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Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear. Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019. Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant. Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted. [ABSTRACT FROM AUTHOR]

Objective: To examine lifetime drinking patterns in men and women with alcohol-induced pancreatitis (AIP) in comparison with patients with alcoholic use disorder (AUD) without pancreatic disease. Methods: Alcohol consumption patterns were assessed using a validated questionnaire, the Lifetime Drinking History (LDH), during an outpatient visit. Patients diagnosed with AIP were matched for gender and age (+/− 5 years) with patients with AUD in addiction treatment. Results: A total of 45 patients with AIP (35 males, 10 females) and 45 AUD patients were included. Alcohol consumption patterns were not significantly different between males and females with AIP and those with history of acute AIP and chronic pancreatitis (CP). Alcohol consumption patterns of AIP and AUD patients were similar in terms of onset age and duration of alcohol consumption, lifetime alcohol intake and drinks per drinking day. A higher proportion of binge drinking was found among patients with AUD than those with AIP (median 1.00 vs. 0.94, p = .01). Males with AUD had lower onset age (15 vs. 16 years, p = .03), higher total amount of spirits (35520 vs. 10450 drinks, p = .04) and higher proportion of binge drinking (1.00 vs. 0.97, p = .01) than males with AIP, whereas females with AIP and AUD had similar drinking patterns. Conclusions: Alcohol drinking patterns and lifetime drinking history was similar in patients with AIP and patients with AUD. Males with AIP had lower total amount of spirits and lower proportion of binge drinking than those with AUD, suggesting the idiosyncratic etiology of AIP. [ABSTRACT FROM AUTHOR]

Objective. Based on the ampullary obstruction and reflux theory, six endoscopic retrograde cholangiopancreatography (ERCP) studies have investigated the effect of (early) biliary decompression versus conservative management on the course and outcome of patients with acute biliary pancreatitis (ABP) showing inconsistent and contradictory outcomes. We investigated the opinion and attitude of Dutch gastroenterologists regarding the application of (early) ERCP in the clinical management of ABP by means of a nationwide survey. Material and methods. An anonymous questionnaire was sent to all registered consultant gastroenterologists ( n = 283) across the Netherlands. Results. The response rate was 52%. The vast majority of consulting gastroenterologists declared that early ERCP may be indicated in ABP (96.6%). Fourteen percent stated that they always perform ERCP in ABP. The remainder of the respondents consider ERCP only if a concomitant condition is present such as a dilated CBD (95%), co-existent cholangitis (87%), common bile duct stone(s) (CBDS) (72%), jaundice (59%), ampullary stone (68%) or (predicted) severe ABP (35%). About half of the consultant gastroenterologists (51.4%) consider the optimal time point for ERCP in ABP to be within 24 h after admission or symptom onset. If ERCP is performed for suspected APB, 55% of the respondents perform an endoscopic sphincterotomy (ES), regardless of the findings on cholangiography. Conclusions. The vast majority of Dutch gastroenterologists attest to a role for ERCP in ABP, but indications when to perform ERCP, its timing, and the application of ES vary greatly and are not always in line with the Dutch or other published national guidelines. The results of this survey highlight the need for additional comparative randomized studies to define the role of (early) ERCP in ABP. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis is a common disorder of which the underlying pathogenic mechanisms still are incompletely understood. In the last decade, increasing evidence has shown that activated pancreatic stellate cells play a key role in the fibrosis development associated with chronic pancreatitis as well as pancreatic cancer. During pancreatic injury or inflammation, quiescent stellate cells undergo a phenotypic transformation, characterized by smooth muscle α-actin expression and increased synthesis of extracellular matrix proteins. Hitherto, specific therapies to prevent or reverse pancreatic fibrosis are unavailable. This review addresses current insights into pathological mechanisms underlying chronic pancreatitis and their applicability as concerns the development of potential future therapeutic approaches. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the diagnostic yield of endoscopic ultrasonography (EUS) in patients with idiopathic acute pancreatitis (IAP), find factors predictive of a positive EUS finding in these patients and investigate whether these etiological findings are maintained during follow-up. Material and methods. We performed EUS in patients with IAP between July 2004 and August 2007. We recorded epidemiological data, the number and severity of previous bouts of pancreatitis and gallbladder status. Results. A total of 44 patients were included in the study. EUS was normal in seven patients (16%). In the remaining 37 patients (84%) we found cholelithiasis ( n = 3), microlithiasis ( n = 20), chronic pancreatitis ( n = 14), pancreas divisum ( n = 3), pancreatic mass ( n = 1), apudoma ( n = 1), cystic tumor of the pancreas ( n = 2) and choledocholithiasis ( n = 2). Positive EUS findings were not influenced by sex, severity of pancreatitis or recurrent disease. Patients aged < 65 years (age > or < 65 years: 73.9% versus 95.2%; P = 0.097) and patients with gallbladder in situ (cholecystectomy versus non-cholecystectomy: 63.6% versus 90.9%; P = 0.054) showed a tendency to have positive EUS findings. Mean follow-up was 28.95 ± 10.86 months (range 12–64 months; median 28 months). During follow-up the etiological diagnosis was changed in two patients, lowering the diagnostic yield to 79%. Conclusions. EUS identified the cause of IAP in 79% of patients. Patients with gallbladder in situ and patients aged < 65 years showed a tendency to have positive EUS findings. The majority of the diagnoses provided by EUS are maintained during follow-up and seem to be reliable. [ABSTRACT FROM AUTHOR]

