Mild chronic pancreatitis. Chronic pancreatitis without severe acute exacerbations, bulky steatorrhoea, or pronounced weight loss.
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Dietary Fiber↗
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ErbB2 oncogene expression supports the acute pancreatitis-chronic pancreatitis sequence.
The pathogenesis of chronic pancreatitis remains controversial. According to the general opinion, chronic pancreatitis is a de novo disease with a silent but progressive restructure of the pancreas in response to environmental, nutritional or genetic factors. The necrosis-fibrosis sequence hypothesis, on the other hand, postulates that relapsing attacks of acute pancreatitis with subsequent development of fibrosis leads to chronic pancreatitis. Since in our previous studies the expression of two anti-ErbB2 growth factor receptor (ErbB2) antibodies was shown to discriminate between primary chronic pancreatitis, normal tissue, and secondary chronic pancreatitis caused by pancreatic cancer, we studied the ErbB2 expression in tissues obtained from acute, recurrent acute, and chronic pancreatitis to investigate a possible evolution of the ErbB2 expression pattern during the course of the disease. We subjected 14 normal pancreas, 15 chronic pancreatitis, and 12 acute pancreatitis (three with recurrent acute pancreatitis) specimens to immunohistochemical studies using polyclonal anti-ErbB2 antibodies from Santa Cruz and Dako. The immunoreactivity of islet cells in acute pancreatitis cases with the Santa Cruz antibody was less than that in normal pancreas in relation to the degree of tissue damage and fibrosis, and was negative in recurrent acute and chronic pancreatitis tissues. The Dako antibody, on the other hand, revealed a membrane staining of ductal and ductular cells only in chronic pancreatitis specimens and in some areas of recurrent acute pancreatitis. In conclusion, the similarities in the immunoreactivity of anti-ErbB2 antibodies in recurrent acute pancreatitis and chronic pancreatitis support the hypothesis that acute pancreatitis can be a forerunner of chronic pancreatitis.
Acute Disease↗
Endoscopic measurement of pancreatic juice secretory flow rates and pancreatic secretory pressures after secretin administration in human controls and in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer.
Secretory flow rates were measured inside the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer and in controls after intravenous administration of secretin. Peak secretory flow rates in these groups were 5.04 +/- 1.74, 0.71 +/-1.28, 0.60 +/- 1.37, and 4.13 +/- 0.88 ml/min, respectively. Peak secretory pressures were also measured intraductally in patients with acute relapsing pancreatitis and pancreatic cancer and in controls and were 402 +/- 69, 75 +/- 161, and 403 +/- 99 mm pancreatic juice, respectively. Peak secretory flow rates and pressures measured in controls during constant administration of secretin were similar to those measured when secretin was administered as a bolus.
Endoscopy↗
[CLINICAL IMPORTANCE OF THE PROSERIN TEST IN CHRONIC PANCREATITIS, CHRONIC CHOLECYSTITIS AND OBSTRUCTIVE JAUNDICE].
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Cholecystitis↗
Differences in the expression of glutathione S-transferases in normal pancreas, chronic pancreatitis, secondary chronic pancreatitis, and pancreatic cancer.
INTRODUCTION: In our previous study, glutathione S-transferase-pi (GST-pi), a phase II drug metabolizing enzyme, was found to be expressed in pancreatic ductal and ductular cells but not acinar cells of the normal pancreas, chronic pancreatitis, and secondary pancreatitis caused by pancreatic cancer. A greater percentage of the cells expressing GST-pi was shown in the islets of chronic pancreatitis specimens compared with the normal pancreas and secondary pancreatitis. AIMS AND METHODOLOGY: To examine whether the increased number of islet cells expressing GST-pi and the absence in the acinar cells are compensated for by other GST isozymes, we investigated the expression of GST-alpha and GST-mu in the same specimens. RESULTS: Unlike the distribution of GST-pi, the distribution of GST-alpha and GST-mu in islets did not show marked differences between the three groups. However, in four of 18 primary chronic pancreatitis specimens, more islet cells (approximately 25%) expressed GST-alpha than in the normal pancreas and secondary chronic pancreatitis (both approximately 10%). The reactivity of cancer cells to GST-alpha, GST-mu, and GST-pi was similar to the ductal cells in the normal pancreas, chronic pancreatitis, and secondary chronic pancreatitis. Contrary to the expression of GST-pi, no statistically significant differences were found in the distribution of GST-alpha and GST-mu in the normal pancreas, chronic pancreatitis, and secondary chronic pancreatitis. CONCLUSION: The expression of the other GSTs does not compensate for the variation of expression of GST-pi. There was no specimen in each group that did not express at least one GST isozyme in islet, acinar, and ductal cells.
Adolescent↗
Modern diagnostics of chronic pancreatitis.
