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Hagn-Meincke R, Yadav D, Andersen DK, Vege SS, Fogel EL, Serrano J, Bellin MD, Topazian MD, Conwell DL, Li L, Van Den Eeden SK, Drewes AM, Pandol SJ, Forsmark CE, Fisher WE, Hart PA, Olesen SS, Park WG. Circulating immune signatures in chronic pancreatitis with and without preceding acute pancreatitis: A pilot study. Pancreatology 2024; 24:384-393. [PMID: 38461145 PMCID: PMC11023786 DOI: 10.1016/j.pan.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/05/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To investigate profiles of circulating immune signatures in healthy controls and chronic pancreatitis patients (CP) with and without a preceding history of acute pancreatitis (AP). METHODS We performed a phase 1, cross-sectional analysis of prospectively collected serum samples from the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translation StuDies (PROCEED) study. All samples were collected during a clinically quiescent phase. CP subjects were categorized into two subgroups based on preceding episode(s) of AP. Healthy controls were included for comparison. Blinded samples were analyzed using an 80-plex Luminex assay of cytokines, chemokines, and adhesion molecules. Group and pairwise comparisons of analytes were performed between the subgroups. RESULTS In total, 133 patients with CP (111 with AP and 22 without AP) and 50 healthy controls were included. Among the 80 analytes studied, CP patients with a history of AP had significantly higher serum levels of pro-inflammatory cytokines (interleukin (IL)-6, IL-8, IL-1 receptor antagonist, IL-15) and chemokines (Cutaneous T-Cell Attracting Chemokine (CTACK), Monokine induced Gamma Interferon (MIG), Macrophage-derived Chemokine (MDC), Monocyte Chemoattractant Protein-1 (MCP-1)) compared to CP without preceding AP and controls. In contrast, CP patients without AP had immune profiles characterized by low systemic inflammation and downregulation of anti-inflammatory mediators, including IL-10. CONCLUSION CP patients with a preceding history of AP have signs of systemic inflammatory activity even during a clinically quiescent phase. In contrast, CP patients without a history of AP have low systemic inflammatory activity. These findings suggest the presence of two immunologically diverse subtypes of CP.
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Affiliation(s)
- Rasmus Hagn-Meincke
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark; Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Melena D Bellin
- Division of Pediatric Endocrinology, University of Minnesota, Minnesota, MN, USA
| | - Mark D Topazian
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Darwin L Conwell
- Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Liang Li
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition. University of Florida, Gainesville, FL, USA
| | - William E Fisher
- Division of General Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Walter G Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Cook ME, Bruun NH, Davidsen L, Drewes AM, Olesen SS. Multistate Model of the Natural History of Inflammatory Pancreatic Diseases: A Nationwide Population-based Cohort Study. Gastroenterology 2023; 165:1547-1557.e4. [PMID: 37659669 DOI: 10.1053/j.gastro.2023.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND & AIMS Understanding the nature of inflammatory pancreatic diseases is essential for planning health care system requirements and interventions. The aim of this study was to quantify the trajectories of inflammatory pancreatic diseases and their association with pancreatic cancer in a population-based setting. METHODS National health registries were used to identify all Danish residents (18 years or older) in the period from 2000 through 2018 with incident cases of acute pancreatitis (AP), recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), and pancreatic cancer. We used a multistate model to examine transitions from a healthy state to intermediate states of acute pancreatic inflammation (AP and RAP) to chronic states (CP and pancreatic cancer) and, ultimately, death. Results were reported as transition incidence rates per 1000 person-years with 95% CIs. RESULTS There were 4,663,864 individuals included (mean age, 46 years; 51% were women). During a mean follow-up of 16.8 years, 31,396 individuals were diagnosed with incident AP, 5546 with RAP, 8898 with CP, and 18,182 with pancreatic cancer. The cumulative incidence of pancreatitis (acute and chronic) during the study period was 0.80% (95% CI, 0.79%-0.80%). The transition incidence rates to CP were 12.1 (95% CI, 8.1-18.1) from AP, 46.8 (95% CI, 31.6-69.3) from RAP, and 0.07 (95% CI, 0.04-0.13) from a healthy state. Similar patterns were observed for transitions to pancreatic cancer. Most patients diagnosed with CP (64.2%) and pancreatic cancer (96.4%) transitioned directly from a healthy state. Among patients with pancreatitis, 41.0% (95% CI, 40.5%-41.5%) died during follow-up. CONCLUSIONS The study findings revealed an increased risk of CP and pancreatic cancer in patients with a history of AP. However, most patients with CP and pancreatic cancer transitioned directly from a healthy state.
