Cigarette smoking increases the risk of pancreatic calcification in late-onset but not early-onset idiopathic chronic pancreatitis

Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.

Classification of Early-Onset and Late-Onset Idiopathic Chronic Pancreatitis Needs Reconsideration

Bimodal classification of idiopathic chronic pancreatitis (ICP) into early-onset (<35 years) and late-onset (>35 years) ICP was proposed in 1994 based on a study of 66 patients. However, bimodal distribution wasn’t sufficiently demonstrated. Our objective was to examine the validity and relevance of the age-based bimodal classification of ICP. We analyzed the distribution of age at onset of ICP in our cohort of 1633 patients admitted to our center from January 2000 to December 2013. Classify ICP patients into early-onset ICP_(a) and late-onset ICP_(a) according to different cut-off values (cut-off value, a = 15, 25, 35, 45, 55, 65 years old) for age at onset. Compare clinical characteristics of early-onset ICP_(a) and late-onset ICP_(a). We found slightly right skewed distribution of age at onset for ICP in our cohort. There were differences between early-onset and late-onset ICP with respect to basic clinical characteristics and development of key clinical events regardless of the cut off age at onset i.e. 15, 25, 35, 45 or even higher. The validity of the bimodal classification of early-onset and late-onset ICP could not be established in our large patient cohort and therefore such a classification needs to be reconsidered.

A population-based study of chronic pancreatitis in Finland: Effects on quality of life

BACKGROUND/OBJECTIVES

In Finland the incidence of chronic pancreatitis (CP) is high compared to that in most European countries. Recent epidemiological data is lacking. Our aim was to investigate the current epidemiologic and behavioural data on CP patients in Finland.

METHODS

CP patients according to M-ANNHEIM criteria in Tampere University Hospital (TAUH) during 2014-2015 were included. Aetiology, time from diagnosis, pancreatic function, treatment, complications, smoking, alcohol consumption (AUDIT) and quality of life (QoL) (QLQ C30, PAN26) were gathered.

RESULTS

235 CP patients (57 (26-88) years, 65% men) were included. Time since diagnosis was 5.5 (1-41) years. Aetiology was alcohol in 67%, and smoking contributed in 54%. Of these patients 78% continued smoking and 58% continued to consume alcohol even after CP diagnosis. CP related complications were common. Pseudocysts were more common in alcohol related CP than in non-alcohol related CP (60% vs. 38%, p < 0.05). Reported QoL and pain were worse in the CP patients than in controls. Alcohol consumption differed from that of the Finnish population; the CP patients were either total abstainers or heavy alcohol consumers.

CONCLUSIONS

CP constitutes a great burden on the health care system and on the patients. The patients frequently develop complications and symptoms and their QoL is inferior to that of controls. The most important measure to halt the progression of CP would be to prevent acute phases and for patients to stop smoking, which does not happen in many CP patients. It would be beneficial to increase awareness among CP patients and medical professionals.

Pancreatic calcifications associate with diverse aetiological risk factors in patients with chronic pancreatitis: A multicentre study of 1500 cases

BACKGROUND

Pancreatic calcifications is a common finding in patients with chronic pancreatitis (CP), but the underlying pathophysiology is incompletely understood. Past studies for risk factors of calcifications have generally been focused on single parameters or limited by small sample sizes. The aim of this study was to explore several patient and disease characteristics and their associations with pancreatic calcifications in a large cohort of CP patients with diverse aetiological risk factors.

METHODS

This was a multicentre, cross-sectional study including 1509 patients with CP. Patient and disease characteristics were compared for patients with calcifications (n = 912) vs. without calcifications (n = 597). Multivariable logistic regression was performed to assess the parameters independently associated with calcifications.

RESULTS

The mean age of patients was 53.9 ± 14.5 years and 1006 (67%) were men. The prevalence of calcifications was 60.4% in the overall patient cohort, but highly variable between patients with different aetiological risk factors (range: 2-69%). On multivariate analysis, alcoholic aetiology (OR 1.76 [95% CI, 1.39-2.24]; p < 0.001) and smoking aetiology (OR 1.77 [95% CI, 1.39-2.26], p < 0.001) were positively associated with the presence of calcifications, while an autoimmune aetiology was negatively associated with calcifications (OR 0.15 [95% CI, 0.08-0.27], p < 0.001). Patients with pancreatic calcifications were more likely to have undergone pancreatic duct stenting (OR 1.59 [95%CI, 1.16-2.19], p = 0.004).

CONCLUSION

The presence of pancreatic calcifications is associated with diverse aetiological risk factors in patients with CP. This observation attest to the understanding of CP as a complex disease and may have implications for disease classification.

New-Onset Diabetes Mellitus After Chronic Pancreatitis Diagnosis: A Systematic Review and Meta-analysis

OBJECTIVES

The aim of this study was to assess the occurrence of new-onset diabetes mellitus (DM) after chronic pancreatitis (CP) diagnosis via systematic review and meta-analysis.

METHODS

A systematic review of literature and meta-analysis of relevant reports were performed. The primary outcome measures studied were newly diagnosed DM and DM treated with insulin. For the binary outcomes, pooled prevalence and 95% confidence interval (CI) were calculated.

METHODS

Fifteen studies involving 8970 patients were eligible. The incidence of new-onset DM after CP diagnosis was 30% (95% CI, 27%-33%). Among all patients, 17% (95% CI, 13%-22%) developed insulin-dependent new-onset DM. The prevalence of newly diagnosed DM after CP diagnosis increased from 15% within 36 months to 33% after 60 months. The proportion of alcoholic CP, sex, age, and body mass index had minimal effect on the studied outcomes.

CONCLUSIONS

This systematic review identified a clinically relevant risk of new-onset DM after CP diagnosis. Therefore, patients should be informed of the risk of DM and monitored.

Impact of fatty pancreas and lifestyle on the development of subclinical chronic pancreatitis in healthy people undergoing a medical checkup

Background

Although fat accumulation in human organs is associated with a variety of diseases, there is little evidence about the effect of a fatty pancreas on the development of subclinical chronic pancreatitis over the clinical course.

Methods

We conducted a prospective cohort study from 2008 to 2014 of patients who underwent a medical checkup consultation for fat accumulated in the pancreas. Patients included in the analysis were divided into a non-fatty pancreas group (n = 9710) and fatty pancreas group (n = 223). The primary end point was the odds ratio (OR) for chronic pancreatitis associated with fatty pancreas, which was diagnosed using ultrasonography. We used a multiple logistic regression model to estimate the OR and the corresponding 95% confidence interval (CI).

