Pancreas stiffness in liver cirrhosis is an indicator of insulin secretion caused by portal hypertension and pancreatic congestion

Pancreatic congestion is associated with exocrine pancreatic function in liver cirrhosis

AIM

Portal hypertension resulting from liver cirrhosis (LC) can lead to pancreatic congestion and impaired insulin secretion. Therefore, this prospective study aimed to assess the association between pancreatic congestion and exocrine pancreatic function in patients with LC.

METHODS

In our clinical study, pancreatic congestion and exocrine pancreatic function were evaluated using shear wave dispersion (SWD) and fecal elastase-1 (FE-1). Additionally, pancreatic acinar cells, venous walls, and fibrosis were assessed in an autopsy study.

RESULTS

The FE-1 levels were lower in the LC group (n = 41) than in the control group (n = 41) (312 ± 89 vs. 442 ± 100 μg/g, p < 0.001). The LC group included six patients (14.6%) with exocrine pancreatic insufficiency, whereas there were none in the control group. Pancreatic SWD values were significantly higher in the LC group than in the control group (14.8 ± 2.3 vs. 10.0 ± 1.28 [m/s]/kHz, p < 0.001). Fecal elastase-1 was significantly negatively correlated with pancreatic SWD (R = -0.55, p < 0.001). As for the autopsy study, the percentage of the trypsin-positive area was significantly lower in the LC group (n = 11) than in the control group (n = 10) (38.1 ± 10.1% vs. 26.5 ± 3.0%, p = 0.0055). The percentage of trypsin-positive area was significantly negatively correlated with the wall thickness of the pancreatic vein (R = -0.76, p < 0.001).

CONCLUSIONS

Exocrine pancreatic function was reduced and significantly correlated with pancreatic congestion in patients with LC. Portal hypertension may affect the exocrine pancreatic function.

Unraveling the mechanisms of hepatogenous diabetes and its therapeutic perspectives

The review focused mainly on the pathogenesis of hepatogenous diabetes (HD) in liver cirrhosis (LC). This review reveals parallels between the mechanisms of metabolic dysfunction observed in LC and type II diabetes (T2DM), suggesting a shared pathway leading to HD. It underscores the role of insulin in HD pathogenesis, highlighting key factors such as insulin signaling, glucose metabolism, insulin resistance (IR), and the influence of adipocytes. Furthermore, the impact of adipose tissue accumulation, fatty acid metabolism, and pro-inflammatory cytokines like Tumor necrosis factor-α (TNF-α) on IR are discussed in the context of HD. Altered signaling pathways, disruptions in the endocrine system, liver inflammation, changes in muscle mass and composition, and modifications to the gut microbiota collectively contribute to the complex interplay linking cirrhosis and HD. This study highlights how important it is to identify and treat this complex condition in cirrhotic patients by thoroughly analyzing the link between cirrhosis, IR, and HD. It also emphasizes the vitality of targeted interventions. Cellular and molecular investigations into IR have revealed potential therapeutic targets for managing and preventing HD.

Ultrasonographic Assessment of Tissue Stiffness: Recent Progress in Transient Elastography and Shear Wave Elastography in the Liver and Various Organs

Ultrasonography is a noninvasive and widely accessible modality in clinical practice. Recently, ultrasonography has been used to evaluate tissue stiffness; the two representative techniques are transient elastography (FibroScan®) and shear wave elastography. These modalities are now generally used for the assessment of liver fibrosis, the prediction of hepatocarcinogenesis, and determining prognosis. In addition, shear wave elastography is available, not only for the liver but also for various other organs, including the breast and brain. In the breast and brain, shear wave elastography distinguishes malignant lesions from benign ones. Moreover, shear wave elastography can be useful for differentiating between ischemic and hemorrhagic strokes. This review summarizes the recent progress in transient elastography and shear wave elastography of the liver and introduces the advantages of ultrasonographic assessment of tissue stiffness in various organs, including the breast, brain, kidney, heart, thyroid, pancreas, muscle, and bone.

The feasibility of point shear wave elastography (pSWE) in the assessment of pancreas stiffness in diabetic patients and healthy volunteers

Type 1 diabetes mellitus (T1DM) is an autoimmune disease characterized by the dysfunctional metabolism of carbohydrates, fats, and proteins caused by impaired insulin secretion and insulin resistance. This study investigated the feasibility of using point shear wave elastography (pSWE) of the pancreas by comparing the shear wave velocity (SWV) measurements of three anatomical areas in patients with T1DM and healthy volunteers. This study included 30 patients with T1DM (9 male, 21 female) and 23 healthy controls (11 men, 12 women). Two experienced certified operators performed the examinations and took the SWV measurements. The mean SWV of the entire pancreas parenchyma differed significantly between patients and controls (1.1 ± 0.29 and 0.74 ± 0.19 m/s, respectively; p ≤ 0.001). Moreover, the SWVs of the pancreatic segments were significantly different in patients and controls; the mean SWV values of the pancreas head, body, and tail (respectively) in patients vs. controls were 0.99 ± 0.36 vs. 0.76 ± 0.26 m/s (p  = 0.012), 1.1 ± 0.52 vs. 0.74 ± 0.23 (p ≤ 0.001), and 1.0 ± 0.34 vs. 0.73 ± 0.28 (p  ≤ 0.001). This study confirmed the feasibility of quantifying pancreas tissue stiffness with pSWE and revealed that patients with T1DM had higher pancreas tissue stiffness than controls. Further studies are required to determine the potential value of pSWE as a screening tool in patients with prediabetes.

