Polymorphisms at PRSS1-PRSS2 and CLDN2-MORC4 loci associate with alcoholic and non-alcoholic chronic pancreatitis in a European replication study

OBJECTIVE

Several genetic risk factors have been identified for non-alcoholic chronic pancreatitis (NACP). A genome-wide association study reported an association of chronic pancreatitis (CP) with variants in PRSS1-PRSS2 (rs10273639; near the gene encoding cationic trypsinogen) and CLDN2-MORC4 loci (rs7057398 in RIPPLY1 and rs12688220 in MORC4). We aimed to refine these findings in a large European cohort.

DESIGN

We studied 3062 patients with alcohol-related CP (ACP) or NACP and 5107 controls. Also, 1559 German patients with alcohol-associated cirrhosis or alcohol dependence were included for comparison. We performed several meta-analyses to examine genotype-phenotype relationships.

RESULTS

Association with ACP was found for rs10273639 (OR, 0.63; 95% CI 0.55 to 0.72). ACP was also associated with variants rs7057398 and rs12688220 in men (OR, 2.26; 95% CI 1.94 to 2.63 and OR, 2.66; 95% CI 2.21 to 3.21, respectively) and in women (OR, 1.57; 95% CI 1.14 to 2.18 and OR 1.71; 95% CI 1.41 to 2.07, respectively). Similar results were obtained when German patients with ACP were compared with those with alcohol-associated cirrhosis or alcohol dependence. In the overall population of patients with NACP, association with rs10273639 was absent (OR, 0.93; 95% CI 0.79 to 1.01), whereas rs7057398 of the X chromosomal single nucleotide polymorphisms was associated with NACP in women only (OR, 1.32; 95% CI 1.15 to 1.51).

CONCLUSIONS

The single-nucleotide polymorphisms rs10273639 at the PRSS1-PRSS2 locus and rs7057398 and rs12688220 at the CLDN2-MORC4 locus are associated with CP and strongly associate with ACP, but only rs7057398 with NACP in female patients.

Change of Both Endocrine and Exocrine Insufficiencies After Acute Pancreatitis in Non-Diabetic Patients: A Nationwide Population-Based Study

Acute pancreatitis (AP) is the most common pancreatic disease and consists of an acute inflammation of the pancreas. AP can contribute to endocrine and exocrine insufficiencies in survivors as a result of the key role of the pancreas in both glucose metabolism and nutritional digestion. The aim of this population-based study was to determine the endocrine or exocrine insufficiencies in patients after initial AP with biliary or alcohol-associated causes.We conducted a nationwide cohort study using data from Taiwan's National Health Insurance Research Database collected between 2001 and 2010. A total of 12,284 patients with AP were identified.Alcohol-associated AP (odds ratio, 1.894; 95% CI, 1.520-2.268; P < 0.001) and ≥2 admissions for AP (odds ratio, 1.937; 95% CI, 1.483-2.391; P < 0.001) were significantly associated with newly diagnosed diabetes mellitus after AP. Further, only alcohol-associated AP (odds ratio, 1.215; 95% CI, 1.133-1.297; P < 0.001) was significantly associated with pancreatic exocrine insufficiency after AP. Additionally, alcohol-associated AP (odds ratio, 1.804; 95% CI, 1.345-2.263; P < 0.001) and ≥2 readmissions for AP (odds ratio, 3.190; 95% CI, 2.317-4.063; P < 0.001) were significantly associated with both exocrine and endocrine insufficiencies after AP.Our data showed that alcohol-associated AP, rather than a biliary cause, contributed to a higher extent to exocrine or endocrine insufficiencies. Furthermore, recurrent AP also led to endocrine insufficiency.

Pharmacological attenuation of chronic alcoholic pancreatitis induced hypersensitivity in rats

AIM

To characterize an alcohol and high fat diet induced chronic pancreatitis rat model that mimics poor human dietary choices.

METHODS

Experimental rats were fed a modified Lieber-DeCarli alcohol (6%) and high-fat (65%) diet (AHF) for 10 wk while control animals received a regular rodent chow diet. Weekly behavioral tests determined mechanical and heat sensitivity. In week 10 a fasting glucose tolerance test was performed, measuring blood glucose levels before and after a 2 g/kg bodyweight intraperitoneal (i.p.) injection of glucose. Post mortem histological analysis was performed by staining pancreas and liver tissue sections with hematoxylin and eosin. Pancreas sections were also stained with Sirius red and fast green to quantify collagen content. Insulin-expressing cells were identified immunohistochemically in separate sections. Tissue staining density was quantified using Image J software. After mechanical and heat sensitivity became stable (weeks 6-10) in the AHF-fed animals, three different drugs were tested for their efficacy in attenuating pancreatitis associated hypersensitivity: a Group II metabotropic glutamate receptor specific agonist (2R,4R)-4-Aminopyrrolidine-2,4-dicarboxylate (APDC, 3 mg/kg, ip; Tocris, Bristol, United Kingdom), nociceptin (20, 60, 200 nmol/kg, ip; Tocris), and morphine sulfate (3 mg/kg, μ-opioid receptor agonist; Baxter Healthcare, Deerfield, IL, United States).

RESULTS

Histological analysis of pancreas and liver determined that unlike control rats, AHF fed animals had pancreatic fibrosis, acinar and beta cell atrophy, with steatosis in both organs. Fat vacuolization was significantly increased in AHF fed rats (6.4% ± 1.1% in controls vs 23.8% ± 4.2%, P < 0.05). Rats fed the AHF diet had reduced fasting glucose tolerance in week 10 when peak blood glucose levels reached significantly higher concentrations than controls (127.4 ± 9.2 mg/dL in controls vs 161.0 ± 8.6 mg/dL, P < 0.05). This concurred with a 3.5 fold higher incidence of single and small 2-10 cell insulin-positive cell clusters (P < 0.05). Insulin expressing islet of Langerhans cells appeared hypertrophied while islet number and area measurements were not different from controls. Weekly behavioral tests determined that mechanical and heat sensitivities were significantly increased by 4 wk on AHF diet compared to controls. Hypersensitivity was attenuated with efficacy similar to morphine with single dose treatment of either metabotropic glutamate receptor 2/3 agonist APDC, or nociceptin, the endogenous ligand for opioid-receptor-like 1 receptor.

