Nationwide epidemiological survey of chronic pancreatitis in Japan

Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis

BACKGROUND

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.

METHODS

The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.

RESULTS

Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.

CONCLUSIONS

EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

Certain background factors exhibit an association with an increased risk for pancreatic calcification among Japanese male alcoholics

OBJECTIVE

This was a cross-sectional study conducted from April 2003 through March 2004 to investigate the background factors related to pancreatic calcification (PC) in male Japanese alcoholics.

METHODS AND RESULTS

Helical computed tomography examination revealed PC in 44 of 263 alcoholics, and this group was further divisible into 3 subgroups: "scant" (n = 24), "moderate" (n = 6), and "extensive" PC subgroups (n = 14). The extensive subgroup was associated with larger daily ethanol consumption (P = 0.05) and high-alcohol beverages, such as whisky (P = 0.02). The moderate subgroup was associated with a longer duration of habitual drinking (P = 0.04), whereas the scant PC group was associated with never having smoked (P = 0.05) and with low-alcohol beverages, such as beer (P = 0.09). None of the 40 subjects with inactive mitochondrial aldehyde dehydrogenase (ALDH2*2 allele) exhibited PC (P = 0.004). Heterozygous alcohol dehydrogenase 2 genotype (ADH2*1/2*2) exhibited an association with the scant subgroup (P = 0.02). The TG12 repeats in the cystic fibrosis transmembrane conductance regulator (CFTR) gene tended to have a weak association with PC.

CONCLUSION

Drinking behavior, smoking status, and genetic backgrounds are associated with PC and are likely to increase the risk for alcoholic chronic pancreatitis.

Prevalence and determinants of exocrine pancreatic insufficiency among older adults: results of a population-based study

OBJECTIVE

The prevalence and main determinants of exocrine pancreatic insufficiency were investigated in a large population-based sample of older adults by measuring pancreatic elastase-1 in stool.

MATERIAL AND METHODS

The study comprised 914 participants aged 50 to 75 years recruited by their general practitioner during a general health examination. All participants and their physicians were asked to fill out a standardized questionnaire which contained information on socio-demographic and lifestyle factors as well as medical history. Native stool was examined for pancreatic elastase-1 with a commercially available ELISA (ScheBo Tech, Giessen, Germany).

RESULTS

Overall, 524 women and 390 men aged 50 to 75 years (mean age 61.9 years) were included in the analysis. In total, 105 (11.5%) of the 914 subjects showed signs of exocrine pancreatic insufficiency (EPI) with =200 microg elastase-1/g stool, and 47 (5.1%) subjects showed signs of a severe exocrine pancreatic insufficiency (SEPI, < 100 microg elastase-1/g stool). There was a clear increase in EPI with age. Patients taking angiotensin-converting enzyme (ACE) inhibitors had a lower prevalence than subjects without this medication; these associations persisted after adjustment for covariates.

CONCLUSIONS

Prevalence of EPI increases with age and seems to be tentatively higher in men than in women. However, smoking seems to be an independent risk factor for EPI and SEPI whereas ACE-inhibitor intake might be a protective factor. The latter finding may even point to new options in the treatment of chronic pancreatitis.

Mutations N34S and P55S of the SPINK1 gene in patients with chronic pancreatitis or pancreatic cancer and in healthy subjects: a report from Finland

OBJECTIVE

Mutations in the Kazal type 1 serine protease inhibitor (SPINK1) gene have recently been associated with chronic pancreatitis (CP), an established risk factor for pancreatic cancer. The aim of this study was to investigate the frequency of the SPINK1 gene mutations (N34S and P55S) in patients with CP, or pancreatic cancer, and in healthy subjects in Finland.

MATERIAL AND METHODS

The N34S and P55S mutations were determined by PCR amplification followed by solid-phase minisequencing in 116 patients with CP and in 188 with pancreatic cancer. In patients with CP, alcohol was the aetiological factor in 87 (75%), pancreas divisum in 4 (3%), gallstones in 5 (5%) and 20 patients (17%) had an idiopathic disease; 459 healthy individuals were enrolled as controls.

