Role of genetic disorders in acute recurrent pancreatitis

Impact of recurrent acute pancreatitis on the natural history and progression to chronic pancreatitis

BACKGROUND AND AIMS

It is believed that acute pancreatitis (AP), recurrent AP (RAP) and chronic pancreatitis (CP) represent stages of the same disease spectrum. We aimed to identify risk factors, clinical presentation and outcomes in patients with prior RAP who develop CP.

METHODS

We retrospectively reviewed patients with CP who were seen at our Pancreas Center during 2016-2021. We divided them into two groups: with and without RAP (≥2 episodes of AP). We compared demographics, clinical presentation and resource utilization between the two groups.

RESULTS

We identified 440 patients with CP, of which 283 (64%) patients had preceding RAP. These patients were younger (55.6 vs 63.1 years), active smokers (36% vs 20%) and had alcohol-related CP (49% vs 25%) compared to those without RAP and CP (p < 0.05). More patients with RAP had chronic abdominal pain (89% vs 67.9%), nausea (43.3% vs 27.1%) and exocrine pancreatic insufficiency (65.8% vs 46.5%) (p < 0.05). More patients with RAP used opioids (58.4% vs 32.3%) and gabapentinoids (56.6% vs 34.8%) (p < 0.05). They also had more ED visits resulting in an opioid prescription (9.68% vs 2%) and more CP flares requiring hospitalization (3.09 vs 0.87) (p < 0.05).

CONCLUSION

Young age, smoking and alcohol use are seen in patients with RAP who progress to CP. These patients are highly symptomatic and use more healthcare resources, suggestive of an overall a more course compared to those patients who develop CP without preceding RAP. Early identification and counselling of these patients may slow down progression to CP.

Risk factors and prediction score for chronic pancreatitis: A nationwide population-based cohort study

AIM

To explore the risk factors of developing chronic pancreatitis (CP) in patients with acute pancreatitis (AP) and develop a prediction score for CP.

METHODS

Using the National Health Insurance Research Database in Taiwan, we obtained large, population-based data of 5971 eligible patients diagnosed with AP from 2000 to 2013. After excluding patients with obstructive pancreatitis and biliary pancreatitis and those with a follow-up period of less than 1 year, we conducted a multivariate analysis using the data of 3739 patients to identify the risk factors of CP and subsequently develop a scoring system that could predict the development of CP in patients with AP. In addition, we validated the scoring system using a validation cohort.

RESULTS

Among the study subjects, 142 patients (12.98%) developed CP among patients with RAP. On the other hand, only 32 patients (1.21%) developed CP among patients with only one episode of AP. The multivariate analysis revealed that the presence of recurrent AP (RAP), alcoholism, smoking habit, and age of onset of < 55 years were the four important risk factors for CP. We developed a scoring system (risk score 1 and risk score 2) from the derivation cohort by classifying the patients into low-risk, moderate-risk, and high-risk categories based on similar magnitudes of hazard and validated the performance using another validation cohort. Using the prediction score model, the area under the curve (AUC) [95% confidence interval (CI)] in predicting the 5-year CP incidence in risk score 1 (without the number of AP episodes) was 0.83 (0.79, 0.87), whereas the AUC (95%CI) in risk score 2 (including the number of AP episodes) was 0.84 (0.80, 0.88). This result demonstrated that the risk score 2 has somewhat better prediction performance than risk score 1. However, both of them had similar performance between the derivation and validation cohorts.

CONCLUSION

In the study,we identified the risk factors of CP and developed a prediction score model for CP.

Is acute recurrent pancreatitis in children a precursor of chronic pancreatitis? A long-term follow-up study of 93 cases

BACKGROUND/AIMS

In view of paucity of literature we analyzed our experience of acute recurrent pancreatitis (ARP) to study clinical profile and long-term outcome.

METHODS

Over 13 years, 93 consecutive children (≤18 years) diagnosed to have ARP were included in this study. Magnetic resonance cholangiopancreatography was done at baseline and on follow-up. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease inhibitor (PRSS1 R122S) and cystic fibrosis transmembrane conductance regulator (CFTR deltaF508, 5T) were studied in 22 idiopathic cases.

