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Sissingh NJ, de Rijk FEM, Timmerhuis HC, Umans DS, Anten MPGF, Bouwense SAW, van Delft F, van Eijck BC, Erkelens WG, Hazen WL, Kuiken SD, Quispel R, Romkens TEH, Schwartz MP, Seerden TC, Spanier BWM, Verlaan T, Vleggaar FP, Voermans RP, Verdonk RC, van Hooft JE. Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study. Br J Surg 2024; 111:znae107. [PMID: 38713609 DOI: 10.1093/bjs/znae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/21/2024] [Accepted: 04/07/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis. METHODS Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up. RESULTS A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038). CONCLUSION Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.
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Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Fleur E M de Rijk
- Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Hester C Timmerhuis
- Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Devica S Umans
- Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Foke van Delft
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Willemien G Erkelens
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Tessa E H Romkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander MC, Amersfoort, The Netherlands
| | - Tom C Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - B W Marcel Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Den Bosch, The Netherlands
| | - Tessa Verlaan
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Amsterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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Arteel GE, Singhvi A, Feldman R, Althouse AD, Bataller R, Saul M, Yadav D. Coexistent Alcohol-Related Liver Disease and Alcohol-Related Pancreatitis: Analysis of a Large Health Care System Cohort. Dig Dis Sci 2022; 67:2543-2551. [PMID: 33961195 PMCID: PMC9366918 DOI: 10.1007/s10620-021-07010-5] [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: 01/24/2021] [Accepted: 04/14/2021] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Although coexistence of alcohol-related liver disease (ALD) and pancreatitis (ALP) is seen in clinical practice, a clear understanding of the overlap between these diseases is lacking. Moreover, the relative risks for certain population groups have not been studied. We determined the prevalence and coexistence of ALD and ALP in patients with an alcohol use disorder using retrospective analysis of a large patient cohort from Western Pennsylvania. We specifically emphasized the analysis of underrepresented populations, including women and blacks. METHODS We identified all unique patients who received care in UPMC health system during 2006-2017 with at least one International Classification of Diseases versions 9 and/or 10 codes for alcohol misuse, ALD and pancreatitis. We noted their sex, race and age of first diagnosis and duration of contact. RESULTS Among 89,774 patients that fit our criteria, the prevalence of ALD, ALP and coexistent ALD and ALP in patients with alcohol misuse was 11.7%, 7.4% and 2.5%, respectively. Prevalence of ALP in ALD was 16.4%, and ALD in ALP was 33.1%. Prevalence of ALP in ALD was slightly more prevalent in women (18.6% vs. 15.6%, p < 0.001). Prevalence of ALP in ALD was 2-4 folds greater in blacks than other races. DISCUSSION A sizeable fraction of patients with ALD or ALP has coexistent disease. This is the first study to identify that blacks are at a higher risk for ALP in the presence of ALD. Future studies should define the clinical impact of coexistent disease on clinical presentation and short- and long-term outcomes.
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Affiliation(s)
- Gavin E Arteel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ajay Singhvi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Feldman
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- University of Pittsburgh Medical Center, 200 Lothrop St, M2, C-Wing, Pittsburgh, PA, 15213, USA.
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Argueta PP, Salazar M, Vohra I, Corral JE, Lukens FJ, Vargo JJ, Chahal P, Simons-Linares CR. Thirty-Day Readmission Among Patients with Alcoholic Acute Pancreatitis. Dig Dis Sci 2021; 66:4227-4236. [PMID: 33469806 DOI: 10.1007/s10620-020-06765-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/09/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Alcoholic acute pancreatitis (AAP) comprises the second most common cause of acute pancreatitis in the USA, and there is lack of data regarding 30-day specific readmission causes and predictors. We aim to identify 30-day readmission rate, causes, and predictors of readmission. METHODS Retrospective analysis of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for AAP. RESULTS Totally, 76,609 AAP patients were discharged from the hospital in 2016. The 30-day readmission rate was 12%. The main cause of readmission was another episode of AAP. Readmission was not associated with higher mortality (1.3% vs. 1.2%; P = 0.21) or prolonged length of stay (5.2 vs. 5.0 days; P = 0.06). The total health care economic burden was $354 million in charges and $90 million in costs. Independent predictors of readmission were having Medicaid insurance, a Charlson comorbidity index score ≥ 3, use of total parenteral nutrition, opioid abuse disorder, prior pancreatic cyst, chronic alcoholic pancreatitis, and other chronic pancreatitis. Obesity was associated with lower odds of readmission. CONCLUSION Readmission rate for AAP is high and its primary cause are recurrent episodes of AAP. Alcohol and substance abuse pose a high burden on our health care system. Public health strategies should be targeted to provide alcohol abuse disorder rehabilitation and cessation resources to alleviate the burden on readmission, the health care system and to improve patient outcomes.
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Affiliation(s)
- Pedro Palacios Argueta
- Internal Medicine Department, John Stroger Hospital of Cook County, Rush University, Chicago, IL, USA
| | - Miguel Salazar
- Gastroenterology, Hepatology and Nutrition Department, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ishaan Vohra
- Internal Medicine Department, John Stroger Hospital of Cook County, Rush University, Chicago, IL, USA
| | - Juan E Corral
- Gastroenterology and Hepatology Department, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Frank J Lukens
- Gastroenterology and Hepatology Department, Mayo Clinic Florida, Jacksonville, FL, USA
| | - John J Vargo
- Gastroenterology, Hepatology and Nutrition Department, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Prabhleen Chahal
- Gastroenterology, Hepatology and Nutrition Department, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - C Roberto Simons-Linares
- Gastroenterology, Hepatology and Nutrition Department, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Jeon CY, Papachristou GI, Pisegna JR, Pendergast FJ, Lin YC, Cherpitel CJ, Ye Y, Pandol SJ, Yadav D. A Case-CrossovEr study deSign to inform tailored interventions to prevent disease progression in Acute Pancreatitis (ACCESS-AP) - study design and population. Pancreatology 2021; 21:1231-1236. [PMID: 34229971 DOI: 10.1016/j.pan.2021.06.007] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Alcohol is the most common etiology of recurrent acute pancreatitis and chronic pancreatitis. The extent and timing of drinking that increases the transient risk of acute pancreatitis is yet unknown. METHODS We designed a case-crossover study to determine the effective hazard period of drinking in relation to episodes of pancreatitis. We aim to evaluate the dose-response relationship between excess drinking and pancreatitis comparing the extent of drinking during case and control periods from the same individual. We aim to recruit 160 patients hospitalized with acute pancreatitis, whose AUDIT-C score reaches 3 or higher. Interviews of each enrolled patient to define their 15-day history of alcohol consumption employing the timeline follow-back method. Long-term drinking and smoking will be investigated as modifiers of the impact of short-term excess drinking. Patients are followed-up for evaluation of usual alcohol consumption during asymptomatic periods following the index hospitalization. Blood and urine specimens are collected while the patients are hospitalized and during a standard-of-care follow-up visit. RESULTS We have recruited 31 patients to date, with a median age of 33 years. Females and non-White participants make up 26% and 35% of the enrolled population, respectively. Forty-eight % of patients have had a prior history of acute pancreatitis. CONCLUSIONS Our study will shed light on the impact of short-term changes in drinking on triggering acute pancreatitis. It will provide data on other covarying factors of drinking and behaviors changes after acute pancreatitis.
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Affiliation(s)
- Christie Y Jeon
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | | | - Joseph R Pisegna
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Yu-Chen Lin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Yu Ye
- Alcohol Research Group, Emeryville, CA, USA
| | - Stephen J Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Oh TK, Song IA. Five-year mortality trends associated with chronic pancreatitis in South Korea: A population based cohort study. Pancreatology 2020; 20:828-833. [PMID: 32646739 DOI: 10.1016/j.pan.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 03/06/2020] [Revised: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pancreatitis (CP) is associated with all-cause and cancer-related mortality; however, the risk of mortality associated with alcoholic and non-alcoholic CP remains controversial. This study investigated whether CP increased the risk of 5-year all-cause and cancer-specific mortality compared to a control population. METHODS This population-based study used data from a sample cohort of the National Health Insurance Service (NHIS) database in South Korea. CP was defined as disease code K86.0 (alcohol-induced CP) and K86.1 (other CP and non-alcoholic CP) from the tenth edition of the International Classification of Diseases. RESULTS The prevalence of chronic alcoholic pancreatitis increased from 0.01% in 2002 to 0.07% in 2015, and the prevalence of chronic non-alcoholic pancreatitis increased from 0.08% in 2002 to 0.50% in 2015. In the 2010 NHIS cohort (n = 826,909), CP was associated with an increased risk of 5-year all-cause mortality (hazard ratio [HR] = 1.25, 95% confidence interval [CI]: 1.25 to 1.66, P < 0.001). Additionally, non-alcoholic CP was associated with an increased risk of 5-year all-cause mortality (HR = 1.47, 95% CI: 1.27 to 1.71, P < 0.001); in contrast, alcohol-induced CP was not significantly associated with mortality risk (P = 0.569). Similar tendencies were observed for the 5-year cancer-related mortality risk. CONCLUSIONS In South Korea, the prevalence of alcoholic and non-alcoholic CP increased during 2002-2015. CP may be an independent risk factor for 5-year all-cause and cancer-related mortality. In this study, this association was more evident in patients with non-alcoholic CP.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Usategui-Martín R, Carbonell C, Novo-Veleiro I, Hernández-Pinchete S, Mirón-Canelo JA, Chamorro AJ, Marcos M. Association between genetic variants in CYP2E1 and CTRC genes and susceptibility to alcoholic pancreatitis: A systematic review and meta-analysis. Drug Alcohol Depend 2020; 209:107873. [PMID: 32045777 DOI: 10.1016/j.drugalcdep.2020.107873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 12/03/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Genetic predisposition plays an important role in the development of alcoholic pancreatitis (AP), with previous studies suggesting that genetics variants in certain genes, such asCYP2E1 and CTRC, partially explain individual susceptibility to this disease. Therefore, the aim of this work was to conduct a systematic review and meta-analysis of existing studies that analyzed how polymorphisms within CYP2E1 and CTRC genes influence the risk of AP. MATERIAL AND METHODS We performed a systematic review of studies that analyzed the genotype distribution of CYP2E1 and CTRC allelic variants among patients with AP and a group of controls. A meta-analysis was conducted using a random effects model. Odds ratios (ORs) and their confidence intervals (CIs) were calculated. RESULTS The T allele of theCTRC 180 C > T variant was significantly more prevalent among patients with AP compared to all controls (OR = 1.79, 95% CI = 1.43-2.24; P < 0.00001) and healthy subjects (OR = 1.84, 95% CI = 1.46-2.31; P < 0.00001). The Trp variant of CTRC Arg254Trp polymorphism was also more prevalent in patients with AP; however, these results were not significant after excluding one study. We found no clear evidence that CYP2E1-DraI or of CYP2E1-RsaI/PstI polymorphisms modulate the risk of developing AP. CONCLUSIONS Our meta-analysis supports that the T allele ofCTRC 180C > T polymorphisms modulates the risk of alcoholic pancreatitis. No clear evidence was found for the remaining SNPs being associated with this disease.