Results

Ninety-two people were diagnosed with chronic pancreatitis, including both presumptive and definitive diagnoses. Twelve people were diagnosed with chronic pancreatitis by ultrasonography among the 223 patients with fatty pancreas, and 80 patients among 9710 were diagnosed with non-fatty pancreas. The crude OR was 6.85 (95% CI 3.68, 12.75), and the multiple adjusted OR was 3.96 (95% CI 2.04, 7.66).

Conclusions

Fat accumulation in the pancreas could be a risk factor for developing subclinical chronic pancreatitis.

Risk Factors for Pancreatic Stone Formation in Type 1 Autoimmune Pancreatitis: A Long-term Japanese Multicenter Analysis of 624 Patients

OBJECTIVE

Autoimmune pancreatitis (AIP) has the potential to transform into chronic pancreatitis with pancreatic stone involvement. This retrospective investigation sought to clarify the risk factors for stone formation in type 1 AIP.

METHODS

Questionnaires on patients with type 1 AIP were sent to 22 high-volume medical centers across Japan to compare the clinical features of patients with and without pancreatic stone formation.

RESULTS

Of the completed records on 624 type 1 AIP patients, 31 (5%) had experienced pancreatic stones. Median follow-up duration was 1853 days. Bentiromide test values at diagnosis were significantly lower, and hemoglobin A1c values after corticosteroid treatment were significantly higher in patients with pancreatic stones. Imaging results disclosed that pancreatic atrophy and hilar or intrahepatic bile duct stenosis were significantly more frequent in patients with pancreatic stone formation. Pancreatic head swelling tended to be more frequent in this group as well. On the other hand, a shorter follow-up period was associated with the nonformation of pancreatic stones.

CONCLUSIONS

The increased frequency of pancreatic head swelling in type 1 AIP patients exhibiting pancreatic stones indicated a propensity for pancreatic juice stasis with subsequent stone development and pancreatic dysfunction occurring over longer periods of disease duration.

Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club

This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).

Myths and realities about alcohol and smoking in chronic pancreatitis

PURPOSE OF REVIEW

Alcohol and smoking play an important role in pancreatitis. The present review will address the myths and evidences about alcohol and smoking with pancreatitis to help improve the approach of healthcare professionals when managing of these patients.

RECENT FINDINGS

There is a growing recognition that chronic pancreatitis is a multifactorial disease. Eliciting an accurate history of alcohol consumption and smoking from patients, and if necessary, family members, can help determine their contribution to the patient's disease. In the absence of a convincing history, physicians should be open to consideration of other etiologies. The amount and duration of alcohol consumption is the most important determinant in increasing pancreatitis risk. Alcohol sensitizes the pancreas to other insults or injury and promotes disease progression. Smoking is an independent risk factor or chronic pancreatitis and has synergistic pathogenic effects with alcohol. The natural history of chronic pancreatitis is highly variable. A patient with alcoholic pancreatitis can have symptoms, recurrences or exacerbations from disease-related complications or nonpancreatic causes. Novel strategies are needed to enable patients quit smoking.

SUMMARY

Obtaining accurate history, appropriate evaluation and management can help to achieve meaningful improvement in symptoms in patients with chronic pancreatitis. Abstinence from alcohol and smoking cessation, when applicable, should be recommended in all patients to prevent disease recurrences and progression.

Total pancreatectomy for recurrent acute and chronic pancreatitis: a critical review of patient selection criteria

PURPOSE OF REVIEW

Critical review of the indications for total pancreatectomy and highlight limitations in current diagnostic criteria for chronic pancreatitis.

RECENT FINDINGS

The diagnosis of noncalcific chronic pancreatitis remains controversial because of an overreliance on nonspecific imaging and laboratories findings. Endoscopic ultrasound, s-magnetic resonance cholangiopancreatography, and/or endoscopic pancreatic function testing are often used to diagnose noncalcific chronic pancreatitis despite the fact that there is no gold standard for this condition. Abdominal pain is not specific for chronic pancreatitis and is more likely to be encountered in patients with functional gastrointestinal disorders based on the high incidence of these conditions. The duration of pain and opioid analgesic use results in central sensitization that adversely affects pain outcomes after total pancreatectomy. An alcoholic cause is associated with poorer pain outcomes after total pancreatectomy.

SUMMARY

The lack of a gold standard for noncalcific chronic pancreatitis limits the diagnostic accuracy of imaging and laboratory tests. The pain of chronic pancreatitis is nonspecific and is affected by duration, preoperative opioid use, and cause. These factors will need to be considered in the development of future selection criteria for this morbid surgery.

Negotiating the complexities of exocrine and endocrine dysfunction in chronic pancreatitis. Proc Nutr Soc. 2017;76:484-494. [PMID: 28735575 DOI: 10.1017/s0029665117001045]

Chronic pancreatitis is a chronic inflammatory disease of the pancreas characterised by irreversible morphological change and typically causing pain and/or permanent loss of function. This progressive, irreversible disease results in destruction of healthy pancreatic tissue and the development of fibrous scar tissue. Gradual loss of exocrine and endocrine function follows, along with clinical manifestations such as steatorrhoea, abdominal pain and diabetes. Nutrition in chronic pancreatitis has been described as a problem area and, until recently, there was little research on the topic. It is often asserted that >90 % of the pancreas must be damaged before exocrine insufficiency occurs; however, an exploration of the original studies from the 1970s found that the data do not support this assertion. The management of steatorrhoea with pancreatic enzyme replacement therapy is the mainstay of nutritional management, and early identification and treatment is a key. The presence of steatorrhoea, coupled with poor dietary intake (due to intractable abdominal pain, gastrointestinal side effects and often alcoholism) renders the chronic pancreatitis patients at considerable risk for undernutrition, muscle depletion and fat-soluble vitamin deficiency. Premature osteoporosis/osteopenia afflicts two-thirds of patients as a consequence of poor dietary intake of calcium and vitamin D, low physical activity, low sunlight exposure, heavy smoking, as well as chronic low-grade inflammation. Bone metabolism studies show increased bone formation as well as bone resorption in chronic pancreatitis, indicating that bone turnover is abnormally high. Loss of the pancreatic islet cells occurs later in the disease process as the endocrine cells are diffusely distributed throughout the pancreatic parenchyma. Patients may develop type 3c (pancreatogenic) diabetes, which is complicated by concurrent decreased glucagon secretion, and hence an increased risk of hypoglycaemia. Diabetes control is further complicated by poor diet, malabsorption and (for some) alcoholism, and therefore those with type 3c diabetes have clinical characteristics and therapeutic goals that are different from that of type 1 and type 2 diabetes patients. This review describes emerging research and clinical guidelines for nutrition in chronic pancreatitis.

