Idiopathic chronic pancreatitis: Beyond antioxidants

Heterogeneity in Pancreatitis: Recognizing Heterogeneity and Its Role in the Management of Pancreatitis Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

ABSTRACT

Both the clinical management and study of recurrent acute pancreatitis and chronic pancreatitis are complicated by significant heterogeneity in the etiology, mechanisms, symptoms, and complications of pancreatitis. The National Institutes of Diabetes and Digestive and Kidney Disease recently convened a workshop to address current knowledge and knowledge gaps in the field. Preclinical models that better replicate human disease are important for development of new therapies. Pain is often the most common and most difficult symptom to treat, as the causes are multifactorial and effective treatment may vary depending on whether pain is neuropathic or nociceptive in origin, and the placebo effect can complicate evaluation of the efficacy of medical and procedural interventions. Novel technologies like functional magnetic resonance imaging and virtual reality may offer novel means for assessing and treating pain, respectively. Clinical trial designs will need to consider best approaches to addressing the heterogeneity of chronic pancreatitis, including careful attention to designing eligibility criteria, and establishing accepted and validated core outcomes criteria for the field. The latter may be informed by consensus in pain research. Recruitment of participants into clinical trials has been challenging, often requiring multiple centers. Establishment of a clinical trials network would facilitate greater opportunities for therapeutic trials in pancreatitis.

Management of chronic pancreatitis

Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.

Pregnancy Outcomes in Patients with Early-Onset Idiopathic Chronic Pancreatitis

BACKGROUND

Early-onset idiopathic chronic pancreatitis (EOICP) is a disease that affects young individuals. Data on pregnancy outcomes in EOICP are limited.

AIM

To assess the pregnancy outcomes in patients with EOICP and the effect of pregnancy on the course of EOICP.

METHODS

Patients with EOICP with disease onset before their pregnancy were recruited. Data regarding demographic variables, disease duration, pregnancy outcomes, and course of illness were noted.

RESULTS

50 patients were included in the study contributing to a total of 86 pregnancies. The mean age of onset of symptoms and at the time of delivery was 17.95 (5.71) and 23.44 (4.28) years, respectively. Gestational diabetes (GD) and gestational hypertension (GH) noted in one (1.5%) each. 3 (4.5%) pregnancies were preterm. 19 (22.1%) pregnancies did not have successful outcomes (7 (8.1%) were induced abortions). 12 (15.2%) pregnancies had spontaneous pregnancy losses. 8 (10.1%) were spontaneous abortions and 4 (5.1%) were stillbirths. Of 67 successful pregnancies, 33 (49.3%) pregnancies were delivered by LSCS. Compared to average rates of LSCS in India, this was significantly higher (21.5% vs 49.3%-p ≤ 0.001). The average birth weight was 2.87 (0.48) kg. There was one (1.5%) neonatal death. Compared to the published Indian data, there was no significant difference in the incidence of spontaneous pregnancy losses, GD, GH, preterm labor, and birth weight. Pancreatic pain was reported by 21 (42%) women in total 27 (31.4%) pregnancies. There was no difference in maternal or fetal outcomes between pregnancies with or without pancreatic pain. There were no pancreatitis-related complications reported during the pregnancies.

CONCLUSION

The present study shows that mothers affected with EOICP have pregnancy outcomes similar to healthy women in India.

Natural History, Clinical Characteristics, and Outcomes in Idiopathic Chronic Pancreatitis

BACKGROUND AND AIMS

Chronic pancreatitis (CP) is a fibroinflammatory syndrome of the pancreas associated with pain and poor quality of life. It has toxic and genetic risk factors but can also be idiopathic. The natural history of idiopathic CP (ICP) is not well-known. Therefore, we studied clinical characteristics and outcomes of these patients followed in our Pancreas Center.

METHODS

Review of CP patients between January 1, 2016, and April 30, 2021. Patients were divided into 2 groups based on diagnosis, ICP vs non-ICP. CP patients with a smoking history were placed in the non-ICP group. Statistical analysis was performed to identify differences in demographics, comorbidities, complications, controlled medications, and resource utilization.

RESULTS

Out of 450 patients, 101 (22%) were diagnosed with ICP and 349 (78%) were non-ICP. ICP patients were mainly female (59.4% vs 40.5%; P = .005), had less comorbid anxiety (10.5% vs 22.1%; P = .002), depression (24.2% vs 35.8%; P < .001), disability (13% vs 16.3%; P = .021), exocrine pancreatic insufficiency (45.3% vs 62.6%; P = .004), splanchnic vein thrombosis (1.04% vs 14.9%; P < .001), pseudocysts (16.7% vs 41.6%; P < .001), and biliary obstruction (3.12% vs 19.2%; P < .001). They underwent less abdominal imaging (2.63 vs 3.42; P = .048) and endoscopic retrograde cholangiopancreatography (0.88 vs 1.32; P = .030). They also had less opioid use (29.6% vs 54.4%; P < .001), gabapentinoid use (34% vs 52.3%; P = .002), and celiac blocks (7.22% vs 16.1%; P < .041).

CONCLUSION

Our study demonstrates that the clinical course of ICP is less morbid compared to non-ICP. This study specifically removes smoking, a significant risk factor for CP, to study a truly idiopathic cohort.

Calcium, mitochondria and the initiation of acute pancreatitis

Acute pancreatitis is characterized by necrosis of its parenchymal cells and influx and activation of inflammatory cells that further promote injury and necrosis. This review is intended to discuss the central role of disorders of calcium metabolism and mitochondrial dysfunction in the mechanism of pancreatitis development. The disorders are placed in context of calcium and mitochondria in physiologic function of the pancreas. Moreover, we discuss potential therapeutics for preventing pathologic calcium signals that injure mitochondria and interventions that promote the removal of injured mitochondria and regenerate new and heathy populations of mitochondria.