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Lee AA, Gupta S, Labban M, Cao FT, Trinh QD, McNabb-Baltar J. Drug-induced acute pancreatitis due to medications used for inflammatory bowel disease: A VigiBase pharmacovigilance database study. Pancreatology 2023; 23:569-573. [PMID: 37302896 DOI: 10.1016/j.pan.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/14/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Nearly all medications used for inflammatory bowel disease (IBD) have been reported as causes of acute pancreatitis (AP), with the thiopurines being among the most frequently described. However, with the development of newer medications, thiopurine monotherapy has largely been replaced by newer immunosuppressive drugs. There are few data on the association between AP and biologic/small molecule agents. METHODS VigiBase, the World Health Organization's Global Individual Case Safety Report database, was used to assess the association between AP and common IBD medications. A case/non-case disproportionality analysis was performed and disproportionality signals were reported as a reporting odds ratio (ROR) with 95% confidence intervals (CIs). RESULTS A total of 4,223 AP episodes were identified for common IBD medications. Azathioprine (ROR 19.18, 95% CI 18.21-20.20), 6-mercaptopurine (ROR 13.30, 95% CI 11.73-15.07), and 5-aminosalicylic acid (ROR 17.44, 95% CI 16.24-18.72) all had strong associations with AP, while the biologic/small molecule agents showed weaker or no disproportionality. The association with AP was much higher for thiopurines when used for Crohn's disease (ROR 34.61, 95% CI 30.95-38.70) compared to ulcerative colitis (ROR 8.94, 95% CI 7.47-10.71) or rheumatologic conditions (ROR 18.87, 95% CI 14.72-24.19). CONCLUSIONS We report the largest real-world database study investigating the association between common IBD medications and AP. Among commonly used IBD medications including biologic/small molecule agents, only thiopurines and 5-aminosalicylic acid are strongly associated with AP. The association between thiopurines and AP is much stronger when the drug is used for Crohn's disease compared to ulcerative colitis and rheumatologic conditions.
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Affiliation(s)
- Alice A Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.
| | - Sanchit Gupta
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Muhieddine Labban
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
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2
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Conti Bellocchi MC, Crinò SF, De Marchi G, De Pretis N, Ofosu A, Caldart F, Ciccocioppo R, Frulloni L. A Clinical and Pathophysiological Overview of Intestinal and Systemic Diseases Associated with Pancreatic Disorders: Causality or Casualty? Biomedicines 2023; 11:biomedicines11051393. [PMID: 37239064 DOI: 10.3390/biomedicines11051393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
The relationship between chronic intestinal disease, including inflammatory bowel disease (IBD) and celiac disease (CelD), and pancreatic disorders has been little investigated. Although an increased risk of acute pancreatitis (AP), exocrine pancreatic insufficiency with or without chronic pancreatitis, and chronic asymptomatic pancreatic hyperenzymemia have been described in these patients, the pathogenetic link remains unclear. It may potentially involve drugs, altered microcirculation, gut permeability/motility with disruption of enteric-mediated hormone secretion, bacterial translocation, and activation of the gut-associated lymphoid tissue related to chronic inflammation. In addition, the risk of pancreatic cancer seems to be increased in both IBD and CelD patients with unknown pathogenesis. Finally, other systemic conditions (e.g., IgG4-related disease, sarcoidosis, vasculitides) might affect pancreatic gland and the intestinal tract with various clinical manifestations. This review includes the current understandings of this enigmatic association, reporting a clinical and pathophysiological overview about this topic.
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Affiliation(s)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Giulia De Marchi
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Nicolò De Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Federico Caldart
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
| | - Luca Frulloni
- Gastroenterology Unit, Department of Medicine, Pancreas Institute, University of Verona, 37134 Verona, Italy
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3
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Mathew A, Fernandes D, Andreyev HJN. What is the significance of a faecal elastase-1 level between 200 and 500μg/g? Frontline Gastroenterol 2023; 14:371-376. [PMID: 37581180 PMCID: PMC10423608 DOI: 10.1136/flgastro-2022-102271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/26/2023] [Indexed: 08/16/2023] Open
Abstract
Background Pancreatic exocrine insufficiency is a cause of malabsorption. It is generally diagnosed if faecal elastase-1 (FE-1) levels are below 200 µg/g. Pancreatic function is assumed to be normal when faecal elastase levels are >500 µg/g. The significance of faecal elastase levels above 200 µg/g but less than 500 µg/g is unclear. Methods This retrospective study reports the response to treatment in patients who had an FE-1 level between 200 and 500 µg/g. Results Of these 82 patients, 28 were offered pancreatic enzyme replacement therapy (PERT). A clinical response, defined as an improvement in their initial symptoms after commencing PERT, was seen in 20 patients (71%), 7 with potentially predisposing conditions and 13 with functional diarrhoea. PERT particularly abolished or improved diarrhoea, steatorrhoea and flatulence. Conclusion Clinicians should, therefore, be aware that a trial of PERT given to patients with FE-1 levels between 200 and 500 µg/g may lead to improvement in gastrointestinal symptoms.
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Affiliation(s)
| | - Darren Fernandes
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- School of Health and Social Care, Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - H Jervoise N Andreyev
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- The Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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4
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Massironi S, Fanetti I, Viganò C, Pirola L, Fichera M, Cristoferi L, Capurso G, Invernizzi P, Danese S. Systematic review-pancreatic involvement in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:1478-1491. [PMID: 35505465 PMCID: PMC9322673 DOI: 10.1111/apt.16949] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/28/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic inflammatory immune-mediated disorder of the gut with frequent extra-intestinal complications. Pancreatic involvement in IBD is not uncommon and comprises a heterogeneous group of conditions, including acute pancreatitis (AP), chronic pancreatitis (CP), autoimmune pancreatitis (AIP) and pancreatic exocrine insufficiency (PEI); however, data on such an association remain sparse and heterogeneous. METHOD PubMed/MEDLINE and EMBASE databases were searched for studies investigating pancreatic involvement in patients with IBD. RESULTS Four thousand one hundred and twenty-one records were identified and 547 screened; finally, 124 studies were included in the review. AP is the most frequent pancreatic manifestation in IBD; the majority of AP cases in IBD are due to gallstones and drugs but cases of idiopathic AP are increasingly reported. AIP is a rare disease, but a strong association with IBD has been demonstrated, especially for type 2 and ulcerative colitis. The pathogenetic link between IBD and AIP remains unclear, but an immune-mediated pathway seems plausible. An association between CP and PEI with IBD has also been suggested, but data are to date scarce and conflicting. CONCLUSION This is the first systematic review of the association between IBD and pancreatic diseases. Gallstones and drugs should be considered the most probable causes of AP in IBD, with type 2 AIP also being possible.
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Affiliation(s)
- Sara Massironi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Ilaria Fanetti
- Gastroenterology and Endoscopy Unit, ASST Ovest MilaneseLegnano HospitalLegnanoItaly
| | - Chiara Viganò
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Lorena Pirola
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Maria Fichera
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Laura Cristoferi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato‐Biliary Endoscopy & Endosonography DivisionSan Raffaele Scientific Institute IRCCSMilanItaly
| | - Pietro Invernizzi
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMonzaItaly
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)San Gerardo HospitalMonzaItaly
| | - Silvio Danese
- Gastroenterology and EndoscopyIRCCS Ospedale San Raffaele and Vita‐Salute San Raffaele UniversityMilanItaly
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Adamkova P, Hradicka P, Kupcova Skalnikova H, Cizkova V, Vodicka P, Farkasova Iannaccone S, Kassayova M, Gancarcikova S, Demeckova V. Dextran Sulphate Sodium Acute Colitis Rat Model: A Suitable Tool for Advancing Our Understanding of Immune and Microbial Mechanisms in the Pathogenesis of Inflammatory Bowel Disease. Vet Sci 2022; 9:238. [PMID: 35622766 PMCID: PMC9147231 DOI: 10.3390/vetsci9050238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 01/27/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a group of disorders causing inflammation in the digestive tract. Recent data suggest that dysbiosis may play a pivotal role in the IBD pathogenesis. As microbiome-based therapeutics that modulate the gut ecology have been proposed as a novel strategy for preventing IBD, the aim of presenting study was to evaluate the dextran sulphate sodium (DSS) rat model mainly in terms of microbial shifts to confirm its suitability for dysbiosis study in IBD. Acute colitis was induced using 5% DSS solution for seven days and rats were euthanized five days after DSS removal. The faecal/caecal microbiota was analyzed by next generation sequencing. Disease activity index (DAI) score was evaluated daily. Blood and colon tissue immunophenotyping was assessed by flow cytometry and histological, haematological, and biochemical parameters were also evaluated. The colitis induction was reflected in a significantly higher DAI score and changes in all parameters measured. This study demonstrated significant shifts in the colitis-related microbial species after colitis induction. The characteristic inflammation-associated microbiota could be detected even after a five day-recovery period. Moreover, the DSS-model might contribute to an understanding of the effect of different treatments on extraintestinal organ impairments. The observation that certain bacterial species in the gut microbiota are associated with colitis raises the question of whether these organisms are contributors to, or a consequence of the disease. Despite some limitations, we confirmed the suitability of DSS-induced colitis model to monitor microbial changes during acute colitis, in order to test attractive new microbiome-based therapies.