Early diagnosis of chronic pancreatitis: understanding the factors associated with the development of chronic pancreatitis

The prognosis of advanced chronic pancreatitis (CP) is poor with the mortality rate approximately two-fold higher than the general population according to a survey of the prognosis of CP.　From this standpoint, the concept of early CP was propagated in Japan in 2009 to encourage the medical treatment for the earlier stages of CP.　That is, picking up the patients suspicious for early CP and then providing medical treatment for them are very important not only for patients, but also for health care economics.　In this review, we described some potential factors associated with the development of CP (alcohol, smoking, past history of acute pancreatitis, aging, gallstone, and gender) that are extremely important to discover patients with early-stage CP.

Genetic Background and Clinical Characters of Pediatric Chronic Pancreatitis: Data and Implications from the East

Background. The clinical pattern and genetic background of juvenile idiopathic chronic pancreatitis (ICP) are yet unclear. Methods. A retrospective study of 73 Chinese juvenile ICP patients was performed, and genetic tests were carried out to detect relevant mutations using direct sequencing technique and high-resolution melting technique. Subjects without pancreatitis served as controls. Results. The SPINK1 c.194+2T>C variant was present in 56.16% and 42.00% of juvenile and adult ICP patients, respectively (p = 0.020), but was not present in any of the control subjects. Thirty-four (46.58%) of the 73 juvenile ICP patients were male, and a significantly higher ratio of male patients in the adult group was identified (46.58% versus 64.00%, p = 0.022). Although most of the juvenile patients presented with abdominal pain (70/73, 95.89%), the patterns of pain attack are significantly different in patients with or without SPINK1 c.194+2T>C mutation. Patients carrying the mutation are more likely to present with recurrent acute pancreatitis (70.70%). Conclusions. The main symptom of pediatric ICP was abdominal pain. SPINK1 c.194+2T>C mutation had a higher occurrence in juvenile ICP patients than in adult group and typically presented with recurrent acute pancreatitis. There may be unidentified factors that lead to a greater incidence rate of ICP in adult male population.

Chronic pancreatitis: Multicentre prospective data collection and analysis by the Hungarian Pancreatic Study Group

Introduction

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life.

Aims and methods

Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions.

Results

Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004).

Conclusions

According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.

Risk Factors for Diabetes Mellitus in Chronic Pancreatitis: A Cohort of 2,011 Patients

Diabetes mellitus (DM) is a common complication of chronic pancreatitis (CP) and increases the mortality. The identification of risk factors for DM development may contribute to the early detection and potential risk reduction of DM in patients with CP.Patients with CP admitted to Changhai Hospital (Shanghai, China) from January 2000 to December 2013 were enrolled. Cumulative rates of DM after the onset of CP were calculated by Kaplan-Meier method. Risk factors for DM development after the diagnosis of CP were identified by Cox proportional hazards regression model.A total of 2011 patients with CP were enrolled. During follow-up (median duration, 22.0 years), 564 patients developed DM. Cumulative rates of DM 20 and 50 years after the onset of CP were 45.8% (95% confidence interval [CI], 41.8%-50.0%) and 90.0% (95% CI, 75.4%-97.7%), respectively. Five risk factors for DM development after the diagnosis of CP were identified: male sex (hazard ratio [HR], 1.51; 95% CI, 1.08-2.11), alcohol abuse (HR, 2.00; 95% CI, 1.43-2.79), steatorrhea (HR, 1.46; 95% CI, 1.01-2.11), biliary stricture (HR, 2.25; 95% CI, 1.43-3.52), and distal pancreatectomy (HR, 3.41; 95% CI, 1.80-6.44).In conclusion, the risk of developing DM in patients with CP is not only influenced by the development of biliary stricture and steatorrhea indicating disease progression, and inherent nature of study subjects such as male sex, but also by modifiable factors including alcohol abuse and distal pancreatectomy.

Evidence-based clinical practice guidelines for chronic pancreatitis 2015

Chronic pancreatitis is considered to be an irreversible progressive chronic inflammatory disease. The etiology and pathology of chronic pancreatitis are complex; therefore, it is important to correctly understand the stage and pathology and provide appropriate treatment accordingly. The newly revised Clinical Practice Guidelines of Chronic Pancreatitis 2015 consist of four chapters, i.e., diagnosis, staging, treatment, and prognosis, and includes a total of 65 clinical questions. These guidelines have aimed at providing certain directions and clinically practical contents for the management of chronic pancreatitis, preferentially adopting clinically useful articles. These revised guidelines also refer to early chronic pancreatitis based on the Criteria for the Diagnosis of Chronic Pancreatitis 2009. They include such items as health insurance coverage of high-titer lipase preparations and extracorporeal shock wave lithotripsy, new antidiabetic drugs, and the definition of and treatment approach to pancreatic pseudocyst. The accuracy of these guidelines has been improved by examining and adopting new evidence obtained after the publication of the first edition.

Surgical Management of Chronic Pancreatitis

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.

Epidemiologic and Mechanistic Associations Between Smoking and Pancreatitis

OPINION STATEMENT

Alcohol has long been associated with pancreatitis. Although first described more than three decades ago, smoking has been widely accepted as an important risk factor for all forms of pancreatitis only in the past few years. Empiric data has confirmed smoking as an independent and dose-dependent risk for both acute and chronic pancreatitis. Smoking also increases the risk of recurrences and progression of established chronic pancreatitis. The effects of smoking are enhanced in the presence of alcohol consumption. Indirect evidence suggests that smoking cessation may be beneficial in preventing disease progression. Smoking cessation can therefore be an important strategy for primary as well as secondary prevention of pancreatitis. Therefore, in addition to alcohol, physicians should routinely counsel patients for the benefits of smoking cessation. The mechanisms through which cigarette smoke triggers pathological cellular events, resulting in pancreatitis, are unresolved. Although cigarette smoke contains greater than 4000 compounds, principally nicotine and the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) have been broadly studied with regard to pancreatic diseases. Both nicotine and NNK have been shown to induce morphological changes in the pancreas consistent with those seen in pancreatitis. Furthermore, nicotine affects pancreatic secretion and NNK induces premature zymogen activation, two well-known features of pancreatitis. These cigarette toxins may mediate both pro- and anti-inflammatory pathways and can induce changes in pancreatic acinar cell function at the level of transcription, leading to conditions such as thiamin deficiency and mitochondrial dysfunction. Such circumstances could leave the pancreas prone to the development of pancreatitis. This review summarizes relevant research findings and focuses on the epidemiologic links between smoking and pancreatitis, and the cellular pathways that may be significant in induction and evolution of smoking-related pancreatitis.

The seventh nationwide epidemiological survey for chronic pancreatitis in Japan: clinical significance of smoking habit in Japanese patients

OBJECTIVES

A nationwide survey was conducted to clarify the epidemiological features of patients with chronic pancreatitis (CP) in Japan.