RESULTS

The median age of the children with ARP was 13 (10-14.5) years, 53 were males. Etiology included biliary in 14 (15%), pancreas divisum in 6 (7%), others in 3 (3.5%) and idiopathic in the remaining 70 (75%). SPINK1 mutation was found in 10/22 (45%) cases. Over a median follow-up of 25.5 (8.25-48) months, 37 (42%) of 88 (5 lost to follow-up) developed chronic pancreatitis (CP). On multivariate analysis idiopathic etiology (p<0.03), presence of SPINK1 mutation (p=0.01), longer follow-up (p<0.001) were associated with progression to CP.

CONCLUSIONS

Biliopancreatic structural/obstructive causes should always be looked for. It seems ARP is a precursor of CP and progression is associated with idiopathic etiology and presence of genetic mutations. Hence, patients with ARP should be kept on regular follow-up to detect CP.

A Report of 320 Cases of Childhood Pancreatitis: Increasing Incidence, Etiologic Categorization, Dynamics, Severity Assessment, and Outcome

OBJECTIVES

Because there is paucity of data on natural history of pediatric pancreatitis, we studied prevalence, etiology, severity, and outcome of pancreatitis.

METHODS

Over 12 years consecutive children with pancreatitis were included. Pancreatitis was classified as acute (AP), acute recurrent (ARP), and chronic pancreatitis (CP) as per standard definitions.

RESULTS

The study group comprised of 320 children (age, 11.4 ± 3.5 years, 201 males); AP, 160 (50%); ARP, 67 (21%); and CP, 93 (29%). The number of cases increased progressively from 28 to 157 between first and last quarter, and there was a significant increase (r = 0.92, P < 0.001) in AP-related hospitalizations over the years. Half of AP were idiopathic, 69% had severe pancreatitis (6 died) and on follow-up (21.1 ± 20.9 months) 21.5% progressed to either ARP (n = 8) or CP (n = 24). Progression was significantly associated with idiopathic etiology. The majority of ARP (70%) and CP (88%) were idiopathic and on follow-up (23.2 ± 28.9 months) 22% of ARP developed CP.

CONCLUSIONS

There was 7-fold increase in number of hospitalization due to pancreatitis over the years. Progression of AP to ARP/CP was noted in 21.5% and ARP to CP in 22%. Thus, a subset of pancreatitis seems to be a continuum of acute to ARP and CP.

Ablation of huntingtin in adult neurons is nondeleterious but its depletion in young mice causes acute pancreatitis

The Huntington's disease (HD) protein, huntingtin (HTT), is essential for early development. Because suppressing the expression of mutant HTT is an important approach to treat the disease, we must first understand the normal function of Htt in adults versus younger animals. Using inducible Htt knockout mice, we found that Htt depletion does not lead to adult neurodegeneration or animal death at >4 mo of age, which was also verified by selectively depleting Htt in neurons. On the other hand, young Htt KO mice die at 2 mo of age of acute pancreatitis due to the degeneration of pancreatic acinar cells. Importantly, Htt interacts with the trypsin inhibitor, serine protease inhibitor Kazal-type 3 (Spink3), to inhibit activation of digestive enzymes in acinar cells in young mice, and transgenic HTT can rescue the early death of Htt KO mice. These findings point out age- and cell type-dependent vital functions of Htt and the safety of knocking down neuronal Htt expression in adult brains as a treatment.

Genetic predisposition and its impact on natural history of idiopathic acute and acute recurrent pancreatitis in children

BACKGROUND

Genetic predisposition in paediatric idiopathic acute, acute recurrent pancreatitis and its consequences are unknown. We studied frequency of genetic markers in acute, acute recurrent, chronic pancreatitis and their impact on natural history.

METHODS

Over a period of 2 years 68 consecutive children with pancreatitis (35.3% acute, 32.3% acute recurrent, 32.3% chronic) and 25 controls were recruited in a single centre. Common mutations for serine-protease-inhibitor (SPINK1 N34S), protease-inhibitor (PRSS1 R122H) and cystic fibrosis transmembrane conductance regulator (CFTR DeltaF508, 5T) were analysed.