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Affiliation(s)
- Petra Adamkova
- Faculty of Science, Institute of Biology and Ecology, Pavol Jozef Safarik University in Kosice, 041 54 Kosice, Slovakia; (P.A.); (P.H.); (M.K.)
| | - Petra Hradicka
- Faculty of Science, Institute of Biology and Ecology, Pavol Jozef Safarik University in Kosice, 041 54 Kosice, Slovakia; (P.A.); (P.H.); (M.K.)
| | - Helena Kupcova Skalnikova
- Institute of Animal Physiology and Genetics of the Czech Academy of Sciences, 277 21 Libechov, Czech Republic; (H.K.S.); (V.C.); (P.V.)
| | - Veronika Cizkova
- Institute of Animal Physiology and Genetics of the Czech Academy of Sciences, 277 21 Libechov, Czech Republic; (H.K.S.); (V.C.); (P.V.)
| | - Petr Vodicka
- Institute of Animal Physiology and Genetics of the Czech Academy of Sciences, 277 21 Libechov, Czech Republic; (H.K.S.); (V.C.); (P.V.)
| | - Silvia Farkasova Iannaccone
- Department of Forensic Medicine, Faculty of Medicine, Pavol Jozef Safarik University in Kosice, 040 11 Kosice, Slovakia;
| | - Monika Kassayova
- Faculty of Science, Institute of Biology and Ecology, Pavol Jozef Safarik University in Kosice, 041 54 Kosice, Slovakia; (P.A.); (P.H.); (M.K.)
| | - Sona Gancarcikova
- Department of Microbiology and Immunology, University of Veterinary Medicine and Pharmacy in Kosice, 041 81 Kosice, Slovakia;
| | - Vlasta Demeckova
- Faculty of Science, Institute of Biology and Ecology, Pavol Jozef Safarik University in Kosice, 041 54 Kosice, Slovakia; (P.A.); (P.H.); (M.K.)
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6
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Hosoi K, Minowa K, Suzuki M, Kudo T, Ohtsuka Y, Tomomasa T, Tajiri H, Ishige T, Yamada H, Arai K, Yoden A, Ushijima K, Aomatsu T, Nagata S, Uchida K, Takeuchi K, Shimizu T. Characteristics and Frequency of Pediatric Inflammatory Bowel Disease-Associated Pancreatitis: A Japanese Nationwide Survey. JPGN REPORTS 2022; 3:e162. [PMID: 37168759 PMCID: PMC10158371 DOI: 10.1097/pg9.0000000000000162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/03/2021] [Indexed: 05/13/2023]
Abstract
Acute pancreatitis (AP) develops in approximately 2% of patients with the diagnosis of inflammatory bowel disease (IBD), but the characteristics and frequency of childhood-onset IBD-associated AP in Japan have not been studied. The present study aimed to clarify the characteristics of IBD-associated AP in Japan. Methods A nationwide survey of pediatric patients with IBD (age, <17 years) was conducted from December 2012 to March 2013 at 683 hospitals and medical centers in Japan. A secondary survey was also sent to the centers with the target patients to evaluate their characteristics. Results The response rate to the first part of the survey was 61.2% (n = 418). In total, 871 patients with Crohn disease and 1671 patients with ulcerative colitis were enrolled. The second part of the survey found that 11 (1.3%) patients with Crohn disease and 23 (1.4%) patients with ulcerative colitis experienced IBD-associated AP caused by medication (n = 18, 53%), a primary disease (n = 11, 32%), autoimmune pancreatitis (n = 1, 3%), or an anatomical abnormality (n = 1, 3%). All the patients had only mild AP. Conclusions IBD-associated AP was not very frequent and was generally mild. The major cause of the pancreatitis was the medication used to treat the IBD.
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Affiliation(s)
- Kenji Hosoi
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
- Division of Gastroenterology, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Kei Minowa
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Mitsuyoshi Suzuki
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
| | - Takahiro Kudo
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
| | - Yoshikazu Ohtsuka
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
| | - Takeshi Tomomasa
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- PAL Children’s Clinic, Gunma, Japan
| | - Hitoshi Tajiri
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Kinki University Faculty of Medicine, Osaka, Japan
| | - Takashi Ishige
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroyuki Yamada
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Osaka Hospital, Japan Community of Healthcare Organization, Osaka, Japan
| | - Katsuhiro Arai
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsushi Yoden
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
- Department of Pediatrics, Dainikyoritsu Hospital, Hyogo, Japan
| | - Kosuke Ushijima
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics and Child Health, Kurume University, Fukuoka, Japan
| | - Tomoki Aomatsu
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Satoru Nagata
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Pediatrics, Tokyo Women’s Medical University Hospital, Tokyo, Japan
| | - Keiichi Uchida
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Kazuo Takeuchi
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
- General Health Support Center, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Toshiaki Shimizu
- From the Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
- Members of the Japanese Society for Pediatric Inflammatory Bowel Disease Working Group
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7
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Montenegro ML, Corral JE, Lukens FJ, Ji B, Kröner PT, Farraye FA, Bi Y. Pancreatic Disorders in Patients with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:423-436. [PMID: 33625614 DOI: 10.1007/s10620-021-06899-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) can involve multiple organ systems, and pancreatic manifestations of IBD are not uncommon. The incidence of several pancreatic diseases is more frequent in patients with Crohn's disease and ulcerative colitis than in the general population. Pancreatic manifestations in IBD include a heterogeneous group of disorders and abnormalities ranging from mild, self-limited disorders to severe diseases. Asymptomatic elevation of amylase and/or lipase is common. The risk of acute pancreatitis in patients with IBD is increased due to the higher incidence of cholelithiasis and drug-induced pancreatitis in this population. Patients with IBD commonly have altered pancreatic histology and chronic pancreatic exocrine dysfunction. Diagnosing acute pancreatitis in patients with IBD is challenging. In this review, we discuss the manifestations and possible causes of pancreatic abnormalities in patients with IBD.
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Affiliation(s)
- Marilia L Montenegro
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Juan E Corral
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Baoan Ji
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | - Paul T Kröner
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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8
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Kunovský L, Dítě P, Jabandžiev P, Eid M, Poredská K, Vaculová J, Sochorová D, Janeček P, Tesaříková P, Blaho M, Trna J, Hlavsa J, Kala Z. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021; 10:jcm10245779. [PMID: 34945075 PMCID: PMC8708123 DOI: 10.3390/jcm10245779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malnutrition, results from primary pancreatic disease or is secondary to impaired exocrine pancreatic function. Although chronic pancreatitis is the most common cause of EPI, several additional causes exist. These include pancreatic tumors, pancreatic resection procedures, and cystic fibrosis. Other diseases and conditions, such as diabetes mellitus, celiac disease, inflammatory bowel disease, and advanced patient age, have also been shown to be associated with EPI, but the exact etiology of EPI has not been clearly elucidated in these cases. The causes of EPI can be divided into loss of pancreatic parenchyma, inhibition or inactivation of pancreatic secretion, and postcibal pancreatic asynchrony. Pancreatic enzyme replacement therapy (PERT) is indicated for the conditions described above presenting with clinically clear steatorrhea, weight loss, or symptoms related to maldigestion and malabsorption. This review summarizes the current literature concerning those etiologies of EPI less common than chronic pancreatitis, the pathophysiology of the mechanisms of EPI associated with each diagnosis, and treatment recommendations.
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Affiliation(s)
- Lumír Kunovský
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Petr Dítě
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Petr Jabandžiev
- Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, 61300 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 62500 Brno, Czech Republic
| | - Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic;
| | - Karolina Poredská
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Jitka Vaculová
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavel Janeček
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavla Tesaříková
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
| | - Martin Blaho
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Jan Trna
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute Brno, 60200 Brno, Czech Republic
- Correspondence: (J.T.); (J.H.)
| | - Jan Hlavsa
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
- Correspondence: (J.T.); (J.H.)