CONCLUSION

The AHF diet induces a chronic alcoholic pancreatitis in rats with measurable features resembling clinical patients with chronic pancreatitis and type 3c diabetes mellitus.

Short- and long-term results of modified Frey's procedure in patients with chronic pancreatitis: a retrospective Japanese single-center study

BACKGROUND

The study aim was to determine the short- and long-term results of surgical drainage procedure for chronic pancreatitis at a single center in Japan.

METHODS

The records of 28 consecutive patients were retrospectively reviewed. All patients underwent surgery at Kobe University Hospital between June 1999 and April 2013. Long-term follow-up was performed in all patients for a median period of 77 months.

RESULTS

The 26 men (93%) and 2 women (7%) had a mean age of 47 years. The etiology of pancreatitis was chronic alcohol abuse in 24 patients (86%). The major indication for surgery was persistent symptoms (97%). Modified Frey's procedure in 21 patients, lateral pancreaticojejunostomy (LPJ) in 6 patients, LPJ and distal pancreatectomy in one patient, were performed. There was no postoperative mortality. Postoperative morbidity occurred in 6 patients (21%). The percentage of pain-free patients after surgery was 97%, and further acute exacerbation was prevented in 97%. Two patients (6%) required subsequent surgery for infectious pancreatic cyst and intraabdominal abscess. Of the patients that completed follow-up, 13 (46%) had diabetes mellitus, including 5 patients (19%) with new-onset diabetes, and 6 patients (19%) developed pancreatic exocrine insufficiency.

CONCLUSIONS

Modified Frey's procedure is safe, feasible, and effective to manage chronic pancreatitis. The technique prevents further exacerbations and maintains appropriate pancreatic endocrine and exocrine function.

Recent advances in the epidemiology of alcoholic pancreatitis

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.

Determinants of accelerated small intestinal transit in alcohol-related chronic pancreatitis

Patients with chronic pancreatitis may have abnormal gastrointestinal transit, but the factors underlying these abnormalities are poorly understood. Gastrointestinal transit was assessed, in 40 male outpatients with alcohol-related chronic pancreatitis and 18 controls, by scintigraphy after a liquid meal labeled with (99m)technetium-phytate. Blood and urinary glucose, fecal fat excretion, nutritional status, and cardiovascular autonomic function were determined in all patients. The influence of diabetes mellitus, malabsorption, malnutrition, and autonomic neuropathy on abnormal gastrointestinal transit was assessed by univariate analysis and Bayesian multiple regression analysis. Accelerated gastrointestinal transit was found in 11 patients who showed abnormally rapid arrival of the meal marker to the cecum. Univariate and Bayesian analysis showed that diabetes mellitus and autonomic neuropathy had significant influences on rapid transit, which was not associated with either malabsorption or malnutrition. In conclusion, rapid gastrointestinal transit in patients with alcohol-related chronic pancreatitis is related to diabetes mellitus and autonomic neuropathy.

[Natural history of alcoholic chronic pancreatitis in north-western Romania]

AIM

To describe the natural history of alcoholic chronic pancreatitis (ACP) patients form north-western Romania.

METHODS

We performed a retrospective analysis and a subsequent prospective follow-up (mean = 7.3 years) of 99 patients with ACP. Average duration of ACP was 15.6 years.

RESULTS

Patients were mostly men (93%), with a mean age of 42.9 years at the time of operation and 35.7 years at the disease onset. Indications for surgery were: intractable pain (12%), complications (83%) and suspicion of malignancy (5%). During the evolution, 35 patients needed two to four surgical procedures. Calcifications developed in 63.6% of patients, steatorrhea in 41.4% and secondary diabetes in 43.4%.

CONCLUSION

ACP in north-western Romania is characterized by early onset of the disease and a severe evolution with multiple complications needing repeated surgery. The "burnout" of the disease, with calcifications, secondary diabetes and marked exocrine insufficiency leads to lasting pain relief.

Factors associated with abnormal gastric emptying in alcohol-related chronic pancreatitis

BACKGROUND

Patients with alcohol-related chronic pancreatitis (ARCP) may present with abnormal gastric emptying (GE), which has been ascribed mainly to nutrient maldigestion. Nevertheless, many patients also have diabetes with autonomic dysfunction and malnutrition and the role of these factors on abnormal GE has not been investigated.

GOALS

To determine the influences of malabsorption, diabetes, malnutrition, and autonomic dysfunction on GE abnormalities in patients with ARCP.

STUDY

Forty ARCP outpatients and 18 healthy controls were studied. GE was measured by scintigraphy after a standard, liquid, nutrient meal labeled with Technetium-phytate. Autonomic function was evaluated by cardiovascular tests. The influence of each factor on abnormal GE was assessed by Bayesian multiple regression analysis.

RESULTS

In the ARCP group, GE was abnormal in 19 patients (47.5%), who showed either accelerated (N=12) or delayed emptying (N=7). Diabetes was highly prevalent (P<0.01) in ARCP patients with either rapid or delayed GE (18/19). Multiple regression analysis showed that not only diabetes, but also autonomic dysfunction has significant effects on abnormal GE, whereas malabsorption and malnutrition seemed not to be associated to abnormal emptying.

CONCLUSIONS

A substantial proportion of patients with ARCP may have abnormal GE. Either delayed or accelerated GE seem to be related to underlying diabetes mellitus and autonomic neuropathy rather than to nutrient malabsorption and malnutrition.