RESULTS

Mean age was 13.4±2.5 years. Overall, 30 cases (SPINK1 N34S n=26, CFTR 5T n=4) and 1 control (SPINK1 N34S) had mutations (p=0.0001). The prevalence of SPINK1 N34S mutation was similar in chronic and acute recurrent pancreatitis (45%). Six children with severe acute pancreatitis had SPINK1 N34S mutations (25%, p<0.05), and 4 were homozygous. On follow-up 5 acute pancreatitis patients with mutations and 1 without mutations developed chronic pancreatitis (p=0.004); 8 cases of acute recurrent pancreatitis progressed to chronic pancreatitis (38%); of these 66.7% had mutations vs. 16.7% who did not (p=0.03).

CONCLUSIONS

Almost 50% of idiopathic chronic, acute recurrent and 33% of acute pancreatitis in children are genetically predisposed. Presence of genetic mutations in acute and recurrent acute pancreatitis increases the risk of developing chronic pancreatitis.

Prospective evaluation of the aetiological profile of acute pancreatitis in young adult patients

BACKGROUND

The aetiologies of acute pancreatitis in young adult patients are poorly known.

AIMS

To prospectively evaluate the causes of acute pancreatitis in patients aged less than 35 years.

METHODS

Overall, 309 consecutive patients admitted to our centre for acute pancreatitis received first-line investigations, including medical history, standard laboratory tests, abdominal ultrasound and computed tomography. If no aetiology was found, second-line investigations were performed, including endoscopic ultrasound, magnetic-resonance cholangiopancreatography and genetic testing in cases of idiopathic pancreatitis.

RESULTS

Overall, 66 patients aged between 16 and 35 years were included. After first-line investigations, 49% of cases of acute pancreatitis remained idiopathic. Second-line investigations reduced this rate to 21%. The frequency of aetiologies for acute pancreatitis significantly differed in adults aged ≤ 35 compared to those aged >35 years: biliary aetiology was less frequent (23% versus 43%, p=0.003) as well as alcohol-related (8% versus 24%, p=0.01); drug-induced was more common (16% versus 4%, p=0.0007), as well as cannabis-related (13% versus 1%, p<0.0001), or genetic (10% versus 1.5%, p=0.003).

CONCLUSIONS

The aetiologies of acute pancreatitis significantly differed in adults aged less than 35 years when compared to older patients. Thus, use of medications, exposure to cannabis, and genetic mutations should be actively sought in these patients.

Endoscopic ultrasonography for surveillance of individuals at high risk for pancreatic cancer

Pancreatic cancer is a highly lethal disease with a genetic susceptibility and familial aggregation found in 3%-16% of patients. Early diagnosis remains the only hope for curative treatment and improvement of prognosis. This can be reached by the implementation of an intensive screening program, actually recommended for individuals at high-risk for pancreatic cancer development. The aim of this strategy is to identify pre-malignant precursors or asymptomatic pancreatic cancer lesions, curable by surgery. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) seems to be the most promising technique for early detection of pancreatic cancer. It has been described as a highly sensitive and accurate tool, especially for small and cystic lesions. Pancreatic intraepithelial neoplasia, a precursor lesion which is highly represented in high-risk individuals, seems to have characteristics chronic pancreatitis-like changes well detected by EUS. Many screening protocols have demonstrated high diagnostic yields for pancreatic pre-malignant lesions, allowing prophylactic pancreatectomies. However, it shows a high interobserver variety even among experienced endosonographers and a low sensitivity in case of chronic pancreatitis. Some new techniques such as contrast-enhanced harmonic EUS, computer-aided diagnostic techniques, confocal laser endomicroscopy miniprobe and the detection of DNA abnormalities or protein markers by FNA, promise improvement of the diagnostic yield of EUS. As the resolution of imaging improves and as our knowledge of precursor lesions grows, we believe that EUS could become the most suitable method to detect curable pancreatic neoplasms in correctly identified asymptomatic at-risk patients.