Objective. Serum leptin and adiponectin determinations have been proposed as markers for distinguishing pancreatic cancer and chronic pancreatitis from autoimmune pancreatitis; however, no studies exist in patients with autoimmune pancreatitis and in those with intraductal papillary mucinous tumors of the pancreas. The aim of this paper was to evaluate the circulating concentrations of receptor for advanced glycation end products (RAGE), leptin and adiponectin in patients with chronic pancreatic diseases. Material and methods. Seventy-five consecutive patients with chronic pancreatic diseases (47 males, 28 females; mean age 67.0 ± 13.2 years; range 37–97 years) were studied: six (8.0%) had autoimmune pancreatitis, 23 (30.7%) had chronic pancreatitis, 34 (45.3%) had pancreatic cancer and the remaining 12 (16.0%) had intraductal papillary mutinous tumors of the pancreas. Leptin, adiponectin and RAGE were determined in serum using commercially available kits. The leptin concentrations were normalized to the lower and upper reference limits because of the different gender reference ranges. Results. Normalized leptin concentrations were significantly lower in chronic pancreatitis patients (0.53 ± 1.28; p = 0.008) and in those with pancreatic cancer (0.12 ± 0.33; p < 0.001) compared to the overall population (0.58 ± 1.23), whereas autoimmune pancreatitis patients had significantly higher concentrations of this protein (2.18 ± 2.56; p = 0.004) compared to the overall population. RAGE and adiponectin concentrations were similar among the four groups of patients studied. Among the clinical variables considered, only pain was significantly related to leptin concentrations (patients with pain 0.18 ± 0.54, patients without pain 1.07 ± 1.64; p = 0.001). Conclusion. Serum leptin seems to be a good serum marker for differentiating autoimmune pancreatitis patients from those with chronic pancreatitis and pancreatic cancer. [ABSTRACT FROM AUTHOR]

Background. Autoimmune pancreatitis (AIP) is a relatively newly recognized type of pancreatitis that is characterized by diffuse or focal swelling of the pancreas due to lymphoplasmacytic infiltration and fibrosis of the pancreatic parenchyma. Material and methods. A PubMed literature search was performed using the keywords “autoimmune pancreatitis”. Sometimes, bibliographies were cross-referenced and related article searches were performed once an article of interest was identified. Results. Pathologically, AIP shows narrowing of the pancreatic ducts and the intrapancreatic portion of the common bile duct. Obstructive jaundice is a common symptom at presentation, and pancreatic cancer represents an important clinical differential diagnosis. In late stages of the disease, the normal pancreatic parenchyma is often replaced by large amounts of fibrosis. Histologically, there seem to be two subtypes of the disease–one showing infiltration with IgG4-positive plasma cells but lacking granulocytic epithelial lesions (GELs), the other showing GELs but lacking strong IgG4 positivity. AIP is in at least some instances the pancreatic manifestation of a clinicopathological entity of IgG4-related systemic sclerosing disease. On the basis of pancreatic imaging, together with serological measurement of IgG4 and evaluation of other organ involvement, many AIP patients can be identified. The remaining patients require further diagnostic work-up. In these patients, pancreatic core needle biopsy and, as AIP responds to steroid treatment, also a trial with steroids, can help to differentiate AIP from pancreatic cancer. Outlook and discussion. This review presents the pathological, radiologic and laboratory findings of AIP. Moreover, the treatment and pathogenesis are discussed. [ABSTRACT FROM AUTHOR]