MR Elastography of the Pancreas: Bowel Preparation and Repeatability Assessment in Pancreatic Cancer Patients and Healthy Controls

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) stromal viscoelasticity can be measured using MR elastography (MRE). Bowel preparation regimens could affect MRE quality and knowledge on repeatability is crucial for clinical implementation.

PURPOSE

To assess effects of four bowel preparation regimens on MRE quality and to evaluate repeatability and differentiate patients from healthy controls.

STUDY TYPE

Prospective.

POPULATION

15 controls (41 ± 16 years; 47% female), 16 PDAC patients (one excluded, 66 ± 12 years; 40% female) with 15 age-/sex-matched controls (65 ± 11 years; 40% female). Final sample size was 25 controls and 15 PDAC.

FIELD STRENGTH/SEQUENCE

3-T, spin-echo echo-planar-imaging, turbo spin-echo, and fast field echo gradient-echo.

ASSESSMENT

Four different regimens were used: fasting; scopolaminebutyl; drinking 0.5 L water; combination of 0.5 L water and scopolaminebutyl. MRE signal-to-noise ratio (SNR) was compared between all regimens. MRE repeatability (test-retest) and differences in shear wave speed (SWS) and phase angle (ϕ) were assessed in PDAC and controls. Regions-of-interest were defined for tumor, nontumorous (n = 8) tissue in PDAC, and whole pancreas in controls. Two radiologists delineated tumors twice for evaluation of intraobserver and interobserver variability.

STATISTICAL TESTS

Repeated measures analysis of variance, coefficients of variation (CoVs), Bland-Altman analysis, (un)paired t-test, Mann-Whitney U-test, and Wilcoxon signed-rank test. P-value<0.05 was considered statistically significant.

RESULTS

Preparation regimens did not significantly influence MRE-SNR. Therefore, the least burdensome preparation (fasting only) was continued. CoVs for tumor SWS were: intrasession (12.8%) and intersession (21.7%), and intraobserver (7.9%) and interobserver (10.3%) comparisons. For controls, CoVs were intrasession (4.6%) and intersession (6.4%). Average SWS for tumor, nontumor, and healthy tissue were: 1.74 ± 0.58, 1.38 ± 0.27, and 1.18 ± 0.16 m/sec (ϕ: 1.02 ± 0.17, 0.91 ± 0.07, and 0.85 ± 0.08 rad), respectively. Significant differences were found between all groups, except for ϕ between healthy-nontumor (P = 0.094).

DATA CONCLUSION

The proposed bowel preparation regimens may not influence MRE quality. MRE may be able to differentiate between healthy tissue-tumor and tumor-nontumor.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 2.

Liver resection volume-dependent pancreatic strain following living donor hepatectomy

The liver and pancreas work together to recover homeostasis after hepatectomy. This study aimed to investigate the effect of liver resection volume on the pancreas. We collected clinical data from 336 living liver donors. They were categorized into left lateral sectionectomy (LLS), left lobectomy, and right lobectomy (RL) groups. Serum pancreatic enzymes were compared among the groups. Serum amylase values peaked on postoperative day (POD) 1. Though they quickly returned to preoperative levels on POD 3, 46% of cases showed abnormal values on POD 7 in the RL group. Serum lipase levels were highest at POD 7. Lipase values increased 5.7-fold on POD 7 in the RL group and 82% of cases showed abnormal values. The RL group's lipase was twice that of the LLS group. A negative correlation existed between the remnant liver volume and amylase (r = - 0.326)/lipase (r = - 0.367) on POD 7. Furthermore, a significant correlation was observed between POD 7 serum bilirubin and amylase (r = 0.379)/lipase (r = 0.381) levels, indicating cooccurrence with liver and pancreatic strain. Pancreatic strain due to hepatectomy occurs in a resection/remnant liver volume-dependent manner. It would be beneficial to closely monitor pancreatic function in patients undergoing a major hepatectomy.

Intravoxel incoherent motion diffusion-weighted imaging for evaluating the pancreatic perfusion in cirrhotic patients

PURPOSE

To assess the characteristics of pancreatic perfusion in normal pancreas versus cirrhotic patients using intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI).

