Chronic pancreatitis

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection

The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.

Ethanol exposure of human pancreatic normal ductal epithelial cells induces EMT phenotype and enhances pancreatic cancer development in KC (Pdx1-Cre and LSL-KrasG12D ) mice

Alcohol is a risk factor for pancreatic cancer. However, the molecular mechanism by which chronic alcohol consumption influences pancreatic cancer development is not well understood. We have recently demonstrated that chronic ethanol exposure of pancreatic normal ductal epithelial cells (HPNE) induces cellular transformation by generating cancer stem cells (CSCs). Here, we examined whether chronic ethanol treatment induces epithelial–mesenchymal transition in HPNE cells and promotes pancreatic cancer development in KC (Pdx1‐Cre, and LSL‐Kras^G12D) mice. Our data demonstrate that chronic ethanol exposure of HPNE cells induces SATB2 gene and those cells became highly motile. Ethanol treatment of HPNE cells results in downregulation of E‐Cadherin and upregulation of N‐Cadherin, Snail, Slug, Zeb1, Nanog and BMI‐1. Suppression of SATB2 expression in ethanol‐transformed HPNE cells inhibits EMT phenotypes. KC mice fed with an ethanol‐containing diet show enhanced pancreatic cancer growth and development than those fed with a control diet. Pancreas isolated from KC mice fed with an ethanol‐containing diet show higher expression of stem cell markers (CD133, CD44, CD24), pluripotency‐maintaining factors (cMyc, KLF4, SOX‐2, and Oct‐4), N‐Cadherin, EMT‐transcription factors (Snail, Slug, and Zeb1), and lower expression of E‐cadherin than those isolated from mice fed with a control diet. Furthermore, pancreas isolated from KC mice fed with an ethanol‐containing diet show higher expression of inflammatory cytokines (TNF‐α, IL‐6, and IL‐8) and PTGS‐2 (COX‐2) gene than those isolated from mice fed with a control diet. These data suggest that chronic alcohol consumption may contribute to pancreatic cancer development by generating inflammatory signals and CSCs.

Reduced pancreatic polypeptide response is associated with early alteration of glycemic control in chronic pancreatitis

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.

Chronic ethanol exposure of human pancreatic normal ductal epithelial cells induces cancer stem cell phenotype through SATB2

The incidence of pancreatic cancer is on the rise. Risk factors for pancreatic cancer include alcohol toxicity and metabolic conditions such as obesity, hypertension, dyslipidaemia, insulin resistance and type 2 diabetes. However, the molecular mechanism by which chronic alcohol consumption contributes to pancreatic cancer is not well understood. The purpose of the study was to demonstrate the effects of long-term chronic ethanol exposure on the transformation of human pancreatic normal ductal epithelial (HPNE) cells. Our data showed that ethanol-transformed HPNE cells were more progressively transformed exhibiting spheroids and colonies, and anchorage-independent growth. These transformed cells contained high levels of reactive oxygen species and induced SATB2 expression. Furthermore, during ethanol-induced cellular transformation, cells gained the phenotypes of cancer stem cells (CSCs) by expressing pluripotency maintaining factors (Oct4, Sox2, cMyc and KLF4) and stem cell markers (CD24, CD44 and CD133). Ethanol-induced SATB2 can bind to the promoters of KLF4, Oct4, cMyc, Sox2, Bcl-2 and XIAP genes. Suppression of SATB2 expression in ethanol-transformed HPNE cells inhibited cell proliferation, colony formation and markers of CSCs and pluripotency. These data suggest that chronic alcohol consumption may contribute toward the development of pancreatic cancer by converting HPNE cells to cancer stem-like cells.

Chronic pancreatitis: Multicentre prospective data collection and analysis by the Hungarian Pancreatic Study Group

INTRODUCTION

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life.

AIMS AND METHODS

Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions.

RESULTS

Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004).

CONCLUSIONS

According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.

Model-based iterative reconstruction and adaptive statistical iterative reconstruction: dose-reduced CT for detecting pancreatic calcification

Background

Iterative reconstruction methods have attracted attention for reducing radiation doses in computed tomography (CT).

Purpose

To investigate the detectability of pancreatic calcification using dose-reduced CT reconstructed with model-based iterative construction (MBIR) and adaptive statistical iterative reconstruction (ASIR).