Chronic pancreatitis is a well-defined disease on histopathological grounds, but for clinical purposes diagnosis is generally not based on histological specimens. Imaging procedures, non-invasive or with different degrees of invasiveness, and pancreatic function tests are therefore the diagnostic mainstay in patients with suggestive clinical history. The correct diagnosis of chronic pancreatitis is easy in late stages but difficult in an early stage of the disease. A particular challenge is the differentiation between acute or recurrent acute and early chronic pancreatitis. Earlier classifications (Cambridge and Marseille) did not consider the complex interrelationship between (especially alcoholic) acute and chronic pancreatitis. A possible solution is to separate the entities into probable and definite alcoholic chronic pancreatitis, with the assignment into the latter category achieved by follow-up investigations. Up to now the best diagnostic accuracy at an early stage is achieved by the detection of abnormalities of the ductal system in endoscopic retrograde pancreatography or by assessing exocrine function with the secretin-ceruletide test. The endoscopic ultrasound may substitute the endoscopic retrograde pancreatography as superior imaging modality that detects both parenchymal and ductal changes of chronic pancreatitis at an early stage. Magnetic resonance pancreatography is a further promising diagnostic tool without the risk of pancreatitis after endoscopic retrograde pancreatography, but imaging of the side branches, which is crucial for detection of early chronic pancreatitis, is not yet sufficient. Faecal elastase is a progress in non-invasive testing of exocrine pancreatic function, but its value for the diagnosis of chronic pancreatitis under conditions of clinical practice is limited. Several (13)C breath tests have been developed, but their availability and their diagnostic accuracy in chronic pancreatitis is still limited. Light to moderate exocrine pancreatic insufficiency is not detectable with adequate accuracy by tubeless function tests. A specific serum marker of pancreatic fibrosis which would reliably indicate the presence of chronic pancreatitis or its progression to is not available.
Chronic Disease↗
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.
Chronic Disease↗
[Natural course and medical treatment of chronic pancreatitis].
Chronic pancreatitis is a progressive disease without curative treatment. Abdominal pain is the most predominant symptom of chronic pancreatitis that initially brings most of the patients to the physician's attention. Some studies have correlated the course of pain in chronic pancreatitis in comparison with the duration of the disease, progressing exocrine and endocrine pancreatic insufficiency, and morphological changes such as pancreatic calcification and duct abnormalities. Furthermore, the course of pain has been studied after alcohol abstinence or surgery in some groups. However, there are only few well-performed and valid studies, and some of them even have produced diversing results, in part. Further controlled studies harboring a large number of patients in a multicenter setting should be considered. Therapeutic efforts on chronic pancreatitis have focused on palliative treatment of pain which is present in about 80% of cases. Endoscopic treatment of pain in chronic pancreatitis is useful and feasible in many patients. Selecting candidate for endotherapy is mandatory. Main indication of pancreatic stent insertion in chronic pancreatitis is the presence of an obvious ductal stricture. Complications of chronic pancreatitis are also indications of endoscopic intervention. Exocrine and endocrine insufficiencies should be meticulously managed to prevent complications and to maintain good quality of life.
Humans↗
Correlation of imaging and function in chronic pancreatitis.
Chronic pancreatitis is a slowly progressive disease. Initially, only focal changes occur, but diffuse structural abnormalities accompanied by various degrees of functional impairment are seen in the late stage. Morphological abnormalities in chronic pancreatitis can now be detected with high accuracy by several imaging methods. The most sensitive method is ERP, which is able to detect slight ductal changes at an early stage. High-resolution US has become a valid alternative to CT for the visualization of parenchymal abnormalities. However, CT is more accurate than US in detecting small cysts and calcifications. By comparing ductal abnormalities (ERP) and parenchymal lesions (CT, US) with pancreatic function impairment, it has become quite clear that the morphofunctional correlation is tight only in the "late" or severe stages of chronic pancreatitis. In "early" or "moderate" stages of chronic pancreatitis, correlation of the degree of morphological abnormalities and pancreatic dysfunction is frequently poor. Studies comparing the value of the different imaging methods with pancreatic function tests in the diagnosis of chronic pancreatitis have found ERP and the duodenal intubation SC test to have the highest diagnostic accuracies. Correlation between the degree of ductal abnormalities (ERP) and pancreatic dysfunction in the SC test, and between the degree of parenchymal abnormalities (CT and US) and the SC test both proved significant. However, prediction of exocrine function based on morphological alterations, or vice versa, is not possible. The value of combining function testing with imaging is enhancement of the diagnostic accuracy in the presence of only "mild" morphologic abnormalities detected with the imaging techniques. In advanced stages of chronic pancreatitis, function testing is a valid complementary tool to characterize the clinical stage of the disease and may have an impact on therapeutic decisions in patients with advanced stages of chronic pancreatitis. Invasive function testing (SC test) can be replaced by oral pancreatic function tests, which yield equivalent results or clinical decisions.