Objective . Experimental studies have shown that pancreatic activation of polyamine catabolism occurs during the early stage of acute pancreatitis. Changes in pancreatic polyamines are reflected in the red blood cell (RBC) polyamine contents, correlating with the extent of pancreatic necrosis. The aim of this human study was to examine the changes in polyamine levels in the RBCs of patients with acute pancreatitis. Material and methods . Twenty-four patients with acute pancreatitis (7 alcoholic, 10 gallstone and 7 of unknown etiology) were recruited in the study. Eighteen patients with non-pancreatic acute abdominal diseases were included as controls, and 6 volunteers were studied as references. Blood samples were collected on admission and during hospitalization to assess polyamine levels. After clinical recovery, the patients revisited the clinic, and RBC polyamine levels were measured again. For comparison, plasma interleukin-6 (IL-6), IL-10 and C-reactive protein (CRP) were measured. Results . In acute pancreatitis patients, there was no difference in RBC polyamine levels on admission compared with those in controls or in volunteers. Putrescine levels on admission were higher in patients with pancreatic necrosis than in patients without necrosis, but there was no difference in spermidine and spermine levels. Patients with pancreatitis of unknown etiology had significantly higher levels of polyamines on admission and throughout hospitalization, but they also had more necrosis, which explained the difference in multivariate analysis. Spermidine and spermine levels increased after clinical recovery. RBC putrescine correlated with IL-6 and IL-10, and spermine correlated with CRP. Conclusions . The results of this study suggest that RBC polyamines change in human acute pancreatitis in several respects, as has been previously observed in experimental pancreatitis. [ABSTRACT FROM AUTHOR]

Objective. Prospectively to evaluate patients with chronic asymptomatic pancreatic hyperenzymemia in order to identify possible pancreatic and non-pancreatic diseases. Material and methods. Seventy-five asymptomatic subjects with long-standing pancreatic hyperenzymemia (45 M, 30 F; mean age±SD 51.5±16.0 years, range 19-78 years, mean duration±SD of pancreatic hyperenzymemia 14.7±7.0 months, range 7-34 months) and normal ultrasonographic evaluation were included in this study. The subjects enrolled were carefully interviewed and prospectively evaluated. All patients underwent blood screening. An additional abdominal ultrasound was also carried out and, if considered necessary, other imaging and endoscopic evaluation procedures were used. Results. The follow-up of the patients after enrolment in the study was 3.3±1.8 years (mean±SD). In 38 patients (50.7%), pancreatic or extrapancreatic disease was diagnosed: 20 patients had chronic pancreatitis, 1 had autoimmune chronic pancreatitis, 1 had a benign cyst of the pancreas, 2 had serous cystadenomas, 5 had an intraductal papillary mucinous tumor of the pancreas, 3 had a ductal pancreatic adenocarcinoma, 4 patients had chronic viral hepatitis, and 2 had Crohn's disease. In 37 subjects (49.3%), no pancreatic or extrapancreatic diseases were found (3 subjects had macroamylasemia, 3 had familial hyperenzymemia, 31 had chronic non-pathological pancreatic hyperenzymemia). Conclusions. Subjects having an increase of either amylase or lipase serum levels should undergo a thorough diagnostic work-up prior to establishing the existence of chronic non-pathological pancreatic hyperenzymemia. [ABSTRACT FROM AUTHOR]

The article presents information on familial pancreatic cancer (FPC). FPC is inherited as an autosomal dominant disease with involvement of different genes and modifying genes. It is believed that tobacco smoking could be responsible for 14% of all pancreatic cancer cases. Cystic fibrosis gives a 32% higher risk of pancreatic cancer. Chronic pancreatitis is responsible for 5% of the pancreatic cancer cases.