Prediction of acute pancreatitis risk based on PIP score in children with cystic fibrosis

BACKGROUND

Currently no tools to predict risk of acute (AP) and recurrent pancreatitis (ARP) in children with cystic fibrosis (CF) are available. We assessed the prevalence of AP/ARP and tested the potential role of Pancreatic Insufficiency Prevalence (PIP) score in a cohort of children with CF.

METHODS

We identified two groups of children, on the basis of presence/absence of AP/ARP, who were compared for age at diagnosis, clinical features, genotypes and sweat chloride level. PIP score was calculated for each patient.

RESULTS

10/167 (5.9%) experienced at least one episode of AP during follow up; 10/10 were pancreatic sufficient (PS). Patients with AP/ARP showed a PIP score ≤0.25 more frequently (6/10) than patients without AP/ARP. The odds ratio (95% CI) of developing pancreatitis was 4.54 (1.22-16.92) for patients with PIP <0.25 when compared with those who have a PIP score >0.25 (p 0.0151). PIP score was correlated with sweat chloride test (p < 0.01).

CONCLUSION

PIP score, PS status and normal/borderline sweat chloride levels could be applied to predict pancreatitis development in children with CF. ARP could lead to pancreatic insufficiency.

A review of animal models of nonneoplastic pancreatic diseases

The nonneoplastic diseases of the human pancreas generally comprise the inflammatory and degenerative conditions that include acute and chronic pancreatitis, with cystic fibrosis being arguably one of the most important diseases that induce the condition. Both acute and chronic conditions vary in severity, but both can be life threatening; and because of this fact, the study of their progression, and their responsiveness to therapy, is largely conducted by indirect means using serum markers of damage and repair such as amylase and lipase activities that normally occur at very low levels in the circulation but can be significantly increased during inflammatory episodes. Progress in the understanding the pathogenesis of both conditions has therefore been largely due to time course studies in animal models of pancreatitis, and it is in this context that animal model development has been so significant. In general terms, the animal models can be divided into the invasive, surgical procedures, and those induced by the administration of chemical secretagogues that induce hypersecretion of the pancreatic enzymes. The former include ligation and/or cannulation of the biliopancreatic ducts with infusion of solutions of various kinds, or the formation of closed duodenal loops. Secretagogue administration includes administration of caerulein or l-arginine in various protocols. An additional model involves administration of dibutyltin dichloride, which induces a partial blockage of the pancreatic ducts to induce pancreatic disease through enzymic reflux into the gland. The models have been invaluable in generating testable hypotheses for the human diseases. These hypotheses for the production of cellular damage as the initiating events in the disease include (1) intracellular chemical activation, (2) pancreatic secretion reflux, (3) intracellular production of reactive oxygen species, and (4) intracellular production of free radicals.

A comprehensive study indicates PRSS1 gene is significantly associated with pancreatitis

This comprehensive meta-analysis was applied to case-control studies of the association between pancreatitis and PRSS1 gene to assess the joint evidence for the association, the influence of individual studies, and evidence for publication bias. PubMed, EMBASE, and Cochrane Library were searched in order to identify longitudinal studies evaluating pancreatitis disease and PRSS1 gene. Odds ratios (ORs) were pooled using a random-effects model. For the case-control studies, the authors found 1) support for the association between total pancreatitis and PRSS1 gene, both totally analyzed and subdivided analyzed {total: [OR:10.799, 95%CI:(5.489-21.242), p<0.000]; Europe: [OR:9.795, 95%CI:(2.923-32.819), p<0.000]; Asia: [OR:11.994, 95%CI:(5.156-27.898), p<0.000]}. 2) no evidence showed that this association was accounted for by any one study, and 3) no evidence showed any publication bias exist. In conclusion, PRSS1 gene was significantly associated with total pancreatitis disease, both totally and separately.

Acute and recurrent pancreatitis in children: exploring etiological factors

OBJECTIVE

Etiologies of acute pancreatitis (AP) in children are more variable than in adults, including drugs, traumas, infections and multisystem disorders as well as biliary anomalies. While causes of pancreatitis have been extensively analyzed, different series reported different causes. The aims of this study were: 1) to assess the etiological factors of acute and recurrent pancreatitis in a pediatric population from a tertiary care hospital; 2) to assess the usefulness of imaging studies in diagnosing etiologies of pancreatitis.