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Affiliation(s)
- Ricardo Usategui-Martín
- Instituto Universitario de Oftalmobiología Aplicada (IOBA). University of Valladolid, Valladolid, Spain.
| | - Cristina Carbonell
- Alcoholism Unit. Department of Internal Medicine, University Hospital of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Working Group on Alcohol and Alcoholism. Spanish Society of Internal Medicine (SEMI), Spain.
| | - Ignacio Novo-Veleiro
- Working Group on Alcohol and Alcoholism. Spanish Society of Internal Medicine (SEMI), Spain; Department of Internal Medicine, University Hospital of Santiago de Compostela, A Coruña, Spain.
| | | | | | - Antonio-Javier Chamorro
- Alcoholism Unit. Department of Internal Medicine, University Hospital of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Working Group on Alcohol and Alcoholism. Spanish Society of Internal Medicine (SEMI), Spain; Department of Medicine, University of Salamanca, Salamanca, Spain.
| | - Miguel Marcos
- Alcoholism Unit. Department of Internal Medicine, University Hospital of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain; Working Group on Alcohol and Alcoholism. Spanish Society of Internal Medicine (SEMI), Spain; Department of Medicine, University of Salamanca, Salamanca, Spain.
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Rosendahl J, Kirsten H, Hegyi E, Kovacs P, Weiss FU, Laumen H, Lichtner P, Ruffert C, Chen JM, Masson E, Beer S, Zimmer C, Seltsam K, Algül H, Bühler F, Bruno MJ, Bugert P, Burkhardt R, Cavestro GM, Cichoz-Lach H, Farré A, Frank J, Gambaro G, Gimpfl S, Grallert H, Griesmann H, Grützmann R, Hellerbrand C, Hegyi P, Hollenbach M, Iordache S, Jurkowska G, Keim V, Kiefer F, Krug S, Landt O, Leo MD, Lerch MM, Lévy P, Löffler M, Löhr M, Ludwig M, Macek M, Malats N, Malecka-Panas E, Malerba G, Mann K, Mayerle J, Mohr S, te Morsche RHM, Motyka M, Mueller S, Müller T, Nöthen MM, Pedrazzoli S, Pereira SP, Peters A, Pfützer R, Real FX, Rebours V, Ridinger M, Rietschel M, Rösmann E, Saftoiu A, Schneider A, Schulz HU, Soranzo N, Soyka M, Simon P, Skipworth J, Stickel F, Strauch K, Stumvoll M, Testoni PA, Tönjes A, Werner L, Werner J, Wodarz N, Ziegler M, Masamune A, Mössner J, Férec C, Michl P, P H Drenth J, Witt H, Scholz M, Sahin-Tóth M. Genome-wide association study identifies inversion in the CTRB1-CTRB2 locus to modify risk for alcoholic and non-alcoholic chronic pancreatitis. Gut 2018; 67:1855-1863. [PMID: 28754779 PMCID: PMC6145291 DOI: 10.1136/gutjnl-2017-314454] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/16/2017] [Accepted: 06/24/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Alcohol-related pancreatitis is associated with a disproportionately large number of hospitalisations among GI disorders. Despite its clinical importance, genetic susceptibility to alcoholic chronic pancreatitis (CP) is poorly characterised. To identify risk genes for alcoholic CP and to evaluate their relevance in non-alcoholic CP, we performed a genome-wide association study and functional characterisation of a new pancreatitis locus. DESIGN 1959 European alcoholic CP patients and population-based controls from the KORA, LIFE and INCIPE studies (n=4708) as well as chronic alcoholics from the GESGA consortium (n=1332) were screened with Illumina technology. For replication, three European cohorts comprising 1650 patients with non-alcoholic CP and 6695 controls originating from the same countries were used. RESULTS We replicated previously reported risk loci CLDN2-MORC4, CTRC, PRSS1-PRSS2 and SPINK1 in alcoholic CP patients. We identified CTRB1-CTRB2 (chymotrypsin B1 and B2) as a new risk locus with lead single-nucleotide polymorphism (SNP) rs8055167 (OR 1.35, 95% CI 1.23 to 1.6). We found that a 16.6 kb inversion in the CTRB1-CTRB2 locus was in linkage disequilibrium with the CP-associated SNPs and was best tagged by rs8048956. The association was replicated in three independent European non-alcoholic CP cohorts of 1650 patients and 6695 controls (OR 1.62, 95% CI 1.42 to 1.86). The inversion changes the expression ratio of the CTRB1 and CTRB2 isoforms and thereby affects protective trypsinogen degradation and ultimately pancreatitis risk. CONCLUSION An inversion in the CTRB1-CTRB2 locus modifies risk for alcoholic and non-alcoholic CP indicating that common pathomechanisms are involved in these inflammatory disorders.
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Affiliation(s)
- Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Holger Kirsten
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
- LIFE- Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
- Department of Cell Therapy, Fraunhofer Institute for Cell Therapy and Immunology (IZI), Leipzig, Germany
| | - Eszter Hegyi
- Department of Molecular and Cell Biology, Center for Exocrine Disorders, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Peter Kovacs
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Frank Ulrich Weiss
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Helmut Laumen
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Peter Lichtner
- Institute of Human Genetics, Helmholtz Centre Munich, German Research Centre for Environmental Health, Neuherberg, Germany
| | - Claudia Ruffert
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Jian-Min Chen
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1078; Etablissement Français du Sang (EFS) – Bretagne; Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale; Laboratoire de Génétique Moléculaire et d’Histocompatibilité, Centre Hospitalier Régional Universitaire (CHRU) Brest, Hôpital Morvan, Brest, France
| | - Emmanuelle Masson
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1078; Etablissement Français du Sang (EFS) – Bretagne; Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale; Laboratoire de Génétique Moléculaire et d’Histocompatibilité, Centre Hospitalier Régional Universitaire (CHRU) Brest, Hôpital Morvan, Brest, France
| | - Sebastian Beer
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Constantin Zimmer
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Katharina Seltsam
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Hana Algül
- Department of Gastroenterology, Technische Universität München (TUM), Munich, Germany
| | - Florence Bühler
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Peter Bugert
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, German Red Cross Blood Service of Baden-Württemberg, Mannheim, Germany
| | - Ralph Burkhardt
- LIFE- Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
| | - Giulia Martina Cavestro
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University - San Raffaele Scientific Institute, Milan, Italy
| | - Halina Cichoz-Lach
- Department of Gastroenterology, Medical University of Lublin, Lublin, Poland
| | - Antoni Farré
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Josef Frank
- Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Giovanni Gambaro
- Division of Nephrology and Dialysis, Institute of Internal Medicine, Renal Program, Columbus-Gemelli University Hospital, Catholic University, Rome, Italy
| | - Sebastian Gimpfl
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Harald Grallert
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Heidi Griesmann
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Robert Grützmann
- Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Chirurgische Klinik, Erlangen, Germany
| | - Claus Hellerbrand
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Péter Hegyi
- Institute for Translational Medicine and First Department of Internal Medicine, University of Pécs, Pécs, Hungary
- HAS-SZTE, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Marcus Hollenbach
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Sevastitia Iordache
- Department of Internal Medicine and Gastroenterology, University of Medicine and Pharmacy, Craiova, Romania
| | - Grazyna Jurkowska
- Department of Gastroenterology and Internal Medicine, Medical University Bialystok, Bialystok, Poland
| | - Volker Keim
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Falk Kiefer
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sebastian Krug
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | | | - Milena Di Leo
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University - San Raffaele Scientific Institute, Milan, Italy
| | - Markus M Lerch
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Philippe Lévy
- Pôle des Maladies de l’Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
- LIFE- Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
| | - Matthias Löhr
- Gastrocentrum, Karolinska Institutet CLINTEC, Stockholm, Sweden
| | - Maren Ludwig
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Milan Macek
- Department of Biology and Medical Genetics, University Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nuria Malats
- Grupo de Epidemiología Genética y Molecular Programa de Genética del Cáncer Humano Centro Nacional de Investigaciones Oncológicas (CNIO), Madrid, Spain
- CIBERONC, Spain
| | - Ewa Malecka-Panas
- Department of Digestive Tract Diseases, Medical University of Łódź, Łódź, Poland
| | - Giovanni Malerba
- Biology and Genetics, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - Karl Mann
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sonja Mohr
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Rene H M te Morsche
- Department of Gastroenterology and Hepatology, Radboud umc, Nijmegen, The Netherlands
| | - Marie Motyka
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Sebastian Mueller
- Department of Internal Medicine, Salem Medical Centre and Centre for Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Thomas Müller
- Department of Pediatrics I, Medical University, Innsbruck, Austria
| | - Markus M Nöthen
- Department of Genomics, Life & Brain Center, University of Bonn, Bonn, Germany
- Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - Sergio Pedrazzoli
- Department of Medical and Surgical Sciences, IV Surgical Clinic, University of Padua, Padua, Italy
| | - Stephen P Pereira
- Division of Medicine, UCL Institute for Liver and Digestive Health, University College London, London, UK
| | - Annette Peters
- Institute of Epidemiology II, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Roland Pfützer
- Clinic for Internal Medicine, Hospital Döbeln, Döbeln, Germany
| | - Francisco X Real
- CIBERONC, Spain
- Epithelial Carcinogenesis Group, Molecular Pathology Programme, Centro Nacional de Investigaciones Oncológicas, Madrid, Spain
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
| | - Vinciane Rebours
- Pôle des Maladies de l’Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Monika Ridinger
- Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - Marcella Rietschel
- Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Eva Rösmann
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Adrian Saftoiu
- Department of Internal Medicine and Gastroenterology, University of Medicine and Pharmacy, Craiova, Romania
| | - Alexander Schneider
- Department of Gastroenterology, Hepatology, Infectious Diseases, Medical Faculty of Mannheim University of Heidelberg, Mannheim, Germany
| | - Hans-Ulrich Schulz
- Department of Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Nicole Soranzo
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - Michael Soyka
- Psychiatric Hospital, University of Munich, Munich, Germany
| | - Peter Simon
- Department of Internal Medicine A, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - James Skipworth
- Department of Surgery and Interventional Science, University College London, London, UK
| | - Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Konstantin Strauch
- Institute of Genetic Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Medical Informatics, Biometry and Epidemiology, Chair of Genetic Epidemiology, Ludwig-Maximilians-Universität, Munich, Germany
| | - Michael Stumvoll
- Leipzig University Medical Center, IFB Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Internal Medicine, Neurology and Dermatology, Division of Endocrinology, University of Leipzig, Leipzig, Germany
| | - Pier Alberto Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University - San Raffaele Scientific Institute, Milan, Italy
| | - Anke Tönjes
- Department of Internal Medicine, Neurology and Dermatology, Division of Endocrinology, University of Leipzig, Leipzig, Germany
| | - Lena Werner
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Norbert Wodarz
- Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - Martin Ziegler
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, SendaiMiyagi, Japan
| | - Joachim Mössner
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology, University of Leipzig, Leipzig, Germany
| | - Claude Férec
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1078; Etablissement Français du Sang (EFS) – Bretagne; Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale; Laboratoire de Génétique Moléculaire et d’Histocompatibilité, Centre Hospitalier Régional Universitaire (CHRU) Brest, Hôpital Morvan, Brest, France
| | - Patrick Michl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud umc, Nijmegen, The Netherlands
| | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin (EKFZ), Paediatric Nutritional Medicine, Technische Universität München (TUM), Freising, Germany
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
- LIFE- Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
| | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Center for Exocrine Disorders, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
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Liu X, Tu M, Dai X, Zhu Y, Ge Q, Gao W, Miao Y. PRSS1 and SPINK1 Mutations in Alcoholic and Idiopathic Chronic Pancreatitis. J Nanosci Nanotechnol 2017; 17:2358-2362. [PMID: 29641165 DOI: 10.1166/jnn.2017.12626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Several recent studies have reported associations between gene mutations and chronic pancreatitis (CP); however, little is known about their association with risk of CP in the Chinese Han population. The aim of this study was to describe mutations in the cationic trypsinogen (PRSS1) and serine protease inhibitor Kazal type 1 (SPINK1) genes in patients with alcoholic chronic pancreatitis (ACP) and idiopathic chronic pancreatitis (ICP) and to investigate their influence on the clinical course of the disease. One hundred patients (24 with ACP, 76 with ICP) and 100 healthy volunteers (control group) were enrolled in the study. PRSS1 (R122H) mutations were detected in one (1.3%) patient with ICP and SPINK1 (N34S) mutations were present in one (4.1%) patient with ACP. PRSS1 and SPINK1 mutations were not detected in the control populations. There were no statistically significant differences between the CP patients and the control group. Those preliminary data suggest low prevalence of SPINK1 and PRSS1 mutations in the Chinese population, generally, as well as in CP patients, indicating that these mutations do not contribute to the development of CP.