Activated perilobular, not periacinar, pancreatic stellate cells contribute to fibrogenesis in chronic alcoholic pancreatitis

The authors investigated the role of activated perilobular, not periacinar, pancreatic stellate cells, in fibrogenesis in chronic pancreatitis, based on the distribution of myofibroblasts. Twenty-four patients with clinically diagnosed chronic alcoholic pancreatitis were studied histopathologically, immunohistochemically and quantitatively. In all cases, fibrosis was patchily distributed in the perilobular, or interlobular, areas, accompanied by a cirrhosis-like appearance; it had extended into the intralobular area in advanced cases. Seven patients had a massive or confluent loss of exocrine tissue, resulting in extensive interlobular fibrosis; the more extensive the interlobular fibrosis, the smaller the lobules. Immunoreactivity to alpha-smooth muscle actin, a myofibroblast marker, was found mostly in the same areas of the fibrosis, mainly the interlobular, and less often the periacinar, areas; the average percentage area of perilobular myofibroblasts was significantly higher than that of periacinar myofibroblasts in 20 randomly selected lobules (P > 0.001), in which the average value for the former was 38.03% (range: 13.54-61.32%; SD, 13.8%) and that for the latter was 4.85% (range 0.90-9.57%; SD, 2.22%). Fibrosis also immunostained positive for collagen types I and III. In conclusion, activated perilobular, not periacinar, pancreatic stellate cell contribute to fibrogenesis in chronic pancreatitis.

Role of alcohol metabolism in chronic pancreatitis

Alcohol abuse is the major cause of chronic inflammation of the pancreas (i.e., chronic pancreatitis). Although it has long been thought that alcoholic pancreatitis is a chronic disease from the outset, evidence is accumulating to indicate that chronic damage in the pancreas may result from repeated attacks of acute tissue inflammation and death (i.e., necroinflammation). Initially, research into the pathogenesis of alcoholic pancreatitis was related to ductular and sphincteric abnormalities. In recent years, the focus has shifted to the type of pancreas cell that produces digestive juices (i.e., acinar cell). Alcohol now is known to exert a number of toxic effects on acinar cells. Notably, acinar cells have been shown to metabolize alcohol (i.e., ethanol) via both oxidative (i.e., involving oxygen) and nonoxidative pathways. The isolation and study of pancreatic stellate cells (PSCs)-the key effectors in the development of connective tissue fibers (i.e., fibrogenesis) in the pancreas-has greatly enhanced our understanding of the pathogenesis of chronic pancreatitis. Pancreatic stellate cells become activated in response to ethanol and acetaldehyde, a toxic byproduct of alcohol metabolism. In addition, PSCs have the capacity to metabolize alcohol via alcohol dehydrogenase (the major oxidizing enzyme for ethanol). The fact that only a small percentage of heavy alcoholics develop chronic pancreatitis has led to the search for precipitating factors of the disease. Several studies have investigated whether variations in ethanol-metabolizing enzymes may be a trigger factor for chronic pancreatitis, but no definite relationship has been established so far.

Pathophysiology of alcoholic pancreatitis: an overview

Use of alcohol is a worldwide habit regardless of socio-economic background. Heavy alcohol consumption is a potential risk factor for induction of pancreatitis. The current review cites the updated literature on the alcohol metabolism, its effects on gastrointestinal and pancreatic function and in causing pancreatic injury, genetic predisposition of alcohol induced pancreatitis. Reports describing prospective mechanisms of action of alcohol activating the signal transduction pathways, induction of oxidative stress parameters through the development of animal models are being presented.

Chronic pancreatitis of alcoholic and nonalcoholic origin

Fibroinflammatory changes to the pancreatic tissue characterize chronic pancreatitis. This article summarizes the current state of knowledge on the pathology and pathogenesis of chronic pancreatitis associated with alcohol, hereditary factors, metabolic conditions, and anatomical abnormalities. Specifically, the pathogenetic mechanisms that lead to chronic pancreatitis in patients with alcohol abuse will be discussed. In addition, brief descriptions of the features of chronic pancreatitis of nonalcoholic origin and of the pancreatic fibrosis that is not associated with symptoms of chronic pancreatitis will be given.

Determination of plasma trypsin-like activity in healthy subjects, patients with mild to moderate alcoholic chronic pancreatitis, and patients with nonjaundice pancreatic cancer

Trypsin-like activity is released after stimulation of the exocrine pancreas. We investigated under basal conditions and after stimulation by a meal whether patients suffering from pancreatic disorders differ with respect to plasma trypsin-like activity (PTLA). In 45 subjects (healthy volunteers: n = 18, mild/moderate alcoholic chronic pancreatitis: n = 16, nonjaundice pancreatic cancer n = 7, and calcifying chronic pancreatitis: n = 4), basal and postprandial levels of PTLA were measured over a period of 2 hours. Basal plasma levels were similar in the first 3 groups. After stimulation, healthy volunteers and patients with pancreatic cancer showed significant decreases in trypsin-like activity; however, plasma levels did not decrease in patients with mild/moderate chronic pancreatitis (P < .001). Healthy individuals demonstrate a consistent decrease in postprandial trypsin-like plasma activity. This response is not altered in patients with pancreatic cancer, and it is not seen in patients with mild/moderate alcoholic chronic pancreatitis.

Genetic polymorphisms in alcoholic pancreatitis

BACKGROUND

Chronic, excessive alcohol consumption is clearly associated with acute and chronic pancreatitis. However, both clinical and laboratory studies demonstrate that alcohol consumption alone does not directly cause alcoholic chronic pancreatitis. Growing evidence suggests that environmental and possibly genetic cofactors must also be present to overcome the redundant mechanisms protecting the pancreas from pancreatitis and facilitating complete recovery.

METHODS

The SAPE hypothesis model was used to organize potential triggering factors, susceptibility factors and disease-modifying factors based on insights from animal studies. A systematic review of genetic studies on alcoholic pancreatitis was conducted and the results were analyzed in the context of animal studies.

RESULTS

To date, no major genetic cofactors for susceptibility or progression have been identified in approximately 90% of cases of human alcoholic chronic pancreatitis. Mutations have been identified in the pancreatic secretory trypsin inhibitor gene (SPINK1) in about 8% of cases, and an excess in cystic fibrosis transmembrane conductance inhibitor (CFTR) gene variants have been reported, but the details of the complex genetics with CFTR have not been clarified. None of the polymorphisms in alcohol-metabolizing genes or detoxifying genes appear to explain pancreatic susceptibility.

CONCLUSIONS

New, adequately powered genetic studies are needed. Several major genetic epidemiology studies are underway in both Europe and the United States to help determine why only a subset of alcoholics develop alcoholic chronic pancreatitis.