Cholangiopancreatography, Endoscopic Retrograde↗
A degradation-sensitive anionic trypsinogen (PRSS2) variant protects against chronic pancreatitis.
Chronic pancreatitis is a common inflammatory disease of the pancreas. Mutations in the genes encoding cationic trypsinogen (PRSS1) and the pancreatic secretory trypsin inhibitor (SPINK1) are associated with chronic pancreatitis. Because increased proteolytic activity owing to mutated PRSS1 enhances the risk for chronic pancreatitis, mutations in the gene encoding anionic trypsinogen (PRSS2) may also predispose to disease. Here we analyzed PRSS2 in individuals with chronic pancreatitis and controls and found, to our surprise, that a variant of codon 191 (G191R) is overrepresented in control subjects: G191R was present in 220/6,459 (3.4%) controls but in only 32/2,466 (1.3%) affected individuals (odds ratio 0.37; P = 1.1 x 10(-8)). Upon activation by enterokinase or trypsin, purified recombinant G191R protein showed a complete loss of trypsin activity owing to the introduction of a new tryptic cleavage site that renders the enzyme hypersensitive to autocatalytic proteolysis. In conclusion, the G191R variant of PRSS2 mitigates intrapancreatic trypsin activity and thereby protects against chronic pancreatitis.
Base Sequence↗
The role of pancreaticoduodenectomy in the treatment of severe chronic pancreatitis.
Chronic pancreatitis remains a debilitating disease with few definitive options for treatment. The purpose of this study was to evaluate the benefit of pancreaticoduodenectomy in the treatment of chronic pancreatitis. The results were evaluated by standard descriptive statistics. In a retrospective study, we reviewed the patients at a single institution undergoing pancreaticoduodenectomy between 1994 and 1997 for complications of chronic pancreatitis. Patients were evaluated for preoperative indication for surgery and perioperative morbidity and mortality, as well as long-term results. Thirty-two patients underwent pancreaticoduodenectomy for chronic pancreatitis; 56 per cent (18) underwent pylorus-preserving and 44 per cent (14) underwent classic pancreaticoduodenectomy. The mean age of these patients was 56+/-14.7 years (range, 23-79). All patients underwent preoperative CT scan and endoscopic retrograde cholangiopancreatography. The preoperative indication for surgery in 81 per cent (26) of these patients was intractable pain in the setting of a nondilated pancreatic duct. The other 19 per cent were treated for biliary/pancreatic duct stricture and pancreatic head fibrosis (mass suspicious of malignancy). Fifty-three per cent of the patients had a history of previous abdominal surgery. There were no perioperative deaths. The mean postoperative stay was 12.2+/-7.4 days. The postoperative morbidity rate was 31 per cent (10), consisting of 25 per cent with delayed gastric emptying, 3 per cent with pneumonia, and 3 per cent with wound infections. There was no occurrence of pancreatic fistulas. With a mean follow-up of 40 months (range, 10-52 months), 85 per cent reported a significant improvement in pain with 71 per cent being pain free and not requiring narcotics. Twenty per cent developed new-onset diabetes. The overall event survival rate at 5 years was 97 per cent. Thus, in a selected group of patients with severe chronic pancreatitis, resection of the head of the pancreas achieved relief of symptoms and was a safe and effective treatment for chronic pancreatitis.
Adult↗
[Clinico-diagnostic aspects of chronic pancreatitis].
Chronic pancreatitis are mainly classified as chronic calcifying pancreatitis (CCP) and chronic obstructive pancreatitis (COP). The first classification was performed in 1963 and reproposed in 1984. Clinical symptoms and natural history of chronic pancreatitis are presented. Pre-operative clinico-radiological findings may be pathognomonic of the disease. Endoscopic retrograde cholangio-pancreatography (ERCP) and per-operative pancreatography and cholangiography are extremely useful for diagnostic purpose. Chronic pancreatitis may induce local inflammatory complications (pseudocysts, chronic serosal effusions, fistulae) duodenal stenosis and segmental portal hypertension. A strict correlation of clinico-pathological findings is very important in the diagnostic procedure of chronic pancreatitis. Intraoperative diagnosis (either histologic, either cytologic) is of paramount importance in the diagnosis of a pancreatic mass. Histology is prominent in the definition of the specific form of pancreatitis.
Adult↗
Balance of expression of genes coding for extracellular matrix proteins and extracellular matrix degrading proteases in chronic pancreatitis.