Material and Methods

This prospective study approved by Institutional Review Board included 85 patients (57 men, 28 women; mean age, 69.9 years; mean body weight, 61.2 kg). Unenhanced CT was performed three times with different radiation doses (reference-dose CT [RDCT], low-dose CT [LDCT], ultralow-dose CT [ULDCT]). From RDCT, LDCT, and ULDCT, images were reconstructed with filtered-back projection (R-FBP, used for establishing reference standard), ASIR (L-ASIR), and MBIR and ASIR (UL-MBIR and UL-ASIR), respectively. A lesion (pancreatic calcification) detection test was performed by two blinded radiologists with a five-point certainty level scale.

Results

Dose-length products of RDCT, LDCT, and ULDCT were 410, 97, and 36 mGy-cm, respectively. Nine patients had pancreatic calcification. The sensitivity for detecting pancreatic calcification with UL-MBIR was high (0.67–0.89) compared to L-ASIR or UL-ASIR (0.11–0.44), and a significant difference was seen between UL-MBIR and UL-ASIR for one reader (P = 0.014). The area under the receiver-operating characteristic curve for UL-MBIR (0.818–0.860) was comparable to that for L-ASIR (0.696–0.844). The specificity was lower with UL-MBIR (0.79–0.92) than with L-ASIR or UL-ASIR (0.96–0.99), and a significant difference was seen for one reader (P < 0.01).

Conclusion

In UL-MBIR, pancreatic calcification can be detected with high sensitivity, however, we should pay attention to the slightly lower specificity.

Prevalence of exocrine pancreatic insufficiency in type 2 diabetes mellitus with poor glycemic control

OBJECTIVES

To evaluate the relationship between exocrine pancreatic insufficiency and the level of glycemic control in diabetes (DM).

METHODS

Patients with type 2 DM treated in our clinic were prospectively recruited into the study. Pancreatic diabetes was excluded. Cases with HbA1c ≥7% formed Group A (n = 59), and with HbA1c <7% Group B (n = 42). The fecal level of pancreatic elastase (PE-1) was measured and morphological examinations of the pancreas were performed.

RESULTS

The PE-1 level was significantly lower in Group A than in Group B (385.9 ± 171.1 μg/g, vs. 454.6 ± 147.3 μg/g, p = 0.038). The PE-1 level was not correlated with HbA1c (r = -0.132, p = 0.187), the duration of DM (r = -0.046, p = 0.65), age (r = 0.010, p = 0.921), BMI (r = 0.203, p = 0.059), or pancreatic steatosis (r = 0.117, p = 0.244). The size of the pancreas did not differ significantly between Groups A and B.

CONCLUSIONS

An exocrine pancreatic insufficiency demonstrated by fecal PE-1 determination is more frequent in type 2 DM patients with poor glycemic control. The impaired exocrine pancreatic function cannot be explained by an alteration in the size of the pancreas or by pancreatic steatosis.

Quantification of pancreatic function using a clinically feasible short endoscopic secretin test

OBJECTIVES

Clinical and morphological criteria are not precise enough to diagnose early chronic pancreatitis (CP). We investigated if short endoscopic pancreas function testing as a part of routine upper endoscopy could improve clinical diagnostics.

METHODS

Patients with suspected CP underwent modified secretin-stimulated upper endoscopy (short endoscopic secretin test, or EST). Duodenal juice was collected during 15 minutes starting 30 minutes after stimulation. A modified scoring system for CP after Layer with bicarbonate and fecal elastase 1 (FE1) was used. We tested with receiver operating characteristic curves the diagnostic accuracy of bicarbonate and FE1 and with analysis of variance how precise the 2 parameters can discriminate the groups.

RESULTS

Fifty-two patients aged 19 to 67 years and 25 healthy controls aged 19 to 64 years were included. Twenty-four patients fulfilled the modified Layer Score for CP or non-CP. The overall accuracy of the EST versus FE1 test was 85%/71%, with positive and negative predictive values of 100%/79% and 80%/69%, respectively.

CONCLUSIONS

Short EST is rapid and easy to perform and can be incorporated in daily routines. We demonstrate that EST is superior to FE1 in the assessment of pancreatic insufficiency and may prove to be useful in diagnosing early or mild CP.

Clinical strategies for differentiating autoimmune pancreatitis from pancreatic malignancy to avoid unnecessary surgical resection

OBJECTIVE

The study aimed to determine a practical strategy for differentiating between autoimmune pancreatitis (AIP) and pancreatic malignancy in order to avoid unnecessary surgical resection.

METHODS

Altogether, 19 patients with AIP or other pancreatic diseases underwent routine examinations including liver function test and carbohydrate antigen 19-9, computed tomography and/or magnetic resonance imaging. Serum immunoglobulin G (IgG) and/or IgG4 was determined in patients with clinically suspected or pathologically proven AIP. Patients with suspected AIP either received diagnostic steroid therapy or laparotomy (if malignant tumors could not be excluded). Surgery was not performed in patients with a definite diagnosis of AIP by fast intraoperative frozen biopsy. Those with confirmed AIP received steroid treatment.