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
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9
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Phillips ME, Hopper AD, Leeds JS, Roberts KJ, McGeeney L, Duggan SN, Kumar R. Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000643. [PMID: 34140324 PMCID: PMC8212181 DOI: 10.1136/bmjgast-2021-000643] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency is a finding in many conditions, predominantly affecting those with chronic pancreatitis, pancreatic cancer and acute necrotising pancreatitis. Patients with pancreatic exocrine insufficiency can experience gastrointestinal symptoms, maldigestion, malnutrition and adverse effects on quality of life and even survival.There is a need for readily accessible, pragmatic advice for healthcare professionals on the management of pancreatic exocrine insufficiency. METHODS AND ANALYSIS A review of the literature was conducted by a multidisciplinary panel of experts in pancreatology, and recommendations for clinical practice were produced and the strength of the evidence graded. Consensus voting by 48 pancreatic specialists from across the UK took place at the 2019 Annual Meeting of the Pancreatic Society of Great Britain and Ireland annual scientific meeting. RESULTS Recommendations for clinical practice in the diagnosis, initial management, patient education and long term follow up were developed. All recommendations achieved over 85% consensus and are included within these comprehensive guidelines.
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Affiliation(s)
- Mary E Phillips
- Nutrition and Dietetics, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Keith J Roberts
- HPB Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Laura McGeeney
- Nutrition and Dietetics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Rajesh Kumar
- HPB Surgery, Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
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10
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Carnie LE, Lamarca A, Vaughan K, Kapacee ZA, McCallum L, Backen A, Barriuso J, McNamara MG, Hubner RA, Abraham M, Valle JW. Prospective observational study of prevalence, assessment and treatment of pancreatic exocrine insufficiency in patients with inoperable pancreatic malignancy (PANcreatic cancer Dietary Assessment (PanDA): a study protocol. BMJ Open 2021; 11:e042067. [PMID: 33986039 PMCID: PMC8126274 DOI: 10.1136/bmjopen-2020-042067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/11/2020] [Accepted: 03/12/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Pancreatic exocrine insufficiency (PEI) in patients with pancreatic malignancy is well documented in the literature and is known to negatively impact on overall survival and quality of life. A lack of consensus opinion remains on the optimal diagnostic test that can be adapted for use in a clinical setting for this cohort of patients. This study aims to better understand the prevalence of PEI and the most suitable diagnostic techniques in patients with advanced pancreatic malignancy. METHODS AND ANALYSIS This prospective observational study will be carried out in patients with pancreatic malignancy (including adenocarcinoma and neuroendocrine neoplasms). Consecutive patients with inoperable pancreatic malignancy referred for consideration of first-line chemotherapy will be considered for eligibility. The study comprises three cohorts: demographic cohort (primary objective to prospectively investigate the prevalence of PEI in patients with inoperable pancreatic malignancy); sample size 50, diagnostic cohort (primary objective to design and evaluate an optimal diagnostic panel to detect PEI in patients with inoperable pancreatic malignancy); sample size 25 and follow-up cohort (primary objective to prospectively evaluate the proposed PEI diagnostic panel in a cohort of patients with inoperable pancreatic malignancy); sample size 50. The following is a summary of the protocol and methodology. ETHICS AND DISSEMINATION Full ethical approval has been granted by the North West Greater Manchester East Research and Ethics Committee, reference: 17/NW/0597. This manuscript reflects the latest protocol V.8 approved 21 April 2020. Findings will be disseminated by presentation at national/international conferences, publication in peer-review journals and distribution via patient advocate groups. TRIAL REGISTRATION NUMBER 194255, NCT0361643.
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Affiliation(s)
- Lindsay E Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Kate Vaughan
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | | | | | - Alison Backen
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Jorge Barriuso
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Richard A Hubner
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Marc Abraham
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
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11
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Andrade AR, da Rocha TRF, Ortiz-Agostinho CL, Nishitokukado I, Carlos AS, de Azevedo MFC, Hashimoto CL, Damião AOMC, Carrilho FJ, D’Amico E, Sipahi AM, de Arruda Leite AZ. Endoscopic activity, tissue factor and Crohn's disease: findings in clinical remission patients. Therap Adv Gastroenterol 2020; 13:1756284820939412. [PMID: 34025780 PMCID: PMC8114167 DOI: 10.1177/1756284820939412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/14/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND As Crohn's disease (CD) is associated with a high risk of thromboembolic events (TE), including patients with subclinical inflammation, we aim to evaluate the correlation between the impact of endoscopic activity (EA) in the coagulation profiling of CD patients while in clinical remission. METHODS From 164 consecutive CD patients included in clinical remission [Crohn's disease activity index (CDAI) < 150], 75 were in the EA group [Simplified Endoscopic Score for CD (SES-CD) ⩾ 7], 89 were in the endoscopic remission (ER) group (SES-CD ⩽ 2), and 50 were included as healthy controls in the study. Blood samples were analyzed for tissue factor (TF), factor VIII (FVIII), thrombomodulin (TM), ADAMTS-13, von Willebrand factor (VWF), and endogenous thrombin potential (ETP), as well as collecting data regarding risk factors for TE and CD profile. RESULTS Mean plasma TF activity showed significantly higher levels in the EA group when compared with the ER and control groups (127 pM versus 103 pM versus 84 pM; p = 0.001), although the VWF:Ag (160% versus 168% versus 110%; p = 0.001), VWF/ADAMTS-13 (191 versus 219 versus 138; p = 0.003), FVIII (150% versus 144% versus 90%; p = 0.001) and TM (5.13 ng/ml versus 4.91 ng/mL versus 3.81 ng/ml; p < 0.001) were only increased in CD regardless of EA status when compared with controls. Lastly, ETP with and without TM remained the same in all three groups. CONCLUSIONS CD patients in clinical remission with EA present endothelial lesion inducing TF exposure and subsequent coagulation cascade activation. Recommended thromboprophylaxis for EA outpatient subgroups will require additional investigation in order to be validated.
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Affiliation(s)
- Adriana Ribas Andrade
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Tania Rubia Flores da Rocha
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Carmen Lucia Ortiz-Agostinho
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Iêda Nishitokukado
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Alexandre Sousa Carlos
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Matheus Freitas Cardoso de Azevedo
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Claudio Lioshi Hashimoto
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Aderson Omar Moura Cintra Damião
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Flair José Carrilho
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Elbio D’Amico
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
| | - Aytan Miranda Sipahi
- Gastroenterology, Laboratório de Gastroenterologia Clínica e Experimental (LIM 07), University of Sao Paulo School of Medicine, Sao Paulo, Brazil,Division of Hematology, Coagulation Laboratory, University of Sao Paulo School of Medicine, Av. Dr. Eneas de Carvalho Aguiar, Sao Paulo, Brazil
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12
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Li P, Chen K, Mao Z, Luo Y, Xue Y, Zhang Y, Wang X, Zhang L, Gu S, Dou D. Association between Inflammatory Bowel Disease and Pancreatitis: A PRISMA-Compliant Systematic Review. Gastroenterol Res Pract 2020; 2020:7305241. [PMID: 32831829 PMCID: PMC7422476 DOI: 10.1155/2020/7305241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 06/21/2020] [Accepted: 07/04/2020] [Indexed: 12/14/2022] Open
Abstract
METHODS MEDLINE, Embase, and CENTRAL were systematically searched for correlative studies till 2 November 2019. RevMan5.3 was used to estimate relevance. RESULTS Three studies with 166008 participants were included. The risk of pancreatitis significantly increased in the patients with CD (OR, 3.40; 95% CI, 2.70-4.28; P < 0.00001) and UC (OR, 2.49; 95% CI, 1.91-3.26; P < 0.00001). Increased risks of CD (OR, 12.90; 95% CI, 5.15-32.50; P < 0.00001) and UC (OR, 2.80; 95% CI, 1.00-7.86; P = 0.05) were found in patients with chronic pancreatitis. As for patients with acute pancreatitis, there were significant association of CD (OR, 3.70; 95% CI, 1.90-7.60; P = 0.0002), but were not UC. CONCLUSIONS The evidence confirmed an association between pancreatitis and IBD. When pancreatitis patients have chronic diarrhea and mucus blood stool or IBD patients have repeated abdominal pain and weight loss, they should consult pancreatic and gastrointestinal specialists.