METHODS

In the first survey, both the prevalence and the incidence of CP in 2011 were estimated. In the second survey, the clinicoepidemiological features of the patients were clarified by mailed questionnaires. Patients were diagnosed by the Japanese diagnostic criteria for chronic pancreatitis 2009.

RESULTS

The estimated annual prevalence and incidence of CP in 2011 were 52.4/100,000 and 14.0/100,000, respectively. The sex ratio (male/female) of patients was 4.6, with a mean age of 62.3 years. Alcoholic (67.5%) was the most common and idiopathic (20.0%) was the second most common cause of CP. Comorbidity with diabetes mellitus (DM) and pancreatic calcifications (PC) occurred more frequent in ever smokers independently of their drinking status. Among patients without drinking habit, the incidences of DM and PC were significantly higher in ever smokers than in never smokers. The multiple logistic regression analysis revealed smoking was an independent factor of DM and PC in CP patients: DM, Odds ratio (OR) 1.644, 95% confidence interval (CI) 1.202 to 2.247 (P = 0.002): PC, OR 2.010, 95% CI 1.458 to 2.773 (P < 0.001). On the other hand, smoking was not identified as an independent factor for the appearance of abdominal pain by this analysis.

CONCLUSION

The prevalence of Japanese patients with CP has been increasing. Smoking was identified as an independent factor related to DM and PC in Japanese CP patients.

An overview of the diagnosis and management of nutrition in chronic pancreatitis

Chronic pancreatitis is characterized by long-standing inflammation of the pancreas, which results in fibrosis and the gradual loss of pancreatic function. The loss of islets and acinar cells results in diabetes and exocrine insufficiency, respectively. Exocrine insufficiency can result in maldigestion of fat, protein, and carbohydrate as well as vitamins and minerals. Patients may present with variable severity of disease, from mild to severe. The diagnosis of chronic pancreatitis can be challenging, especially in patients with early or mild disease who have few to no morphologic abnormalities on standard abdominal imaging studies. A number of imaging modalities and tests have evolved to aid in the diagnosis of chronic pancreatitis based on changes in structure or function. Clinicians typically focus on treating pain in chronic pancreatitis as opposed to exocrine insufficiency, despite the fact that maldigestion and malabsorption can result in nutrition deficiencies. The aims of this review are to describe the various modalities used to diagnose chronic pancreatitis, to illustrate the nutrition deficiencies associated with exocrine insufficiency, and to provide an overview of nutrition assessment and treatment in these patients.

Smoking as a risk factor for complications in chronic pancreatitis

OBJECTIVES

Several recent studies have demonstrated the association between smoking and chronic pancreatitis (CP). However, less is known about the role of smoking in the development of CP-related complications. Our aim was to investigate the impact of smoking and alcohol consumption on age of onset and complications at CP diagnosis.

METHODS

A cross-sectional case-case study was performed within a prospectively collected cohort of patients with CP. Alcohol consumption and smoking habits were assessed using a standardized questionnaire. Morphologic severity was defined based on endoscopic ultrasound criteria for CP and classified as mild (3-4 criteria), moderate (5-6 criteria), and severe (≥7 criteria or calcifications). Pancreatic exocrine insufficiency (PEI) was diagnosed using the C-mixed triglyceride breath test. Odds ratios (OR) with 95% confidence intervals (CI) for CP-related complications were calculated using a case-case design.

RESULTS

A total of 241 patients were included. Smoking was associated with PEI (OR [95% CI], 2.4 [1.17-5.16]), calcifications (OR [95% CI], 2.33 [1.10-4.95]), and severe morphologic changes (OR [95% CI], 3.41 [1.31-8.85]) but not with pseudocysts or diabetes. Neither smoking nor alcohol consumption was associated with age of onset.

CONCLUSIONS

Tobacco, but not alcohol, is associated with PEI, calcifications, and severe morphologic (≥7 criteria or calcifications) CP at diagnosis. Smoking cessation should be encouraged in patients with CP.

Pharmacological management of pain in chronic pancreatitis

Introduction:

Chronic pancreatitis is a condition that is rising in incidence in the Western World. It is predominated by severe intractable abdominal pain that presents a significant impact on patients’ quality of life and physical functioning. The pain is persistent in many patients, requiring admission to hospital for the majority at some stage in their illness. There is no current NICE or SIGN guideline with associated grading for the pharmacological management of this symptom. This paper aims to investigate and summarise the current pharmacological therapies for pain control in an attempt to formulate the levels of evidence supporting their use.

Methods:

The online digital archives PubMed, Science Direct, Medscape and the Cochrane Library were searched for the keywords pain and chronic pancreatitis. Hand searches of relevant journals and citations were used to complete the investigation of current literature on the topic. Relevant articles and studies were critically analysed in a standard format with relation to study type, population, number, end point and outcomes. Publications not relevant to the management of pain in chronic pancreatitis were excluded.

Results:

Medical therapies, including oral analgesics and enzyme preparations, were included in the analysis of current modalities for treating pain in chronic pancreatitis.

Conclusions:

A summary of the evidence base for different pharmacological treatments in the context of chronic pancreatitis has shown that large number trials evaluating their efficacy in managing pain are lacking and offer scope for future research on this topic. The use of ‘alternative’ treatments such as antioxidant preparations and enzyme antagonists has shown promise. With regard to opioids, tramadol is as effective as morphine with less neuropsychiatric and gastrointestinal side effects. Oxycodone may derive more benefit than morphine due to an additional Κ-agonist effect.

Pathophysiology of chronic pancreatitis

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas characterized by progressive fibrotic destruction of the pancreatic secretory parenchyma. Despite the heterogeneity in pathogenesis and involved risk factors, processes such as necrosis/apoptosis, inflammation or duct obstruction are involved. This fibrosing process ultimately leads to progressive loss of the lobular morphology and structure of the pancreas, deformation of the large ducts and severe changes in the arrangement and composition of the islets. These conditions lead to irreversible morphological and structural changes resulting in impairment of both exocrine and endocrine functions. The prevalence of the disease is largely dependent on culture and geography. The etiological risk-factors associated with CP are multiple and involve both genetic and environmental factors. Throughout this review the M-ANNHEIM classification system will be used, comprising a detailed description of risk factors such as: alcohol-consumption, nicotine-consumption, nutritional factors, hereditary factors, efferent duct factors, immunological factors and miscellaneous and rare metabolic factors. Increased knowledge of the different etiological factors may encourage the use of further advanced diagnostic tools, which potentially will help clinicians to diagnose CP at an earlier stage. However, in view of the multi factorial disease and the complex clinical picture, it is not surprising that treatment of patients with CP is challenging and often unsuccessful.