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Fjeld K, Beer S, Johnstone M, Zimmer C, Mössner J, Ruffert C, Krehan M, Zapf C, Njølstad PR, Johansson S, Bugert P, Miyajima F, Liloglou T, Brown LJ, Winn SA, Davies K, Latawiec D, Gunson BK, Criddle DN, Pirmohamed M, Grützmann R, Michl P, Greenhalf W, Molven A, Sutton R, Rosendahl J. Length of Variable Numbers of Tandem Repeats in the Carboxyl Ester Lipase (CEL) Gene May Confer Susceptibility to Alcoholic Liver Cirrhosis but Not Alcoholic Chronic Pancreatitis. PLoS One 2016; 11:e0165567. [PMID: 27802312 PMCID: PMC5089759 DOI: 10.1371/journal.pone.0165567] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Carboxyl-ester lipase (CEL) contributes to fatty acid ethyl ester metabolism, which is implicated in alcoholic pancreatitis. The CEL gene harbours a variable number of tandem repeats (VNTR) region in exon 11. Variation in this VNTR has been linked to monogenic pancreatic disease, while conflicting results were reported for chronic pancreatitis (CP). Here, we aimed to investigate a potential association of CEL VNTR lengths with alcoholic CP. METHODS Overall, 395 alcoholic CP patients, 218 patients with alcoholic liver cirrhosis (ALC) serving as controls with a comparable amount of alcohol consumed, and 327 healthy controls from Germany and the United Kingdom (UK) were analysed by determination of fragment lengths by capillary electrophoresis. Allele frequencies and genotypes of different VNTR categories were compared between the groups. RESULTS Twelve repeats were overrepresented in UK ACP patients (P = 0.04) compared to controls, whereas twelve repeats were enriched in German ALC compared to alcoholic CP patients (P = 0.03). Frequencies of CEL VNTR lengths of 14 and 15 repeats differed between German ALC patients and healthy controls (P = 0.03 and 0.008, respectively). However, in the genotype and pooled analysis of VNTR lengths no statistical significant association was depicted. Additionally, the 16-16 genotype as well as 16 repeats were more frequent in UK ALC than in alcoholic CP patients (P = 0.034 and 0.02, respectively). In all other calculations, including pooled German and UK data, allele frequencies and genotype distributions did not differ significantly between patients and controls or between alcoholic CP and ALC. CONCLUSIONS We did not obtain evidence that CEL VNTR lengths are associated with alcoholic CP. However, our results suggest that CEL VNTR lengths might associate with ALC, a finding that needs to be clarified in larger cohorts.
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Affiliation(s)
- Karianne Fjeld
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway
- Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sebastian Beer
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
| | - Marianne Johnstone
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Constantin Zimmer
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
| | - Joachim Mössner
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
| | - Claudia Ruffert
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Mario Krehan
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
| | - Christian Zapf
- Department of Internal Medicine, Neurology and Dermatology, Division of Gastroenterology and Rheumatology, University of Leipzig, Leipzig, Germany
| | - Pål Rasmus Njølstad
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Stefan Johansson
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway
- Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
| | - Peter Bugert
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, German Red Cross Blood Service of Baden-Württemberg-Hessen, Mannheim, Germany
| | - Fabio Miyajima
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Triantafillos Liloglou
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Laura J. Brown
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Simon A. Winn
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Kelly Davies
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Diane Latawiec
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Bridget K. Gunson
- NIHR Birmingham Liver Biomedical Research Unit, Queen Elizabeth Hospital and University of Birmingham, Birmingham, United Kingdom
| | - David N. Criddle
- Department of Cellular & Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Robert Grützmann
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Patrick Michl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - William Greenhalf
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Anders Molven
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway
- Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Robert Sutton
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
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Mikolasevic I, Milic S, Orlic L, Poropat G, Jakopcic I, Franjic N, Klanac A, Kristo N, Stimac D. Metabolic syndrome and acute pancreatitis. Eur J Intern Med 2016; 32:79-83. [PMID: 27157403 DOI: 10.1016/j.ejim.2016.04.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 01/18/2016] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 01/16/2023]
Abstract
AIM The aim of our study was to investigate the influence of metabolic syndrome on the course of acute pancreatitis determined by disease severity, the presence of local and systemic complications and survival rate. PATIENTS AND METHODS 609 patients admitted to our hospital in the period from January 1, 2008 up to June 31, 2015 with the diagnosis of acute pancreatitis were analyzed. The diagnosis and the severity of acute pancreatitis were made according to the revised Atlanta classification criteria from 2012. RESULTS Of 609 patients with acute pancreatitis, 110 fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome had statistically significantly higher incidence of moderately severe (38.2% vs. 28.5%; p=0.05) and severe (22.7% vs. 12.8%; p=0.01) acute pancreatitis in comparison to those without metabolic syndrome, while patients without metabolic syndrome had higher incidence of mild acute pancreatitis in comparison to those patients with metabolic syndrome (58.7% vs. 39.1%; p<0.001). Patients with metabolic syndrome had a higher number of local and systemic complications, and higher APACHE II score in comparison to patients without metabolic syndrome. In multivariable logistic regression analysis, the presence of metabolic syndrome was independently associated with moderately severe and severe acute pancreatitis. Comparing survival rates, patients suffering from metabolic syndrome had a higher death rate compared to patients without metabolic syndrome (16% vs. 4.5%; p<0.001). CONCLUSION The presence of metabolic syndrome at admission portends a higher risk of moderately severe and severe acute pancreatitis, as well as higher mortality rate.
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Affiliation(s)
- I Mikolasevic
- Department of Gastroenterology, UHC Rijeka, Croatia.
| | - S Milic
- Department of Gastroenterology, UHC Rijeka, Croatia
| | - L Orlic
- Department of Nephrology, Dialysis and Kidney Transplantation, UHC Rijeka, Croatia
| | - G Poropat
- Department of Gastroenterology, UHC Rijeka, Croatia
| | | | - N Franjic
- Department of Gastroenterology, UHC Rijeka, Croatia
| | - A Klanac
- School of Medicine, Rijeka, Croatia
| | - N Kristo
- School of Medicine, Rijeka, Croatia
| | - D Stimac
- Department of Nephrology, Dialysis and Kidney Transplantation, UHC Rijeka, Croatia
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Nesvaderani M, Eslick GD, Vagg D, Faraj S, Cox MR. Epidemiology, aetiology and outcomes of acute pancreatitis: A retrospective cohort study. Int J Surg 2015; 23:68-74. [PMID: 26384834 DOI: 10.1016/j.ijsu.2015.07.701] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/30/2015] [Accepted: 07/27/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute pancreatitis is a common acute surgical presentation in Western Society. The causes and pattern of pancreatitis has not been previously documented for Western Sydney. As Western Sydney contains many areas of low socio-economic status with an expected high level of alcohol abuse, it was hypothesised that alcoholic pancreatitis would be more prevalent in this population. The aims of this study were to determine the epidemiology, aetiology and outcomes of acute pancreatitis. METHODS A retrospective analysis of patients presenting with acute pancreatitis to four tertiary hospitals over a four-year period was undertaken. RESULTS 932 patients presented with acute pancreatitis with a median age of 50 years (range 16-95); 470 (50.4%) were female. Almost half had gallstones (40%), 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP. 69 (7.4%) of patients were admitted to ICU/HDU, with a median length of stay in ICU was 6 days (range 1-106). 85 (11.1%) patients had severe pancreatitis (score ≥ 3). Mortality in this study was 1% (9). CONCLUSION The majority of patients with acute pancreatitis in Western Sydney present with mild disease and have a low risk of morbidity or mortality. The ratio of gallstone to alcohol aetiology was 2:1. Idiopathic pancreatitis is responsible for more cases than expected.
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Affiliation(s)
- Maryam Nesvaderani
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Daniel Vagg
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Shadi Faraj
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Michael R Cox
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia.
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12
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Papita R, Nazir A, Anbalagan VP, Anjana RM, Pitchumoni C, Chari S, Mohan V. Secular trends of fibrocalculous pancreatic diabetes and diabetes secondary to alcoholic chronic pancreatitis at a tertiary care diabetes centre in South India. JOP 2012; 13:205-209. [PMID: 22406602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Data on prevalence and trends in diabetes secondary to chronic pancreatitis in developing countries is scarce. OBJECTIVE To compare the secular trends in the prevalence of fibrocalculous pancreatic diabetes (FCPD) and diabetes secondary to alcoholic chronic pancreatitis (ACP) at a diabetes centre in south India. DESIGN A retrospective analysis was done of all patients registered at Dr. Mohan's Diabetes Specialties Centre, Chennai, India between January 1991 and December 2010. PATIENTS A total of 1,079 subjects with diabetes secondary to chronic pancreatitis were identified, of whom 47 were excluded because of difficulty in classification. MAIN OUTCOME MEASURE The number of patients with FCPD and diabetes secondary to ACP were calculated as a percentage of the total number of diabetes patients seen at the centre during five year blocks. RESULTS Of the total of 1,032 cases of diabetes secondary to chronic pancreatitis, FCPD comprised 898 (87%) and ACP 134 (13%). The prevalence of FCPD decreased from 1.6% during 1991-1995 to 0.2% during 2006-2010 (P<0.001). The prevalence of ACP remained constant at 0.1%. The age at diagnosis of FCPD increased (P=0.002) while that of ACP decreased (P=0.025) during the study period. There was a significant increase in BMI of FCPD P<0.001), but not of ACP (P=0.248) patients. CONCLUSIONS At this centre, FCPD continues to be more common than ACP, but there is a decline in its frequency. The age at diagnosis of FCPD has increased, while that of ACP has decreased. The decline in FCPD probably reflects improved nutrition.