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Affiliation(s)
- Pengfan Li
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Kanjun Chen
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Zheng Mao
- Department of Foreign Language Teaching Center, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yue Luo
- Department of Dermatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China
| | - Yan Xue
- Institute of Tramotology and Orthopedics, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yuli Zhang
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Xueying Wang
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Lihang Zhang
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Sizhen Gu
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Danbo Dou
- Department of Traditional Chinese Medicine, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
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13
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Garcia Garcia de Paredes A, Rodriguez de Santiago E, Rodriguez-Escaja C, Iborra M, Algaba A, Cameo JI, de la Peña L, Gomollon F, Van Domselaar M, Busta R, Castaño Garcia A, Del Val A, Bermejo F, Gutierrez A, Guardiola J, Mesonero F, Riestra S, Nos P, Albillos A, Lopez-Sanroman A. Idiopathic acute pancreatitis in patients with inflammatory bowel disease: A multicenter cohort study. Pancreatology 2020; 20:331-337. [PMID: 32165149 DOI: 10.1016/j.pan.2020.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/02/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Idiopathic acute pancreatitis (IAP) in patients with inflammatory bowel disease (IBD) is not well characterized. Our purpose was to better understand this condition and its natural history. METHODS Retrospective cohort study conducted at nine Spanish IBD referral centers. Patients with IBD and a first episode of acute pancreatitis (AP) between 1998 and 2018 were included. Patients with a previous episode of AP or a diagnosis of chronic pancreatitis were excluded. IAP and non-IAP were compared by multivariate logistic regression and survival analysis. RESULTS We identified 185 patients with IBD (68.7% Crohn's disease) and a first episode of AP. Thirty-eight of those 185 (20.6%) fulfilled criteria for IAP. There were no severe cases of IAP. On multivariate analysis, AP before IBD diagnosis (21.1% vs. 3.4%, p = 0.04) and ulcerative colitis (52.6% vs. 23.1%, p = 0.002) were significantly more common in IAP. Further work-up was performed in 16/38 (42%) IAP patients, and a cause was identified in 6/16 (37.5%). Median time from AP to the end of follow-up was 6.3 years (3.1-10). Five-year risk of AP recurrence was significantly higher in IAP group (28% vs. 5.1%, log-rank p = 0.001), with a median time to first recurrence of 4.4 months (2.9-12.2). CONCLUSIONS IAP represents the second cause of AP in patients with IBD. It is more frequent in ulcerative colitis, and presents a high risk of recurrence. Additional imaging work-up after a first episode of IAP in IBD patients is highly advisable, as it identifies a cause in more than one-third of cases.
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Affiliation(s)
- Ana Garcia Garcia de Paredes
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain.
| | - Enrique Rodriguez de Santiago
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Carlos Rodriguez-Escaja
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Marisa Iborra
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Alicia Algaba
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Instituto de Investigación Sanitaria Hospital La Paz (IdiPaz), Madrid, Spain
| | - Jose Ignacio Cameo
- Gastroenterology and Hepatology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Luisa de la Peña
- Gastroenterology and Hepatology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Fernando Gomollon
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain; Gastroenterology and Hepatology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Manuel Van Domselaar
- Gastroenterology and Hepatology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Reyes Busta
- Gastroenterology and Hepatology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Andres Castaño Garcia
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Adolfo Del Val
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fernando Bermejo
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Instituto de Investigación Sanitaria Hospital La Paz (IdiPaz), Madrid, Spain
| | - Ana Gutierrez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain; Gastroenterology and Hepatology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Jordi Guardiola
- Gastroenterology and Hepatology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Francisco Mesonero
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Sabino Riestra
- Gastroenterology and Hepatology Department, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria Del Principado de Asturias (ISPA), Oviedo, Spain
| | - Pilar Nos
- Gastroenterology and Hepatology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Agustin Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
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14
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Hedström A, Steiner C, Valente R, Haas SL, Löhr JM, Vujasinovic M. Pancreatic exocrine insufficiency and Crohn's disease. MINERVA GASTROENTERO 2019; 66:17-22. [PMID: 31760738 DOI: 10.23736/s1121-421x.19.02636-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND According to the European evidence-based consensus, published by European Crohn's and Colitis Organization (ECCO), diseases of the pancreas are included as extra-intestinal manifestations in IBD in the forms of acute pancreatitis (AP), chronic pancreatitis (CP), autoimmune pancreatitis (AIP), pancreatic duct abnormalities and pancreatic exocrine insufficiency (PEI). Presence of pancreatic autoantibodies directed against the exocrine of the pancreas has been reported in about one-third of CD. However, association between CD and PEI is not fully elucidated. METHODS Patients with a diagnosis of CD were recruited at the Department for Digestive Diseases at Karolinska University Hospital in Stockholm, Sweden. Demographic, clinical and laboratory data were analyzed. Fecal elastase-1 (FE-1) measurements were performed using the enzyme-linked immunosorbent assay (ELISA) method. RESULTS There were 20 patients included in the study, 13 (65%) males and 7 (35%) females, mean age 48.3±1.4 years (range 29-67 years). Mean duration of CD was 15.7±2.1 years (range 1-40 years). There were 11 (55%) patients without history of bowel surgery and 9 (45%) patients after ileocecal resection. FE-1 test was normal in all patients, among them 15 (75%) patients with the values of FE-1>500. CONCLUSIONS Fecal elastase-1 level was normal in all patients with CD strongly indicated absence of PEI in this group of patients.
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Affiliation(s)
- Aleksandra Hedström
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Corinna Steiner
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Valente
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stephan L Haas
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden -
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15
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Lam KW, Leeds J. How to manage: patient with a low faecal elastase. Frontline Gastroenterol 2019; 12:67-73. [PMID: 33489070 PMCID: PMC7802491 DOI: 10.1136/flgastro-2018-101171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Kwan Wai Lam
- Pancreaticobiliary Medicine, Freeman Hospital, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - John Leeds
- Pancreaticobiliary Medicine, Freeman Hospital, Newcastle upon Tyne, Newcastle upon Tyne, UK
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16
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Chen L, Strohmeier V, He Z, Deshpande M, Catalan-Dibene J, Durum SK, Moran TM, Kraus T, Xiong H, Faith JJ, Sodhi CP, Hackam DJ, Lira SA, Furtado GC. Interleukin 22 disrupts pancreatic function in newborn mice expressing IL-23. Nat Commun 2019; 10:4517. [PMID: 31586069 PMCID: PMC6778080 DOI: 10.1038/s41467-019-12540-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/17/2019] [Indexed: 12/19/2022] Open
Abstract
Neonatal inflammatory diseases are associated with severe morbidity, but the inflammatory factors underlying them and their potential effector mechanisms are poorly defined. Here we show that necrotizing enterocolitis in neonate mice is accompanied by elevation of IL-23 and IL-22 and decreased production of pancreatic enzymes. These phenotypes are mirrored in neonate mice overexpressing IL-23 in CX3CR1+ myeloid cells or in keratinocytes. The mice fail to grow and die prematurely, displaying systemic inflammation, nutrient malabsorption and decreased expression of intestinal and pancreatic genes mediating digestion and absorption of carbohydrates, proteins, and lipids. Germ-free environment improves, and genetic ablation of IL-22 restores normal growth in mice overexpressing IL-23. Mechanistically, IL-22 acts directly at the level of pancreatic acinar cells to decrease expression of the pancreas associated transcription factor 1a (PTF1a). These results show that augmented production of IL-23 and IL-22 in early life has a negative impact on pancreatic enzyme secretion and food absorption.
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Affiliation(s)
- Lili Chen
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Valentina Strohmeier
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Faculty of Biology, University of Freiburg, Schaenzlestrasse 1, 79104, Freiburg, Germany
| | - Zhengxiang He
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Madhura Deshpande
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jovani Catalan-Dibene
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Scott K Durum
- Center for Cancer Research, National Cancer Institute, Frederick, MD, 21702, USA
| | - Thomas M Moran
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Center for Therapeutic Antibody Development, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Thomas Kraus
- Center for Therapeutic Antibody Development, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Huabao Xiong
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jeremiah J Faith
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Chhinder P Sodhi
- Division of General Pediatric Surgery, Johns Hopkins University and Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - David J Hackam
- Division of General Pediatric Surgery, Johns Hopkins University and Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD, 21287, USA
| | - Sergio A Lira
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
| | - Glaucia C Furtado
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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17
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The Etiology of Pancreatic Manifestations in Patients with Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8070916. [PMID: 31247968 PMCID: PMC6679036 DOI: 10.3390/jcm8070916] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an idiopathic chronic and recurrent condition that comprises Crohn's disease and ulcerative colitis. A pancreatic lesion is one of the extraintestinal lesions in patients with IBD. Acute pancreatitis is the representative manifestation, and various causes of pancreatitis have been reported, including those involving adverse effects of drug therapies such as 5-aminosalicylic acid and thiopurines, gall stones, gastrointestinal lesions on the duodenum, iatrogenic harm accompanying endoscopic procedures such as balloon endoscopy, and autoimmunity. Of these potential causes, autoimmune pancreatitis (AIP) is a relatively newly recognized disease and is being increasingly diagnosed in IBD. AIP cases can be divided into type 1 cases involving lymphocytes and IgG4-positive plasma cells, and type 2 cases primarily involving neutrophils; the majority of AIP cases complicating IBD are type 2. The association between IBD and chronic pancreatitis, exocrine pancreatic insufficiency, pancreatic cancer, etc. has also been suggested; however, studies with high-quality level evidence are limited, and much remains unknown. In this review, we provide an overview of the etiology of pancreatic manifestation in patients with IBD.
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Malluta ÉF, Maluf-Filho F, Leite AZDA, Ortiz-Agostinho CL, Nishitokukado I, Andrade AR, Lordello MLL, dos Santos FM, Sipahi AM. Pancreatic endosonographic findings and clinical correlation in Crohn's disease. Clinics (Sao Paulo) 2019; 74:e853. [PMID: 31166473 PMCID: PMC6542499 DOI: 10.6061/clinics/2019/e853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.