RESULTS

The frequency of the N34S mutation was significantly higher in patients with CP (14/116, 12%) than in controls (12/459, 2.6%) (p<0.0001). There was no difference in the frequency of the P55S mutation between patients with CP (1/116, 0.9%) and controls (6/459, 1.3%). The N34S mutation was present in 9 (10%) out of 87 patients with alcoholic CP, and in 5 (25%) patients with idiopathic CP. No SPINK1 mutations were found in patients with CP caused by anatomical variations or gallstones. Among the 188 patients with a pancreatic malignant tumour, the N34S mutation was present in 7 cases (3.7%). The frequency of the N34S mutation in healthy controls in this study was significantly higher than earlier reported in other countries (p=0.03).

CONCLUSIONS

The SPINK1 N34S mutation was significantly associated with an increased risk of CP. The association of the N34S mutation with alcoholic CP was marginally stronger than in earlier studies, whereas in the Finnish population in general, this mutation was significantly more frequent than reported elsewhere.

Alcoholic pancreatitis

Without doubt, alcohol consumption is one of the most important considerations in adults with acute or chronic pancreatitis. Understanding chronic pancreatitis as a complex disorder in which complimentary factors are required for recurrent acute and late chronic pancreatitis to develop in subsets of patients is critical for the early diagnosis and management of these individuals. Recent pathophysiological and genetic findings represent the beginning of major diagnostic and treatment breakthroughs that are likely to continue for the foreseeable future. The information provided in this article should provide the physician with a fresh perspective and remind the clinician of the importance of an accurate and complete history, and the need to document the actual alcohol consumption, pattern of drinking, and raise appropriate concerns if signs of alcoholism are detected. If alcohol-associated pancreatitis is detected, then limitation of pancreatic damage, limitation of progression, or preventative intervention should become the major concern.

Susceptibility to pancreatitis related to PSTI/SPINK1 expression

This article summarized several observations on the role of pancreatic secretory trypsin inhibitor in the pancreas. Although it long has been suspected that endogenous pancreatic trypsin inhibitors protect against inadvertent activation of trypsinogen, this hypothesis has gained strength from recent biochemical investigations and genetic studies of populations suffering from chronic pancreatitis. There is now considerable evidence from clinical disease associations and burgeoning experimental models that some forms of pancreatitis may be the result of an imbalance between active pancreatic proteases and their inhibitors within the pancreas. Future studies should clarify the precise molecular interactions between enzymes and inhibitors and how these may be manipulated to prevent or treat pancreatitis.

Survey on chronic pancreatitis in the Asia-Pacific region

BACKGROUND AND AIMS

A survey was conducted of chronic pancreatitis (CP) in different countries in the Asia-Pacific region. The main objective of the survey was to generate a database containing information regarding the prevalence, etiology, clinical presentation, diagnostic work-up, and management of CP in the Asia-Pacific region.

METHODS

Data were collected from seven countries using a structured questionnaire. Expert participants were asked to respond to the questionnaire based on the data of patients with CP studied in their centers.

RESULTS

The prevalence of CP was found to be very high in southern India (114-200/100 000 population), in contrast to the low reported rate of 4.2/100 000 population in Japan. Alcohol was the most common etiological factor in Australia (95%) and Japan (54%) while idiopathic pancreatitis was the most common type in India (tropical pancreatitis) and China, accounting for approximately 70% of all cases of CP. Pain was the most common clinical feature. Diabetes and steatorrhea were uncommon. With regard to the diagnosis of CP, all the experts believed that a patient could be diagnosed as having CP in the presence of any one or more of the following: ductal changes on endoscopic retrograde cholangiopancreatography, a positive secretin test, pancreatic calcification, and endosonographic abnormalities suggestive of CP. Most experts suggested pancreatic enzymes and analgesics as initial medical therapy for pain relief in CP. Endotherapy was suggested as the therapy of choice if medical therapy failed. Surgery was offered only after the failure of endotherapy. Most experts agreed that research should focus on genetic abnormalities in CP and the role of endotherapy for pain relief.

CONCLUSION

The survey brought out the prevalent types and presentation of CP, common management practices, and also the shortcomings in the existing knowledge of CP in the Asia-Pacific region. These findings might help focus attention on the research priorities for CP in this region.