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Affiliation(s)
- Rozario Papita
- Dr.Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, India
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13
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Barreto SG, Tiong L, Williams R. Drug-induced acute pancreatitis in a cohort of 328 patients. A single-centre experience from Australia. JOP 2011; 12:581-585. [PMID: 22072247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Acute pancreatitis is associated with risk of morbidity and even mortality. Routine prescription drugs have been linked to the causation of acute pancreatitis. OBJECTIVE To determine the incidence, presentation, course and outcome of drug-induced acute pancreatitis amongst patients admitted to a public hospital. DESIGN/SETTING A retrospective analysis of patients presenting with acute pancreatitis to the Modbury Hospital, South Australia from January 2006 to April 2011. MAIN OUTCOME MEASURE Each admission was reviewed within the electronic database for patient details as well as to determine the aetiological factor. In patients with drug-induced acute pancreatitis, the WHO Probability Scale was used to evaluate causality relationship. RESULTS Three-hundreds and 28 patients were treated for acute pancreatitis during the study period. Biliary and alcohol-induced acute pancreatitis accounted for 80.8% of cases. Eleven patients (2 male and 9 female patients; median age: 59 years) were diagnosed with drug-induced acute pancreatitis. These included 5 cases of codeine-, 2 cases of azathioprine-, and 1 case each of chlorothiazide-, valproic acid-, oestradiol- and simvastatin-induced acute pancreatitis. Nine patients had a mild disease while 2 patients had severe acute pancreatitis with a median hospital stay of 4 days. Withdrawal of the drug resulted in cessation of the attacks in all patients over a median follow-up of 24 months. CONCLUSIONS Routine prescription drugs, as an aetiological factor, accounted for 3.4% of cases of acute pancreatitis. The disease appeared to be more common in middle-aged women. It is likely that the overall incidence of this entity is under-reported owing to the stringent criteria needed to conclusively determine a causal relationship.
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Affiliation(s)
- Savio G Barreto
- Department of Surgery, Modbury Hospital, Modbury, South Australia, Australia
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14
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da Costa MZG, Guarita DR, Ono-Nita SK, Paranaguá-Vezozzo DC, Felga GEG, Pedroso MRA, de Souza MMT, Nasser PD, Ferreira CDS, Carrilho FJ. Genetic risk for alcoholic chronic pancreatitis. Int J Environ Res Public Health 2011; 8:2747-57. [PMID: 21845156 PMCID: PMC3155327 DOI: 10.3390/ijerph8072747] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 06/20/2011] [Indexed: 12/14/2022]
Abstract
In recent years many studies have examined the genetic predisposition to pancreatic diseases. Pancreatic disease of an alcoholic etiology was determined to be a multi-factorial disease, where environmental factors interact with the genetic profile of the individual. In this review we discuss the main results from studies examining the frequency of genetic mutations in alcoholic chronic pancreatitis.
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Abstract
Clinical observation has defined the medical profile of alcoholic pancreatitis, but its low incidence and prevalence has limited characterizing the disease at a population level, the contribution of environmental exposures, and a clear picture of its natural history. Recent studies have defined the impact of alcohol use and smoking on disease risk, and a threshold for alcohol consumption has been identified. Recurrent attacks of acute pancreatitis have been linked with continued alcohol consumption, and aggressive alcohol intervention has been shown to decrease recurrence. Progression from alcoholic acute pancreatitis to chronic pancreatitis is now believed to occur infrequently, and factors associated with progression have been identified. Alcoholic pancreatitis reduces lifespan in these patients, and the economic impact of pancreatitis is substantial. Efforts are needed to increase awareness of the impact of alcohol consumption and smoking on risk for pancreatitis and the benefits of cessation for primary and secondary prevention.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, 200 Lothrop Street, M2, C Wing, Pittsburgh, PA 15213, USA.
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Khan AS, Latif SU, Eloubeidi MA. Controversies in the etiologies of acute pancreatitis. JOP 2010; 11:545-552. [PMID: 21068485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Ali Safdar Khan
- Department of Medicine, the University of Alabama in Birmingham, Birmingham, AL 35294-0007, USA
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Nøjgaard C, Bendtsen F, Matzen P, Becker U. The aetiology of acute and chronic pancreatitis over time in a hospital in Copenhagen. Dan Med Bull 2010; 57:A4103. [PMID: 20175946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION The change in aetiology over time of acute and chronic pancreatitis has been sparsely described, as has also the validity of the diagnostic codes. The aim of the study was 1) to clarify whether the aetiology of acute and chronic pancreatitis changed during the period 1983-2005, and 2) to validate the diagnostic codes over time for acute and chronic pancreatitis registered in the Danish National Patient Registry (NPR) in the same period. MATERIAL AND METHODS All admissions at Hvidovre Hospital coded in the NPR in 1983, 1994 and 2005 with a diagnosis of either acute or chronic pancreatitis were included. After exclusion of readmissions, the cohorts consisted of 92, 146 and 118 patients, respectively. Medical records from every admission were retrieved, the aetiology was assessed and the coding of the diagnoses was related to internationally approved criteria. RESULTS AND CONCLUSION Gallstone disease significantly (p = 0.04) increased as the cause of acute pancreatitis over the 22-year period, while alcohol remained the major cause of chronic pancreatitis. The validity of the diagnoses for patients with acute pancreatitis varied between 51% and 73%, and for chronic pancreatitis between 63 and 78%.
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Affiliation(s)
- Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre Hospital, Kettegård Alle 30, DK-2650 Hvidovre, Denmark.
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Pelli H, Sand J, Nordback I. [Can the recurrence of alcohol-induced pancreatitis be prevented?]. Duodecim 2009; 125:1195-1200. [PMID: 19579580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
70% of pancreatitis cases are considered to be induced by alcohol. Half of those fallen ill with alcohol-induced acute pancreatitis will have relapses. A prospective follow-up study showed that the level of dependence on alcohol constitutes the most important risk factor. Continued drinking was shown to be a dose-responsive risk factor for relapse; abstinence provided for a complete protection against renewed pancreatitis. In a randomized study, a semi-annual meeting with a healthcare professional specialized in substance abuse problems significantly reduced new episodes of acute pancreatitis. It is thus possible to at least reduce relapses by intervening in the risk factors.
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Kristiansen L, Grønbaek M, Becker U, Tolstrup JS. Risk of pancreatitis according to alcohol drinking habits: a population-based cohort study. Am J Epidemiol 2008; 168:932-7. [PMID: 18779386 DOI: 10.1093/aje/kwn222] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The association between alcohol intake and pancreatitis has been examined previously in case-control studies, mostly consisting of men. The significance of beverage type and drinking pattern is unknown. The objective of this study was to assess the association between amount, type, and frequency of alcohol intake and risk of pancreatitis. For this purpose, the authors used data on 17,905 men and women who participated in the Copenhagen City Heart Study in 1976-1978, 1981-1983, 1991-1994, and 2001-2003 in Copenhagen, Denmark. Alcohol intake and covariates were assessed by questionnaire. Information on pancreatitis was obtained from national registers. A high alcohol intake was associated with a higher risk of pancreatitis. Hazard ratios associated with drinking 1-6, 7-13, 14-20, 21-34, 35-48, and >48 drinks/week were 1.1 (95% confidence interval (CI): 0.8, 1.6), 1.2 (95% CI: 0.8, 1.8), 1.3 (95% CI: 0.8, 2.1), 1.3 (95% CI: 0.7, 2.2), 2.6 (95% CI: 1.4, 4.8), and 3.0 (95% CI: 1.6, 5.7), respectively, compared with 0 drinks/week (P(trend) < 0.001). Associations were similar for men and women. Drinking frequency did not seem to be independently associated with pancreatitis.
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Affiliation(s)
- Louise Kristiansen
- National Institute of Public Health, Oster Farimagsgade 5a, DK-1399 Copenhagen K, Denmark.
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Balakrishnan V, Unnikrishnan AG, Thomas V, Choudhuri G, Veeraraju P, Singh SP, Garg P, Pai CG, Devi RNS, Bhasin D, Jayanthi V, Premalatha N, Chacko A, Kar P, Rai RR, Rajan R, Subhalal N, Mehta R, Mishra SP, Dwivedi M, Vinayakumar KRN, Jain AK, Biswas K, Mathai S, Varghese J, Ramesh H, Alexander T, Philip J, Raj VV, Vinodkumar A, Mukevar S, Sawant P, Nair P, Kumar H, Sudhindran S, Dhar P, Sudheer OV, Sundaram KR, Tantri BV, Singh D, Nath TR. Chronic pancreatitis. A prospective nationwide study of 1,086 subjects from India. JOP 2008; 9:593-600. [PMID: 18762690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
CONTEXT Chronic pancreatitis is common in India. However, its risk factors are not clear. There is sparse data on the current prevalence of tropical pancreatitis in India. OBJECTIVE To undertake a prospective nationwide study of the risk factors and clinical profile of chronic pancreatitis. SETTING Thirty-two major centers from different regions of India contributed data on 1,086 patients to a common online website (www.ipans.org). MAIN OUTCOME MEASURES Risk factors, clinical features complications and treatment of chronic pancreatitis. RESULTS Of the 1,086 subjects, complete data on risk factors were available for 1,033 subjects. Idiopathic pancreatitis was the most common form of pancreatitis (n=622; 60.2%) and alcoholic chronic pancreatitis accounted for about a third of the cases (n=400; 38.7%); the rest (n=11; 1.1%) had rare risk factors. Smoking and cassava intake were documented in 292 (28.3%) and 189 (18.3%) subjects, respectively. Using well-defined criteria, only 39 (3.8%)cases could be labeled as 'tropical pancreatitis'. Pain occurred in 971 patients (94.0%). Four hundred and eighteen (40.5%) subjects had diabetes mellitus. Of alcohol consumers, alcoholism and female gender were independent risk factors for diabetes in subjects with chronic pancreatitis (OR=1.48, P=0.003; and OR=1.75, P<0.001, respectively). The most common complications were pseudocysts (15.8%) and biliary obstruction (8.2%). Pancreatic cancer occurred in 42 subjects (4.1%). Ultrasound detected calculi in 69.7%, ductal dilatation in 63.4% and atrophy in 27.3%. The majority of patients were on medical therapy (n=849; 82.2%); endotherapy and surgery accounted for the rest. About 50% percent of the patients with diabetes required insulin (198/418). CONCLUSIONS In this first nationwide prospective survey of chronic pancreatitis in India, idiopathic pancreatitis was the most common form, followed by alcoholic pancreatitis. The classical form of tropical chronic pancreatitis is becoming less common.