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Affiliation(s)
- Éverson Fernando Malluta
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fauze Maluf-Filho
- Departamento de Gastroenterologia, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, SP, BR
| | - André Zonetti de Arruda Leite
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carmen Lucia Ortiz-Agostinho
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Iêda Nishitokukado
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Adriana Ribas Andrade
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Laura Lacava Lordello
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabiana Maria dos Santos
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aytan Miranda Sipahi
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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Fousekis FS, Theopistos VI, Katsanos KH, Christodoulou DK. Pancreatic Involvement in Inflammatory Bowel Disease: A Review. J Clin Med Res 2018; 10:743-751. [PMID: 30214645 PMCID: PMC6135003 DOI: 10.14740/jocmr3561w] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/21/2018] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a multisystemic disease, and pancreatic manifestations of IBD are not uncommon. The incidence of several pancreatic diseases in Crohn’s disease and ulcerative colitis is more frequent compared to the general population. Pancreatic manifestations in IBD include a wide heterogenic group of disorders and abnormalities of the pancreas and range from mild self-limited diseases to severe disorders. Acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, pancreatic autoantibodies, exocrine pancreatic insufficiency and asymptomatic imaging and laboratory abnormalities are included in related-IBD pancreatic manifestations. Involvement of the pancreas in IBD may be the result of IBD itself or of medications used.
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Affiliation(s)
- Fotios S Fousekis
- Department of Gastroenterology and Hepatology, Medical School of Ioannina, Greece
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20
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Schneider A, Hirth M, Weiss C, Weidner P, Antoni C, Thomann A, Reindl W, Ebert MP, Pfützer RH. Prevalence of inflammatory bowel disease in alcoholic, non-alcoholic and autoimmune pancreatitis. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2018; 56:469-478. [PMID: 29734447 DOI: 10.1055/s-0043-123881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients with inflammatory bowel disease (IBD) frequently reveal features of pancreatic inflammation. However, the prevalence of IBD in patients with alcoholic pancreatitis (AP) and nonalcoholic pancreatitis (NAP) has not yet been determined, and the prevalence of IBD in patients with autoimmune pancreatitis (AiP) from Germany is unknown. AIMS Thus, we aimed, first, to determine the prevalence of IBD in AP, NAP, and AiP from a tertiary center in Germany and, second, to characterize patients with AiP and IBD. METHODS We performed a retrospective cross-sectional study to determine the prevalence of IBD in patients with different forms of pancreatitis presenting to our clinic. RESULTS Compared to the general population and to a control group with viral hepatitis from our clinic, we observed the most significant increase of IBD in patients with AiP (n = 3/28; p < 0.0001 vs. general population, binomial proportion test; p = 0.0112 vs. hepatitis group, Fisher's exact test), followed by a significant increase in subjects with NAP (n = 11/278; p < 0.0001 vs. general population, binomial proportion test; p = 0.0338 vs. hepatitis group, Fisher's exact test). A review of previous studies on the prevalence of IBD among patients with AiP revealed a combined prevalence of 12 % (n = 43/355). Type 2 AiP is significantly more often associated with IBD than type 1 AiP (n = 28/48, 58 % vs. n = 7/129, 5 %; combined patient cohort, p < 10E - 12; Fisher's exact test). CONCLUSIONS Immune-mediated mechanisms related to IBD may participate in the development of AiP, especially AiP type 2, and may also increase the risk for the development of other forms of pancreatic inflammation.
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Affiliation(s)
- Alexander Schneider
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Michael Hirth
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Philip Weidner
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Christoph Antoni
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Anne Thomann
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Wolfgang Reindl
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Matthias P Ebert
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Roland H Pfützer
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany
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21
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Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 2017; 23:7059-7076. [PMID: 29093615 PMCID: PMC5656454 DOI: 10.3748/wjg.v23.i39.7059] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 05/27/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases (diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin (CCK); celiac or inflammatory bowel disease (IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery (asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy (PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI (66%-92%). EPI occurs in patients with type 1 (26%-57%) or type 2 diabetes (20%-36%) and is typically mild to moderate; by definition, all patients with type 3c (pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease (4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD (14%-74%) and up to 100% of gastrointestinal surgery patients (47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Mark E Haupt
- Medical Affairs, AbbVie Inc., North Chicago, IL 60064, United States
| | - David E Geller
- Cystic Fibrosis Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
| | - Jerry A Hall
- CREON® Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
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22
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Chen YL, Hsu CW, Cheng CC, Yiang GT, Lin CS, Lin CL, Sung FC, Liang JA. Increased subsequent risk of inflammatory bowel disease association in patients with chronic pancreatitis: a nationwide population-based cohort study. Curr Med Res Opin 2017; 33:1077-1082. [PMID: 28277863 DOI: 10.1080/03007995.2017.1300143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate the relationship between chronic pancreatitis (CP) and inflammatory bowel disease (IBD) in a large population-based cohort study. METHODS Data was obtained from the Taiwan National Health Insurance Research Database. The cohort study comprised 17,796 patients newly diagnosed with CP between 2000 and 2010 and 71,164 matched controls. A Cox proportional hazards model was used for evaluating the risk of IBD in the CP and comparison cohorts. RESULTS When examined with a mean follow-up period of 4.87 and 6.04 years for the CP and comparison cohorts, respectively, the overall incidence of IBD was 10.3 times higher in the CP cohort than in the comparison cohort (5.75 vs. 0.56 per 10,000 person-years). Compared with the comparison cohort, the CP cohort exhibited a higher risk of IBD, irrespective of age, sex, and presence or absence of comorbidities. Moreover, the CP cohort was associated with a significantly higher risk of Crohn's disease (adjusted hazard ratio [aHR] = 12.9, 95% confidence interval [CI] = 5.15-32.5) and ulcerative colitis (aHR = 2.80, 95% CI = 1.00-7.86). CONCLUSIONS This nationwide population-based cohort study revealed a significantly higher risk of IBD in patients with CP compared with control group. Clinicians should notice this association to avoid delayed diagnosis of IBD in patients with CP.
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Affiliation(s)
- Yu-Long Chen
- a Department of Emergency Medicine , Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , Taipei , Taiwan
- e Department of Emergency Medicine, School of Medicine , Tzu Chi University , Taipei , Taiwan
| | - Chin-Wang Hsu
- b Department of Emergency Medicine, School of Medicine, College of Medicine , Taipei Medical University , Taipei , Taiwan
- c Department of Emergency and Critical Medicine , Wan Fang Hospital, Taipei Medical University , Taipei , Taiwan
| | - Cheng-Chung Cheng
- d Division of Cardiology, Department of Medicine , Tri-Service General Hospital, National Defense Medical Center , Taipei , Taiwan
| | - Giou-Teng Yiang
- a Department of Emergency Medicine , Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , Taipei , Taiwan
- e Department of Emergency Medicine, School of Medicine , Tzu Chi University , Taipei , Taiwan
| | - Chin-Sheng Lin
- d Division of Cardiology, Department of Medicine , Tri-Service General Hospital, National Defense Medical Center , Taipei , Taiwan
| | - Cheng-Li Lin
- f Management Office for Health Data, China Medical University Hospital , Taichung , Taiwan
- g College of Medicine , China Medical University , Taichung , Taiwan
| | - Fung-Chang Sung
- h Department of Health Services Administration , China Medical University , Taichung , Taiwan
- i Faculty of Public Health , Mahidol University , Bangkok , Thailand
| | - Ji-An Liang
- j Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine , China Medical University , Taichung , Taiwan
- k Department of Radiation Oncology , China Medical University Hospital , Taichung , Taiwan
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23
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Abstract
Autoimmune pancreatitis (AIP) occurring in association with inflammatory bowel disease (IBD) is rather rare and carries a worse prognosis and greater disease severity compared with IBD alone. Although it is an infrequently documented association, progress over the last 20 years has led to better understanding of the association between AIP and IBD. IBD has a stronger association with type 2 than with type 1 AIP. Clinical and histologic features of AIP-IBD more often reveal features of type 2 AIP. Imaging is not helpful in facilitating the diagnosis of AIP and IBD. Similarly, attempts to identify a serological marker have not yielded better result. A proposed lymphocyte homing mechanism provides some insight into the mechanism of pathogenesis. This review represents an update of our current knowledge of the association between AIP and IBD.
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Abstract
Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.
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Affiliation(s)
- M Raman
- University of Calgary, Calgary, AB, Canada.