RESULTS

In total, 15 cases were finally confirmed as AIP with eight diagnosed preoperatively, five confirmed by surgical pathology (preoperatively misdiagnosed) and two by intraoperative biopsy. Of these 15 patients with AIP and one without AIP, 14 had elevated serum γ-globulin levels. It was proven by subsequent antibody tests that serum IgG or IgG4 were simultaneously increased.

CONCLUSIONS

Elevated serum γ-globulin level can be used as a preoperative sentinel indicator for differentiating between IgG4-related AIP and pancreatic malignancy. Serum IgG or IgG4 tests should be further performed in those with elevated serum γ-globulin level, which helps to identify AIP in order to avoid unnecessary operation.

Diarrhoea due to pancreatic diseases

The exocrine pancreas provides essential digestive enzymes necessary for the proper breakdown and absorption of ingested food in humans. Any disruption of this process can lead to malabsorption and resultant diarrhoea. Typically, disruption of over 90 percent of the pancreatic parenchyma is needed to result in diarrhoea. This disruption can result from widespread pancreatic necrosis in acute pancreatitis, fibrotic replacement of the parenchyma as seen in chronic pancreatitis and in patients with pancreatic cancer where normal tissue is replaced by tumour and/or the pancreatic duct becomes obstructed. Several uncommon tumours of the pancreas can also cause diarrhoea through the secretion of hormones. This article will explore each of these diseases, including the pathogenesis and treatment.

Definitions of pediatric pancreatitis and survey of present clinical practices

OBJECTIVES

There is limited literature on acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP) in children. The International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE) consortium was formed to standardize definitions, develop diagnostic algorithms, investigate disease pathophysiology, and design prospective multicenter studies in pediatric pancreatitis.

METHODS

Subcommittees were formed to delineate definitions of pancreatitis, and a survey was conducted to analyze present practice.

RESULTS

AP was defined as requiring 2 of the following: abdominal pain compatible with AP, serum amylase and/or lipase values ≥3 times upper limits of normal, and imaging findings of AP. ARP was defined as ≥2 distinct episodes of AP with intervening return to baseline. CP was diagnosed in the presence of typical abdominal pain plus characteristic imaging findings, or exocrine insufficiency plus imaging findings, or endocrine insufficiency plus imaging findings. We found that children with pancreatitis were primarily managed by pediatric gastroenterologists. Unless the etiology was known, initial investigations included serum liver enzymes, triglycerides, calcium, and abdominal ultrasound. Further investigations (usually for ARP and CP) included magnetic resonance or other imaging, sweat chloride, and genetic testing. Respondents' future goals for INSPPIRE included determining natural history of pancreatitis, developing algorithms to evaluate and manage pancreatitis, and validating diagnostic criteria.

CONCLUSIONS

INSPPIRE represents the first initiative to create a multicenter approach to systematically characterize pancreatitis in children. Future aims include creation of patient database and biologic sample repository.

Insulin-like growth factor axis gene polymorphisms modify risk of pancreatic cancer

OBJECTIVE

Insulin-like growth factor (IGF)-axis genes plays a critical role in cancer development and progression via their impact on the RAS/MAPK/ERK and PI3K/AKT/mTOR signaling pathways. We hypothesized that IGF-axis genetic variants modify individual susceptibility to pancreatic cancer.

METHODS

We retrospectively genotyped 41 single-nucleotide polymorphisms of 10 IGF-axis genes (IGF1, IGF2, IGF1R, IGF2R, IGFBP1, IGFBP3, IGFBP5, IRS1, IRS2, and IRS4) in 706 pancreatic cancer patients and 706 cancer-free controls using Sequenom and TaqMan technology. The association between genotype and pancreatic cancer risk was evaluated using multivariate logistic regression. A P value ≤.007 at a false discovery rate of 10% was set as the significance level.

RESULTS

We observed that the IGF1 *10212C>A and Ex4+2776G>A and IGF1R IVS2-70184A>G and IVS2+46329T>C variant genotypes were significantly associated with decreased pancreatic cancer risk (odds ratio [OR] range, 0.60-0.75) and that IGFBP1 Ex4+111A>G (I253M) was significantly associated with increased pancreatic cancer risk (OR=1.46) after adjusted for other risk factors and multiple comparisons (P≤.007). IGF2R and IGFBP3 variant haplotypes were associated with increased and decreased pancreatic cancer risk, respectively (P<.001). We also observed a weak interaction of the IGF1R IVS2+46329T>C and IGF2R Ex45+11C>T (L2222L) genotypes with diabetes (P(interaction)=.05) and interaction of IGF2R and IRS1 genotypes with alcohol consumption (P(interaction)=.03 and .019, respectively) on increased pancreatic cancer risk.