Tropical pancreatitis

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

Genetic testing in chronic pancreatitis

Genetic changes associated with some forms of chronic pancreatitis have been recently defined. There are three genes that play a role, each with a variety of genotypes and different pathologic mechanisms and clinical correlations. Selection of the appropriate diagnostic tests requires integration of the clinical and family history and the interpretation of results has a significant impact on genetic counseling for the patient and family. The relative significance of some variant alleles is still under investigation as they are common in the population and show low penetrance. Knowledge of the pathophysiology of each abnormal allele could lead the way towards more specific therapeutic options in the future.

The epidemiology of alcohol-induced pancreatitis

Although the association between alcohol and pancreatitis has been recognized for centuries, the precise magnitude of the impact of alcohol remains poorly quantified. Epidemiologic research on this condition has been seriously handicapped by several factors. Classifications are based on morphology rather than on etiology; the diagnostic differences between acute and chronic pancreatitis are imprecise and confusing; and coding by the International Classification of Diseases (ICD) has been inadequate. The current ICD (ICD-10), used in the United States since 1999, identifies alcohol-induced chronic pancreatitis as a separate code for the first time, an enhancement that will greatly improve the quality of data collected in current and future studies. Unfortunately, no code yet exists for acute alcoholic pancreatitis. Of the approximately 2.4 million deaths in the United States in 1999, pancreatitis was listed as the underlying cause for 3289 deaths, making it the 235th leading cause of death. Acute pancreatitis accounted for 84% of these deaths, and chronic pancreatitis the remaining 16%. Alcohol is a primary cause of both acute and chronic pancreatitis in most developed countries. About one-third of acute pancreatitis in the United States is alcohol-induced. In the United States and other developed countries, 60%-90% of chronic pancreatitis is alcohol induced. Both forms are more common in men. The development of chronic pancreatitis is proportional to the dose and duration of alcohol consumption (minimum, 6-12 years of approximately 80 g of alcohol per day). Autopsy studies reveal subclinical chronic pancreatitis in another 10% of alcohol abusers. Yet, since <10% of chronic alcoholics develop chronic pancreatitis, clearly other predisposing factors besides alcohol are involved. Genetic variability and environmental exposures, such as diet, are prime candidates for further investigation. To date, there have been few large epidemiological studies of alcoholic pancreatitis in the United States or other developed countries. Additional studies are needed to improve the quality of existing baseline epidemiologic data and allow better assessment of risk. Improved diagnostic precision, more complete and specific coding, and greater understanding of covariables and mechanisms would also advance the field.

Salivary gland involvement in chronic pancreatitis of various etiologies

OBJECTIVE

Both the pancreas and salivary glands show many histological and functional similarities. Recently, autoimmune pathogenesis has been postulated in some chronic pancreatitis cases. To examine whether a cell-mediated phenomenon involving the pancreas has a secondary effect on the salivary glands, we assessed the frequency of salivary gland dysfunction in patients with chronic pancreatitis of various etiologies.

METHODS

Function of the salivary glands was examined by sialochemistry and salivary gland scintigraphy in patients with chronic pancreatitis (n = 33), Sjogren's syndrome (n = 45), and controls (n = 28). Etiologies of chronic pancreatitis were alcoholic (19 cases), idiopathic (seven cases), and autoimmune (seven cases).

RESULTS

Concentrations of Na+, amylase, and beta2-microglobulin in saliva were investigated. In submandibular and parotid gland scintigraphy, time-activity curves were generated, and the ratios of peak count density and washout were calculated. Concentrations of Na+ in saliva of patients with idiopathic chronic pancreatitis and of beta2-microglobulin in saliva of patients with idiopathic and autoimmune chronic pancreatitis were significantly elevated than those of the control group. In submandibular and parotid gland scintigraphy, the peak count density ratio of patients with all chronic pancreatitis and washout ratio of patients with alcoholic and idiopathic chronic pancreatitis were significantly lower than those of the control group.

CONCLUSIONS

Salivary gland function was frequently impaired in the course of chronic pancreatitis of various etiologies. Salivary gland dysfunction might be the result of a common pathophysiological effect of alcohol in patients with alcoholic chronic pancreatitis and the aggressive immune mechanism against the pancreatic and the salivary ducts in patients with autoimmune and idiopathic chronic pancreatitis.