MATERIAL AND METHODS

Thirty-four children (median age 11 years, 23 males) with AP and 11 with recurrent pancreatitis were retrospectively studied to assess etiology of pancreatitis in children.

RESULTS

The most common etiologies of AP were medications (11/34) and biliary tract diseases (9/34), whereas systemic diseases accounted for a small percentage of case. Among patients with recurrent episodes, biliary anomalies were the most common cause (6/11), whereas only 2 out of 11 patients with recurrent pancreatitis presented a hereditary cause.

CONCLUSIONS

This study highlights that etiologies of AP in children are variable. Epidemiology of AP could be influenced by single center's characteristics. Anatomic anomalies should be ruled out and genetic causes should be considered in recurrent cases.

CFTR polymorphisms of healthy individuals in two Chinese cities--Changchun and Nanjing

BACKGROUND AND AIM

Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, which encodes a chloride channel, cause cystic fibrosis. In order to investigate the polymorphic backgrounds of CFTR genes of healthy populations in different Chinese cities (Changchun and Nanjing), we analyzed 119 blood samples (Changchun 64, Nanjing 55) of randomly selected healthy individuals for poly T, TG-repeats and M470V polymorphisms. We analyzed the differences of CFTR polymorphic distributions between the two Chinese cities from the south and the north. Methods Genomic DNA was extracted from whole blood. DNA fragments of CFTR gene were amplified by polymerase chain reaction (PCR). Poly-T and TG repeats were directly sequenced by auto sequencer (ABI 310). M470V was detected by a HphI restriction enzyme.

RESULTS

The T7 allele was the most common haplotype in Changchun (0.938) and Nanjing (0.927) populations. The T5 allele was present in only 7 Changchun and 3 Nanjing subjects. The TG11 and TG12 alleles were dominant haplotypes in Changchun (TG11 0.500, TG12 0.453) and Nanjing (TG11 0.345, TG12 0.609). The frequency of the V470 allele was 0.633 in Changchun, which was higher than that in Nanjing (0.500) (p < 0.05). There were three major haplotypes: T7-TG11-V470, T7-TG12-M470 and T7-TG12-V470. The T7-TG11-V470 was the most common haplotype in Changchun (0.514), while T7-TG12-M470 was the most common haplotype in Nanjing (0.500).

CONCLUSION

Though Changchun and Nanjing are in the same country, their polymorphic backgrounds of CFTR gene are very different. Most of the two populations have genotypes that cause lower CFTR function.

Screening of R122H and N29I mutations in the PRSS1 gene and N34S mutation in the SPINK1 gene in Mexican pediatric patients with acute and recurrent pancreatitis

OBJECTIVES

The study's objective was to assess the association between the PRSS1 R122H and N29I and the SPINK1 N34S mutations and acute pancreatitis (AP) and recurrent pancreatitis in Mexican pediatric patients.

METHODS

The N34S and R122H mutations were detected using polymerase chain reaction-restriction fragment length polymorphism, and the N29I mutation was detected using allele-specific polymerase chain reaction in 92 pancreatitis patients (58 AP and 34 recurrent pancreatitis patients) and 144 controls.

RESULTS

We found 1 mutated allele in 4 (4.3%) of 92 pancreatitis patients and none in the controls. All 4 patients bearing mutations had AP, with a frequency of 6.8% (4/58). Three (5.2%) of 58 patients were heterozygous for the N34S mutation, and 1 (1.7%) of 58 patients was heterozygous for the N29I mutation. The comparison between the AP and control groups revealed both a significant number of patients carrying any mutations in the screened genes (P = 0.008) and bearing the N34S mutation (P = 0.023). Moreover, we found that the N34S G allele increased the risk of developing AP (odds ratio, 10.3; confidence interval, 1.1-248.8).