Alcoholic pancreatitis

Without doubt, alcohol consumption is one of the most important considerations in adults with acute or chronic pancreatitis. Understanding chronic pancreatitis as a complex disorder in which complimentary factors are required for recurrent acute and late chronic pancreatitis to develop in subsets of patients is critical for the early diagnosis and management of these individuals. Recent pathophysiological and genetic findings represent the beginning of major diagnostic and treatment breakthroughs that are likely to continue for the foreseeable future. The information provided in this article should provide the physician with a fresh perspective and remind the clinician of the importance of an accurate and complete history, and the need to document the actual alcohol consumption, pattern of drinking, and raise appropriate concerns if signs of alcoholism are detected. If alcohol-associated pancreatitis is detected, then limitation of pancreatic damage, limitation of progression, or preventative intervention should become the major concern.

Theories, mechanisms, and models of alcoholic chronic pancreatitis

Alcoholic chronic pancreatitis is a severe, disabling, chronic inflammatory condition of the pancreas that is seen in fewer than 5% of alcoholics. The severity and unpredictability of this condition has lead to several theories on the mechanism causing chronic pancreatitis based on careful clinical observation. Hypothetical mechanisms were applied to various animal models. Finally, following multiple lines of evidence, there is a convergence of thought and development of some new models that are quite instructive. Taken together, chronic alcohol consumption by rats results in multiple effects on the pancreas that increase the risk of acute pancreatitis, including ongoing acinar cell injury that lowers the threshold for hyperstimulation-induced acute pancreatitis, neurohormonal injury, and adaptation that results in acinar cell hyperstimulation, increased susceptibility to viral mediated acute pancreatitis, and possibly other factors. After acute pancreatitis initiates the inflammatory process, the chronic inflammation and fibrosis of alcoholic chronic pancreatitis are driven by diet, the acinar cell stress response to continued alcohol that may be potentiated by toxic alcohol metabolites, hypoxia, hyperstimulation, and partial duct obstruction; plus the effects of proinflammatory immunocytes and cytokines; and by stellate cell-mediated fibrosis driven by anti-inflammatory cytokines, alcohol, and alcohol metabolites. The factors determining which alcoholic will develop alcoholic chronic pancreatitis likely involve genetic factors, dietary factors, and susceptibility to pancreatic injury through several mechanisms ranging from trauma to gallstones to viruses.

Fat malabsorption screening in chronic pancreatitis

OBJECTIVES

As the major metabolic complications of chronic pancreatitis are exocrine and endocrine dysfunction, leading to malabsorption and diabetes, the aims of this study were to screen patients with chronic pancreatitis for exocrine dysfunction, to correlate the prevalence of such dysfunction with the etiology and severity of pancreatitis, and to evaluate the effect of dysfunction on weight loss.

METHODS

Sixty patients were studied. In 44 patients, pancreatitis was alcoholic, and in 16, idiopathic. Patients' age, sex, alcohol consumption and smoking habits, duration of the disease, body mass index, and the presence of steatorrhea were recorded. The severity of pancreatitis was assessed by imaging procedures, including secretin-enhanced magnetic resonance cholangiopancreatography, and patients were classified according to the Cambridge system. Exocrine function was evaluated by the triolein breath test and acid steatocrit.

RESULTS

A significant positive correlation was found between breath test and steatocrit values. As a screening test for exocrine pancreatic dysfunction, the sensitivity of clinical steatorrhea was insufficient (38%). Of the 60 patients, 38 (63%) developed exocrine dysfunction within 5 yr of the onset of the pancreatitis and 56 (94%) after 10 yr. Moreover, undetected or untreated malabsorption had a harmful effect on weight, even in the absence of overt clinical steatorrhea.

CONCLUSIONS

To avoid nutritional deterioration, early screening for fat malabsorption should be recommended in chronic pancreatitis, whatever its etiology, using the acid steatocrit, a reliable, easy, and inexpensive test.

Clinical features of patients with chronic pancreatitis complicated by bile duct strictures

BACKGROUND/AIMS

Distal bile duct stenosis is relatively rare in patients with non-alcoholic chronic pancreatitis.

METHODOLOGY

The clinical features of eight patients who had chronic pancreatitis complicated by bile duct strictures who underwent surgical treatments were reviewed.

RESULTS

Ages ranged from 38 to 80 years, with a mean of 53.4 years. All but one patient were male. Six patients had moderate or slight epigastric pain. Five patients had obstructive jaundice and underwent biliary drainage. All patients had liver dysfunction due to biliary obstruction. Although four of the eight patients were heavy or moderate drinkers, none of the patients had a history of chronic pancreatitis. Stricture shapes of the common bile ducts were smooth and tapering in five patients, funnel-shaped in two, and rat-tail in one. Four patients underwent a pancreatoduodenectomy and one patient underwent a pylorus-preserving pancreatoduodenectomy for clinically suspected pancreatic malignancy that was later proven histopathologically to be chronic pancreatitis. The other three patients underwent a choledochoduodenostomy. There were no postoperative complications or deaths. During the follow-up period, all patients were asymptomatic.

CONCLUSIONS

In conclusion, bile duct stricture potentially occurs not only in patients with alcoholic chronic pancreatitis but also in patients with nonalcoholic chronic pancreatitis. Furthermore, in some cases, it is impossible to differentiate chronic pancreatitis from pancreatic or periampullary malignancy.