CONCLUSION

These findings support our hypothesis that polymorphic variants of IGF-axis genes act alone or jointly with other risk factors to affect susceptibility to pancreatic cancer.

Improved glycemic control in pancreatic diabetes through intensive conservative insulin therapy

OBJECTIVE

The aim of this study was to evaluate the effectivity and safety of insulin therapy in patients with DM secondary to underlying chronic pancreatitis with initially inappropriate glycemic control.

METHODS

Pancreatic DM patients treated with oral antidiabetics (OAD) or pre-mixed insulin (PMI) with HbA1c ≥7.0% were recruited. Intensive conservative insulin treatment (ICT) (Group A, n = 16) or PMI (Group B, n = 8) was introduced instead of OAD, or the initial PMI therapy was switched to ICT (Group C, n = 10). The changes in HbA1c, fasting plasma glucose, body weight and hypoglycemic events from baseline to 2 years were followed.

RESULTS

The patients in Group A and B had been treated with oral antidiabetics for 55 ± 68 months before switching to insulin therapy. The level of HbA1c had worsened from 8.3 ± 1.5% to 9.8 ± 1.7% during this period. The ICT had reduced HbA1c significantly from 9.7 ± 1.8% to 7.6 ± 1.4% after 12 weeks, in Group A, and five patients had HbA1c<7.0%. The introduction of PMI in Group B reduced HbA1c from 10.0 ± 1.4% to 9.0 ± 0.6% by 12 weeks. None of the patients had HbA1c<7.0%. By 12 weeks, the introduction of ICT in Group C had reduced the level of HbA1c from 8.8 ± 1.7% to 7.7 ± 1.2%. Two patients reached HbA1c<7.0%. There were two severe hypoglycemic episodes during the 2 years, one-one case in Group A and B.

CONCLUSIONS

Oral medication becomes insufficient early in pancreatic DM. Long-term improvement of glycemic control can be achieved through intensified insulin therapy and in selected cases through PMI with a low risk of hypoglycemia.

Chronic pancreatitis: an update for home care and hospice clinicians

Chronic pancreatitis is a relentlessly painful condition associated most commonly with alcoholism. Patients suffer wasting and depression as a result of chronic pain. It is important for home care clinicians to recognize the signs of pancreatitis and understand the current evidence-based treatment strategies to control the symptoms. Although alcoholism and depression are frequent comorbidities of pancreatitis, a full discussion of alcoholism and depression is outside the scope of this article.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the past year.

RECENT FINDINGS

Tropical pancreatitis associates with SPINK1 and/or CFTR gene mutations in approximately 50% of patients, similar to the frequency in idiopathic chronic pancreatitis. Corticosteroids increase secretin-stimulated pancreatic bicarbonate concentrations in autoimmune pancreatitis (AIP) by restoring mislocalized CFTR protein to the apical ductal membrane. Most patients with asymptomatic hyperenzymemia have pancreatic lesions of unclear significance or no pancreatic lesions. Common pitfalls in the use of diagnostic tests for exocrine pancreatic insufficiency (EPI) confound interpretation of findings in irritable bowel syndrome and severe renal insufficiency. Further study is needed to improve the accuracy of endoscopic ultrasonography (EUS) to diagnose chronic pancreatitis. Celiac plexus block provides short-term pain relief in a subset of patients.

SUMMARY

Results of this year's investigations further elucidated the genetic associations of tropical pancreatitis, a reversible mislocalization of ductal CFTR in AIP, the association of asymptomatic pancreatic hyperenzymemia with pancreatic disorders, limitations of diagnostic tests for EPI, diagnosis of chronic pancreatitis by EUS and endoscopic pancreatic function testing and treatment of pain.

Alcoholic acute pancreatitis: pathogenesis and clinical characteristics

Animal and clinical studies have shown that alcohol and its metabolic products, endotoxin, viral infection, drinking pattern, smoking, obesity, genetic variability, and gene polymorphisms were very important in the pathogenesis of alcoholic acute pancreatitis (AAP). The morbidity of AAP has been increased in the past decade, and male gender is strongly associated with increased risk of AAP. The mortality of AAP is high, while the quality of life of survivors of severe AAP is low. In this paper, we review the pathogenesis and clinical characteristics of AAP.