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Affiliation(s)
- Mathias Ellgaard Cook
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Line Davidsen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Ahmed A, Shah I, Bocchino R, Freedman SD, Kothari DJ, Sheth SG. Natural history, clinical characteristics, outcomes, and long-term follow-up of pain-free chronic pancreatitis. Gastroenterol Rep (Oxf) 2023; 11:goad024. [PMID: 37153703 PMCID: PMC10162807 DOI: 10.1093/gastro/goad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 05/10/2023] Open
Abstract
Background Chronic pancreatitis (CP) is characterized by chronic abdominal pain and functional insufficiency. However, a small subset of patients with prior acute pancreatitis (AP) and/or underlying risk factors for developing CP may be pain-free at diagnosis and may have a different clinical course. We aimed to compare the clinical characteristics, outcomes, and healthcare utilization between CP patients with and without pain. Methods Reviewed patients with established CP were followed in our Pancreas Center between January 2016 and April 2021. Patients without risk factors for developing CP and/or without AP prior to their diagnosis and only with incidental radiologic features of CP were excluded, so as to minimize confounding factors of pancreatopathy unrelated to CP. Patients were divided into painful and pain-free groups to analyze differences in demographics, outcomes, and healthcare utilization. Results Of 368 CP patients, 49 (13.3%) were pain-free at diagnosis and had remained so for >9 years. There were no significant differences in body mass index, race, sex, or co-morbidities between the two groups. Pain-free patients were older at diagnosis (53.9 vs 45.7, P = 0.004) and had less recurrent AP (RAP) (43.8% vs 72.5%, P < 0.001) and less exocrine pancreatic insufficiency (EPI) (34.7% vs 65.7%, P < 0.001). Pain-free patients had less disability (2.2% vs 22.0%, P = 0.003), mental illness (20.4% vs 61.0%, P < 0.001), surgery (0.0% vs 15.0%, P = 0.059), and therapeutic interventions (0.0% vs 16.4%, P = 0.005) for pain. Conclusions We described a unique subset of patients with underlying risk factors for CP and/or prior AP who were pain-free at diagnosis. They were older at diagnosis, had less EPI and RAP, and overall favorable outcomes with minimal resource utilization.
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Affiliation(s)
- Awais Ahmed
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ishani Shah
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rachel Bocchino
- Department of Medicine, Division of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Steven D Freedman
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Darshan J Kothari
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC, USA
| | - Sunil G Sheth
- Corresponding author. Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Rabb 423, Boston, MA 02215, USA.
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Singh VK, Whitcomb DC, Banks PA, AlKaade S, Anderson MA, Amann ST, Brand RE, Conwell DL, Cote GA, Gardner TB, Gelrud A, Guda N, Forsmark CE, Lewis M, Sherman S, Muniraj T, Romagnuolo J, Tan X, Tang G, Sandhu BS, Slivka A, Wilcox CM, Yadav D, Guda N, Banks P, Conwell D, Lo SK, Gelrud A, Gardner T, Baillie J, Forsmark CE, Muniraj T, Sherman S, Singh VK, Lewis M, Romagnuolo J, Hawes R, Cote GA, Lawrence C, Anderson MA, Amann ST, Etemad B, DeMeo M, Kochman M, Abberbock JN, Barmada MM, Bauer E, Brand RE, Kennard E, LaRusch J, O'Connell M, Stello K, Slivka A, Talluri J, Tang G, Whitcomb DC, Wisniewski SR, Yadav D, Burton F, AlKaade S, DiSario J, Sandhu BS, Money M, Steinberg W. Acute pancreatitis precedes chronic pancreatitis in the majority of patients: Results from the NAPS2 consortium. Pancreatology 2022; 22:1091-1098. [PMID: 36404201 PMCID: PMC10122210 DOI: 10.1016/j.pan.2022.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/19/2022] [Accepted: 10/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The mechanistic definition of chronic pancreatitis (CP) identifies acute pancreatitis (AP) as a precursor stage. We hypothesized that clinical AP frequently precedes the diagnosis of CP and is associated with patient- and disease-related factors. We describe the prevalence, temporal relationship and associations of AP in a well-defined North American cohort. METHODS We evaluated data from 883 patients with CP prospectively enrolled in the North American Pancreatitis Studies across 27 US centers between 2000 and 2014. We determined how often patients had one or more episodes of AP and its occurrence in relationship to the diagnosis of CP. We used multivariable logistic regression to determine associations for prior AP. RESULTS There were 624/883 (70.7%) patients with prior AP, among whom 161 (25.8%) had AP within 2 years, 115 (18.4%) within 3-5 years, and 348 (55.8%) >5 years prior to CP diagnosis. Among 504 AP patients with available information, 436 (86.5%) had >1 episode. On multivariable analyses, factors associated with increased odds of having prior AP were a younger age at CP diagnosis, white race, abdominal pain, pseudocyst(s) and pancreatic duct dilatation/stricture, while factors associated with a lower odds of having prior AP were exocrine insufficiency and pancreatic atrophy. When compared with patients with 1 episode, those with >1 AP episode were diagnosed with CP an average of 5 years earlier. CONCLUSIONS Nearly three-quarters of patients were diagnosed with AP prior to CP diagnosis. Identifying which AP patients are at-risk for future progression to CP may provide opportunities for primary and secondary prevention.