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Pezzilli R, Lioce A, Frulloni L. Chronic pancreatitis: a changing etiology? JOP 2008; 9:588-592. [PMID: 18762689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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O'Farrell A, Allwright S, Toomey D, Bedford D, Conlon K. Hospital admission for acute pancreatitis in the Irish population, 1997 2004: could the increase be due to an increase in alcohol-related pancreatitis? J Public Health (Oxf) 2008; 29:398-404. [PMID: 17998260 DOI: 10.1093/pubmed/fdm069] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To investigate trends in the incidence of acute pancreatitis by examining emergency admissions to acute public hospitals over an 8-year period; to compare trends for alcohol-related pancreatitis admissions with biliary tract-related admissions and to profile the patients admitted with an acute pancreatitis diagnosis. METHODS All in-patient emergency admissions for which an acute pancreatitis diagnosis (ICD-9-CM Code 577.0) was recorded as principal diagnosis were identified for years 1997-2004 inclusive. Alcohol-related acute pancreatitis admissions (i.e. had alcohol misuse recorded as co-morbidity) were identified using ICD-9-CM-codes 303 and 305. Biliary tract disease-related admissions (i.e. had biliary tract disease recorded as co-morbidity) were identified using ICD-9-CM codes 574.0-576.0 inclusive. Pearson's chi2-test was used to compare proportions in groups of categorical data and chi2-tests for trend were used to identify linear trends. RESULTS There were 6291 emergency admissions with a principal diagnosis of acute pancreatitis during the 8 year study period, with 622 admissions in 1997 compared to 959 admissions in 2004, an increase of 54.1%. Age standardized rates rose significantly from 17.5 per 100,000 population in 1997 to 23.6 per 100,000 in 2004, (P<0.01 for linear trend). There were 1205 admissions with alcohol misuse recorded as a co-morbidity increasing from 13.9% (87/622) of acute pancreatitis admissions in 1997 to 23.2% (223/959) in 2004. This increase was significantly greater than the increase observed for biliary tract disease-related admissions, 19.6% (122/622) in 1997 to 23.5% (225/959) in 2004. Rates for total acute pancreatitis admissions were highest in those aged 70 years and over; the majority (3563, 56.6%) of the admissions were male with a mean age of 51.1 years (SD 19.9); the mean age for male admissions was significantly younger than for female admissions (49.1 versus 53.6 years, P<0.001). However, for alcohol-related admissions, rates were highest in those aged 30-49 years and patients admitted with alcohol misuse recorded were significantly younger than those who did not have alcohol misuse recorded (42.0 versus 53.2 years, P<0.001). Median length of stay was 7 days. CONCLUSIONS Hospital admissions for acute pancreatitis rose from 17.5 per 100,000 population in 1997 to 23.6 per 100,000 in 2004. The proportion of admissions that had alcohol misuse recorded as a co-morbidity rose more markedly than those with biliary tract disease and the rise was more pronounced in younger age groups. The increasing trend in alcohol-related acute pancreatitis parallels the rise in per capita alcohol consumption. Given the continuing rise in binge drinking, particularly among young people, this is a cause for concern.
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Affiliation(s)
- A O'Farrell
- Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, Adelaide and Meath Hospital Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland.
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Abstract
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.
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Affiliation(s)
- Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Abstract
OBJECTIVES To determine the prevalence of pancreatitis and associated risk factors among heavy-drinking veterans. METHODS At a large Veterans Administration Outpatient Detoxification Program (ODP) that systematically collects risk information, 1409 black and white male veterans with International Classification of Diseases, Ninth Revision codes for alcohol abuse enrolling in the ODP from January 2002 to December 2003 were identified. Among these patients, pancreatitis at any time (before the ODP admission or occurring through June 2005) was identified using International Classification of Diseases, Ninth Revision codes. Cases were verified by chart review. Logistic regression analyses were used for multivariable analyses. RESULTS Overall, history of smoking (89.6%) and current or past drug use (90.1%) were very common, whereas intravenous drug use (22.3%) was less so. Although 87 (6.2%) subjects had pancreatitis codes (acute, 50; chronic, 15; both, 22), chart review verified only 42 cases (acute, 29; chronic, 5; both, 8) for a 3% prevalence. Alcohol appeared to be the definite etiology in 39 of these 42 patients. In bivariate analyses, patients with pancreatitis were older, had more substance abuse admissions, reported a significantly heavier current alcohol use, and lower drug dependence (each P < 0.05). In multivariable models, alcoholic pancreatitis was associated positively with age (odds ratio, 1.08; 95% confidence interval, 1.04-1.12) and number of substance abuse admissions (odds ratio, 1.08; 95% confidence interval, 0.995-1.18; P = 0.06). CONCLUSIONS In this high-risk population of heavy drinkers, the prevalence of pancreatitis is at least 3%. Our study provides preliminary data regarding potential cofactors for pancreatitis in heavy drinkers.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology and Hepatology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Ito T, Otsuki M, Itoi T, Shimosegawa T, Funakoshi A, Shiratori K, Naruse S, Kuroda Y. Pancreatic diabetes in a follow-up survey of chronic pancreatitis in Japan. J Gastroenterol 2007; 42:291-7. [PMID: 17464458 DOI: 10.1007/s00535-006-1996-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 12/11/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND We aimed to determine the cumulative rate of diabetes mellitus (DM) and the risk factors for DM in patients with chronic pancreatitis (CP) in Japan. METHODS We conducted a follow-up survey of CP in 2002 in patients registered as having CP in 1994, and confirmed 656 patients to be checked in regard to the survey items concerning diabetes. We analyzed the cumulative rate of DM and the risk factors for DM over an 8-year follow up period. RESULTS In 1994, 35.1% of 656 CP patients had DM, and the incidence of diabetes had increased to 50.4% in 2002. Of 418 patients without diabetes in 1994, 28.9% (121/418) were newly diagnosed with DM in 2002. Alcoholic CP was the most common type of CP in patients with newly developed diabetes, accounting for 67.8%. The incidence of DM was highest in those with alcoholic CP (34.3%) followed by idiopathic CP (23.0%). The risk of diabetes increased 1.32-fold after the onset of pancreatic calcification. Of 121 patients with newly diagnosed DM in 2002, 37 (30.6%) had pancreatic stones in 1994 and 49 (40.5%) had a stone in 2002. The highest incidence of newly diagnosed DM was observed in patients with continuous alcoholic intake (40.9%). Patients treated with camostat mesilate developed DM less frequently than those without camostat mesilate. CONCLUSIONS The present study showed that the incidence of DM in patients with CP increased with time. Of 418 CP patients without DM in 1994, 28.9% developed DM over a period of 8 years. Continuous alcoholic intake aggravated CP and increased the risk of DM in those with CP.
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Affiliation(s)
- Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
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Abstract
OBJECTIVE To estimate the incidence of alcoholic pancreatitis, a dependence questionnaire survey was administered to male members of the sobriety association in Japan. METHODS Questionnaires asking about age, age at start of alcohol drinking, amount of alcohol consumption, duration of drinking, the initiated age of abstinence, medical history of pancreatitis, the age at diagnosis of pancreatitis, and the etiology of pancreatitis were sent to 7876 male members of a sobriety association in Japan. RESULTS Of 4120 members who replied to the questionnaire, 857 (20.8%) had a medical history of pancreatitis. Of these 857 members, 418 (10.1%) had been diagnosed with alcoholic pancreatitis, 32 (0.8%) as gallstone pancreatitis, and 407 (9.9%) with unknown etiology or etiology forgotten. A clear history of pancreatitis and information on habitual heavy drinking and the consumed amount of alcohol could be obtained from 373 of the 418 members diagnosed with alcoholic pancreatitis and from 345 of the 407 members with pancreatitis of unknown etiology. These 718 respondents were considered to be true alcoholic pancreatitis cases, with an extrapolated incidence of 9.1% (718/7876) to 17.4% (718/4120) cases of alcoholic pancreatitis in alcoholics in Japan. Alcoholics with a history of pancreatitis began drinking at relatively younger age and consumed a significantly greater amount of alcohol per day compared with 3113 alcoholics without a medical history of pancreatitis. CONCLUSION This survey suggests that the incidence of alcoholic pancreatitis in alcoholics is much higher than previously reported.
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Affiliation(s)
- Katsuya Maruyama
- Department of Clinical Research, National Hospital Organization, Kurihama Alcoholism Center, Kurihama, Japan
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Shaddique S, Cahill RA, Watson RG, O'Connor J. Trends in the incidence and significance of presentations to the emergency department due to acute pancreatitis. Eur J Emerg Med 2006; 13:209-13. [PMID: 16816584 DOI: 10.1097/01.mej.0000209062.90826.e7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute pancreatitis is an important cause of abdominal pain that may be associated with significant morbidity for the patient and considerable workload for the hospital. Our impression has been that it is becoming increasingly common, perhaps in tandem with increased rates of other alcohol-related disease. METHODS The medical records of all patients attending our emergency department with acute pancreatitis by Hospital Inpatient Enquiry coding over a 9-year period were examined to determine its incidence, aetiology and significance (Imrie severity of pancreatitis scoring, length of hospital stay and interventional workload). RESULTS The incidence of acute pancreatitis (n=97, 40 male patients) increased approximately threefold over the study period (especially in the lattermost triennial period with 75 patients) in a fashion disproportionate to changes in our locality's population. Gallstone-related disease continues to be most prevalent although alcohol-related disease also became more common. Disease severity (length of hospital stay and Imrie score) was similar throughout with a mean length of hospital stay exceeding that of the majority of accident and emergency admissions. Seven acute complications of acute pancreatitis were noted while 34 chronic sequelae developed. Requirement for invasive intervention doubled (n=19 in first triennial period in the study vs 39 in the latter triennial period), although the relative need for endoscopic retrograde cholangiopancreaticography diminished with increased availability of magnetic resonance cholangiography imaging. Nine patients with gallstone-related acute pancreatitis suffered recurrent attacks while awaiting cholecystectomy. CONCLUSION Acute pancreatitis is an increasingly frequent cause of hospital admission while the clinical significance of each incident remains high. The presentation of acute pancreatitis to the emergency department as an early declaration of symptomatic cholelithiasis is especially worrisome as it suggests a failing of recognition and/or effective referral of premonitory biliary complaints.
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Affiliation(s)
- Shahid Shaddique
- Department of Surgery, Waterford Regional Hospital, Waterford, Ireland
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Kamisawa T, Tu Y, Egawa N, Tsuruta K, Okamoto A. Clinical implications of incomplete pancreas divisum. JOP 2006; 7:625-30. [PMID: 17095842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
CONTEXT Incomplete pancreas divisum is a pancreatic anomaly that results in an inadequate communication between the ventral and dorsal pancreatic ducts. Although the relationship between complete pancreas divisum and pancreatitis has been contentious, clinical implications of incomplete pancreas divisum have not been noted. OBJECTIVE This study was done to investigate the clinical significance of incomplete pancreas divisum. PATIENTS AND METHODS We studied the anatomy of the pancreatic duct system in 3,220 cases using endoscopic retrograde pancreatography; 44 cases had complete pancreas divisum, and 41 had incomplete pancreas divisum. MAIN OUTCOME MEASURE The prevalence of chronic and acute pancreatitis associated with complete or incomplete pancreas divisum was compared with that of cases with neither complete nor incomplete pancreas divisum (controls). RESULTS All of the patients with complete or incomplete pancreas divisum who abused alcohol had chronic or acute pancreatitis. The prevalence of chronic pancreatitis in patients with complete or incomplete pancreas divisum was significantly higher than in controls (P<0.001 and P=0.001, respectively), but acute pancreatitis occurred more frequently only in patients with complete pancreas divisum (P=0.010). When we considered pancreatic-type pain as a pancreatitis-like disease, complete and incomplete pancreas divisum were suspected as the cause of pancreatitis-like disease in 39% (15/38: chronic dorsal pancreatitis, n=5; acute pancreatitis, n=7; pancreatic-type pain, n=3) and 30% (10/33: chronic dorsal pancreatitis, n=2; acute relapsing pancreatitis, n=1; pancreatic-type pain, n=7) of patients who did not abuse alcohol, respectively. CONCLUSIONS Although the precise pathophysiology may differ, patients with complete pancreas divisum and patients with incomplete pancreas divisum may have similar presentations and a similar prevalence. The clinical implications of incomplete pancreas divisum may be similar to those of complete pancreas divisum.