Immunohistochemical localization of somatostatin and pancreatic polypeptide in smokers with chronic pancreatitis

Recent studies have demonstrated a significant role of tobacco smoking in the development of chronic pancreatitis. Although there are published papers on the effects of cigarette smoking on insulin secretion in patients, no data are available on the effects of smoking on pancreatic endocrine cells secreting somatostatin and pancreatic polypeptide. The aim of the study was to evaluate the effects of cigarette smoking on endocrine pancreatic function by immunolocalization of somatostatin and pancreatic polypeptide in the pancreas from smokers and non-smoking patients with chronic pancreatitis in comparison with healthy controls. The LSAB2-HRP technique with polyclonal antibodies was used for the immunolocalization of somatostatin and pancreatic polypeptide in histological preparations of the pancreas. The intensity of immunohistochemical reaction was calculated with digital image analysis. The study demonstrated increased numbers of somatostatin (D) secreting cells and pancreatic polypeptide (PP) cells and their altered location in pancreatic islets and parenchyma of smoking patients with chronic pancreatitis, as compared to non-smoking patients and healthy controls. Smoking patients showed significantly higher immunostaining of the hormones in the pancreas compared to non-smoking patients and healthy persons. This study indicates that smoking may play a significant role in the development of endocrine disturbances in the development of chronic pancreatitis.

Pancrelipase: an evidence-based review of its use for treating pancreatic exocrine insufficiency

Pancreatic exocrine insufficiency (PEI) is often observed in patients with pancreatic diseases, including chronic pancreatitis, cystic fibrosis, and tumors, or after surgical resection. PEI often results in malnutrition, weight loss and steatorrhea, which together increase the risk of morbidity and mortality. Therefore, nutritional interventions, such as low-fat diets and pancreatic enzyme replacement therapy (PERT), are needed to improve the clinical symptoms, and to address the pathophysiology of pancreatic exocrine insufficiency. PERT with delayed-release pancrelipase is now becoming a standard therapy for pancreatic exocrine insufficiency because it significantly improves the coefficients of fat and nitrogen absorption as well as clinical symptoms, without serious treatment-emergent adverse events. The major adverse events were tolerable gastrointestinal tract symptoms, such as stomach pain, nausea, and bloating. Fibrosing colonopathy, a serious complication, is associated with high doses of enzymes. Several pancrelipase products have been approved by the US Food and Drug Administration in recent years. Although many double-blind, placebo-controlled trials of pancrelipase products have been conducted in recent years, these studies have enrolled relatively few patients and have often been less than a few weeks in duration. Moreover, few studies have addressed the issue of pancreatic diabetes, a type of diabetes that is characterized by frequent hypoglycemia, which is difficult to manage. In addition, it is unclear whether PERT improves morbidity and mortality in such settings. Therefore, large, long-term prospective studies are needed to identify the optimal treatment for pancreatic exocrine insufficiency. The studies should also examine the extent to which PERT using pancrelipase improves mortality and morbidity. The etiology and severity of pancreatic exocrine insufficiency often differ among patients with gastrointestinal diseases or diabetes (type 1 and type 2), and among elderly subjects. Finally, although there is currently limited clinical evidence, numerous extrapancreatic diseases and conditions that are highly prevalent in the general population may also be considered potential targets for PERT and related treatments.

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

BACKGROUND

Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking.

OBJECTIVE

To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes.

DESIGN

Cross-sectional study, retrospective chart review.

SETTING

Virginia Mason Medical Center, Seattle, Washington.

PATIENTS

This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire.

INTERVENTION

P-ESWL and ERCP, outcomes survey.

MAIN OUTCOME MEASUREMENTS

Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery.

RESULTS

A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071).

LIMITATIONS

Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales.

CONCLUSION

P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Factors associated with long-term mortality in acute pancreatitis

BACKGROUND AND AIMS

Knowledge of the long-term prognosis of acute pancreatitis (AP) is limited. The aims were to investigate: (1) prognostic factors associated with long-term mortality in patients with AP; (2) whether or not the level of serum (S-)amylase at admission had an impact on the prognosis; (3) causes of death in these patients.

METHODS

During 1977-1982, patients who were admitted to the five main hospitals in Copenhagen with a diagnosis of AP or chronic pancreatitis (CP) were included in a prospective cohort, the Copenhagen Pancreatitis Study (CPS); in 2008, they were followed up by linkage to the Danish Registries. The analyzed subcohort consisted of 352 patients with probable AP (n = 54) or definite AP (n = 298).

RESULTS

Multivariate Cox regression analysis showed that significant factors associated with mortality were age, alcohol, and diabetes, whereas female gender, co-living and employment were associated with better survival. The S-amylase level had no impact on mortality. The most frequent causes of death were cardiovascular diseases, digestive diseases, and malignancies.

CONCLUSIONS

Age, alcohol and diabetes had a significant impact on survival whereas the S-amylase level did not.

Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis

BACKGROUND & AIMS

Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers.

METHODS

We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified).

RESULTS

The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP.

CONCLUSIONS

The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.

Smoking is underrecognized as a risk factor for chronic pancreatitis

BACKGROUND/AIMS

Smoking is an established risk factor for chronic pancreatitis (CP). We sought to identify how often and in which CP patients physicians consider smoking to be a risk factor.

METHODS

We analyzed data on CP patients and controls prospectively enrolled from 19 US centers in the North American Pancreatitis Study-2. We noted each subject's self-reported smoking status and quantified the amount and duration of smoking. We noted whether the enrolling physician (gastroenterologist with specific interest in pancreatology) classified alcohol as the etiology for CP and selected smoking as a risk factor.

RESULTS

Among 382/535 (71.4%) CP patients who were self-reported ever smokers, physicians cited smoking as a risk factor in only 173/382 (45.3%). Physicians cited smoking as a risk factor more often among current smokers, when classifying alcohol as CP etiology, and with higher amount and duration of smoking. We observed a wide variability in physician decision to cite smoking as a risk factor. Multivariable regression analysis however confirmed that the association of CP with smoking was independent of physician decision to cite smoking as a risk factor.

CONCLUSIONS

Physicians often underrecognize smoking as a CP risk factor. Efforts are needed to raise awareness of the association between smoking and CP. and IAP.

Alcohol and smoking as risk factors in an epidemiology study of patients with chronic pancreatitis

BACKGROUND & AIMS

Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers.

METHODS

We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified).

RESULTS

The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP.

CONCLUSIONS

The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.

Nutrition treatment of deficiency and malnutrition in chronic pancreatitis: a review

Chronic pancreatitis results in exocrine and endocrine dysfunction, affecting normal digestion and absorption of nutrients. In individuals with chronic pancreatitis, nutrition status may be further affected by poor dietary intake, often related to alcoholism. However, some deficiencies may be overlooked, potentially leading to nutrition-related problems with bone health and fatigue. The aim of this article is to describe the deficiencies that occur and to propose an evidence-based algorithm for the nutrition assessment and treatment of patients with chronic pancreatitis.