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25
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Ray P, Van Arsdall MR. Elevated Lipase during Initial Presentation of Ulcerative Colitis in a Pediatric Patient: Do We Check for It. Case Rep Gastroenterol 2016; 10:568-573. [PMID: 27920643 PMCID: PMC5121551 DOI: 10.1159/000450699] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/08/2016] [Indexed: 11/19/2022] Open
Abstract
There are very few reports of elevated lipase in pediatric inflammatory bowel disease (IBD). Symptoms of pancreatitis may be masked by abdominal pain in pediatric IBD. During the initial presentation of IBD in our patient, lipase was elevated to more than 3 times the upper limit of normal. Normalization of values coincided with remission of IBD. This may be due to extraintestinal involvement of the pancreas as part of the inflammatory process or due to leakage of pancreatic enzymes from an inflamed gut or mediated by inflammatory cytokines. Checking pancreatic enzymes during initial presentation of IBD may, therefore, be important to determine if pancreatic involvement has resulted from the inflammation in IBD or as an adverse effect of therapy. If unchecked, recurrent subclinical pancreatitis may be masked by IBD symptoms and missed prior to starting IBD therapy. This may result in chronic pancreatic insufficiency as reported in 50% of adults with IBD. Early detection of elevated pancreatic enzymes in IBD may help direct the management strategy, as treatment of the underlying inflammation in IBD may be the most important management for resolution of pancreatitis instead of cessation of therapy for fear of iatrogenic medication-induced pancreatitis.
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Affiliation(s)
- Piyali Ray
- University of Texas Health Science Center, Houston, Tex., USA
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26
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Antonini F, Pezzilli R, Angelelli L, Macarri G. Pancreatic disorders in inflammatory bowel disease. World J Gastrointest Pathophysiol 2016; 7:276-282. [PMID: 27574565 PMCID: PMC4981767 DOI: 10.4291/wjgp.v7.i3.276] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/08/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
An increased incidence of pancreatic disorders either acute pancreatitis or chronic pancreatitis has been recorded in patients with inflammatory bowel disease (IBD) compared to the general population. Although most of the pancreatitis in patients with IBD seem to be related to biliary lithiasis or drug induced, in some cases pancreatitis were defined as idiopathic, suggesting a direct pancreatic damage in IBD. Pancreatitis and IBD may have similar presentation therefore a pancreatic disease could not be recognized in patients with Crohn’s disease and ulcerative colitis. This review will discuss the most common pancreatic diseases seen in patients with IBD.
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27
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Abstract
Inflammatory bowel disease (IBD) has been increasingly diagnosed in children and adults. Similarly, acute and chronic pancreatitis are increasingly prevalent conditions with potentially devastating consequences. There is a growing body of literature linking these 2 conditions. The purpose of this review is to provide a comprehensive outline of the association between IBD and pancreatitis and to explore their putative pathophysiology. Based on the collective reports, 2 outstanding reasons for pancreatitis in patients with IBD are medications and IBD complications.
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28
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Ramos LR, Sachar DB, DiMaio CJ, Colombel JF, Torres J. Inflammatory Bowel Disease and Pancreatitis: A Review. J Crohns Colitis 2016; 10:95-104. [PMID: 26351384 DOI: 10.1093/ecco-jcc/jjv153] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 08/19/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Pancreatic abnormalities are common in inflammatory bowel disease (IBD) patients and represent a heterogeneous group of conditions that include acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis and asymptomatic abnormalities. We sought to review the available evidence concerning the aetiology, clinical presentation, diagnosis and treatment of pancreatic conditions in IBD patients. METHODS A PubMed/Medline query was conducted addressing pancreatic disorders in IBD. Reference lists from studies selected were manually searched to identify further relevant reports. Relevant manuscripts about pancreatic disorders in patients with IBD were selected and reviewed. RESULTS Thiopurines and gallstones are the most frequent causes of acute pancreatitis in IBD patients. Thiopurine-induced acute pancreatitis is usually uncomplicated and self-limited. Some evidence suggests that chronic pancreatitis may be more common in IBD. Most cases are idiopathic, affecting young males and patients with ulcerative colitis. Autoimmune pancreatitis is a relatively newly recognized disease and is increasingly diagnosed in IBD, particularly for type 2 autoimmune pancreatitis in ulcerative colitis patients. Asymptomatic exocrine insufficiency, pancreatic duct abnormalities and hyperamylasaemia have been identified in up to 18% of IBD patients, although their clinical significance and relationship with IBD remain undefined. CONCLUSIONS The wide spectrum of pancreatic manifestations in IBD is growing and may represent a challenge to the clinician. A collaborative approach with a pancreas specialist may be the most productive route to determine aetiology, guide additional diagnostic workup, illuminate the aetiology and define the treatment and follow-up of these patients.
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Affiliation(s)
- Lídia Roque Ramos
- Ichan School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - David B Sachar
- Ichan School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Christopher J DiMaio
- Ichan School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Jean-Frédéric Colombel
- Ichan School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
| | - Joana Torres
- Ichan School of Medicine at Mount Sinai, Dr Henry D. Janowitz Division of Gastroenterology, New York, NY, USA
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29
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Natural history of pancreatic involvement in paediatric inflammatory bowel disease. Dig Liver Dis 2015; 47:384-9. [PMID: 25704068 DOI: 10.1016/j.dld.2015.01.155] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/01/2015] [Accepted: 01/27/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Few case reports describe the clinical features of pancreatic involvement in inflammatory bowel disease. AIM To investigate prevalence and disease course of inflammatory bowel disease children with pancreatitis and with exclusive hyperamylasemia and hyperlipasemia. METHODS We used a web-registry to retrospectively identify paediatric inflammatory bowel disease patients with hyperamylasemia and hyperlipasemia. Participants were re-evaluated at 6 months and 1 year. RESULTS From a total of 649 paediatric patients, we found 27 with hyperamylasemia and hyperlipasemia (4.1%). Eleven patients (1.6%) fulfilled diagnostic criteria for acute pancreatitis. Female gender was significantly associated with acute pancreatitis (p=0.04). Twenty-five children (92.5%) had colonic disease. At 6 months 1/11 children with acute pancreatitis (9%) showed acute recurrent pancreatitis, while 1 patient (9%) had persistent hyperamylasemia and hyperlipasemia. At 12 months, 1 patient showed chronic pancreatitis (9.1%). Of the 16 children with exclusive hyperamylasemia and hyperlipasemia, 4 developed acute pancreatitis (25%), while 1 patient (6.2%) still presented exclusive hyperamylasemia and hyperlipasemia at 6 months. At 12 months, 11/16 patients (68.7%) reached a remission of pancreatic involvement, whereas 5 remaining patients (32.3%) had persistent hyperamylasemia and hyperlipasemia. CONCLUSIONS In inflammatory bowel disease children, acute pancreatitis is more common in colonic disease and in female gender. Pancreatic function should be monitored, considering that pancreatic damage may evolve.
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30
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Faria RJ, Clemente CM, Carneiro FP, Santos-Neto L. Can IgG4 Levels Identify the Ulcerative Colitis Subtype of Inflammatory Bowel Disease? Gastroenterology Res 2015; 8:178-185. [PMID: 27785293 PMCID: PMC5051143 DOI: 10.14740/gr648w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 12/24/2022] Open
Abstract
Background Pancreatitis and exocrine pancreatic insufficiency may occur as extraintestinal manifestations of inflammatory bowel disease. Recently, autoimmune pancreatitis and colitis have been described as presentations of IgG4-related disease. IgG4+ plasma cells have been identified in colon tissue from patients with refractory forms of inflammatory bowel disease. The presence of elevated serum/tissue levels of IgG4 and the frequency of exocrine pancreatic insufficiency in inflammatory bowel disease are still a source of controversy. Our aim was to investigate the meaning of elevated IgG4 levels in patients with inflammatory bowel disease. Methods A cross-sectional study analyzed 56 patients with a diagnosis of inflammatory bowel disease recruited by convenience sampling from two tertiary centers in Midwestern Brazil. All patients underwent fecal pancreatic elastase testing for detection of exocrine pancreatic insufficiency and serum IgG4 measurement. Findings were correlated with clinical and epidemiological data and disease activity. Results Elevated serum IgG4 levels were found in 10 patients, and were most frequent in ulcerative colitis (nine cases), with a prevalence ratio of 16.42 (95% CI: 3.32 - 79.58). Ten patients (10 of 56, 17.8%) were diagnosed with exocrine pancreatic insufficiency, which did not correlate with disease activity, and serum IgG4 levels. Conclusion Exocrine pancreatic insufficiency is prevalent in patients with inflammatory bowel disease, but it is not associated with elevated serum IgG4 levels. The high prevalence of elevated serum IgG4 in ulcerative colitis suggests that this parameter has potential for use as a diagnostic biomarker.