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A Banks
- Division of Gastroenterology, Brigham & Women's Hospital, Boston, MA, USA
| | | | | | | | - Randall E Brand
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Darwin L Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health Science University, Portland, OR, USA
| | - Timothy B Gardner
- Division of Gastroenterology & Hepatology, Dartmouth-Hitchcock Medical Center, Hanover, NH, USA
| | | | - Nalini Guda
- Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, FL, USA
| | - Michele Lewis
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Stuart Sherman
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | | | - Joseph Romagnuolo
- Palmetto Health, Columbia Gastroenterology Associates, Columbia, SC, USA
| | - Xiaoqing Tan
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - C Mel Wilcox
- Division of Gastroenterology & Hepatology, University of Alabama, Birmingham, AL, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Olesen SS, Toledo FGS, Hart PA. The spectrum of diabetes in acute and chronic pancreatitis. Curr Opin Gastroenterol 2022; 38:509-515. [PMID: 35881972 PMCID: PMC9379856 DOI: 10.1097/mog.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW To discuss the spectrum of diabetes related to acute and chronic pancreatitis (which are types of pancreatogenic diabetes) and its overlapping features with type 1 and type 2 diabetes. RECENT FINDINGS Patients with diabetes related to acute and chronic pancreatitis present clinically within a spectrum of overlapping features with other forms of diabetes. In this spectrum, glucose metabolism alterations range from increased insulin resistance following acute pancreatitis (resembling type 2 diabetes) towards a permanent loss of beta-cell function and impaired insulin secretion in end-stage chronic pancreatitis. Overlapping features with type 1 diabetes (beta cell autoantibodies) and type 2 diabetes (obesity, dyslipidemia, and hereditary/genetic factors) contribute to the heterogeneity of this spectrum. SUMMARY Pancreatogenic diabetes secondary to acute or chronic pancreatitis is a heterogeneous entity with a variable clinical presentation, including many cases that are misdiagnosed and treated as type 2 diabetes. This is problematic as pancreatogenic diabetes is associated with a poor prognosis and entails special considerations for management. Recent discoveries showing overlapping features with type 1 and type 2 diabetes along with an improved understanding of its pathophysiology are expected to improve the diagnosis and treatment of these and other forms of pancreatogenic diabetes.
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Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frederico G S Toledo
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Tao H, Chang H, Li N, Zhu S, Duan L. Clinical Characteristics of Patients With Chronic Pancreatitis With or Without Prior Acute Pancreatitis Are Different. Pancreas 2022; 51:950-6. [PMID: 36607939 DOI: 10.1097/MPA.0000000000002142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of the study is to clarify the clinical characteristics of patients with chronic pancreatitis (CP) who had no prior acute pancreatitis (AP) attack. METHODS We retrospectively analyzed patients with CP who were admitted to our center between January 2012 and January 2020. RESULTS A total of 274 patients were divided into the following 3 groups: group A: CP without prior AP (n = 103 [37.6%]), group B: CP preceded by a single episode of AP (n = 39 [14.23%]), and group C: CP preceded by recurrent AP (n = 132 [48.18%]). At the diagnosis, patients in group A had a higher incidence of pancreatic duct stones (41.7% vs 25.8%, P = 0.012), higher proportion of idiopathic CP (68.9% vs 48.5%, P = 0.001), and higher mean pancreatic volume change rate (37.61% vs 10.48%, P = 0.007) compared with Group C. Patients in group A underwent the most episodes of extracorporeal shockwave lithotripsy therapy among the 3 groups (P < 0.001). CONCLUSIONS Approximately 37.6% of patients had no prior AP attack before CP diagnosis. Patients with CP without prior AP had higher incidence of pancreatic duct stones and pancreas volume shrank faster.
