AETIOLOGY OF CHRONIC PANCREATIC FIBROSIS WITH CALCIFICATION SEEN IN UGANDA

Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP.

METHODS

MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI).

RESULTS

Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively.

CONCLUSION

Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.

Fibrocalculous pancreatic diabetes

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes reported from tropical countries, associated with both endocrine and exocrine disease of the pancreas. The pre-diabetic phase of the disease is called tropical chronic pancreatitis (TCP). Currently FCPD is classified as a secondary form of diabetes called pancreatic diabetes, because essentially the disease is caused by pancreatic damage. There is an overlap of these subjects with idiopathic, non-alcoholic pancreatitis. This review will cover the etiopathogenesis, diagnosis and management of this clinical condition. FCPD could lead to endocrine dysfunction (diabetes and its complications) as well as exocrine dysfunction, and is associated with a higher risk of pancreatic cancer, for which early detection is important.

Emerging concepts in the pathogenesis of diabetes in fibrocalculous pancreatic diabetes

Fibrocalcific pancreatic diabetes (FCPD) is a rare form of diabetes affecting people in the tropics and presenting with unique clinical and radiological features. The onset of diabetes usually follows the first few episodes of abdominal pain and develops by the second or third decade of life. Endocrine and exocrine pancreatic insufficiency, brittle glycemic control, and insulin-requiring, ketosis-resistant diabetes are the novel characteristics of FCPD. The etiopathogenetic mechanisms leading to FCPD remain unknown. Although defects in insulin secretion are the major contributors, growing evidence towards a possible role for insulin resistance and body composition abnormalities have added a new dimension to the disease pathogenesis. Deciphering the key pathogenetic mechanisms may have a profound effect on therapeutic strategies in future studies on FCPD.

[Tropical chronic pancreatitis in a young patient]

Tropical chronic pancreatitis is a form of idiopathic chronic pancreatitis that has not previously been described in Spain. Typically it is related to dietary factors and malnutrition, although genetic factors may also play a significant role in the development of the disease. We report a case of chronic tropical pancreatitis in a 27-year-old woman from the Dominican Republic domiciled in Spain since 1992. The patient was admitted to our hospital for acute pancreatitis that fulfilled the diagnostic criteria (clinical and radiological) for chronic tropical pancreatitis. This case has led us to review this uncommon entity. Because of the increasing number of immigrants from tropical countries, chronic tropical pancreatitis will probably need to be taken into account in the differential diagnosis of chronic pancreatitis in our patients.

Lack of association between cassava consumption and tropical pancreatitis syndrome

Previous studies suggesting an association between use of tubers of cassava and tropical pancreatitis have been weak and conflicting. To test a possible association the cassava consumption of 40 consecutive cases of tropical pancreatitis syndrome were compared with age-matched and sex-matched healthy hospital visitors. The sociodemographic characteristics of the two groups were comparable. There was no association between cassava consumption and tropical pancreatitis syndrome (odds ratio = 0.56; 95% confidence interval = 0.21-1.45). Controlling for the possible confounding effects of low socio-economic status and vegetarian diet did not alter the odds ratio. Testing for interaction also failed to show any effect modification of the association of cassava by economic status, chilli consumption or vegetarian diet. A significantly higher number of cases gave a positive family history of diabetes compared to the controls (odds ratio = 4.11; 95% confidence interval = 1.04-16.30; P = 0.04). In this case-control study which had sufficient power to detect an odds ratio > or = 3.5, there was no association between cassava consumption and tropical pancreatitis syndrome.

Diabetes in tropical Africa: a prospective study, 1981-7. I. Characteristics of newly presenting patients in Dar es Salaam, Tanzania, 1981-7

OBJECTIVE

To study the clinical characteristics of newly diagnosed diabetic patients in tropical Africa.

DESIGN

Prospective study of all newly diagnosed diabetic patients registered at a major urban hospital between 1 June 1981 and 31 May 1987.

SETTING

Muhimbili Medical Centre, Dar es Salaam, Tanzania.

PATIENTS

1250 Patients: 874 men, 376 women.

RESULTS

272 (21.8%) Patients had diabetes requiring insulin, 825 (66.0%) had diabetes not requiring insulin, and 153 (12.2%) had diabetes of uncertain type. Most patients (1103, 88.2%) presented with the classic symptoms of diabetes. The peak time of presentation of diabetic patients requiring insulin was at age 15 to 19 years. Male manual workers and peasant farmers with diabetes not requiring insulin presented at a significantly older age and had a lower body mass index than sedentary office workers. Forty six (18.1%) of the patients requiring insulin diabetes and 111 (14.4%) not requiring insulin had first degree relative with diabetes. Twenty seven per cent of patients were underweight (body mass index less than 20 kg/m2) and 14.6% were obese (body mass index greater than 30 kg/m2). Hypertension was diagnosed in 211 (26.7%) of 791 patients not requiring insulin. Nine (3.3%) of those requiring insulin may have had the protein deficient type of diabetes related to malnutrition. The fibrocalculous variety of diabetes related to malnutrition was not observed.