Ethanol consumption potentiates viral pancreatitis and may inhibit pancreas regeneration: preliminary findings

Alcohol abuse is often associated with acute pancreatitis. The pathogenesis of alcoholic pancreatitis remains poorly understood, in part because of the lack of a suitable animal model to study the mechanism or mechanisms of this disease. It has been proposed that ethanol predisposes or sensitizes the pancreas to the effects of co-factors, and the combination of the effects of ethanol on the pancreas and the actions of these co-factors results in alcoholic pancreatitis. A number of viruses are known to infect the pancreas, and we have suggested that one co-factor that could be involved in the development of alcoholic pancreatitis is a viral infection. One of the most-studied groups of viruses that infect the pancreas and cause pancreatitis in human beings is the coxsackieviruses. We have shown that short-term (5-14 days) and subchronic (>28 days) administration of ethanol to mice increases the severity of coxsackie B3-induced pancreas damage. We hypothesize that consumption of ethanol would result in an impairment of pancreas regeneration after injury, similar to the effect of ethanol on liver regeneration. With the use of the murine model of coxsackie B3-mediated alcoholic pancreatitis we have obtained preliminary data to support the hypothesis. Specifically, consumption of ethanol by mice is associated with changes in the replication of acinar cells and their organization into acini after viral-mediated injury. We believe that this model will be a valuable tool to study the biochemical and molecular mechanisms involved in alcoholic pancreatitis.

Does acute alcoholic pancreatitis precede the chronic form or is the opposite true? A histological study

OBJECTIVES

Whether acute alcoholic pancreatitis occurs in a normal pancreas or in a pancreas that has already been altered by chronic pancreatitis is unclear. Our objective is to clarify the relation between acute and chronic alcoholic pancreatitis by histologic study of the pancreas in a group of patients having a first attack of acute alcoholic pancreatitis.

METHODS

From January 1989 to December 1999, 138 patients with acute pancreatitis, of whom 28 had alcoholic pancreatitis, were seen by us; in 21 of the latter 28 patients, it was the first attack. Of these 21, 6 underwent surgery for acute necrotic pancreatitis. In all 6 patients, adequate pancreatic biopsies were obtained during surgery. Tissue samples were prepared for histologic examination according to standard procedures.

RESULTS

In all 6 patients, both acute necrotic and chronic lesions were found. The chronic lesions had characteristics of chronic calcifying pancreatitis and consisted of perilobular and intralobular fibrosis. loss of exocrine parenchyma, dilated interlobular ducts, and protein plugs within dilated ducts.

CONCLUSIONS

This study suggests that acute alcoholic pancreatitis develops in a pancreas already affected by chronic pancreatitis. The hypothesis that in alcoholics chronic pancreatitis derives from acute pancreatitis is not supported by the present data.

Emerging concepts for the mechanism of alcoholic pancreatitis from experimental models

The pathophysiologic mechanisms that underlie acute and chronic pancreatitis arising from alcohol abuse are poorly understood. The reasons for this state of knowledge result historically from a lack of models for experimental investigation. Ethanol feeding alone, even at high doses, has minimal and inconsistent effects on morphologic findings in the pancreas in experimental animals. This experience, plus the fact that alcohol abuse causes pancreatic pathology in only a minority of patients, suggest that ethanol acts to sensitize the pancreas to the deleterious effects of other stimuli. In this article, we discuss findings to support this concept of ethanol as a sensitizing agent and experimental models developed that can be used to investigate the effects of ethanol on the pathologic processes of pancreatitis. These pathologic processes include inflammation, cell death, intrapancreatic digestive enzyme activation, and fibrosis.

Pathophysiology of alcohol-induced pancreatitis

Excessive ethanol consumption is a common risk factor for acute and chronic pancreatitis. Ethanol could lead to the onset of pancreatitis in a number of ways; the most recently discovered is its effect on intrapancreatic digestive enzyme activation, by either sensitizing acinar cells to pathologic stimuli or stimulating the release of a secretagogue (cholecystokinin) from duodenal I cells. Recent advances in cell biologic and molecular techniques have permitted us to address the intracellular events involved in digestive enzyme activation in a manner that was previously considered impossible. Investigations that used these novel techniques found that (a) trypsin is, in contrast to its role in the small intestine, not necessarily involved in the premature intracellular activation of other digestive proteases such as proelastase; (b) trypsinogen does not autoactivate intracellularly but is instead largely activated by the lysosomal hydrolase cathepsin B; and (c) the role of trypsin in the intrapancreatic protease cascade is most likely one that involves the degradation, rather than the activation, of active digestive proteases including trypsin itself. These studies, as well as investigations that have addressed the role of mutant trypsin in the disease onset of hereditary pancreatitis, suggest that trypsin may not be critical for triggering pancreatitis but might have a protective role against the action of some of the other digestive proteases. While the specific role of different digestive enzymes in initiating pancreatitis is still a matter of debate and the topic of ongoing investigations, experimental evidence suggests that ethanol can directly interfere with the processes involved in digestive zymogen activation.

Pathophysiology of alcohol-induced pancreatic injury

The evidence that ethanol abuse can lead to pancreatitis is overwhelming, but the mechanism(s) by which ethanol causes pancreatic injury and pancreatitis are not known. Many studies have focused on short-term effects of ethanol administration on exocrine pancreatic function, but the results reported have been variable and no clear picture has emerged. Attempts to induce pancreatitis by long-term ethanol administration have, for the most part, failed. We evaluated the effects of ethanol administration on pancreatic secretion of digestive enzymes. These studies indicate that administration of ethanol results in a transient increase in pancreatic amylase output and plasma cholecystokinin (CCK) levels. This phenomenon is mediated by a trypsin-sensitive CCK-releasing factor that is present within the duodenal lumen. These observations lead us to speculate that repeated CCK-mediated, ethanol-induced stimulation of pancreatic digestive enzyme secretion may play a role in the events that link ethanol abuse to the development of pancreatic injury.