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Bouça-Machado T, Andrea-Ferreira P, Pedersen JB, Mortensen MB, Novovic S, Windsor JA, Olesen SS, Drewes AM. Confusion with the definition and diagnostic criteria for acute on chronic pancreatitis: review and recommendations. Scand J Gastroenterol 2022:1-7. [PMID: 35119346 DOI: 10.1080/00365521.2022.2035811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is a fibroinflammatory disease complicated by episodes of acute inflammation (acute on chronic pancreatitis (ACP)). This entity is common, variably defined and can reflect different pathological mechanisms that requires different interventions. The aim of this study is to conduct a systematic review of how ACP is described, defined and diagnosed in the literature. METHODS A systematic search was conducted from January 1993 to June 2020. All articles that used a term to describe ACP in adults were reviewed and definitions and diagnostic criteria were sought. RESULTS After reviewing 2271 abstracts, 848 articles included a term to describe ACP. The most common descriptions were 'acute on/in CP' (374), 'acute exacerbation of CP' (345) and 'flare(-up) of CP' (43). Among the 848 articles, 14 included a pragmatic definition of ACP, and only 2 papers stated diagnostic criteria. These covered both acute inflammation and acute exacerbation of chronic abdominal pain. CONCLUSION There is no universally accepted term, definition or diagnostic criteria for ACP. A consensus definition is needed to improve quality and comparability of future articles as well as clinical management.
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Affiliation(s)
| | | | - Jan Bech Pedersen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Bau Mortensen
- Odense Pancreas Centre, Upper GI and HPB Section, Department of Surgery, Odense University Hospital, Odense C, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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Ru N, Zhu JH, Hu LH, Wu SY, Pan J, Xu XN, Wang L, Yu FF, Yan ZJ, Guo JY, Li ZS, Zou WB, Liao Z. Factors associated with prior acute pancreatitis episodes among patients with chronic pancreatitis. Dig Liver Dis 2021; 53:1148-1153. [PMID: 33757733 DOI: 10.1016/j.dld.2021.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The relationship between chronic pancreatitis (CP) and acute pancreatitis (AP) is complex and not well understood. CP could be preceded by antecedent episodes of AP. AIMS The aim of this study was to explore both genetic and environmental factors associated with AP episodes before the diagnosis of CP. METHODS This was a cross-sectional study including 1022 patients. Detailed demographic, genetic, and clinical data were collected. Based on the presence of AP episode(s) before diagnosis of CP, patients were divided into AP group (further classified into single episode of AP group and recurrent AP group) and non-AP group. Related factors among these groups were assessed using multivariate logistic regression model. RESULTS Before diagnosis of CP, 737 patients (72.1%) had a history of AP. Smoking(P = 0.005) and heavy alcohol consumption(P = 0.002) were risk factors for AP while age at CP onset(P < 0.001), harboring the SPINK1 mutation(P < 0.001), diabetes(P < 0.001) and steatorrhea(P < 0.001) were protective factors. Further, alcoholic CP(P = 0.019) was the only independent risk factor for recurrent AP attacks while age at onset of CP(P < 0.001), pancreatic stones(P = 0.024). and pseudocysts(P = 0.018) served as protective factors. CONCLUSIONS SPINK1 mutations served as protective factor for AP episodes, suggesting SPINK1 mutation might play a pathogenic role in CP occurrence with occult clinical manifestations.
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Affiliation(s)
- Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai 200433, China
| | - Jia-Hui Zhu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai 200433, China
| | - Sheng-Yong Wu
- Department of Health Statistics, Naval Medical University, 800 Xiangyin Road, Shanghai 200433, China
| | - Jun Pan
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Xiao-Nan Xu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Lei Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Fei-Fei Yu
- Naval Medical Center of PLA, Naval Medical University, 880 Xiangyin Road, Shanghai 200052, China
| | - Zi-Jun Yan
- Graduate Management Unit, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Ji-Yao Guo
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai 200433, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai 200433, China.
