatitis has certainly been underestimated and underappreciated so far. In contrast to the management of type 1 or type 2 diabetes mellitus, the endocrinopathy in type 3c is very complex. The course of the disease is complicated by additional present comorbidities such as maldigestion and concomitant qualitative malnutrition. General awareness that patients with known and/or clinically overt chronic pancreatitis will develop type 3c diabetes mellitus (up to 90% of all cases) is rather good. However, in a patient first presenting with diabetes mellitus, chronic pancreatitis as a potential causative condition is seldom considered. Thus many patients are misdiagnosed. The failure to correctly diagnose type 3 diabetes mellitus leads to a failure to implement an appropriate medical therapy. In patients with type 3c diabetes mellitus treating exocrine pancreatic insufficiency, preventing or treating a lack of fat-soluble vitamins (especially vitamin D) and restoring impaired fat hydrolysis and incretin secretion are key-features of medical therapy.
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Banerjee A, Onyuksel H. A novel peptide nanomedicine for treatment of pancreatogenic diabetes. Nanomedicine 2013; 9:722-8. [PMID: 23347897 DOI: 10.1016/j.nano.2012.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 12/26/2012] [Accepted: 12/31/2012] [Indexed: 01/25/2023]
Abstract
UNLABELLED Pancreatogenic diabetes (PD) is a potentially fatal disease that occurs secondary to pancreatic disorders. The current anti-diabetic therapy for PD is fraught with adverse effects that can increase morbidity. Here we investigated the efficacy of novel peptide nanomedicine: pancreatic polypeptide (PP) in sterically stabilized micelles (SSM) for management of PD. PP exhibits significant anti-diabetic efficacy but its short plasma half-life curtails its therapeutic application. To prolong and improve activity of PP in vivo, we evaluated the delivery of PP in SSM. PP-SSM administered to rats with PD, significantly improved glucose tolerance, insulin sensitivity and hepatic glycogen content compared to peptide in buffer. The studies established the importance of micellar nanocarriers in protecting enzyme-labile peptides in vivo and delivering them to target site, thereby enhancing their therapeutic efficacy. In summary, this study demonstrated that PP-SSM is a promising novel anti-diabetic nanomedicine and therefore should be further developed for management of PD. FROM THE CLINICAL EDITOR Pancreatic peptide was earlier demonstrated to address pancreatogenic diabetes, but its short half-life represented major difficulties in further development for therapeutic use. PP-SSM (pancreatic polypeptide in sterically stabilized micelles) is a promising novel anti-diabetic nanomedicine that enables prolonged half-life and increased bioactivity of PP, as shown in this novel study, paving the way toward clinical studies in the near future.
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Rickels MR, Bellin M, Toledo FG, Robertson RP, Andersen DK, Chari ST, Brand R, Frulloni L, Anderson MA, Whitcomb DC; PancreasFest Recommendation Conference Participants. Detection, evaluation and treatment of diabetes mellitus in chronic pancreatitis: recommendations from PancreasFest 2012. Pancreatology 2013; 13:336-42. [PMID: 23890130 DOI: 10.1016/j.pan.2013.05.002] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 05/06/2013] [Accepted: 05/07/2013] [Indexed: 02/07/2023]
Abstract
DESCRIPTION Diabetes and glucose intolerance are common complications of chronic pancreatitis, yet clinical guidance on their detection, classification, and management is lacking. METHODS A working group reviewed the medical problems, diagnostic methods, and treatment options for chronic pancreatitis-associated diabetes for a consensus meeting at PancreasFest 2012. RESULTS Guidance Statement 1.1: Diabetes mellitus is common in chronic pancreatitis. While any patient with chronic pancreatitis should be monitored for development of diabetes, those with long-standing duration of disease, prior partial pancreatectomy, and early onset of calcific disease may be at higher risk. Those patients developing diabetes mellitus are likely to have co-existing pancreatic exocrine insufficiency. Guidance Statement 1.2: Diabetes occurring secondary to chronic pancreatitis should be recognized as pancreatogenic diabetes (type 3c diabetes). Guidance Statement 2.1: The initial evaluation should include fasting glucose and HbA1c. These tests should be repeated annually. Impairment in either fasting glucose or HbA1c requires further evaluation. Guidance Statement 2.2: Impairment in either fasting glucose or HbA1c should be further evaluated by a standard 75 g oral glucose tolerance test. Guidance Statement 2.3: An absent pancreatic polypeptide response to mixed-nutrient ingestion is a specific indicator of type 3c diabetes. Guidance Statement 2.4: Assessment of pancreatic endocrine reserve, and importantly that of functional beta-cell mass, should be performed as part of the evaluation and follow-up for total pancreatectomy with islet autotransplantation (TPIAT). Guidance Statement 3: Patients with pancreatic diabetes shall be treated with specifically tailored medical nutrition and pharmacologic therapies. CONCLUSIONS Physicians should evaluate and treat glucose intolerance in patients with pancreatitis.
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