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Affiliation(s)
- Terumi Kamisawa
- Departments of Internal Medicine and Surgery, Tokyo Metropolitan Komagome Hospital, Bunkyo-ku, Tokyo, Japan.
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Abstract
OBJECTIVE To systematically review trends in the epidemiology of the first attack of acute pancreatitis (AP) based on reported population-based studies. METHODS From Medline, we retrieved 18 full-length English language peer-reviewed original articles published from 1966 to June 2005 with population-based information on the epidemiology of first-attack AP. Trends over time were analyzed based on study- and country-specific data and the study site (UK vs non-UK). RESULTS Eight studies were from the UK and 10 from other European centers. An increase in the annual incidence per 100,000 for first-attack AP was reported in 10 of 12 studies with longitudinal data from 4 countries (UK, Sweden, Denmark, and Netherlands). The overall AP incidence seems to be higher in non-UK studies compared with that of UK, partly explained by a higher incidence of alcoholic pancreatitis in non-UK studies. A linear trend for increase in gallstone pancreatitis incidence over time was observed irrespective of the study site (UK or non-UK). The AP incidence and mortality increased with age. Gallstone pancreatitis was more common in female subjects, and alcoholic pancreatitis was more common in middle-aged male subjects. The AP case fatality (%) has decreased over time, but the overall population mortality rate per 100,000 has remained unchanged. Recurrence after the first attack is milder with a substantially lower mortality. CONCLUSIONS The incidence of AP seems to be increasing. Differences in the incidence and etiology between and within countries reflect differences in the risk factor prevalence. Case-fatality rate, but not the population-based mortality rate, decreased over time.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology and Hepatology, John L. McClellan Memorial Veterans Hospital & University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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Abstract
OBJECTIVE To better define the epidemiology of acute pancreatitis in a racially diverse population. METHODS Analysis of all patients hospitalized in California with first-time acute pancreatitis for the period between January 1994 and September 2001. Subtypes were classified based on the presence or absence of predisposing conditions. RESULTS There were 70,231 patients hospitalized for first-time acute pancreatitis; 32.6% had biliary tract disease alone, 20.3% had alcohol abuse alone, and 36.6% were idiopathic. The age-standardized incidence increased by 32% from 33.2 to 43.8 cases per 100,000 adults for the period between 1994 and 2001, with the largest increase in the biliary group (52%). The standardized incidence rate of alcoholic and idiopathic pancreatitis was highest in African Americans, whereas biliary pancreatitis was highest in Hispanics. There was no change over time in the percentage of patients dying in the first 14 or 91 days; and in a risk-adjusted model, patients with alcoholic pancreatitis had the highest risk of dying. CONCLUSIONS The incidence rate of acute pancreatitis rose for the period between 1994 and 2001. However, there was no reduction in the 14- or 91-day case-fatality rate. Further research is needed to explain both the rise in the incidence rate of pancreatitis and the absence of any improvement in the early case-fatality rate.
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Affiliation(s)
- Charles F Frey
- Department of Surgery, UC Davis Medical Center, Sacramento, CA, USA
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Lévy P, Barthet M, Mollard BR, Amouretti M, Marion-Audibert AM, Dyard F. Estimation of the prevalence and incidence of chronic pancreatitis and its complications. ACTA ACUST UNITED AC 2006; 30:838-44. [PMID: 16885867 DOI: 10.1016/s0399-8320(06)73330-9] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED Incidence and prevalence of chronic pancreatitis (CP) are poorly known and prospective nationwide epidemiologic estimation has never been performed. AIMS To estimate prospectively national incidence and prevalence of patients attending gastroenterologists for CP in France. PATIENTS AND METHODS Study was proposed to all of the French gastroenterologists (N=3215) of whom 753 accepted to participate (24% private, 40% hospital and 36% both). Were included all patients suffering from proved or suspected CP, from 04-2003 to 07-2003. Certain diagnostic criteria were pancreatic calcifications, ductal or histological abnormalities. For all of non-responder gastroenterologists, a tracking system was used (mail or by phone). RESULTS A total of 456 gastroenterologists returned at least 1 case on 1748 patients. Median patient age was 51 years; sex-ratio was 5.07. Median duration between the first CP sign and the inclusion was 41 months. CP cause was alcoholism (84%), hereditary (1%), cystic fibrosis (1%), idiopathic (9%), other (6%). CP diagnosis was certain in 77%: calcifications (85%), ductal abnormalities (57%), and histology (8%). CP symptoms were: chronic abdominal pain (53%), acute pancreatitis episodes (67%), pseudocysts (40%), bi-liary tract compression (21%), diabetes mellitus (32%), pancreatic exocrine insufficiency (36%). Maximal annual incidence was 4,646 (crude annual incidence: 7.7 per 100,000; 12.9 in male; 2.6 in female) and prevalence was 15,832 cases (crude prevalence: 26.4 per 100,000; 43.8 in male; 9.0 in female). CONCLUSION New CP patients attending gastroenterologists are about 5,000 a year. CP prevalence is about 16,000 patients (in France: 60,400,000 inhabitants). Frequency of main complications is close to hospital series, confirming that results issued from these centers are not or a few biased.
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Affiliation(s)
- Philippe Lévy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, APHP, Hôpital Beaujon, Clichy.
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Abstract
BACKGROUND/PURPOSE Changes in lifestyle have led to variation in the etiologies of acute pancreatitis indifferent areas of Taiwan. This study investigated the etiologies and factors associated with severity and recurrence of acute pancreatitis in southern Taiwan. METHODS Eighty acute pancreatitis patients (M/F: 64/16), including 53 (66.2%) with alcohol abuse, 16 (20%) with biliary disease, five (6.3%) with hyperlipidemia, and six (7.5%) with other risk factors, etiologies or idiopathic disease, were included. The mean follow-up period was 20 months. Contrast-enhanced computed tomography (CT) was used to assess the severity of acute pancreatitis. RESULTS Biliary pancreatitis was significantly associated with females while alcoholic pancreatitis occurred predominantly in males. Univariate analysis showed that male gender, alcoholic pancreatitis, and elevated serum triglyceride (>170 mg/dL) were significantly associated with severe acute pancreatitis. Multivariate logistic regression analysis revealed that male gender and abnormal serum triglyceride were independent risk factors for severity. Alcohol abuse was an independent risk factor for recurrent pancreatitis. CONCLUSION Alcoholic pancreatitis was the major etiology of acute pancreatitis in southern Taiwan, exhibiting a strong male predominance and higher risk of severe CT grading. Abnormal serum triglyceride was independently associated with the severity of acute pancreatitis. Alcoholic pancreatitis had a higher risk of recurrence than other etiologies.
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Affiliation(s)
- Chun-Hao Chen
- Department of Internal Medicine, Municipal Hsiao-Kang Hospital, Municipal United Hospital, Kaohsiung, Taiwan
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Miyamoto T, Tashiro M, Otsuki M. [Chronic pancreatitis as a risk factor for pancreatic cancer]. Nihon Rinsho 2006; 64 Suppl 1:22-6. [PMID: 16457214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Tamao Miyamoto
- Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, School of Medicine
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Schneider A, Lamb J, Barmada MM, Cuneo A, Money ME, Whitcomb DC. Keratin 8 mutations are not associated with familial, sporadic and alcoholic pancreatitis in a population from the United States. Pancreatology 2005; 6:103-8. [PMID: 16327287 DOI: 10.1159/000090029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2004] [Accepted: 06/13/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Genetic predispositions play a major role in the development of chronic pancreatitis. Recently, a mutation in the keratin 8 gene (G62C) was reported to be associated with chronic pancreatitis in Italy. We determined whether mutations in the keratin 8 gene are associated with familial, sporadic and alcoholic recurrent acute or chronic pancreatitis in a population from the United States. METHODS We investigated the relevant genomic region of the keratin 8 gene in 80 patients with familial pancreatitis without a cationic trypsinogen (PRSS1) gene mutation from 52 different families, 21 patients with familial hereditary pancreatitis and a PRSS1 mutation from 20 different families, 126 patients with sporadic pancreatitis without a PRSS1 mutation, 61 patients with alcoholic pancreatitis and 271 controls by direct DNA sequencing. RESULTS We found the heterozygous G62C mutation in n = 3/80 patients (n = 2/52 patients from different families, 3.8%) with familial pancreatitis without PRSS1 mutation and in n = 3/126 patients (2.4%) with sporadic pancreatitis. We detected an adjacent heterozygous I63V mutation in n = 2/80 patients (n = 2/52 patients from different families, 3.8%) with familial pancreatitis without PRSS1 mutation and in n = 1/61 patients (1.6%) with alcoholic pancreatitis. We found the G62C mutation in n = 2/271 controls (0.7%) and the I63V mutation in n = 2/271 controls (0.7%). There were no statistically significant differences in the genotype frequencies between patients and controls (p > 0.05). Screening of additional available family members revealed that these variants did not segregate with the disease phenotype. There was no statistically significant difference in the frequency of these keratin 8 variants between patients with chronic pancreatitis and controls (p > 0.05). CONCLUSION These keratin 8 variants are not associated with familial, sporadic or alcoholic pancreatitis.
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Affiliation(s)
- Alexander Schneider
- Department of Medicine, Division of Gastroenterology, University of Pittsburgh, Pittsburgh, PA, USA
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Nakamura Y, Ohmori T, Higuchi S, Maruyama K. Certain background factors exhibit an association with an increased risk for pancreatic calcification among Japanese male alcoholics. Pancreas 2005; 31:225-31. [PMID: 16163053 DOI: 10.1097/01.mpa.0000175180.70539.b6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE This was a cross-sectional study conducted from April 2003 through March 2004 to investigate the background factors related to pancreatic calcification (PC) in male Japanese alcoholics. METHODS AND RESULTS Helical computed tomography examination revealed PC in 44 of 263 alcoholics, and this group was further divisible into 3 subgroups: "scant" (n = 24), "moderate" (n = 6), and "extensive" PC subgroups (n = 14). The extensive subgroup was associated with larger daily ethanol consumption (P = 0.05) and high-alcohol beverages, such as whisky (P = 0.02). The moderate subgroup was associated with a longer duration of habitual drinking (P = 0.04), whereas the scant PC group was associated with never having smoked (P = 0.05) and with low-alcohol beverages, such as beer (P = 0.09). None of the 40 subjects with inactive mitochondrial aldehyde dehydrogenase (ALDH2*2 allele) exhibited PC (P = 0.004). Heterozygous alcohol dehydrogenase 2 genotype (ADH2*1/2*2) exhibited an association with the scant subgroup (P = 0.02). The TG12 repeats in the cystic fibrosis transmembrane conductance regulator (CFTR) gene tended to have a weak association with PC. CONCLUSION Drinking behavior, smoking status, and genetic backgrounds are associated with PC and are likely to increase the risk for alcoholic chronic pancreatitis.