METHODS

A total of 67 cirrhotic patients and 33 healthy subjects underwent IVIM on a 3.0 T MRI scanner. Diffusion coefficient (ADCslow), pseudo-diffusion coefficient (ADCfast), and perfusion fraction (f) were calculated based on the bi-exponential model. The pancreatic IVIM-derived parameters were then compared. In the cirrhotic group, the relationship was analyzed between IVIM-derived pancreatic parameters and different classes of hepatic function as determined by the Child-Pugh classification. Also, the pancreatic IVIM-derived parameters were compared among different classes of cirrhosis as determined by the Child-Pugh classification.

RESULTS

The f value of the pancreas in cirrhotic patients was significantly lower than that in normal subjects (p = 0.01). In the cirrhotic group, the f value of the pancreas decreased with the increase of the Child-Pugh classification (R = - 0.49, p = 0.00). The f value of the pancreas was significantly higher in Child-Pugh class A patients than in class B and C patients (p = 0.02, 0.00, respectively), whereas there was no significant difference between class B and C patients (p = 0.16).

CONCLUSION

The IVIM-derived perfusion-related parameter (f value) could be helpful for the evaluation of pancreatic perfusion in liver cirrhosis. Our data also suggest that the blood perfusion decrease in the pancreas is present in liver cirrhosis, and the pancreatic perfusion tends to decrease with the increasing severity of hepatic function.

TRIAL REGISTRATION

Trial registration number is 2021-ky-68 and date of registration for prospectively registered trials is February 23, 2022.

Clinical significance of dispersion imaging by shear wave elastography in the treatment and diagnosis of pancreatic cancer

BACKGROUND AND AIM

Recently, dispersion imaging by shear wave elastography has been developed to visualize a tissue viscosity-related factor by measuring the dispersion slope. However, clinical significance of dispersion imaging in the field of pancreatic cancer is unknown. This study aimed to investigate the clinical significance of dispersion imaging in the treatment and diagnosis of pancreatic cancer.

METHODS

We measured shear wave dispersion slope (SWD) (m/s/kHz) and shear wave elasticity (SWE) (kPa) in patients with pancreatic ductal adenocarcinoma (PDA). The primary endpoint was the relationship between the changes in SWD and SWE values before and after chemotherapy and the response to chemotherapy. Secondary endpoints included SWD and SWE values in relation to differences between PDA and non-PDA sites and histopathological scores of stroma, inflammation, fibrosis, and necrosis in endoscopic ultrasound-guided fine-needle aspiration specimens.

RESULTS

Fifty-six patients were included, 30 of whom underwent chemotherapy. There was no relationship between the changes of SWD and SWE values and chemotherapy responses. In 56 patients, the median SWD value was 12.20 m/s/kHz (interquartile range [IQR]: 10.88-13.61) at PDA sites and 13.57 m/s/kHz (IQR: 12.28-16.20) at non-PDA sites (P = 0.005). The median SWE value was 8.18 kPa (IQR: 7.00-9.74) at PDA sites and 6.14 kPa (IQR: 5.40-6.77) at non-PDA sites (P < 0.001). Histopathological evaluation revealed that inflammation scores were correlated with SWD values (rs  = 0.42, P < 0.001).

CONCLUSIONS

Dispersion imaging in pancreatic cancer would be useful for diagnosis and assessing inflammation.

Two rare pancreatic parenchymal hemorrhagic lesions associated with acute pancreatitis in acute liver failure: a case report and literature review

Acute pancreatitis is an uncommon occurrence in acute liver failure. Furthermore, such cases are rarely complicated by parenchymal hemorrhages. Herein, we report the case of a 69-year-old male patient with multiple pancreatic parenchymal hemorrhages concomitant with acute liver failure. The patient underwent conservative treatment for acute liver failure caused by hepatitis B virus infection. Plain computed tomography on the 30th day revealed two high-density mass lesions in the pancreatic body and tail, which were suspected to be multiple pancreatic parenchymal hemorrhages. Despite restarting gabexate mesylate, the patient died of multiple organ failure on the 49th day. The clinical information of the present case and our literature review of 61 similar cases in 43 case reports identified via a systematic keyword search of the PubMed database, which described acute pancreatitis concomitant with acute hepatitis and acute liver failure, will aid physicians in the diagnosis and treatment of this rare condition.

Heart Failure and Pancreas Exocrine Insufficiency: Pathophysiological Mechanisms and Clinical Point of View

Heart failure is associated with decreased tissue perfusion and increased venous congestion that may result in organ dysfunction. This dysfunction has been investigated extensively for many organs, but data regarding pancreatic (exocrine) dysfunction are scarce. In the present review we will discuss the available data on the mechanisms of pancreatic damage, how heart failure can lead to exocrine dysfunction, and its clinical consequences. We will show that heart failure causes significant impairment of pancreatic exocrine function, particularly in the elderly, which may exacerbate the clinical syndrome of heart failure. In addition, pancreatic exocrine insufficiency may lead to further deterioration of cardiovascular disease and heart failure, thus constituting a true vicious circle. We aim to provide insight into the pathophysiological mechanisms that constitute this reciprocal relation. Finally, novel treatment options for pancreatic dysfunction in heart failure are discussed.