Acute and chronic pancreatitis--diseases on the rise: a study of hospital admissions in England 1989/90-1999/2000

BACKGROUND

The number of hospital admissions for acute and chronic pancreatitis increased in Britain from the 1960s to the 1980s.

AIMS

To determine time trends in acute and chronic pancreatitis for hospital admissions from 1989/90 to 1999/2000, mortality from 1979 to 1999, and various indices of alcohol consumption.

METHODS

Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics. Alcohol consumption data were obtained from the General Household Survey.

RESULTS

Between 1989/90 and 1999/2000, age-standardized hospital admission rates for acute pancreatitis increased by 43%, whilst those for chronic pancreatitis rose by 100%. The proportions of admissions requiring surgical operations increased for acute pancreatitis, but declined for chronic pancreatitis. Case fatality rates for acute pancreatitis declined, but mortality statistics showed no significant change. The proportion of women who drank more than 14 units of alcohol a week also increased.

CONCLUSIONS

There has been a steady increase in admission rates for both acute and chronic pancreatitis over the study period, and these conditions will become an increasingly important part of the workload of the gastroenterologist.

Clinical evaluation of oral administration of a cholecystokinin-A receptor antagonist (loxiglumide) to patients with acute, painful attacks of chronic pancreatitis: a multicenter dose-response study in Japan

INTRODUCTION

Cholecystokinin (CCK)-receptor antagonists have been found to markedly reduce the severity of pancreatitis and improve survival in experimental animal models of acute pancreatitis. CCK appears to play an important role in the development and progression of acute pancreatitis, and the recent development of CCK antagonists has provided a new approach to the treatment of acute pancreatitis in humans.

AIMS

The therapeutic efficacy of a CCK-A receptor antagonist, loxiglumide, in patients with painful acute attacks of chronic pancreatitis was evaluated.

METHODOLOGY

A multicenter dose-response controlled trial was conducted at 110 institutions in Japan from June 1993 to December 1994. Chronic pancreatitis was diagnosed for all patients on the basis of the Japanese criteria for chronic pancreatitis. Two-hundred seven patients were randomized to oral treatment with loxiglumide (300, 600, and 1,200 mg/d) or placebo for 4 weeks. The efficacy of treatment was evaluated on the basis of clinical symptoms, physical signs, and serum pancreatic enzyme levels. The groups were comparable with respect to age, sex, etiology, complications, and previous treatment.

RESULTS

The improvement rate of the abdominal and/or back pain was 46% in the loxiglumide 300-mg group, 59% in the 600-mg group, and 52% in the 1,200-mg group, and it was 36% in the placebo group (600 mg versus placebo: p < 0.05). The physical signs evaluated--abdominal tenderness and resistance--improved in all three loxiglumide groups, and the serum pancreatic amylase and trypsin levels decreased significantly in the 600-mg group (p < 0.05). The overall clinical improvement rate was 46% in the 300-mg loxiglumide group, 58% in the 600-mg group, and 52% in the 1,200-mg group, and it was 34% in the placebo group.

CONCLUSION

These results indicate that oral administration of loxiglumide may be useful in the treatment of patients with acute, painful attacks of chronic pancreatitis, and 600 mg/d is recommended as a beneficial dosage.

Chronic pancreatitis: Asia-Pacific consensus report

Current knowledge about chronic pancreatitis (CP) is limited and there is a particular dearth of information about the entity known as tropical pancreatitis. A consensus working party was convened by the Trustees of the Journal of Gastroenterology and Hepatology Foundation to conduct a systematic investigation into available evidence about the epidemiology, etiopathogenesis, diagnosis and management of CP. A literature search and formal survey of international experts in the field were used to assemble reliable evidence about these issues. The present review summarizes the results of the working party's findings and presents a series of practice guidelines to improve diagnosis, investigation and treatment of patients with CP, particularly those in the Asia-Pacific region. Areas for further research have also been identified.

Epidemiology of idiopathic cardiomyopathy in Japan: results from a nationwide survey

OBJECTIVE

To estimate the total number of patients with idiopathic cardiomyopathy in Japan and the prevalence of the disorder.