Chronic pancreatitis is characterized by proliferation of the extracellular matrix and by increased deposition of interstitial extracellular matrix proteins (collagens type I and III, fibronectin). In this study we analyzed the balance of expression of mRNAs encoding extracellular matrix components (collagens I, III and IV, laminin, fibronectin), extracellular matrix degrading metalloproteinases (MMP-1, -2 and -3) and tissue inhibitors of metalloproteinases (TIMP-1 and -2) in chronic pancreatitis (n = 8) and control pancreas (n = 7) by northern blot analysis. Transcripts for MMP-1 (interstitial collagenase), MMP-3 (stromelysin) and TIMP-1 were not detectable in chronic pancreatitis and control tissues. Steady-state levels of transcripts encoding extracellular matrix proteins, MMP-2 (72 kDa collagenase IV) and TIMP-2 were enhanced in 7 out of 8 chronic pancreatitis tissue samples and showed a large degree of variation between individual patients. Transcript levels could not be correlated to the histologically detectable degree of inflammation and fibrosis or to the total amount of deposited collagen protein, which was high in all chronic pancreatitis tissue samples as determined by a standard colorimetric procedure. Increased steady state levels of transcripts encoding extracellular matrix proteins or extracellular matrix degrading proteases may thus reflect the activity of processes involved in the remodeling of the gland during chronic inflammation. The precise role of overexpression of MMP-2 and its inhibitor TIMP-2 will have to be elucidated in further studies.
Chronic Disease↗
Chronic pancreatitis.
Chronic pancreatitis is a serious disease with many yet unsolved problems, e.g. pathogenesis, cause of pain and treatment. Danish gastroenterologists have for many years participated actively in the investigation of the disease and have produced many internationally recognized results, especially regarding secretion physiology and pathophysiology, epidemiology, cause of pain and characterization of the secondary diabetes mellitus. In the past 25 years more than 60 Danish papers about chronic pancreatitis have been published in international, reviewed journals. Furthermore six theses on subjects related to chronic pancreatitis have been produced. In this article the Danish contribution to the literature on chronic pancreatitis during the past 25 years is reviewed.
Abdominal Pain↗
Diagnosis and management of chronic pancreatitis.
Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.
Cholangiopancreatography, Endoscopic Retrograde↗
The clinical study of chronic pancreatitis.
Chronic pancreatitis is a relentlessly progressive fibro inflammatory process which may eventually lead to pancreatic insufficiency. This study is done to review the various treatments for chronic pancreatitis and to analyze the clinical features, different etiological factors, comparing different clinical trials in India as well as western countries. One hundred and eight patients with the diagnosis of chronic pancreatitis were included in this study from January 1996 to June 1999. In this present series, most of the patients presented in the 3rd and 4th decades of life. The most common presentation was recurrent episodes of pain in the epigastrium radiating to the back. Most patients are non-alcoholic and the etiological factor in this group may be attributed to the nutritional, idiopathic, hereditary etc, though the single most common etiological factor seemed to be alcohol. The most specific investigation to detect the presence of pancreatic calculi, pseudo cysts, and duct dilatation was ultrasonography. Among the drugs, antioxidant therapy found to have effective role in the conservative management. Puestow's lateral pancreaticojejunostomy is most commonly performed surgery which has good results.
Abdominal Pain↗
Imaging of chronic pancreatitis.
Chronic pancreatitis is characterized by progressive, irreversible morphologic changes whose most common cause is excessive alcohol intake. Radiologic imaging plays a major role in the diagnosis, staging of disease severity, detection of complications and selection of treatment options. The sensitivity of US ranges from 60% to 70% while its specificity is higher reaching 80%-90% in the detection of abnormalities of main pancreatic duct. As for CT, its sensitivity and specificity in the diagnosis of chronic pancreatitis, in recent studies is 74% and 85% respectively. The performance of Magnetic Resonance cholangiopancreatography was shown to be enhanced by secretin stimulation with better visualization of ductal and parenchymal changes. However, endoscopic retrograde cholangiopancreatography is the most sensitive indicator of the presence and extent of the disease. Ductal abnormalities can be used to classify chronic pancreatitis.
Cholangiopancreatography, Endoscopic Retrograde↗
Update on diagnosis and management of chronic pancreatitis.
Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. The importance of small duct disease without obvious radiographic abnormalities is an important new concept. It is meaningful for the clinician to define whether the patient with chronic pancreatitis has small duct or large duct disease. Diagnostic evaluations should begin with a simple, noninvasive, inexpensive test such as serum trypsinogen, to be followed by more complicated testing such as the secretin stimulation test, particularly in those patients with small duct disease. Non-enteric-coated pancreatic enzyme preparations are preferred for the treatment of pain whereas enteric-coated pancreatic enzyme preparations are the drugs of choice for treating steatorrhea. Octreotide may become an important therapy for treating abdominal pain unresponsive to pancreatic enzyme therapy. Endoscopic treatment of the pain of chronic pancreatitis should be used only in highly selected patients and may cause damage to the pancreas. Surgical ductal decompression is appropriate in selected patients.
Cholangiopancreatography, Endoscopic Retrograde↗