Chronic Pancreatitis: Landmark Papers, Management Decisions, and Future.

On May 16, 2015 at the invitation of the American Gastroenterological Association Institute Council E.P.D.

Chronic pancreatitis.

Purpose Of Review: We review selected important clinical observations reported in 2012.

Recent Findings: Celiac disease is a risk factor for pancreatitis. Patients with recurrent acute pancreatitis likely have chronic pancreatitis, do not benefit from pancreatic sphincterotomy, and may not benefit from biliary sphincterotomy.

Chronic pancreatitis.

Purpose Of Review: We review important new clinical observations in chronic pancreatitis reported in 2011.

Recent Findings: Smoking increases the risk of nongallstone acute pancreatitis and the progression of acute pancreatitis to chronic pancreatitis. Binge drinking during Oktoberfest did not associate with increased hospital admissions for acute pancreatitis.

Pancreas divisum does not cause pancreatitis, but associates with CFTR mutations.

Bertin et al. partially dispel arguments that pancreas divisum (PD) causes pancreatitis, but fascinatingly indicate that PD associates with CFTR gene mutations predisposing to pancreatitis. This association, however, does not definitely confer a pathophysiological role for PD in pancreatitis but may denote that PD co-mingles with CFTR mutations without influencing pancreatitis or CFTR mutations influence pancreatic duct embryogenesis.

Chronic pancreatitis.

Purpose Of Review: We review important new clinical observations in chronic pancreatitis made in the past year.

Recent Findings: Tropical pancreatitis associates with SPINK1 and/or CFTR gene mutations in approximately 50% of patients, similar to the frequency in idiopathic chronic pancreatitis. Corticosteroids increase secretin-stimulated pancreatic bicarbonate concentrations in autoimmune pancreatitis (AIP) by restoring mislocalized CFTR protein to the apical ductal membrane.

Chronic pancreatitis.

Purpose Of Review: We review important new clinical observations in chronic pancreatitis made in the past year.

Recent Findings: Cigarette smoking is a dose-dependent risk factor for acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. A minority of chronic alcohol consumers develop recurrent acute pancreatitis but very heavy drinking associates with chronic pancreatitis.

Chronic pancreatitis.

Purpose Of Review: We review important new clinical observations in chronic pancreatitis made in the last year.

Recent Findings: Cholecystokinin-stimulated endoscopic pancreatic function testing has low specificity for diagnosis of early chronic pancreatitis, likely because of correctable technical limitations or failure to exclude confounding diseases. Fecal elastase 1 is a poor test for diagnosing pancreatic malabsorption.

New advances in acute pancreatitis.

Purpose Of Review: We endeavor to review important new advances in acute pancreatitis made in the past year. We focused on clinical aspects of acute pancreatitis, which contained new observations or insights into new or old concepts. For experimental acute pancreatitis we refer readers to a recent comprehensive review.

Chronic pancreatitis.

An increasing number of novel mutations are associated with chronic pancreatitis. Some cause a high-penetrance, autosomal dominant type of clinical picture (eg, mutations at codons 29 and 122 of the cationic trypsinogen gene), whereas others have a low penetrance or are frequent in the general population (eg, mutations in Kazal type 1 [SPINK1] and in codons 16, 22, and 23 of the cationic trypsinogen gene) and act as disease modifiers. The results of recent studies indicate that smoking adversely affects the course and complications of chronic pancreatitis (more frequent and faster rate of calcification and higher risk of development of pancreatic cancer).

Chronic pancreatitis.

In the past year, there has been at least one important clinical paper that sheds light on the character and natural history of painful chronic pancreatitis, which has important clinical implications. In addition, several novel mutations have been described in the cationic trypsinogen gene in patients with hereditary pancreatitis. The mechanism by which these mutations cause pancreatic disease remains speculative.

Chronic pancreatitis.

In the past year, numerous important papers were published on chronic pancreatitis, its causes, and its diagnosis; the cause of fibrosis; and pain in pancreatic cancer. More than 750 mutations have been described in the cystic fibrosis transmembrane regulator (CFTR) gene. Some mutations cause relatively mild reductions in CFTR function and may lead to disease in one organ without clinical involvement of other organs.

Chronic pancreatitis.

Purpose Of Review: As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. Topics recently reviewed were truncated to accommodate a surge in publications on clinical aspects of chronic pancreatitis, which contained new observations or insights into new or old concepts.

Recent Findings: Cystic fibrosis carriers have been found to be at increased risk of pancreatitis.

A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma.

Background: To compare operative morbidity, mortality, quality of life, and survival after pancreatoduodenectomy (PD) versus pancreatoduodenectomy with extended lymphadenectomy (PD/ELND) in patients with resectable pancreatic cancer.

Methods: From May 1997 to July 2003 there were 132 patients with biopsy examination-proven or suspected adenocarcinoma of the pancreatic head who agreed to participate in a single-institution, prospective, randomized trial. If resectable at operation, patients then were randomized to standard PD (40 patients) or PD/ELND (39 patients).

Chronic pancreatitis.

Purpose Of Review: As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. We included articles, including review articles, only if they contained new observations or readdressed old questions and provided new insights into old and new concepts.

Recent Findings: Important observations include the following: (1) Strong association between cystic fibrosis transmembrane regulator dysfunction/mutations and 'recurrent acute pancreatitis', particularly in patients with pancreas divisum (2) Pancreas divisum may be incidental finding in recurrent acute pancreatitis (3) Smoking increases risk of chronic pancreatitis (4) Coxsackie B virus may increase severity of alcoholic chronic pancreatitis (5) CD4+ T cells and an immune reaction against amylase may play a role in pathogenesis of autoimmune pancreatitis (6) 2-(18F)-Fluro-2-deoxy-D-glucose positron emission tomography might be useful to detect pancreatic cancer in chronic pancreatitis patients at risk for developing pancreatic cancer, but contrast-enhanced Doppler ultrasound or endosonography may be as sensitive and better than contrast enhanced computed tomography (7) Superiority of surgery vs endotherapy for long term pain relief and weight gain in painful chronic pancreatitis (8) Early treatment of pain and malabsorption may improve life quality (9) Antifibrogenesis and fibrolytic agents as potential therapies.

'Good mentorship is invaluable' - an interview with Dr. Eugene P. DiMagno. Interview by Martin E. Fernandez-Zapico.

Dr. DiMagno is internationally renowned for his contributions to almost all areas of pancreatology. He helped pioneer discoveries about normal pancreatic function, enzyme-based treatment of exocrine pancreatic insufficiency as well as methods of diagnosing pancreatitis and pancreatic cancer, including the development of function tests and endoscopic ultrasound.

Cigarette smoking accelerates progression of alcoholic chronic pancreatitis.

Background: Smoking is a recognised risk factor for pancreatic cancer and has been associated with chronic pancreatitis and also with type II diabetes.

Aims: The aim of this study was to investigate the effect of tobacco on the age of diagnosis of pancreatitis and progression of disease, as measured by the appearance of calcification and diabetes.

Patients: We used data from a retrospective cohort of 934 patients with chronic alcoholic pancreatitis where information on smoking was available, who were diagnosed and followed in clinical centres in five countries.