Mechanisms of alcoholic pancreatitis. Proceedings of a conference. Chicago, Illinois, USA, November 2002

Long-term, heavy alcohol consumption is associated with both acute and chronic pancreatitis. Progression of pancreatitis may lead to multiple comorbidities including maldigestion, diabetes, and pancreatic cancer. Understanding the underlying molecular, biochemical, and cellular mechanisms by which alcohol ingestion leads to the development of pancreatitis may help to develop strategies for the treatment and prevention of the disease. The National Institute on Alcohol Abuse and Alcoholism and the Office of Rare Diseases of National Institutes of Health sponsored a satellite symposium on "Mechanisms of Alcoholic Pancreatitis" at the annual meeting of the American Pancreatic Association, Chicago, IL, November 2002. For this symposium, 8 speakers were invited to address the following issues: (1) epidemiology of alcoholic pancreatitis; (2) pathophysiology of alcoholic pancreatitis; (3) animal models of alcoholic pancreatitis--roles of cholecystokinin (CCK) and viral infections; (4) alcohol and zymogen activation in the pancreatic acinar cell; (5) role of alcohol metabolism in alcoholic pancreatitis; (6) pancreatic stellate cell activation in alcoholic pancreatitis; and (7) genetic predisposition to alcoholic chronic pancreatitis. It was concluded that alcohol abuse is a major contributory factor to the development of both acute and chronic pancreatitis. The injurious effects of ethanol on the pancreas may be mediated through (1) sensitization of acinar cells to CCK-induced premature activation of zymogens; (2) potentiation of the effect of CCK on the activation of transcription factors, nuclear factor kappaB (NF-kappaB) and activating protein-1 (AP-1); (3) generation of toxic metabolites such as acetaldehyde and fatty acid ethyl esters; (4) sensitization of the pancreas to the toxic effects of coxsackievirus B3; and (5) activation of pancreatic stellate cells by acetaldehyde and oxidative stress and subsequent increased production of collagen and other matrix proteins.

Clinical evidence of pathogenesis in chronic pancreatitis

Chronic pancreatitis is a continuing inflammatory disease characterized by irreversible morphological change and, typically, by pain and permanent impairment of function. The pathogenesis of pancreatitis, either acute or chronic, is still controversial. There have been no widely accepted concepts to provide a reasonable explanation linking the known etiological factors and the pathophysiological aspects of the disease. Alcohol is undoubtedly the major etiological factor in most countries, and the relative importance of alcohol as a cause of chronic pancreatitis ranges from 40% to 90% in various countries. As fewer than 10% of alcoholics develop chronic pancreatitis, other nutritional or genetic influences are likely to be involved in the pathogenesis of alcoholic pancreatitis. Accessory pancreas incidentally found in patients with chronic alcoholic pancreatitis does not always have the pathological findings seen in the main pancreas. Integrity of the pancreatic duct seems to be another important factor for chronic alcoholic pancreatitis. Gene mutations of the cystic fibrosis transmembrane conductance regulator (CFTR), cationic trypsinogen, and pancreatic secretory trypsin inhibitor have been investigated in idiopathic chronic pancreatitis. Molecular and cell biology research during the past few years has elucidated pathophysiological factors that are involved in the pathogenesis of chronic pancreatitis, but cannot demonstrate a common pathway between etiological factors and the pathogenesis or development of the disease.

[Clinical course of alcoholic pancreatitis]

AIM

To study a natural course of alcoholic pancreatitis (AP).

MATERIAL AND METHODS

Follow-up clinical, laboratory and radiation examinations were made of 170 patients with alcoholic pancreatitis. Exocrine secretion of the pancreas was assessed by secretin-pancreozymin test. Morphological signs of pancreatitis were studied in patients who had died of pancreatic cancer.

RESULTS

In 24% of patients AP manifested with acute attack. In 76% it was preceded with weak clinical symptoms. AP ran was complicated with pseudotumorous pancreatitis, calcinosis and pancreatic pseudocysts. Pancreatic secretion was suppressed in 87% patients though clinically it was evident only in 12% cases. Autopsy cases of pancreatic cancer carried morphological markers of chronic pancreatitis.

CONCLUSION

Various clinical forms of AP represent stages of its development: early symptoms, recurrences, complications and decompensated failure of the pancreatic function. The presence of pancreatitis in patients with pancreatic cancer causes difficulties in differential diagnosis between these diseases.

[Interrelations of the pancreas exocrine and endocrine functions in chronic alcohol pancreatitis]

In order to achieve a positive therapeutic effect in case of secondary pancreatic diabetes in patients with chronic pancreatitis, it is necessary to conduct conservative therapy aimed at parallel correction of the excretory and incretory functions of the pancreas.

Animal models in alcoholic pancreatitis--what can we learn?

Although the majority of patients with chronic pancreatitis present a history of excessive alcohol consumption, the pathophysiology underlying chronic alcoholic pancreatitis remains poorly defined. Since experimental animal models represent helpful tools in understanding human disease, numerous laboratory studies have been designed to study the effects of alcohol on the pancreas. In the present article we summarize the existing animal models that have been used to investigate the effects of acute and chronic alcohol application on the development of morphological alterations and pancreatic injury. Despite considerable experimental effort, acute or chronic ethanol feeding alone failed to cause acute or chronic pancreatitis in animals. However, ethanol-feeding and the combination with other procedures has demonstrated several mechanisms that play a role in ethanol-induced pancreatic injury. Among these ethanol-induced alterations and mechanisms are the reduction of pancreatic blood-flow and microcirculation, damaging effects of ethanol metabolites, increased pancreatic acinar cell expression of digestive and lysosomal enzymes, increased glandular enzyme content, additional nutritional factors, pancreatic duct obstruction, and limitations of pancreatic regeneration. Although no satisfactory animal model for alcoholic pancreatitis has been developed, these animal models have provided insights in several factors that predispose the pancreas to development of pancreatic injury and contribute to alcoholic pancreatitis.

Elevated fasting plasma level of islet amyloid polypeptide (IAPP) in chronic alcoholic pancreatitis (CAP)

BACKGROUND/AIMS

The aim of the study was to evaluate fasting plasma level of islet amyloid polypeptide in patients with chronic alcoholic pancreatitis and its possible correlation with the extent of pancreatic structural damage as well as endocrine function.

METHODOLOGY

Fifty-seven non-obese patients with chronic alcoholic pancreatitis and 20 healthy subjects were studied. In all subjects RIA plasma fasting amylin, insulin and C-peptide estimation were performed.

RESULTS

In patients with chronic alcoholic pancreatitis, particularly in those with advanced pancreatic structural damage in imaging techniques, fasting plasma amylin levels were significantly higher (p < 0.01) than in controls. Within chronic alcoholic pancreatitis group the highest plasma islet amyloid polypeptide values of 139.0 +/- 8.7 pg/100 microL were found in patients with glucose impaired tolerance, which was significantly higher (p < 0.01) than in patients with normal endocrine pancreatic function, non-insulin requiring and insulin requiring diabetes where the respective values were: 69.1 +/- 9.2 pg/100 microL, 75.5 +/- 5.2 pg/100 microL and 84.7 +/- 12.5 pg/100 microL.