DESIGN

A nationwide epidemiological survey.

SETTING

Hospitals selected randomly from among all hospitals in Japan.

PATIENTS

Patients presenting with any of the three types of idiopathic cardiomyopathy: dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy.

MAIN OUTCOME MEASURES

The total number of patients in Japan was estimated using the sampling and response rates in each stratum with respect to hospital size. The second survey was conducted for patients reported in the first survey in order to obtain detailed information, including age, sex, and specific clinical data.

RESULTS

Estimated patient totals and 95% confidence intervals (CI) were 17 700 (95% CI 16 500 to 18 800) for dilated cardiomyopathy, 21 900 (95% CI 20 600 to 23 200) for hypertrophic cardiomyopathy, and 300 (95% CI 250 to 350) for restrictive cardiomyopathy. Crude prevalence per 100 000 population was estimated as 14.0 for dilated cardiomyopathy, 17.3 for hypertrophic cardiomyopathy, and 0.2 for restrictive cardiomyopathy; crude incidence per 100 000 person-years was estimated as 3.58, 4.14, and 0.06, respectively.

CONCLUSIONS

The total number and prevalence of patients with idiopathic cardiomyopathy in Japan are estimated for the first time in a nationwide survey. The prevalence of dilated cardiomyopathy in Japan appears to be about half that of Western populations, while that of hypertrophic cardiomyopathy is about the same.

Associations of alcohol drinking and nutrient intake with chronic pancreatitis: findings from a case-control study in Japan

OBJECTIVE

The aim of this study was to examine the association of alcohol drinking and nutrient intake with chronic pancreatitis in a hospital-based case-control study.

METHODS

From July, 1997, to December, 1998, 91 male patients, who were newly diagnosed as having chronic pancreatitis, were recruited as cases, and 175 controls were individually matched to each case for gender, age (+/-5 yr), hospital, and time of the first visit to a hospital (+/-1 yr). Information on demographic characteristics, smoking and drinking, and dietary habits were collected by a self-administered questionnaire. The strength of associations was examined by odds ratios (ORs) and 95% CIs calculated from conditional logistic regression models.

RESULTS

Our study showed that the more the daily amount of alcohol drinking, the larger the OR. Men who consumed > or =100 g ethanol/day were at an approximately 11-fold increased risk as compared with nondrinkers. Long-term alcohol consumption (>35 yr) was associated with the increased risk (OR = 4.0). Risk of chronic pancreatitis remarkably increased with increasing cumulative alcohol consumption (trend p = 0.0001). Intakes of saturated fatty acid and vitamin E were negatively associated with the risk (trend p = 0.05 for saturated fatty acid and 0.03 for vitamin E).

CONCLUSION

Our study clearly demonstrated that prolonged heavy alcohol consumption was an important and independent risk factor, and suggested a role of lower nutrient intakes in the development of chronic pancreatitis.

Chronic pancreatitis: diagnosis, classification, and new genetic developments

The utilization of recent advances in molecular and genomic technologies and progress in pancreatic imaging techniques provided remarkable insight into genetic, environmental, immunologic, and pathobiological factors leading to chronic pancreatitis. Translation of these advances into clinical practice demands a reassessment of current approaches to diagnosis, classification, and staging. We conclude that an adequate pancreatic biopsy must be the gold standard against which all diagnostic approaches are judged. Although computed tomography remains the initial test of choice for the diagnosis of chronic pancreatitis, the roles of endoscopic retrograde pancreatography, endoscopic ultrasonography, and magnetic resonance imaging are considered. Once chronic pancreatitis is diagnosed, proper classification becomes important. Major predisposing risk factors to chronic pancreatitis may be categorized as either (1) toxic-metabolic, (2) idiopathic, (3) genetic, (4) autoimmune, (5) recurrent and severe acute pancreatitis, or (6) obstructive (TIGAR-O system). After classification, staging of pancreatic function, injury, and fibrosis becomes the next major concern. Further research is needed to determine the clinical and natural history of chronic pancreatitis developing in the context of various risk factors. New methods are needed for early diagnosis of chronic pancreatitis, and new therapies are needed to determine whether interventions will delay or prevent the progression of the irreversible damage characterizing end-stage chronic pancreatitis.