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Affiliation(s)
- Ricardo Jacaranda Faria
- Universidade de Brasilia, Brasilia, Distrito Federal, Brazil; Hospital Universitario de Brasilia, Brasilia, Distrito Federal, Brazil; Hospital de Base do Distrito Federal, Brasilia, Distrito Federal, Brazil
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31
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Nakamura K, Ito T, Kotoh K, Ihara E, Ogino H, Iwasa T, Tanaka Y, Iboshi Y, Takayanagi R. Hepatopancreatobiliary manifestations of inflammatory bowel disease. Clin J Gastroenterol 2012; 5:1-8. [PMID: 26181867 DOI: 10.1007/s12328-011-0282-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/13/2011] [Indexed: 12/23/2022]
Abstract
Inflammatory bowel disease (IBD) is frequently associated with extraintestinal manifestations such as hepatopancreatobiliary manifestations (HPBMs), which include primary sclerosing cholangitis (PSC), pancreatitis, and cholelithiasis. PSC is correlated with IBD, particularly ulcerative colitis (UC); 70-80% of PSC patients in Western countries and 20-30% in Japan have comorbid UC. Therefore, patients diagnosed with PSC should be screened for UC by total colonoscopy. While symptoms of PSC-associated UC are usually milder than PSC-negative UC, these patients have a higher risk of colorectal cancer, particularly in the proximal colon. Therefore, regular colonoscopy surveillance is required regardless of UC symptoms. Administration of 5-aminosalicylic acid or ursodeoxycholic acid may prevent colorectal cancer and cholangiocarcinoma. While PSC is diagnosed by diffuse multifocal strictures on cholangiography, it must be carefully differentiated from immunoglobulin G4 (IgG4)-associated cholangitis, which shows a similar cholangiogram but requires different treatment. When PSC is suspected despite a normal cholangiogram, the patient may have small-duct PSC, which requires a liver biopsy. IBD patients have a high incidence of acute and chronic pancreatitis. Most cases are induced by cholelithiasis or medication, although some patients may have autoimmune pancreatitis (AIP), most commonly type 2 without elevation of serum IgG4. AIP should be accurately identified based on characteristic image findings, because AIP responds well to corticosteroids. Crohn's disease is frequently associated with gallstones, and several risk factors are indicated. HPBMs may influence the management of IBD, therefore, accurate diagnosis and an appropriate therapeutic strategy are important, as treatment depends upon the type of HPBM.
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Affiliation(s)
- Kazuhiko Nakamura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazuhiro Kotoh
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Haruei Ogino
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tsutomu Iwasa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoichiro Iboshi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ryoichi Takayanagi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Chase K, Lawler DF, McGill LD, Miller S, Nielsen M, Lark KG. Age relationships of postmortem observations in Portuguese Water Dogs. AGE (DORDRECHT, NETHERLANDS) 2011; 33:461-473. [PMID: 20845083 PMCID: PMC3168605 DOI: 10.1007/s11357-010-9181-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 08/25/2010] [Indexed: 05/29/2023]
Abstract
A dog model has been used to evaluate histological changes arising from senescence. Autopsies of 145 Portuguese Water Dogs have been used to evaluate the individual and group "state of health" at time of death. For each dog, weights or dimensions of organs or tissues were obtained, together with histological evaluation of tissues. Twenty-three morphological metrics correlated significantly to age at death. Many of these involved muscles; others were associated with derivatives of embryonic foregut. The latter included lengths of the small intestine and trachea as well as weights of the stomach and some lung lobes. Nearly all of the dogs examined had histological changes in multiple tissues, ranging from two to 12 per dog. Associations among pathologies included inflammatory bowel disease with osteoporosis and dental calculus/periodontitis with atherosclerosis and amyloidosis. In addition, two clusters of histological changes were correlated to aging: hyperplasia, frequency of adenomas, and hemosiderosis constituted one group; inflammation, plasmacytic and lymphocytic infiltration, fibrosis, and atrophy, another. Heritability analysis indicated that many of the changes in tissue/organ morphology or histology could be heritable and possibly associated with IGF1, but more autopsies will be required to substantiate these genetic relationships.
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Affiliation(s)
- Kevin Chase
- Department of Biology, University of Utah, 257 South 1400 E., Room 201, Salt Lake City, UT 84112 USA
| | | | - Lawrence D. McGill
- Animal Reference Pathology Division, ARUP, 500 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Shawn Miller
- Department of Biology, University of Utah, 257 South 1400 E., Room 201, Salt Lake City, UT 84112 USA
| | - Mark Nielsen
- Department of Biology, University of Utah, 257 South 1400 E., Room 201, Salt Lake City, UT 84112 USA
| | - Karl G. Lark
- Department of Biology, University of Utah, 257 South 1400 E., Room 201, Salt Lake City, UT 84112 USA
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Idiopathic pancreatitis preceding the diagnosis of inflammatory bowel disease is more frequent in pediatric patients. J Pediatr Gastroenterol Nutr 2011; 52:714-7. [PMID: 21478760 DOI: 10.1097/mpg.0b013e3182065cad] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute pancreatitis (AP) can be a rare extraintestinal manifestation of inflammatory bowel disease (IBD). There are only a few reports of AP presenting before the diagnosis of IBD. We aimed to characterize the demographic, clinical, and laboratory data of patients with IBD in whom AP preceded disease onset and compare the presentation of AP between children and adults. PATIENTS AND METHODS Pediatric and adult patients presenting with AP as the first symptom of IBD were retrospectively identified (10 years, 7 university hospitals). Demographic and clinical data, IBD type, disease extension, and laboratory data were extracted from the charts. Imaging methods, number of AP episodes, and lag time between onset of first pancreatitis episode and onset of IBD were recorded. RESULTS AP preceding the diagnosis of IBD was found in 10 in 460 pediatric patients with IBD (2.17%), compared with only 2 in 3500 adults (0.06%). Eight children had colonic disease (4 Crohn disease, 4 ulcerative colitis [3 pancolitis]). Mean amylase level was 1419 and range 100 to 1370. Three children (30%) had mildly elevated transaminases. Median time between onset of first episode of AP in relation to onset of IBD was 24 (range 1-156) weeks. AP most commonly presented with abdominal pain. CONCLUSIONS IBD presenting as AP was more frequent among the pediatric population with IBD in comparison to adults. It was more common in patients with colitis than in those with ileal disease, suggesting that patients with idiopathic AP should be observed carefully for a possible diagnosis of IBD.
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Abstract
Exocrine pancreatic disease is thought to be uncommon in clinical practice and usually secondary to excess alcohol intake. Although excess alcohol intake does account for many cases of exocrine pancreatic disease, other conditions are associated with exocrine pancreatic insufficiency and such dysfunction perhaps occurs more frequently than conventionally expected. A reliable, patient-friendly, cheap and easy to use test for exocrine pancreatic disease is yet to be established; however, in many countries the main (and often only available) method of assessment of exocrine pancreatic function is the fecal-elastase-1 test. This Review examines the role of fecal-elastase-1 testing in detecting exocrine pancreatic insufficiency in a number of gastrointestinal and nongastrointestinal conditions and determines the value of pancreatic enzyme supplementation in these settings.
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Garamszegi M. [Extraintestinal manifestations of inflammatory bowel diseases and their management]. Orv Hetil 2011; 152:663-71. [PMID: 21464024 DOI: 10.1556/oh.2011.29075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extraintestinal manifestations of ulcerative colitis and Crohn's disease are symptoms of varied organ injuries due to systemic inflammatory process. Bowel disease seems to be primary but upon genetic disposition disturbed immune regulation may result in inflammation of other organs that may appear simultaneously, precede bowel disease or follow it in the quiescent phase. As far as possible extraintestinal manifestations have to be distinguished from the complications of the intestinal inflammation and also from side effects of drugs for its treatment. Involvement of bones and joints, skin, eyes, liver and biliary tract is more common but disease of blood coagulation system, lung, kidneys and nervous system may also appear. Treatment of extraintestinal manifestations is influenced by their association with the activity of the bowel disease. Beyond some specific interventions, to achieve improvement of manifestations independent from activity long lasting anti-inflammatory therapy or immunomodulation is almost always needed. Clinical evidence of different levels from reports support the favorable effect of biologic therapy in different extraintestinal manifestations of inflammatory bowel diseases as well. Care and follow-up of patients is a multidisciplinary task.
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Vinklerová I, Procházka M, Procházka V, Urbánek K. Incidence, severity, and etiology of drug-induced acute pancreatitis. Dig Dis Sci 2010; 55:2977-81. [PMID: 20499176 DOI: 10.1007/s10620-010-1277-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 04/30/2010] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Drug-induced acute pancreatitis is considered to be a rare diagnosis. The incidence of drug-induced acute pancreatitis is usually estimated from case reports. AIM The aim of this study was to determine the incidence, etiology, and severity of drug-induced pancreatitis during a 2-year period in a tertiary hospital. METHODS The study was conducted as a retrospective analysis of all cases of pancreatitis in the University Hospital in Olomouc (1,432 beds) in 2006-2007. All cases of acute pancreatitis were re-evaluated and divided according to the causative factor. In drug-induced cases, the WHO Probability Scale for the evaluation of causality relationship was used. RESULTS The inclusion criteria were met by 170 medical files. There were 91 (53%) cases in men and 79 (47%) in women, and mean age was 57 years old (5-91 years old). The etiology was in 53% biliary, 31% alcohol-induced, 12% other determined, and in 4% the cause could not be established. The proportion of drug-induced acute pancreatitis was 5.3% and it was the third most frequent cause of the AP. Azathioprine was the most frequent causative factor (three cases in two patients); all the other causative drugs were documented only in single cases: mesalazine, dexamethasone, ramipril, mycophenolate mofetil, cytarabine, and valproate. CONCLUSIONS The diagnosis of drug-induced acute pancreatitis seems to be underestimated because of the difficulties in determining the causative agent and the need for a retrospective re-evaluation of the suspected causative factors. The disease is more probable in younger persons, women, and patients suffering from Crohn's disease.