CONCLUSIONS

Those findings suggest that islet amyloid polypeptide may play a role in the pathogenesis of chronic alcoholic pancreatitis. In addition increased plasma islet amyloid polypeptide level may prove useful as an indicator of an early phase of pancreatic endocrine function impairment and severe parenchymal damage in chronic pancreatitis.

Pancreatic cholesterol esterase, ES-10, and fatty acid ethyl ester synthase III gene expression are increased in the pancreas and liver but not in the brain or heart with long-term ethanol feeding in rats

INTRODUCTION

Chronic alcohol consumption predisposes susceptible individuals to both acute and chronic pancreatitis.

AIMS

Our hypothesis was that alcohol increases the risk of pancreatitis by disrupting defense mechanisms and/or enhancing injury-associated pathways through altered gene expression. Hence, we studied the expression of pancreatic genes in rats chronically exposed to ethanol.

METHODOLOGY

Male Wistar rats were pair-fed liquid diets without and with ethanol for 4 weeks. Total RNA was extracted from rat pancreas and other organs. The mRNA expression patterns among pancreatic samples from ethanol-fed rats and controls were compared with use of mRNA differential display. The differentially expressed cDNA tags were isolated, cloned, and sequenced.

RESULTS

One cDNA tag that was overexpressed in the pancreas showed 99% sequence homology to a rat pancreatic cholesterol esterase mRNA (CEL; Enzyme Commission number [EC] 3.1.1.13). The differential expression was confirmed by realtime PCR. Gene expression was also increased in the liver but not in the heart or brain of the alcohol-fed rats. Because CEL has fatty acid ethyl ester (FAEE)-generating activity and FAEEs play a major role in acute alcoholic pancreatitis, we determined the expression of other genes encoding for FAEE-generating enzymes and showed similar organ-specific expression patterns.

CONCLUSION

Our results demonstrate that chronic ethanol consumption induced expression of FAEE-related genes in the pancreas and liver. This upregulation may be a central mechanism leading to acinar cell injury.

The pathogenesis of chronic alcoholic pancreatitis

The pathogenesis of chronic alcoholic pancreatitis has not been elucidated yet. There are many theories about this topic. The first regards the initial injuries in the ductal pancreatic system. The second considers that the primary lesion is located in the acinar cells. Three hypotheses are elaborated in this respect: the intervention of toxic metabolites, oxidative stress or neuroimmmune system. The third theory sustains that a severe initial attack of acute pancreatitis may induce lesions typical of chronic pancreatitis. Recently the intervention of genetic factors, responsible for the susceptibility chronic pancreatitis has been put forward.

Effect of somatostatin on the sphincter of Oddi in patients with acute non-biliary pancreatitis

BACKGROUND

Somatostatin has been used to prevent pancreatitis after endoscopic retrograde cholangiopancreatography but its effect on acute non-biliary pancreatitis is still unclear.

AIM

The purpose of this study was to evaluate the function of the sphincter of Oddi (SO) and the effect of somatostatin on patients with non-biliary pancreatitis.

METHODS

Twenty patients (18 males, two females) with acute pancreatitis (alcoholic 18, idiopathic two) received SO manometry within one week after admission. After baseline measurement, a bolus dose of somatostatin (Stilamin, Serono) 250 microg was infused slowly, and SO manometry was repeated after five minutes. Continuous infusion of somatostatin 250 microg/h was given for 12 hours after SO manometry. Serum amylase, lipase, glucose, and C reactive protein (CRP) levels were examined before and after somatostatin infusion.

RESULTS

SO manometry was unsuccessful in six patients due to contracted sphincter. In the remaining 14 patients, high SO basal pressure (SOBP >40 mm Hg) was found in seven patients. After somatostatin infusion, mean SOBP decreased from 48.8 (29) to 31.9 (22) mm Hg (p<0.01). One patient had a paradoxical reaction to somatostatin (SOBP increased from 30 to 50 mm Hg) while the other 13 patients had a fall in SOBP after somatostatin. One patient developed abdominal pain with a serum amylase level of 2516 IU/l after SO manometry. No other side effects or changes in amylase, lipase, glucose, or CRP levels were observed in the other 19 patients after SO manometry and somatostatin infusion.

DISCUSSION

Sphincter of Oddi dysfunction is common in patients with acute non-biliary pancreatitis and in most cases somatostatin can relax the sphincter.

[Alcohol and pancreas]

The mechanism of the pancreatic toxicity of alcohol is not completely elucidated. Many cofactors may contribute to the pancreatic toxicity of alcohol: diet, genetic factors. Chronic pancreatitis occurs after a long lasting and heavy alcoholism. During the first years, acute manifestations occur and, then endocrine and exocrine pancreatic insufficiency.

Comparison of truncal hair distribution in alcoholic liver disease and alcohol-related chronic pancreatitis

The present study shows that scanty hair distribution over the trunk is a specific finding in patients with alcoholic liver disease (ALD), and is not seen in alcoholic pancreatitis. This observation not only provides a useful clinical marker of individuals at increased risk of developing alcohol-related liver disease, but from the pathogenetic viewpoint, it suggests that at the tissue level, the male sex hormones protect the liver against ethanol-related damage.

The natural history of alcoholic chronic pancreatitis

An improved knowledge of the natural history is the indispensible basis for a rational concept in regard to the diagnosis, classification, understanding and management of pain in chronic pancreatitis. Unfortunately, data on the natural history of CP are scarce and conflicting. Some relevant observations of our prospective long-term study of a mixed medical-surgical cohort comprising 207 patients with alcoholic CP (mean follow-up 17 years from onset) are summarized. In early-stage CP, episodes of recurrent pancreatitis were predominant. Severe persistent pain was typically associated with local complications (mainly postnecrotic cysts in 54%; symptomatic cholestasis in 24%) relieved definitely by a drainage procedure. Lasting pain remission was documented in >80% of the whole cohort within 10 years from onset in association with marked pancreatic dysfunction. From our experience, the relief of "chronic" pain regularly follows selective surgery tailored to the presumptive pain cause or it occurs spontaneously in uncomplicated advanced CP (excluding narcotic addiction).