Objective. Obesity is a known risk factor for severe acute pancreatitis (AP), but the mechanism by which it affects the severity of AP is not fully understood. The main objective of this study was to investigate the relationship between obesity and inflammatory markers in AP. Material and methods. Thirty patients with AP who developed organ failure (Group I) and 87 patients with AP who survived without organ failure (Group II) were studied. Patients' height and weight were measured at admission for calculation of body mass index (BMI). Blood samples were taken at admission for measurement of plasma interleukin (IL)-1β, IL-6, IL-10, IL-1 receptor antagonist, procalcitonin, C-reactive protein (CRP) and monocyte human leucocyte antigen (HLA)-DR expression. Results. Group I patients had higher BMI values (median 26.2 kg/m2) than Group II patients (25.2 kg/m2), p=0.033. Both CRP values and monocyte HLA-DR expression showed a significant correlation with BMI (Spearman's rank correlation r=0.32, p=0.003 and r=-0.33, p=0.002, respectively). The correlation between BMI and monocyte HLA-DR expression was significant in Group II patients (r=-0.34, p=0.002) but not in Group I patients (r=-0.02, p>0.05). There was no correlation between BMI and IL-1β, IL-6, IL-10, IL-1 receptor antagonist or procalcitonin. Conclusions. BMI did not affect either pro-inflammatory or anti-inflammatory cytokine levels in early AP. However, in patients with mild AP, BMI correlated positively with CRP levels and inversely with monocyte HLA-DR expression, which might reflect an amplified inflammatory response in these patients. Taken together, acute inflammatory response in AP, which ultimately determines the severity of AP, was little affected by BMI. [ABSTRACT FROM AUTHOR]

Objective. Fine-needle aspiration (FNA) is the procedure of choice for accurate diagnosis of infected necrosis. However, invasive procedures increase the risk of secondary pancreatic infection and the timing of FNA is still a matter for debate. Our objective was to assess the value of routine clinical tests to determine the minimal risk for infected necrosis, thereby optimizing timing and selection of patients for image-guided FNA. Material and methods. This prospective, non-randomized study comprised 90 patients with acute necrotizing pancreatitis. The data of 52 patients were used for discriminant function analysis to determine the differences between patients with infected necrosis and those with sterile necrosis. Cut-off points for variables were established using receiver operating characteristic (ROC) curve analysis and logistic regression was performed to determine the risk of infected necrosis. The clinical relevance of the defined diagnostic system was prospectively tested in a further 38 consecutive patients with acute necrotizing pancreatitis (ANP). Results. Discriminant function analysis showed that C-reactive protein (CRP) and white blood cell (WBC) values were significant discriminators between patients with sterile necrosis and those with infected necrosis. Cut-off values of 81 mg/l for CRP and 13×109/l for WBC were established. The predicted risk for infected necrosis is approx. 1.4% if both tests are below the defined cut-off values. Consequently, we found FNA unnecessary in this subset of patients, unless otherwise indicated, as this invasive procedure per se carries a certain risk of bacterial contamination. Conclusions. Routine clinical tests are helpful in diagnosing the development of infected necrosis. Based on the application of classification functions, the timing and selection of patients for image-guided FNA can be optimized. [ABSTRACT FROM AUTHOR]

Objective. Stents have been used to relieve pancreatic duct stricture and upstream dilatation. However, many of these stents are straight-type stents originally manufactured for biliary use. A plastic stent that was developed for use in the pancreatic duct was used in this study and its usefulness investigated. Material and methods. The stent (s-type stent: 10&ThickSpace;Fr in diameter) has two alternate flexions and the shape resembles the tilde mark “&nvsim;” in appearance. After obtaining informed consent, stents were placed in 20 patients with abdominal pain caused by chronic pancreatitis and stricture of the distal main pancreatic duct. The stents were removed according to the clinical manifestations and replaced with new ones if the stricture persisted. Results. In total, 33 stents were placed in 20 patients. Pain relief was attained in 19 patients (95%). The stricture improved after one stenting in 8 patients (40%). Owing to persistent stricture, the stenting was repeated in 11 patients. The 50% stent indwelling period was 369.0 days. No proximal or distal migration of the stent occurred and there were no serious complications. Conclusions. In view of its long durability as a stent and no migration, the s-stent is safe and useful for the management of pancreatic ductal strictures in patients with chronic pancreatitis. [ABSTRACT FROM AUTHOR]

The article presents an analysis of previous research and literature on the clinical and experimental evidence of pancreatitis-associated liver injury (PALI). Focus was also made on the influence of PALI in the development of other extrapancreatic organ dysfunctions, the pattern of liver cell injury and death, the role of cytokines, the function of pancreatitis-associated ascitic fluid, and changes in liver metabolism.