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Affiliation(s)
- Yuji Nakamura
- Department of Clinical Research, National Hospital Organization Kurihama Alcoholism Center, Kanagawa, Japan.
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Abstract
OBJECTIVES To describe the potential risk factors, clinical features, biochemical and radiological features, and management of chronic calcific pancreatitis. DESIGN Cross-sectional descriptive study. SETTING Tertiary care general hospital. PATIENTS Fifty patients with pancreatic calcification referred to the Colombo South Teaching Hospital, and 50 age-matched controls from healthy relatives or friends of the patients. MEASUREMENT Height and weight measurements, immunoreactive insulin levels and trypsin levels of duodenal aspirates were estimated. Plain abdominal xray and ultrasonography were performed. INTERVENTION Endoscopic retrograde cholangiopancreaticography (ERCP) was attempted on all patients during which duodenal aspirates were collected. Success rates of ERCP and response to endotherapeutic procedures were recorded. RESULTS Twenty two of the 50 chronic calcific pancreatitis (CP) patients were diagnosed to have chronic alcoholic calcific pancreatitis (CACP). Mean age of the CACP patients was significantly higher than that of the chronic calcific pancreatitis of the tropics (CCPT) patients. Severe malnutrition (BMI < 20), frequent consumption of Manihot esculenta (manioc, cassava) and a high consumption of chilli or pepper were identified as possible risk factors for both alcoholic and non-alcoholic CP. Onset of diabetes occurred at a much younger age in the CCPT group than in the CACP group. Mean serum insulin was significantly higher in the CCPT group than in the CACP group and duodenal trypsin level was significantly lower in the CCPT than in CACP group. CONCLUSIONS Our results confirm the existence of both alcoholic (CACP) and non-alcoholic (CCPT) types of chronic calcific pancreatitis in Sri Lanka. A larger study is required to confirm the associated risk factors such as Manihot esculenta and foods with a high content of chilli or pepper.
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Affiliation(s)
- Mohan de Silva
- Faculty of Medical Sciences, University of Sri Jayawardenepura, Nugegoda, Sri Lanka.
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Abstract
Chronic pancreatitis is mostly caused by heavy alcohol consumption and is characterized by the onset of symptoms in the fourth and fifth decade. Beginning in patients older than 65 years of age is rare. Leading symptom is recurrent or persisting abdominal pain which is missed only in approximately 5% of the cases. Chronic pancreatitis is classified as idiopathic if there is no anamnesis of alcohol abuse or some rare specific causes. The Idiopathic Chronic Senile Pancreatitis (ICSP) is a subset of the non-alcoholic pancreatitis and is characterized by advanced age at the time of first manifestation. Although life expectancy especially in chronic alcoholic pancreatitis is reduced, there are many patients who reach older age. The natural history in all forms of chronic pancreatitis shows a decrease in pain and the manifestation of exocrine and endocrine insufficiency as late complications. Especially in the elderly loss of weight may occur with steatorrhea and pancreatic diabetes mellitus as the dominating clinical problem of chronic pancreatitis. If pain persists treatment is symptomatically with analgesics. The possibility of causal surgery or the indication for endoscopic treatment of painful chronic pancreatitis should be proven in every single case. Standard pancreatin treatment consisting of large amounts of enzymes will abolish maldigestion. Pancreatic diabetes requires often insulin, there is a tendency to hypoglycaemia. In contrast to chronic pancreatitis cancer of the pancreas is a typical and frequent disease of the elderly. The prognosis is bad and one year life expectancy is just about 11%. One of the reasons is, that the diagnosis is found lately because early symptoms are missing. Specific symptoms like pain, weight loss or jaundice occur lately. In suspicion of pancreatic cancer a lot of methods of morphological diagnostic are available such as CT, MRCP, ultrasound, ERCP and PET, in addition the specific tumor markers CA 19-9 and CEA. After diagnostic is completed, curative resection is possible in only a low percentage of all cases. Old age is no contraindication for surgery, prognosis and the risk of surgery don't differ to other age groups. In most cases palliative therapy is the only possible option because of an advanced tumor stage. Sufficient pain therapy, endoscopic stenting in case of obstructive jaundice or gastroenterostomy in case of duodenal are useful interventions.
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Affiliation(s)
- M Otte
- Allgemeines Krankenhaus Wandsbek, II. Medizinische Abteilung, Abteilung für Gastroenterologie und Stoffwechselkrankheiten, Hamburg
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Miyasaka K, Ohta M, Takano S, Hayashi H, Higuchi S, Maruyama K, Tando Y, Nakamura T, Takata Y, Funakoshi A. Carboxylester lipase gene polymorphism as a risk of alcohol-induced pancreatitis. Pancreas 2005; 30:e87-91. [PMID: 15841033 DOI: 10.1097/01.mpa.0000160960.21580.ml] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Alcohol abuse causes pancreatic damage in humans. However, only 5% of alcoholic patients have a clinical manifestation of pancreatitis, and the genetic predisposition of alcohol-associated pancreatitis remains elusive. Nonoxidative metabolites of ethanol, fatty acid ethyl esters (FAEEs), might play an important role in pancreatic damage. Carboxylester lipase (CEL) has been known to catalyze FAEE synthesis from fatty acids and ethanol. METHODS The variable number of tandem repeat (VNTR) polymorphism in the coding region of the CEL gene was studied in patients with alcoholic pancreatitis (n = 100), in alcoholics without pancreatitis (n = 52), in patients with nonalcoholic pancreatitis (n = 50), in hyperlipidemia patients (n = 96), and control subjects (n = 435). RESULTS The frequency of the NN-type (wild-type) gene was significantly decreased in patients with alcoholic pancreatitis than in other groups. The frequency of subjects who had the L allele in patients with alcoholic pancreatitis was significantly higher than in other groups. The distribution of the CEL gene polymorphism was not different among the control subjects, alcoholics without pancreatitis, patients with nonalcoholic pancreatitis, and patients with hyperlipidemia. CONCLUSIONS The CEL gene polymorphism, especially an increase in the frequency of the L allele, was found to be associated with alcohol-induced pancreatitis.
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Affiliation(s)
- Kyoko Miyasaka
- Department of Clinical Physiology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.
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Abstract
BACKGROUND A high alcohol intake is significantly associated with diseases of the gastrointestinal tract, but less is known about the effects of moderate consumption, specifically moderate average volume of alcohol consumption. METHODS A systematic computer-assisted literature review was completed in order to review current scientific knowledge surrounding this topic. RESULTS Moderate alcohol consumption is associated with a number of gastrointestinal health risks, including liver diseases, oropharyngeal cancer, esophageal cancer and pancreatitis but may play a positive role in gastritis and cholelithiasis. CONCLUSION Moderate alcohol consumption may play a positive or negative role in disease etiology, but the overall conclusion is that moderate alcohol intake is not a high risk factor for many of the gastrointestinal diseases associated with high levels of consumption. The etiology of alcohol diseases is also linked to patterns of drinking, so this is an important area for future research in this area.
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Affiliation(s)
- Benjamin Taylor
- Centre for Addiction and Mental Health, Toronto, Ont., Canada.
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40
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Abstract
A history of excessive alcohol consumption is found in the majority of patients with chronic pancreatitis, and numerous research efforts revealed insights into the pathogenesis of alcohol-induced pancreatic damage. However, the exact mechanisms underlying the disease are not yet clarified, and the origin of alcoholic chronic pancreatitis continues to be the topic of speculation and investigation. This article provides an overview about the epidemiology of alcoholic chronic pancreatitis, the epidemiologic association of alcohol intake and pancreatitis and the clinical course of the disease. Finally, this article summarizes several hypothetical concepts that try to explain the early and late pathophysiological mechanisms of acute and chronic pancreatitis.
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Affiliation(s)
- Alexander Schneider
- Department of Medicine II (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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Nemoda Z, Teich N, Hugenberg C, Sahin-Tóth M. Genetic and biochemical characterization of the E32del polymorphism in human mesotrypsinogen. Pancreatology 2005; 5:273-8. [PMID: 15855826 PMCID: PMC1401494 DOI: 10.1159/000085282] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [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: 09/21/2004] [Accepted: 11/02/2004] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Mesotrypsin is a minor pancreatic digestive enzyme that degrades dietary trypsin inhibitors in the gut. In this study, we tested the hypothesis that the E32del genetic variant of mesotrypsin might represent a risk factor for the development of chronic pancreatitis, as a result of enhanced degradation of pancreatic secretory trypsin inhibitor. METHODS We screened 97 German patients with chronic pancreatitis of alcoholic etiology and 109 healthy controls for the presence of the E32del variant and characterized the biochemical properties of E32del mesotrypsinogen. RESULTS Higher allele frequency of the E32del variant was detected in the control population (25.7 vs. 18.0%), but the difference was not significant (p = 0.062). Recombinant E32del mesotrypsin exhibited normal catalytic activity, characteristic inhibitor resistance and inability to activate pancreatic zymogens. Degradation of trypsin inhibitors was unaffected by the E32del genotype. Interestingly, mesotrypsinogen-E32del was biochemically distinguishable from mesotrypsinogen by its faster activation with bovine enterokinase, while activation by human enterokinase, trypsin or cathepsin B was unchanged. CONCLUSION The results classify E32del mesotrypsinogen as a frequent polymorphic variant, which is not associated with chronic alcoholic pancreatitis.
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Affiliation(s)
- Zsófia Nemoda
- Department of Molecular and Cell Biology, Boston University Goldman School of Dental Medicine, Boston, MA 02118
| | - Niels Teich
- Medizinische Klinik und Poliklinik II, Universität Leipzig, Leipzig, Germany
| | - Christin Hugenberg
- Medizinische Klinik und Poliklinik II, Universität Leipzig, Leipzig, Germany
| | - Miklós Sahin-Tóth
- Department of Molecular and Cell Biology, Boston University Goldman School of Dental Medicine, Boston, MA 02118
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Abstract
OBJECTIVE Many studies have been published on acute pancreatitis but few, if any, on extrapancreatic manifestations (EPM) in African Americans and Hispanics. We studied the effect of EPM on mortality in these 2 ethnic groups. METHODS Records of 760 acute pancreatitis patients (417 African-American and 343 Hispanic), ages 19-85 years, over a 15-year period were reviewed retrospectively. Data were analyzed for EPM and mortality. RESULTS Of the 760 patients, alcohol use was identified as the etiology in 53% of cases and gallstones in 42%. EPM were present in 148 patients (19.5%). Gastrointestinal bleeding (22%) was the most common EPM. Patients with EPM did not differ from patients without EPM on demographics or acute pancreatitis-related variables (P > 0.05). Patients with EPM had higher odds of having comorbidity relative to patients without EPM (OR = 2.9, CI = 2.0-4.2). Of 760 patients, 109 died (14%). However, mortality was significantly higher (26%) in patients with EPM in comparison to those without EPM (11%), P = 0.001. Controlling for other variables, patients with EPM had higher odds of mortality relative to patients without EPM (OR = 2.8, CI = 1.7-4.4). CONCLUSION Mortality was high in our patients compared with the literature (5%-10%). EPM increased the mortality significantly (26%).