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Affiliation(s)
- Ilona Vinklerová
- 2nd Department of Internal Medicine, Faculty of Medicine and University Hospital, Palacký University, Olomouc, Czech Republic
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Navaneethan U, Shen B. Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease. Inflamm Bowel Dis 2010; 16:1598-619. [PMID: 20198712 DOI: 10.1002/ibd.21219] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.
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Inflammation driven by overexpression of the hypoglycosylated abnormal mucin 1 (MUC1) links inflammatory bowel disease and pancreatitis. Pancreas 2010; 39:510-5. [PMID: 20084048 PMCID: PMC2859977 DOI: 10.1097/mpa.0b013e3181bd6501] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pancreatitis occurs as an extraintestinal complication of inflammatory bowel disease (IBD), but the cause is poorly understood. Mucin 1 (MUC1) is overexpressed in an abnormal, hypoglycosylated form on the colonic epithelium in human IBD where it contributes to inflammation. MUC1 is also expressed on pancreatic ductal epithelia. We tested the possibility that in IBD, MUC1 expression on pancreatic ducts is also abnormal leading to inflammation and pancreatitis. METHODS We used MUC1/interleukin-10 mice that develop IBD. We imaged abnormal MUC1 expression in these mice by adoptively transferring T cells from T cell receptor transgenic mice specific for abnormal MUC1. Cells were labeled with a novel perfluorocarbon tracer reagent and quantified and visualized in vivo using high-throughput F nuclear magnetic resonance spectroscopy and magnetic resonance imaging. RESULTS MUC1-specific T cells migrated to the colon in mice with IBD and also to the pancreas. Immunohistochemistry confirmed increased expression on the pancreatic ducts of the abnormal MUC1 seen in the colon and the presence of cellular infiltrate. CONCLUSIONS Migration of MUC1-specific T cells to the colon and the pancreas in diseased mice suggests that pancreatitis is an extraintestinal site of IBD, characterized by proinflammatory abnormal expression of MUC1. Therapies directed against abnormal MUC1 have the potential of targeting the disease in both sites.
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Keller J, Aghdassi AA, Lerch MM, Mayerle JV, Layer P. Tests of pancreatic exocrine function - clinical significance in pancreatic and non-pancreatic disorders. Best Pract Res Clin Gastroenterol 2009; 23:425-39. [PMID: 19505669 DOI: 10.1016/j.bpg.2009.02.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pancreas functions as the main factory for digestive enzymes and therefore enables food utilisation. Pancreatic exocrine insufficiency, partial or complete loss of digestive enzyme synthesis, occurs primarily in disorders directly affecting pancreatic tissue integrity. However, other disorders of the gastrointestinal tract, such as coeliac disease, inflammatory bowel disease, Zollinger-Ellison syndrome or gastric resection can either mimic or cause pancreatic exocrine insufficiency. The overt clinical symptoms of pancreatic exocrine insufficiency are steatorrhoea and maldigestion, which frequently become apparent in advanced stages. Several direct and indirect function tests are available for assessment of pancreatic function but until today diagnosis of excretory insufficiency is difficult as in mild impairment clinically available function tests show limitations of diagnostic accuracy. This review focuses on diagnosis of pancreatic exocrine insufficiency in pancreatic and non-pancreatic disorders.
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Affiliation(s)
- Jutta Keller
- Department of Medicine, Israelitisches Krankenhaus, Hamburg, Germany
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Kathrani A, Steiner JM, Suchodolski J, Eastwood J, Syme H, Garden OA, Allenspach K. Elevated canine pancreatic lipase immunoreactivity concentration in dogs with inflammatory bowel disease is associated with a negative outcome. J Small Anim Pract 2009; 50:126-32. [DOI: 10.1111/j.1748-5827.2008.00693.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Morselli-Labate AM, Pezzilli R. Usefulness of serum IgG4 in the diagnosis and follow up of autoimmune pancreatitis: A systematic literature review and meta-analysis. J Gastroenterol Hepatol 2009; 24:15-36. [PMID: 19067780 DOI: 10.1111/j.1440-1746.2008.05676.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
High circulating serum immunoglobulin G4 (IgG4) levels have been proposed as a marker of autoimmune pancreatitis (AIP). The aim of the present study was to review the data existing in the English literature on the usefulness of the IgG4 serum levels in the diagnosis and follow up of patients with AIP. A total of 159 patients with AIP and 1099 controls were described in seven selected papers reporting the usefulness of serum IgG4 in diagnosing AIP. In total, 304 controls had pancreatic cancer, 96 had autoimmune diseases, and the remaining 699 had other conditions. The summary receiver-operating characteristic curve analysis was carried out by means of Meta-DiSc open-access software. Serum IgG4 showed good accuracy in distinguishing between AIP and the overall controls, pancreatic cancer and other autoimmune diseases (area under the curve [+/- SE]: 0.920 +/- 0.073, 0.914 +/- 0.191, and 0.949 +/- 0.024, respectively). The studies analyzed showed significantly heterogeneous specificity values in each of the three analyses performed. The analysis of the four studies comparing AIP and pancreatic cancers also showed significantly heterogeneous values of sensitivities and odds ratios. Regarding the usefulness of IgG4 as a marker of efficacy of steroid treatment, a decrease in the serum concentrations of IgG4 was found in the four available studies. The serum IgG4 subclass is a good marker of AIP, and its determination should be included in the diagnostic workup of this disease. However, the heterogeneity of the studies published until now means that more studies are necessary in order to better evaluate the true accuracy of IgG4 in discriminating AIP versus other autoimmune diseases.
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Bermejo F, Lopez-Sanroman A, Taxonera C, Gisbert JP, Pérez-Calle JL, Vera I, Menchén L, Martín-Arranz MD, Opio V, Carneros JA, Van-Domselaar M, Mendoza JL, Luna M, López P, Calvo M, Algaba A. Acute pancreatitis in inflammatory bowel disease, with special reference to azathioprine-induced pancreatitis. Aliment Pharmacol Ther 2008; 28:623-8. [PMID: 18513380 DOI: 10.1111/j.1365-2036.2008.03746.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatitis is a potentially severe condition. Patients with inflammatory bowel disease (IBD) seem to be at increased risk for acute pancreatitis. AIM To describe the incidence, main causes and possible predictive factors of acute pancreatitis in inflammatory bowel disease. METHODS Information was retrospectively extracted from the clinical records of patients followed in the IBD Units of nine hospitals in Madrid (n = 5073). RESULTS A total of 82 acute pancreatitis episodes were diagnosed (cumulative incidence, 1.6%); 98% of them were mild. Recurrent acute pancreatitis developed in 13% of patients. Most cases of acute pancreatitis (63.4%) were attributed to drug exposure [azathioprine/mercaptopurine (AZA/MP) n = 46, mesalazine (mesalamine) n = 6]; 20.7% were idiopathic, and 12.2% were biliary. Incidence of acute pancreatitis in patients treated with AZA/MP was 3.1%. In patients with acute pancreatitis, female gender (OR 3.4 95% CI: 1.3-9.3; P = 0.012) and Crohn's disease (CD) (OR 5.8 95% CI: 1.6-20.6; P = 0.007) were risk factors for AZA/MP-associated acute pancreatitis, the latter also when analysed only in patients treated with AZA/MP (n = 1477) (OR 5.2 95% CI: 1.8-14; P = 0.002). CONCLUSIONS The incidence of acute pancreatitis in our IBD patients (1.6%) is similar to that previously described. Drugs, mainly AZA/MP, are the leading cause. AZA-induced acute pancreatitis is always mild. Patients with CD are at a higher risk for AZA/MP-associated acute pancreatitis. The frequency of idiopathic acute pancreatitis is higher than expected, suggesting that part of these cases could be extraintestinal manifestations of IBD.
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Affiliation(s)
- F Bermejo
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Community of Madrid, Madrid, Spain.
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Sikorski T, Marcinowska-Suchowierska E. Vitamin B12 deficiency following restorative proctocolectomy: is it really related to surgical procedure? Colorectal Dis 2008; 10:410-1; author reply 411-2. [PMID: 18005194 DOI: 10.1111/j.1463-1318.2007.01406.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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