Smoking as a cofactor for causation of chronic pancreatitis: a meta-analysis

OBJECTIVES

To assess the evidence for tobacco smoking as a risk factor for the causation of chronic pancreatitis.

METHODS

We performed a meta-analysis with random-effects models to estimate pooled relative risks (RRs) of chronic pancreatitis for current, former, and ever smokers, in comparison to never smokers. We also performed dose-response, heterogeneity, publication bias, and sensitivity analyses.

RESULTS

Ten case-control studies and 2 cohort studies that evaluated, overall, 1705 patients with chronic pancreatitis satisfied the inclusion criteria. When contrasted to never smokers, the pooled risk estimates for current smokers was 2.8 (95% confidence interval [CI], 1.8-4.2) overall and 2.5 (95% CI, 1.3-4.6) when data were adjusted for alcohol consumption. A dose-response effect of tobacco use on the risk was ascertained: the RR for subjects smoking less than 1 pack per day was 2.4 (95% CI, 0.9-6.6) and increased to 3.3 (95% CI, 1.4-7.9) in those smoking 1 or more packs per day. The risk diminished significantly after smoking cessation, as the RR estimate for former smokers dropped to a value of 1.4 (95% CI, 1.1-1.9).

CONCLUSIONS

Tobacco smoking may enhance the risk of developing chronic pancreatitis. Recommendation for smoking cessation, besides alcohol abstinence, should be incorporated in the management of patients with chronic pancreatitis.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Are genetic variants in the platelet-derived growth factor [beta] gene associated with chronic pancreatitis?

OBJECTIVES

Platelet-derived growth factor [beta] (PDGF-[beta]) is a major signal in proliferation and matrix synthesis through activated pancreatic stellate cells, leading to fibrosis of the pancreas. Recurrent acute pancreatitis (RAP) seems to predispose to chronic pancreatitis (CP) in some patients but not others. We tested the hypothesis that 2 known PDGF-[beta] polymorphisms are associated with progression from RAP to CP. We also tested the hypothesis that PDGF-[beta] polymorphisms in combination with environmental risk factors such as alcohol and smoking are associated with CP.

METHODS

Three hundred eighty-two patients with CP (n = 176) and RAP (n = 206) and 251 controls were evaluated. Platelet-derived growth factor [beta] polymorphisms +286 A/G (rs#1800818) seen in 5'-UTR and +1135 A/C (rs#1800817) in first intron were genotyped using single-nucleotide polymorphism polymerase chain reaction approach and confirmed by DNA sequencing.

RESULTS

The genotypic frequencies for PDGF-[beta] polymorphisms in positions +286 and +1135 were found to be similar in controls and patients with RAP and CP. There was no difference in genotypic frequencies among RAP, CP, and controls in subjects in the alcohol and smoking subgroups.

CONCLUSIONS

Known variations in the PDGF-[beta] gene do not have a significant effect on promoting or preventing fibrogenesis in pancreatitis. Further evaluation of this important pathway is warranted.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the past year.

RECENT FINDINGS

Cigarette smoking is a dose-dependent risk factor for acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. A minority of chronic alcohol consumers develop recurrent acute pancreatitis but very heavy drinking associates with chronic pancreatitis. More patients with alcohol-induced chronic pancreatitis have cirrhosis than patients with cirrhosis have chronic pancreatitis (39 vs. 18%). Most patients with asymptomatic hyperenzymemia have no pancreatic lesions. Pancreatic calcifications are most frequently due to chronic pancreatitis, followed by cystic neoplasms and other disorders. The new Rosemont consensus classification of endoscopic ultrasonography criteria for chronic pancreatitis is unvalidated. Zinc deficiency correlates only with severe chronic pancreatitis and the fecal elastase test is an inaccurate marker of pancreatic steatorrhea. Patients commonly receive insufficient lipase to abolish pancreatic steatorrhea. Ultrastructural neuropathies are common to chronic pancreatitis and pancreatic cancer and correlate with pain severity.

SUMMARY

Results of this year's investigations further elucidated risk factors for pancreatic disease, the natural history of alcoholic pancreatitis, the differential diagnosis of pancreatic calcifications, the diagnosis of chronic pancreatitis with the Rosemont criteria, the limited diagnostic utility of fecal elastate test and zinc measurements, the proper dosing of pancreatic enzyme supplements, and treatment of pancreatic pain.

Danish patients with chronic pancreatitis have a four-fold higher mortality rate than the Danish population

BACKGROUND & AIMS

We investigated mortality of patients with chronic pancreatitis (CP), compared with the Danish population and sought to determine whether clinical presentations of CP can be used in prognosis. We also investigated clinical factors associated with mortality and causes of death among these patients.

METHODS

The Copenhagen Pancreatitis Study is a prospective study of patients admitted from 1977 to 1982 to the 5 main hospitals in Copenhagen with a diagnosis of acute pancreatitis or CP. In 2008, follow-up data were collected from these patients from the Danish Registries; this subcohort comprised 290 patients with probable (n = 41) or definite CP (n = 249).

RESULTS

The mortality of patients with definite CP was 4-fold that of the Danish population and significantly higher than that of patients with probable CP (P = .003; 95% confidence interval [CI], 1.21-2.57); patients with probable CP had a 2- to 3-fold higher mortality rate than the population. In patients with definite CP, factors significantly associated with mortality included non-employment (P = .015; 95% CI, 0.53-0.93), and being underweight (P = .020; 95% CI, 0.52-0.95). Sex, alcohol use, smoking, single versus co-living, exocrine insufficiency, diabetes, pancreatic calcification, CP inheritance, painless CP, acute exacerbation of CP, or surgery for CP had no impact on survival. The most frequent causes of death were digestive diseases (19.5%), malignancies (19.5%), and cardiovascular diseases (11.3%).

CONCLUSIONS

Danish patients with definite CP had a 4-fold higher mortality rate compared with the background population and a higher mortality rate than patients with probable CP. Being nonemployed or underweight had significant impact on survival.

Cigarette smoking is independently associated with chronic pancreatitis

BACKGROUND AND AIMS

It is not completely understood whether smoking contributes to chronic pancreatitis (CP). Past studies have included mostly patients with alcohol-related and severe CP. Our aim was to assess the relationship of smoking and CP adjusting for alcohol and other clinical risk factors.

METHODS

A cross-sectional study was performed of patients referred to the pancreatic disease clinic in the past 2 years with abdominal pain and suspected CP. Patients were questioned on their smoking and alcohol habits. Patients underwent an etiological workup and diagnostic evaluation for early and late CP comprised of computed tomography scan and combined endoscopic ultrasound and secretin endoscopic pancreatic function test if indicated. Logistic regression was used to determine the association of current smoking with CP adjusting for other risk factors.