CONCLUSIONS

Patients bearing the N34S G allele exhibited a 10-fold increased risk of developing AP compared with controls, suggesting that the SPINK1 N34S mutation represents an etiologic risk factor for AP in our Mexican pediatric patients.

Acute pancreatitis in two five-day-old Appaloosa foals

Severe acute pancreatitis (SAP) in foals is rare and treatment has not been documented. This paper describes the clinical, haematological and ultrasonographic findings as well as attempted treatment of SAP in two 5-day-old Appaloosa fillies. Clinical signs, including colic, diarrhoea and coma, may be mistaken for sepsis or neonatal encephalopathy. Hyperlipaemic serum and peritoneal fluid, and elevated serum and peritoneal fluid amylase and lipase activities aided the diagnosis. Severe acute pancreatitis should be included as a differential in an acutely ill foal with diarrhoea, colic, cerebral cortica dysfunction and hyperlipaemia.

Role of endoscopic ultrasound in idiopathic acute pancreatitis with negative ultrasound, computed tomography, and magnetic resonance cholangiopancreatography

BACKGROUND

Idiopathic acute pancreatitis (IAP) is a diagnostic challenge. Finding a treatable cause after appropriate investigation may help to prevent recurrent pancreatitis and further management. The aim of our study was to retrospectively report our experience with endoscopic ultrasound (EUS) in investigating patients with IAP.

METHODS

Forty patients (26 males; age range: 17-72 years) of IAP with no underlying cause identified on transabdominal ultrasound, computed tomography and magnetic resonance cholangiopancreatography were studied. In 23 patients (57.5%), it was the first attack of acute pancreatitis whereas in 17 patients (42.5%) there was at least one previous attack of documented acute pancreatitis. EUS examination was done using a radial echoendoscope.

RESULTS

Twenty (50%) of the patients had biliary tract disease (cholelithiasis in 3, gallbladder sludge in 13, choledocholithiasis in 1 and common bile duct sludge in 3 patients). One each had an 8 mm tumor in the head of pancreas and pancreas divisum. No underlying cause could be found in 18 (45%) patients. Nine patients had features of chronic pancreatitis (CP) and the remaining had a normal pancreas.

CONCLUSIONS

Occult biliary pathology is the predominant cause of IAP. Half of the cases without identified etiology already had an underlying CP. EUS is a very important tool in evaluating IAP especially after an initial negative diagnostic workup.

Advance in understanding the epidemiology and etiology of pancreatic cancer

Pancreatic cancer is a life-threatening digestive system neoplasm with a low rate of surgical resection and poor prognosis. Symptoms of pancreatic cancer are so insidious that it is difficult to identify them at early stage. Due to changes in human lifestyle and diet, the incidence of pancreatic cancer has been increasing worldwide. Both genetic and environmental factors contribute to the pathogenesis of pancreatic cancer. Some hereditary factors, such as genetic mutations and genetic polymorphisms, have been demonstrated to be related to the development of pancreatic cancer. Many risk factors associated with pancreatic cancer, such as smoking, obesity, alcohol consumption, chronic pancreatitis, and diabetes, have also been identified. Here we review the recent advances in understanding the epidemiology and etiology of pancreatic cancer.

Alcoholic acute pancreatitis: pathogenesis and clinical characteristics

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

Etiology and diagnosis of acute biliary pancreatitis

Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.

Transgenic expression of pancreatic secretory trypsin inhibitor-1 rescues SPINK3-deficient mice and restores a normal pancreatic phenotype