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Affiliation(s)
- Abbasi J Akhtar
- Division of Gastroenterology, Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
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Li YQ, Gao YJ, Huang LY, Li SL, Zeng XZ, Wang Q, Wang FX, Yuan SA, Liu CA, Li GQ, Ma J. [The clinical features of acute pancreatitis in 10 cities in Shandong Province]. Zhonghua Nei Ke Za Zhi 2004; 43:672-4. [PMID: 15500780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To investigate and obtain a more comprehensive view of the etiology and clinical features of acute pancreatitis (AP) in Shandong Province. METHODS 1471 cases admitted to hospital for AP were studied and collected from the ten cities of Shandong Province from January 1992 to December 2002 retrospectively. Data of each enrolled patient was recorded in a standardized form. RESULTS In the 1471 patients, the ratio of male: female was 854:617, and also the mean age of them and the range was 43.3 and from 13 - 82 years old. 1280 had mild AP, and 191 had sever AP. Cholelithiasis (20.2%), alcohol (17.3%) and diet-induced (12.4%) were the most frequent etiologic factors, followed by biliary tract infections (5.6%), hyperlipemia (2.3%), other factors (5.1%). But in about 36.1% cases, the etiology of AP still remains unexplained. In coastal regions, cholelithiasis is the most frequent factor but in interior regions alcohol ranked first. In male, a small predominance of alcohol over cholelithiasis was seen (27.4 vs.14.3%, P < 0.01); and in female, there was a clear predominance of cholelithiasis over alcohol (28.4 vs. 3.2%, P < 0.01). The complications of AP were pancreatic pseudocyst, ascites and peritonitis, pulmonary infections, multiple organ failure, diabetes mellitus-2 and shock, etc. according to their frequencies. CONCLUSIONS Cholelithiasis, alcohol and diet-induced factor were main etiologic factors in Shandong Province, whereas cholelithiasis alone predominated in the females. In about 36.1% cases, the etiology remains unknown. So that more attention should be paid to study the etiology of AP.
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Affiliation(s)
- Yan-qing Li
- Department of Digestive Medicine, Qi Lu Hospital, Shandong University, Jinan 250012, China.
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Nakamura Y, Kobayashi Y, Ishikawa A, Maruyama K, Higuchi S. Severe chronic pancreatitis and severe liver cirrhosis have different frequencies and are independent risk factors in male Japanese alcoholics. J Gastroenterol 2004; 39:879-87. [PMID: 15565408 DOI: 10.1007/s00535-004-1405-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2003] [Accepted: 02/27/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chronic pancreatitis and liver cirrhosis are major alcohol-related diseases in most countries. Neither their specific etiologies nor the relationship between them is fully understood. This study was designed to examine a possible association between alcoholic chronic pancreatitis (ACP) and alcoholic liver cirrhosis (ALC), and to identify factors relating to them. METHODS The subjects were 141 consenting participants from 1087 male patients consecutively admitted to Kurihama National Hospital from July 2000 to November 2002. All were negative for major medical disorders (e.g., viral hepatitis, operative history, malignancy), except for ACP and ALC. Analysis of each subject included background information (collected by face-to-face interview, regarding quantity and duration of drinking, usual alcoholic drinks, smoking, education, employment, and marital status) and signs of ACP detected on endoscopic retrograde cholangiopancreatography (ERCP) and ALC indicated by Child-Pugh classification. Subjects consenting to genome analyses ( n = 83) were genotyped for two key alcohol-metabolizing enzymes: alcohol dehydrogenase-2 and aldehyde dehydrogenase-2. RESULTS Grouping patients by ERCP grading and Child classification revealed a nonparallel relationship between the severities of the two diseases. This relationship held, even after controlling for several pertinent background variables (sociofamilial, drinking, clinical, and genetic factors) by logistic regression analysis. The drinking of spirits and a high daily consumption of alcohol were independent risk factors for ACP, while never-married status was the only risk factor identified with ALC among these male Japanese patients. CONCLUSIONS Different risk factors may confer susceptibility to ACP versus ALC, which may explain the nonparallel relationship between the severities of the two diseases in Japanese alcoholics.
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Affiliation(s)
- Yuji Nakamura
- National Alcoholism Center, Kurihama National Hospital, 5-3-1 Nobi, 239-0841 Yokosuka, Japan
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Tao N, Sussman S, Nieto J, Tsukamoto H, Yuan JM. Demographic characteristics of hospitalized patients with alcoholic liver disease and pancreatitis in los angeles county. Alcohol Clin Exp Res 2004; 27:1798-804. [PMID: 14634496 DOI: 10.1097/01.alc.0000095862.30777.d9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study sought to identify demographic characteristics of hospitalized patients with alcoholic liver disease (ALD) in Los Angeles County for the purpose of implementing new preventive and educational programs. Another specific aim of the study was to characterize demographic and comorbid differences between patients with ALD and patients with pancreatitis, another alcohol-related disease. METHODS Analyses were performed on discharge data from all nonfederal short-stay hospitals within Los Angeles County, released for the year 1999 by the Office of Statewide Health Planning and Development. Repeated hospital stays for ALD by the same patients were deleted from the data analysis based on individual identification numbers. For the analysis of medical costs of ALD, repeated hospital stays were included. RESULTS Primary diagnosis of ALD accounted for 1.2% of total deaths among hospitalized patients and was the eighth most common cause of death among diseases examined. Moreover, the fatality rate of primary ALD among ALD hospital visits was the second highest, behind septicemia. ALD was most prevalent in the middle-aged (45-65 years old) and low- to middle-income men. The age-standardized hospitalization rate of ALD was highest in Hispanic men (61.1 per 100,000 per year), whereas that of chronic pancreatitis, another common complication of alcohol abuse, was most prevalent in African American men. CONCLUSIONS Middle-aged Hispanic men with low- to middle-income status were identified as a high-risk group for ALD in Los Angeles County. These data will guide us to develop a new strategy for future preventative and educational programs for ALD.
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Affiliation(s)
- Nico Tao
- Department of Pathology, University of Southern California/University of California-Los Angeles Research Center for Alcoholic Liver and Pancreatic Diseases, 90033, USA
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Kroch S, Kamenczak A, Chrostek Maj J, Polewka A. [Somatic and psychiatric disorders in alcohol-addicted patients treated in a detoxification unit]. Przegl Lek 2004; 61:300-2. [PMID: 15521587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The aim of the presented study was the assessment of somatic and psychiatric disorders in alcohol addicted patients, treated in the Department of Clinical Toxicology detoxification unit in Kraków in 2002 year. The total number of 443 patients (377 men and 66 women) were considered for the research. More than 50% patients were hospitalized repeatedly (2 or more times) due to alcohol problems. Medical history as well as detail medical examination and diagnostic evaluation revealed the concomitance with alcohol disease different somatic illnesses and psychiatric disorders. In 194 patients (43.8%) the alcoholic liver damage was diagnosed, frequently (in 5.2% patients) with chronic pancreatitis. Only 22 patients (5%) were infected with hepatitis virus type B. Diabetes type 2 and different cardiovascular disorders were present in almost one third of patients. In the past 55 patients (12.4%) have had severe head trauma, and 51 (11.3%) were treated because multiorgan trauma. Psychiatric examination revealed in 102 patients (23%) affective disorders, and in 92 (20.7%) personality disturbances. The presented data should be a ground for discussion about treatment model alcohol dependency in Poland.
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Affiliation(s)
- Stanisław Kroch
- Klinika Toksykologii KMPiChS, Collegium Medicum, Uniwersytetu Jagiellońskiego w Krakowie
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Abstract
Although the association between alcohol and pancreatitis has been recognized for centuries, the precise magnitude of the impact of alcohol remains poorly quantified. Epidemiologic research on this condition has been seriously handicapped by several factors. Classifications are based on morphology rather than on etiology; the diagnostic differences between acute and chronic pancreatitis are imprecise and confusing; and coding by the International Classification of Diseases (ICD) has been inadequate. The current ICD (ICD-10), used in the United States since 1999, identifies alcohol-induced chronic pancreatitis as a separate code for the first time, an enhancement that will greatly improve the quality of data collected in current and future studies. Unfortunately, no code yet exists for acute alcoholic pancreatitis. Of the approximately 2.4 million deaths in the United States in 1999, pancreatitis was listed as the underlying cause for 3289 deaths, making it the 235th leading cause of death. Acute pancreatitis accounted for 84% of these deaths, and chronic pancreatitis the remaining 16%. Alcohol is a primary cause of both acute and chronic pancreatitis in most developed countries. About one-third of acute pancreatitis in the United States is alcohol-induced. In the United States and other developed countries, 60%-90% of chronic pancreatitis is alcohol induced. Both forms are more common in men. The development of chronic pancreatitis is proportional to the dose and duration of alcohol consumption (minimum, 6-12 years of approximately 80 g of alcohol per day). Autopsy studies reveal subclinical chronic pancreatitis in another 10% of alcohol abusers. Yet, since <10% of chronic alcoholics develop chronic pancreatitis, clearly other predisposing factors besides alcohol are involved. Genetic variability and environmental exposures, such as diet, are prime candidates for further investigation. To date, there have been few large epidemiological studies of alcoholic pancreatitis in the United States or other developed countries. Additional studies are needed to improve the quality of existing baseline epidemiologic data and allow better assessment of risk. Improved diagnostic precision, more complete and specific coding, and greater understanding of covariables and mechanisms would also advance the field.
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Affiliation(s)
- Mary C Dufour
- Division of Biometry and Epidemiology, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland 20892-7003, USA
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Schneider A. Short note about a symposium on alcoholic pancreatitis. Pancreatology 2003; 3:75-6. [PMID: 12649569 DOI: 10.1159/000069151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- A Schneider
- Department of Medicine II (Gastroenterology, Hepatology and Infectious Diseases), University Hospital of Heidelberg at Mannheim, Germany.
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50
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Abstract
BACKGROUND Alcohol is the most common cause of acute pancreatitis in Finland (70%). The amount of alcohol consumed has been shown to be associated with the prevalence of pancreatitis in the country, and also to be an important determinant of the severity of the first episode of acute alcoholic pancreatitis. We have a clinical suspicion that the use of alcohol and the incidence of pancreatitis are increased during holiday periods in summer, although no seasonal variations have been reported in a German population. METHODS Between 1972 and 1992 a total of 1556 episodes with acute alcoholic pancreatitis were treated at Tampere University Hospital; 552 were first episodes and 1004 were recurrent. For comparison, we investigated 297 episodes of acute biliary pancreatitis treated in that same time period. We investigated the monthly prevalence of acute alcoholic (first and recurrent) pancreatitis and compared this with the monthly absolute alcohol consumption. RESULTS Taking all alcoholic pancreatitis episodes into account, significant differences can be seen between prevalence and month of onset of the disease (P < 0.0001), whereas among biliary pancreatitis episodes there were no differences (P = 0.3). Prevalence of acute alcoholic pancreatitis was significantly higher than the expected prevalence in July and August, and the amount of alcohol consumption (100% alcohol, litres) was highest during these same months. Also during March, October and December the prevalence was higher than expected. CONCLUSION Months with holiday seasons, Christmas, Easter, summer and autumn, are associated with the highest alcohol consumption and the highest prevalence of acute alcoholic pancreatitis.
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Affiliation(s)
- S Räty
- Dept. of Surgery, Tampere University Hospital, Tampere, Finland.
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