RESULTS

The adjusted odds ratio (OR) for current smoking was 1.99 (95% CI 1.01, 3.91). Other significant predictors included consumption of > or =10 alcohol drinks/week, advancing age, history of acute pancreatitis, and the presence of another etiological factor. Smoking was also independently associated with exocrine insufficiency (OR 2.00, 95% CI 1.07, 3.75) and calcifications (OR 2.68, 95% CI 1.03, 6.94).

CONCLUSION

Active cigarette smoking is associated with CP adjusting for alcohol and other risk factors. and IAP.

Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis

BACKGROUND

Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) are associated with alcohol consumption and cigarette smoking. The etiology of RAP and CP is complex, and effects of alcohol and smoking may be limited to specific patient subsets. We examined the current prevalence of alcohol use and smoking and their association with RAP and CP in patients evaluated at US referral centers.

METHODS

The North American Pancreatitis Study 2, a multicenter consortium of 20 US centers, prospectively enrolled 540 patients with CP, 460 patients with RAP, and 695 controls from 2000 to 2006. Using self-reported monthly alcohol consumption during the maximum lifetime drinking period, we classified subjects by drinking status: abstainer, light drinker (< or =0.5 drink per day), moderate drinker (women, >0.5 to 1 drink per day; men, >0.5 to 2 drinks per day), heavy drinker (women, >1 to <5 drinks per day; men, >2 to <5 drinks per day), or very heavy drinker (> or =5 drinks per day for both sexes). Smoking was classified as never, past, or current and was quantified (packs per day and pack-years).

RESULTS

Overall, participants' mean (SD) age was 49.7 (15.4) years; 87.5% were white, and 56.5% were women. Approximately one-fourth of both controls and patients were lifetime abstainers. The prevalence of very heavy drinking among men and women was 38.4% and 11.0% for CP, 16.9% and 5.5% for RAP, and 10.0% and 3.6% for controls. Compared with abstaining and light drinking, very heavy drinking was significantly associated with CP (odds ratio, 3.10; 95% confidence interval, 1.87-5.14) after controlling for age, sex, smoking status, and body mass index. Cigarette smoking was an independent, dose-dependent risk factor for CP and RAP.

CONCLUSIONS

Very heavy alcohol consumption and smoking are independent risks for CP. A minority of patients with pancreatitis currently seen at US referral centers report very heavy drinking.

Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients

BACKGROUND

No data on chronic pancreatitis in Italy are available yet.

AIM

To evaluate demographic, clinical, diagnostic and therapeutic aspects in patients suffering from chronic pancreatitis.

PATIENTS AND METHODS

Eligible patients were prospectively enrolled from 2000 to 2005. Information concerning demographic data, lifestyle risk factors, family and clinical history, associated factors (alcohol, autoimmunity, cystic dystrophy of the duodenal wall, obstruction, genetic mutations) concomitant diseases, diagnostic findings, and pharmacological, endoscopic and surgical therapy were gathered.

RESULTS

893 patients (74% males, mean age 53.7+/-15.2 years) were evaluated. 519/859 patients (60%) were drinkers and 555/840 (66%) were smokers. A strong positive correlation between drinking and cigarette consumption (R=0.53; p<0.0001) was found. Heavy alcohol consumption (>80g of alcohol/day for more than 5 years) was considered the most important risk factor in 300 patients (34%), obstruction in 238 (27%), alcohol and obstruction in 82 (9%), autoimmunity in 34 (4%), cystic dystrophy of the duodenal wall/groove pancreatitis in 55 (6%), gene mutations in 36 (4%), and none (idiopathic) in 148 (17%). Bile stones were diagnosed in 287 patients (33%) and cholecystectomy was performed in 329 patients (38%). Pancreatic calcifications were diagnosed in 547/879 patients (62%). Pancreatic surgery was performed in 273 patients (31%). Endoscopic sphincterotomy was performed in 371 patients (42%). Exocrine and endocrine insufficiency were found, respectively, in 373/834 (45%) and 275/885 patients (31%).

CONCLUSIONS

An unexpected low frequency of alcohol abuse and new emerging associated risk factors for chronic pancreatitis were observed in Italy.

Alcohol use and cigarette smoking as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis

BACKGROUND & AIMS

Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP.

METHODS

We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement.

RESULTS

The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001).

CONCLUSIONS

Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.

[Treatment of pain in chronic pancreatitis]

Abdominal pain is the most frequent symptom in patients with chronic pancreatitis. Between 70 and 90% of patients experience pain at some point in the course of their disease. In patients with alcoholic pancreatitis, pain is usually experienced at disease onset. Two distinct forms of idiopathic chronic pancreatitis can be distinguished: in early-onset (juvenile) idiopathic chronic pancreatitis, pain occurs initially, while in late-onset (senile) idiopathic chronic pancreatitis, pain is delayed or may even be absent. According to several authors, between 27 and 67% of patients require surgery due to lack of response to medical treatment. Pain may reoccur in more than 30% of patients who have undergone surgery and consequently, reintervention is not uncommon. Several treatment options are currently available: medical, endoscopic and surgical. The most appropriate treatment for each patient should be chosen on an individualized basis.

Idiopathic chronic pancreatitis

Idiopathic pancreatitis is diagnosed in up to 25% of patients with chronic pancreatitis by exclusion of other potential causes including rare ones. It has been shown that idiopathic pancreatitis comprises two clinically distinct entities characterised as early-onset and late-onset disease and that the natural courses of both forms differ from that of alcoholic chronic pancreatitis. Due to considerable progress in our understanding of hereditary and autoimmune mechanisms for development of chronic pancreatitis, a specific aetiology of chronic pancreatitis can be determined in an increasing proportion of cases. Nevertheless, the aetiopathogenesis of idiopathic chronic pancreatitis frequently remains obscure. This review focuses on the pathogenetic relevance of various endogenous and exogenous (co-)factors for the manifestation and the natural course of the disease. Moreover, it presents a multifactorial model for understanding the development of idiopathic chronic pancreatitis.

Smoking cessation at the clinical onset of chronic pancreatitis and risk of pancreatic calcifications

OBJECTIVE

Cigarette smoking is associated with a higher risk of developing chronic pancreatitis (CP) and increases the likelihood of developing pancreatic calcifications. The aim of this study was to know whether smoking cessation modifies the course of the disease.

METHODS

Patients with CP who had been followed up for more than 6 years from clinical onset and who had not developed calcifications after 5 years were analyzed. We studied smokers, never-smokers, and patients who had given up smoking within 5 years. For actuarial analysis, the sixth year was considered as time 0.