Endogenous trypsin inhibitors are synthesized, stored, and secreted by pancreatic acinar cells. It is believed that they play a protective role in the pancreas by inhibiting trypsin within the cell should trypsinogen become prematurely activated. Rodent trypsin inhibitors are highly homologous to human serine protease inhibitor Kazal-type 1 (SPINK1). The mouse has one pancreatic trypsin inhibitor known as SPINK3, and the rat has two trypsin inhibitors commonly known as pancreatic secretory trypsin inhibitors I and II (PSTI-I and -II). Rat PSTI-I is a 61-amino acid protein that shares 65% sequence identity with mouse SPINK3. It was recently demonstrated that mice with genetic deletion of the Spink3 gene (Spink3(-/-)) do not survive beyond 15 days and lack normal pancreata because of pancreatic autophagy. We have shown that targeted transgenic expression of the rat Psti1 gene to acinar cells in mice [TgN(Psti1)] protects mice against caerulein-induced pancreatitis. To determine whether the autophagic phenotype and lethality in Spink3(-/-) mice were due to lack of pancreatic trypsin inhibitor, we conducted breeding studies with Spink3(+/-) heterozygous mice and TgN(Psti1) mice. We observed that, whereas Spink3(+/+), Spink3(+/-), and Spink3(-/-)/TgN(Psti1) mice had similar survival rates, no Spink3(-/-) mice survived longer than 1 wk. The level of expression of SPINK3 protein in acini was reduced in heterozygote mice compared with wild-type mice. Furthermore, endogenous trypsin inhibitor capacity was reduced in the pancreas of heterozygote mice compared with wild-type or knockout mice rescued with the rat Psti1 gene. Surprisingly, the lesser amount of SPINK3 present in the pancreata of heterozygote mice did not predispose animals to increased susceptibility to caerulein-induced acute pancreatitis. We propose that a threshold level of expression is sufficient to protect against pancreatitis.

Rational diagnosis and therapy for recurrent acute pancreatitis: a clinical analysis of 84 cases

AIM: To investigate the characteristics of etiology, clinical features and endoscopic manifestations and prevention methods of recurrent acute pancreatitis.

METHODS: The clinical data of 84 patients with recurrent acute pancreatitis (recurrence group) and 67 patients with incipient acute pancreatitis (control group) at our hospital from September 2001 to December 2007 were retrospectively analyzed; the results of imaging changes and endoscopy therapy were reviewed as well.

RESULTS: Incidence rate of biliary tract diseases was significantly higher in relapse group than in the control group (60.7% vs 38.8%, P < 0.01). Radiation pain, jaundice, intestinal obstruction were increased in the relapse group than in the control group, but there was no marked difference. Crude echo (38.3%), pancreatic duct dilation (21.3%), cholecystitis, the common bile duct stone were also significantly higher in relapse group than in control group. ERCP showed that stones and common bile duct dilation were significantly higher in relapse group than in control group (35.8% vs 11.6%, 32.1% vs9.3%, P < 0.05). Of 84 RAP cases, 20 underwent surgical treatment, 48 conservative treatment, and 16 endoscopy therapy. Three died in each surgery group and conservative treatment group, and none in endoscopy therapy group.

CONCLUSION: Recurrent acute pancreatitis often results from biliary tract diseases including cholelithiasis, chronic cholecystitis, inappropriate eating habit and alcohol use. Rational diagnosis and therapy is important measure to prevent relapse. Endoscopy therapy for RAP is safe, minimally invasive and effective, and is recommended for wide use.

Genetic predisposition and environmental risk factors to pancreatic cancer: A review of the literature

Some cases of pancreatic cancer (PC) are described to cluster within families. With the exception of PALLD gene mutations, which explain only a very modest fraction of familial cases, the genetic basis of familial PC is still obscure. Here the literature was reviewed in order to list the known genes, environmental factors, and health conditions associated with PC or involved in the carcinogenesis of the pancreas. Most of the genes listed are responsible for various well-defined cancer syndromes, such as CDKN2A (familial atypical mole-multiple melanoma, FAMMM), the mismatch repair genes (Lynch Syndrome), TP53 (Li-Fraumeni syndrome), APC (familial adenomatous polyposis), and BRCA2 (breast-ovarian familial cancer), where PC is part of the cancer spectrum of the disease. In addition, in this review I ranked known/possible risk factors extending the analysis to the hereditary pancreatitis (HP), diabetes, or to specific environmental exposures such as smoking. It appears that these factors contribute strongly to only a small proportion of PC cases. Recent work has revealed new genes somatically mutated in PC, including alterations within the pathways of Wnt/Notch and DNA mismatch repair. These new insights will help to reveal new candidate genes for the susceptibility to this disease and to better ascertain the actual contribution of the familial forms.