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai 200433, China.
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Olesen SS, Poulsen JL, Novovic S, Nøjgaard C, Kalaitzakis E, Jensen NM, Engjom T, Tjora E, Waage A, Hauge T, Haas SL, Vujasinovic M, Barauskas G, Pukitis A, Ozola-Zālīte I, Okhlobystin A, Parhiala M, Laukkarinen J, Drewes AM. Multiple risk factors for diabetes mellitus in patients with chronic pancreatitis: A multicentre study of 1117 cases. United European Gastroenterol J 2020; 8:453-461. [PMID: 32213024 DOI: 10.1177/2050640620901973] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Diabetes mellitus is a common complication of chronic pancreatitis. It is traditionally considered to develop as a consequence of beta cell loss, but there might be additional factors. Recent studies have highlighted the importance of type 2 diabetes-related risk factors in this context and population-based studies show increased risk of diabetes following acute pancreatitis. The aim of this study was to explore multiple risk factors for diabetes in patients with chronic pancreatitis. METHODS We conducted a multicentre, cross-sectional study of patients with definitive chronic pancreatitis according to the M-ANNHEIM criteria. We used multivariable logistic regression models to determine risk factors independently associated with diabetes. RESULTS The study included 1117 patients of whom 457 (40.9 %) had diabetes. The mean age was 52.8 ± 14.2 years and 67% were men. On multivariate analysis, parameters indicative of beta cell loss (pancreatic calcification, exocrine insufficiency, pancreatic resection) were confirmed as independent risk factors for diabetes (all p ≤ 0.02). In addition, type 2 diabetes-related risk factors (dyslipidaemia and overweight/obesity) were associated with the presence of diabetes (all p ≤ 0.002). Patients with a history of pancreatic fluid collections (indicative of previous attacks of acute pancreatitis) had a marginally increased risk of diabetes (p = 0.07). CONCLUSION In patients with chronic pancreatitis the presence of diabetes is associated with multiple risk factors including type 2 diabetes-related factors. Our observations attest to the understanding of this entity and may have implications for treatment.
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Affiliation(s)
- Søren S Olesen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Jakob L Poulsen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Gastrounit, Hvidovre University Hospital, Hvidovre, Denmark
| | | | | | - Nanna M Jensen
- Abdominalcenter K, Bispebjerg Hospital, Copenhagen, Denmark
| | - Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Erling Tjora
- Pediatric Department, Haukeland University Hospital, Bergen, Norway
- Center for Diabetes Research, University of Bergen, Bergen, Norway
| | - Anne Waage
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stephan L Haas
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Giedrius Barauskas
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Aldis Pukitis
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Imanta Ozola-Zālīte
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Alexey Okhlobystin
- Chair of Internal Diseases Propedeutics, IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Mikael Parhiala
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
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Abstract
IMPORTANCE Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas with a prevalence of 42 to 73 per 100 000 adults in the United States. OBSERVATIONS Both genetic and environmental factors are thought to contribute to the pathogenesis of CP. Environmental factors associated with CP include alcohol abuse (odds ratio [OR], 3.1; 95% CI, 1.87-5.14) for 5 or more drinks per day vs abstainers and light drinkers as well as smoking (OR, 4.59; 95% CI, 2.91-7.25) for more than 35 pack-years in a case-control study involving 971 participants. Between 28% to 80% of patients are classified as having "idiopathic CP." Up to 50% of these individuals have mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 1% of people diagnosed with CP may have hereditary pancreatitis, associated with cationic trypsinogen (PRSS1) gene mutations. Approximately 80% of people with CP present with recurrent or chronic upper abdominal pain. Long-term sequelae include diabetes in 38% to 40% and exocrine insufficiency in 30% to 48%. The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both. Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal. The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol). A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients. Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, such as pancreaticojejunostomy with or without pancreatic head resection, which may provide better pain relief among people who do not respond to endoscopic therapy. CONCLUSIONS AND RELEVANCE Chronic pancreatitis often results in chronic abdominal pain and is most commonly caused by excessive alcohol use, smoking, or genetic mutations. Treatment consists primarily of alcohol and smoking cessation, pain control, replacement of pancreatic insufficiency, or mechanical drainage of obstructed pancreatic ducts for some patients.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Dhiraj Yadav
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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