CONCLUSIONS

Newly presenting diabetic patients in Tanzania with diabetes requiring insulin are older at presentation than those in Britain; most diabetic patients present with diabetes not requiring insulin and a smaller proportion of Tanzanian patients are obese. Most have a lower socioeconomic state than diabetic patients in Britain. There are often delays in diagnosis in Tanzania, and there is a higher incidence of death shortly after presentation.

Chronic calcific pancreatitis: clinical profile in northern India

Twenty three patients with chronic calcific pancreatitis of the tropics in Northern India were prospectively studied. All had pancreatic calcification and ERCP changes typical of chronic pancreatitis, the most predominant being ductal dilatation which was detected in all patients by both ERCP and by ultrasonography. Pain was present in 19 (83%) patients and diabetes in 11 (48%) patients. Exocrine pancreatic dysfunction was uncommon, steatorrhoea being present in only 9% of patients. Ten of the 11 patients with diabetes required insulin for control and one case was able to be controlled by an oral antidiabetic agent. Two patients developed ketoacidosis during acute episodes of pancreatitis, 3 patients had peripheral neuropathy and one patient had visual changes. Recurrent severe pain was the reason for operation in 7 patients. All had a lateral pancreaticojejunostomy. In order to obtain an objective assessment of pain, a scoring system was developed to grade its severity according to its intensity, frequency and consequences. Six patients who preoperatively had a pain score of 15 or more (out of a maximum score of 24) attained significant relief after the surgery. We feel this scoring system may provide an easy objective assessment of pain in the subsequent follow-up of these patients.

Juvenile tropical pancreatitis syndrome in northern Nigeria: a case report

A six-year-old boy with abdominal pain since the age of two years is described. Physical examination revealed no abnormality but under general anaesthesia a mass could be felt in the left upper abdominal quadrant. An X-ray showed calcification in that quadrant, anterior to the vertebrae and an IVP revealed incomplete duplication of the left ureter. At laparotomy, small multiple calculi were removed from the pancreatic duct and pancreatico-jejunostomy was performed. Following surgery, his crippling abdominal pain ceased dramatically and he has remained symptom-free.

Immunodeficiency and cryptosporidiosis. Demonstration at the Royal College of Physicians of London

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Light microscopic and ultrastructural changes of the exocrine pancreas in magnesium deficient rats

In magnesium deficient rats with a clinical picture of protein malnutrition, pancreatic changes typical of protein malnutrition were expected. However, in rats fed for four weeks on a low magnesium diet (protein content 25%), light and electron microscopic studies revealed that the acinar cells of the pancreas were packed with zymogen granules, suggesting a disturbance in the discharge (rather than in the production) of the pancreatic enzymes. The mitochondria and the lumina of the RER were swollen. The nuclei had an irregular outline, the chromatin was aggregated into irregular granules and the nucleolemma of the nucleolus was fibrillar. It was suggested that the disturbance in the release of pancreatic enzymes might cause a maldigestion of the dietary protein, which eventually would lead to the condition of protein malnutrition in the magnesium deficient rats. The disturbance of exocytosis in the pancreas of magnesium deficient rats might be due to the preferential use of all the available magnesium for protein (enzymes) synthesis so that there were no magnesium ions left for the energy dependent discharge of the zymogen granules.

Pancreatic pseudocysts in children: 4 cases from Uganda

Four cases of pancreatic pseudocyst in African children are described. There is some evidence that they followed pancreatitis of unknown aetiology. None had a history of trauma. Three were treated by cystogastrostomy, and the fourth by excision of the cyst.

Chronic pancreatitis in African diabetics

Steatorrhea due to chronic pancreatitis was found in 23 percent of a consecutive series of 107 new african diabetics; 3 had pancreatic calcification. Of 16, 14 had definitely abnormal exocirne secretion function testing using secreation pancreozymin stimultion. Themorphology and function of the small intestine were normal by local standards. When compared with diabetics without steatorrhea they weighed less, their fasting blood sugars were lower, and their insulin requirements were greater. High alcoholic intake might be significant cause, but the incidence was similar in the diabetics without steatorrhea. No evidence of childhood or adult malnutrition was established. The etiology of this high incidence of chronic pancreatitis among african diabetics remains unexplained.

Intraluminal fat digestion in the chronic alcoholic

Intraluminal fat digestion and absorption were evaluated in 15 chronic alcoholic and nine healthy volunteer males by aspiration of a standard meal from the jejunum. Intraluminal bile salts were present in normal concentrations and micellar solubilization of fatty acids and monoglycerides was within normal limits. Pancreatic lipase concentrations, however, were significantly lower in the alcoholic patients. As a consequence, hydrolysis of triglycerides was slower resulting in abnormally low concentrations of fatty acids and micellar lipids. Recovery of lipase production toward normal was demonstrated after four to six weeks by repeated intubation studies. Thus, in the chronic alcoholic insufficient production of pancreatic lipase seems to be responsible for the reversible abnormality in the intraluminal digestion of fat.

Pancreatic failure with calcification, steatorrhoea, diabetes mellitus and diabetic amyotrophy

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