RESULTS

Of the 360 patients, there were 43 women and 317 men (88.1%) with a mean age of 38.7 years. The median follow-up was 19.0 years. Chronic pancreatitis was alcohol-associated in 255 patients, hereditary in 10, obstructive in 54, and idiopathic in 41. There were 317 smokers (88.1%) and 259 alcohol drinkers (71.9%). At the end of the follow-up, 212 patients (59.8%) developed calcifications. Concerning the risk of calcifications, never-smokers and ex-smokers had similar actuarial curves, and these were significantly different from the curve for smokers (P < 0.003). Considering never-smokers as the reference class, ex-smokers had an odds ratio (OR) of 0.56 (95.0% confidence interval [CI], 0.2-1.4; P = not significant), patients smoking 1 to 10 cigarettes per day had an OR of 1.95 (95.0% CI, 1.1-3.4; P < 0.019), patients smoking 11 to 20 cigarettes per day had an OR of 1.76 (95.0% CI, 1.1-2.8; P < 0.0018), and those smoking more than 20 cigarettes per day had an OR of 1.79 (95.0% CI, 1.1-2.9; P < 0.019). Alcohol cessation seems to have no influence.

CONCLUSIONS

Smoking cessation in the first years from the clinical onset of CP reduces the risk of developing pancreatic calcifications.

Nitric oxide pathways and evidence-based perturbations in acute pancreatitis

Nitric oxide (NO) is a gaseous neurotransmitter, a vasodilator and paracrine regulator. In the pancreas, NO regulates normal pancreatic exocrine secretion, endocrine pancreatic insulin secretion and pancreatic microvascular blood flow. NO has multiple species and is produced de novo by 3 NO synthase enzymes. Endothelial NO synthase reduces the severity of the initial phase of experimental acute pancreatitis (AP). Cigarette smoking and chronic alcohol use disrupt normal NO pathways and are associated with pancreatitis and pancreatic cancer. The aims of this minireview are to describe normal intrapancreatic NO pathways, perturbations during experimental AP and due to epidemiological factors associated with pancreatic pathology, and the clinical implications of NO on AP.

Alcohol-associated pancreatitis

Only a small proportion of heavy drinking individuals develop pancreatitis. The environmental and host cofactors shown to have an association with alcoholic pancreatitis are smoking and race. The known genetic variations and polymorphisms do not seem to play an important role in alcoholic pancreatitis. Newer developments in the understanding of complex disorders allow clinicians to understand better the role of cofactors and interactions between known and yet unknown environmental and genetic factors in causing alcoholic pancreatitis.

Chronic pancreatitis: challenges and advances in pathogenesis, genetics, diagnosis, and therapy

Chronic pancreatitis (CP) is characterized by progressive pancreatic damage that eventually results in significant impairment of exocrine as well as endocrine functions of the gland. In Western societies, the commonest association of chronic pancreatitis is alcohol abuse. Our understanding of the pathogenesis of CP has improved in recent years, though important advances that have been made with respect to delineating the mechanisms responsible for the development of pancreatic fibrosis (a constant feature of CP) following repeated acute attacks of pancreatic necroinflammation (the necrosis-fibrosis concept). The pancreatic stellate cells (PSCs) are now established as key cells in fibrogenesis, particularly when activated either directly by toxic factors associated with pancreatitis (such as ethanol, its metabolites or oxidant stress) or by cytokines released during pancreatic necroinflammation. In recent years, research effort has also focused on the genetic abnormalities that may predispose to CP. Genes regulating trypsinogen activation/inactivation and cystic fibrosis transmembrane conductance regulator (CFTR) function have received particular attention. Mutations in these genes are now increasingly recognized for their potential 'disease modifier' role in distinct forms of CP including alcoholic, tropical, and idiopathic pancreatitis. Treatment of uncomplicated CP is usually conservative with the major aim being to effectively alleviate pain, maldigestion and diabetes, and consequently, to improve the patient's quality of life. Surgical and endoscopic interventions are reserved for complications such as pseudocysts, abscess, and malignancy.

The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease

BACKGROUND

Several classification systems of chronic pancreatitis have been proposed to provide a basis for treatment and research. All of these previous classifications were designed at the height of pancreatic research of their respective times; thus, each represented the most current knowledge available to pancreatologists at the time. However, none of these classifications provide simultaneously a simple standardized system for the clinical classification of chronic pancreatitis according to etiology, clinical stage, and severity of the disease, nor are they consistently useful for directing clinical practice and comparing interinstitutional data. Thus, we aimed to develop a new classification system of chronic pancreatitis to provide a framework for studying the interaction of various risk factors on the course of the disease.

METHODS

We reviewed the literature on the clinical course of all different forms of chronic pancreatitis, and we reviewed all previous classification systems of the disease. This approach provided a basis for the development of a new and unifying classification of chronic pancreatitis.

RESULTS

We established the M-ANNHEIM multiple risk factor classification system based on the current knowledge of acute and chronic pancreatitis. This classification allows patients to be categorized according to the etiology, clinical stage, and severity of their disease. The severity of pancreatic inflammation was assessed using a scoring system that takes into account the clinical symptoms and treatment options of chronic pancreatitis. Finally, four hypothetical patients were categorized according to the M-ANNHEIM classification system to provide examples of its applicability in clinical practice.

CONCLUSIONS

The M-ANNHEIM multiple risk factor classification system is simple, objective, accurate, and relatively noninvasive, and it incorporates etiology, different stages of the disease, and various degrees of clinical severity. This new classification system will be helpful for investigating the impact and interaction of various risk factors on the course of the disease and will facilitate the comparison and combination of interinstitutional data.

Dysfunction of the pancreas in healthy smoking persons and patients with chronic pancreatitis

OBJECTIVES

The aim of the study was to assess the effect of cigarette smoking on the endocrine pancreatic function by determining the levels of serum glucose and plasma insulin as well as by defining immunohistochemical localization of insulin and glucagon in tissue specimens of the pancreata derived from healthy persons and smoking and nonsmoking patients with diagnosed chronic pancreatitis (CP).

METHODS

The oxidative method was used to measure fasting glycemia in blood plasma and the method enzyme-linked immunoassay to determine the level of insulin in plasma. Immunohistochemical localization of hormones in paraffin tissue specimens of the pancreas was performed using the LSAB2-HRP visual test with polyclonal insulin and glucagon antibodies. The intensity of immunohistochemical reaction was calculated with digital imaging methodology.

RESULTS

The study revealed a substantially higher level of serum glucose in smoking CP patients and in healthy persons compared with nonsmoking patients and healthy persons, whereas insulin concentration in smoking patients was statistically lower than in nonsmokers. Smoking patients showed significantly lower expression of insulin and glucagon in the pancreas compared with nonsmoking patients and healthy persons.

CONCLUSIONS

Impairment of the endocrine function of beta and alpha cells in the pancreatic islets is frequently manifested by complications in pancreatitis resulting among others from long-term smoking.