Cigarette smoke enhances ethanol-induced pancreatic injury

Alcohol induces pancreatic ischemia, but the mechanisms promoting pancreatic inflammation are unclear. We investigated whether cigarette smoke inhalation is a cofactor in the development of ethanol-induced pancreatic injury. Cigarette smoke was administered to anesthetized rats alone or in combination with intravenous ethanol infusion. Control animals received either saline or ethanol alone. Pancreatic capillary blood flow and leukocyte-endothelium interaction in postcapillary venules were evaluated by intravital microscopy. Leukocyte sequestration was assessed by measurement of myeloperoxidase activity in pancreatic tissue, and pancreatic injury evaluated by histology. Ethanol decreased pancreatic blood flow progressively over 90 minutes (p < 0.001 vs. baseline), but neither leukocyte-endothelium interaction nor leukocyte sequestration was altered. Cigarette smoke alone reduced pancreatic blood flow temporarily (p < 0.01 vs. baseline) and increased leukocyte-endothelium interaction (roller p < 0.001, sticker p < 0.01 vs. baseline). Cigarette smoke potentiated the impairment of pancreatic capillary perfusion caused by ethanol, and both the number of rolling leukocytes and myeloperoxidase activity levels were increased compared to ethanol or nicotine administration alone (p < or = 0.05 and p < or = 0.01, respectively). This study demonstrates that ethanol induces pancreatic ischemia and that cigarette smoke leads to both temporary pancreatic ischemia and minimal leukocyte sequestration. Cigarette smoke potentiates the amount of pancreatic injury generated by ethanol alone. Smoking therefore seems to be a contributing factor in the development of alcohol-induced pancreatitis in the rat model.

Autonomic nervous function in alcohol-related chronic pancreatitis

Patients with alcohol-related chronic pancreatitis (ARCP) often have peripheral neuropathy, but no data on the occurrence of autonomic neuropathy (AN) are available for this condition. To assess the autonomic function and the significance of its abnormalities for the prognosis of ARCP, 18 patients with ARCP and associated diabetes mellitus (P-DM group), 10 with ARCP without evidence of diabetes mellitus (P group), 17 patients with insulin-dependent diabetes mellitus (IDDM group), and 18 healthy controls answered a structured questionnaire and underwent three standardized cardiovascular (CV) tests that yielded six different parameters for autonomic nerve function. Patients with at least one symptom plus two abnormal results on CV tests were regarded as having AN. ARCP patients were followed up for 48 months and mortality rates were recorded. The proportions of patients with AN were 66.6% in the P-DM group, 30.0% in the P group, and 29.4% in IDDM patients. Seven of 15 ARCP patients with AN died during follow-up, compared with one of 13 of those without AN (p < 0.037). In conclusion, AN is commonly found in ARCP patients and carries an ominous prognosis.

Neurological damage and duodenopancreatic reflux in the pathogenesis of alcoholic pancreatitis

OBJECTIVE

To present a new theory on the pathogenesis of acute alcoholic pancreatitis based on experimental data, the significance of which has not been recognized, and on evidence from the current literature.

HYPOTHESIS

That chronic alcoholism damages muscarinic receptors in the pancreas, duodenum, and Oddi sphincter, producing heightened sensitivity to acetylcholine, stimulation of protein-rich pancreatic juice, hypertonicity of the duodenum and esophagus, relaxation of the Oddi sphincter, and intraduodenal pressures exceeding those shown to cause duodenopancreatic reflux and acute pancreatitis in humans and experimental animals.

OUTCOME

The duodenopancreatic reflux mechanism can explain all of the clinical features of acute alcohol pancreatitis, including the intraductal site and rapid activation of zymogens by enterokinase, the recurrent episodes of pancreatitis, the precipitation of protein plugs by partial proteolytic hydrolysis, the severe vascular changes, the relation to infection by the most direct route, and the progression to chronic pancreatitis via the necrosis-fibrosis sequence.

CONCLUSIONS

Damage to the nervous system, with a time lag of 5 to 15 years between the onset of heavy drinking and the development of neurological disorders (peripheral neuropathy and cerebellar degeneration), is a characteristic complication of chronic alcoholism. The similarity to events in alcoholic pancreatitis is striking.

Long term results of lateral pancreaticojejunostomy for chronic alcoholic pancreatitis

OBJECTIVE

To assess our long term results of lateral pancreaticojejunostomy in patients with alcoholic pancreatitis.

DESIGN

Retrospective study.

SETTING

University hospital, France.

SUBJECTS

57 patients (48 men, 9 women, mean (SD) age 46 (7) years who required surgical treatment of chronic alcoholic pancreatitis between January 1977 and October 1995.

INTERVENTIONS

Lateral pancreaticojejunostomy with or without another procedure. Outcome classified as excellent, good, fair, or poor.

MAIN OUTCOME MEASURES

Postoperative morbidity and mortality; relief of pain; reduction in use of analgesics and exocrine supplements; effect on exocrine and endocrine insufficiency; and return to paid work.

RESULTS

There were no postoperative deaths and no pancreatic fistulae, but there were 17 other postoperative complications (30%). Median follow up was 65 months (range 8-206), during which 12 patients died (21%). Result was judged excellent in 16 (28%), good in 27 (47%), fair in 5 (9%), and poor in 9 (16%). Pain control was significantly improved, analgesic usage decreased, less pancreatic enzyme supplementation was required, and 25 patients returned to paid work (p = 0.0001 in each case). Exocrine and endocrine function remained stable. The results were better if the patient gave up misusing alcohol (p = 0.03) and if the operation was done within 4 years of the development of pancreatitis (p = 0.03).

CONCLUSIONS

Lateral pancreaticojejunostomy is a safe procedure that can improve functional outcome in patients with chronic alcoholic pancreatitis, and does not worsen pancreatic function.