Objective. The aim of this study was to compare long-term recurrence and death rates after a first episode of acute pancreatitis in patients with and without gallstones. Additionally, it was of interest to find out if there were factors predictive of readmission or death. Material and methods. Over a period of 3 years (1995 to 1998), 155 patients admitted with a first attack of acute pancreatitis were included in the study. They followed a specific protocol (ultrasound within 24 h, laboratory tests, Ranson scoring and patients with severe pancreatitis computed tomography scans). In gallstones, pancreatitis, either ERCP or cholecystectomy, was performed at admission or in the case of the latter within 4 weeks. A follow-up was done in January 2002. Results. Forty-one percent of the patients without gallstones were readmitted to hospital during the period of follow-up compared to 10% in the group of patients with gallstones. Using multivariate analysis, no factors were significantly predictive of readmission. Conclusions. We found an identical mortality rate of 15% in the two groups, the only predictive factor being age. [ABSTRACT FROM AUTHOR]

Background: Although many patients with autoimmune pancreatitis undergo steroid therapy, detailed evaluation of morphological changes in the pancreas and bile duct following therapy has not been performed in this disease. In this study serological and morphological changes occurring during steroid treatment of autoimmune pancreatitis are comparatively examined. Methods: Ten patients with autoimmune pancreatitis were treated with corticosteroids. Morphological findings were: pancreatic enlargement ( n = 9), irregular narrowing of the main pancreatic duct ( n = 10), and biliary stenosis ( n = 9). An initial dose of prednisolone was 40-30 mg/day, and this was tapered by 5 mg every 1-2 weeks. All patients underwent ultrasound and serological testing 1-2 weeks after commencing medication, followed by weekly serological testing and by CT and endoscopic retrograde cholangiopancreatography after1-2 months. Radiological and serological changes were compared. Results: All 10 patients were responsive to steroid therapy. Pancreatic size normalized within 1 month; however, irregularity of the pancreatic duct remained in 6 patients. Rigidity or lateral deformity of the bile duct remained in 3 patients and biliary stenosis persisted in 5. Four patients in whom elevated serum IgG4 failed to normalize also showed incomplete morphological improvement. Three patients with complete improvement of the pancreatic duct stopped medication, but recurrence of pancreatitis did not occur. Conclusions: Although steroid therapy was morphologically and serologically effective in patients with autoimmune pancreatitis, cholangiopancreatographic abnormalities remained in many patients. Morphological improvement on cholangiopancreatography and normalization of serum IgG4 after steroid therapy appeared to be good indicators for discontinuing medication in patients with autoimmune pancreatitis. [ABSTRACT FROM AUTHOR]

Examines the state of insufficiency of exocrine in acute pancreatitis. Pathophysiology of acute pancreatitis; Identification of the most important function of the exocrine pancreas which is the secretion of enzymes and fluid into the gut to digest nutrients; Exocrine pancreatic function during the acute phase of acute pancreatitis.

Background: Cytokines are markers of acute pancreatic inflammation and essential for distant organ injury, but they also stimulate pancreatic fibrogenesis and are thus involved in the progression from acute pancreatitis to chronic pancreatic injury and fibrosis. The aim of this study was to evaluate the circulating levels of IL-6, MCP-1, TGF-β1, IGF-1 and IGFBP-3 in patients with alcoholic chronic pancreatitis (CP). Methods: Twelve male patients with severe CP and 11 matched controls ingested 40 g alcohol. Plasma cytokine concentrations were measured for 24 h and assessed by sandwich ELISA techniques. Results: IL-6 was higher in CP at fasting and 1, 4 and 24 h after alcohol intake ( P < 0.04), and a significantly greater rise was found at 1 h compared to pre-stimulatory conditions and controls ( P < 0.01). MCP-1 plasma levels in CP were significantly decreased at 1 h ( P < 0.01) and 4 h ( P < 0.001) compared to pre-stimulatory levels and controls, and a variance analysis showed significantly ( P < 0.001) lower post-stimulatory levels at 1 h and 4 h both in CP and in controls. Alcohol consumption (40 g), however, did not influence plasma levels of TGF-1β, IGF-1 or IGFBP-3 in either of the two groups at the time frame applied. Conclusions: Acute alcohol intake induces a rise in the plasma levels of IL-6 in CP as compared to controls. The low circulating concentrations of MCP-1 1 and 4 h following alcohol consumption might possibly reflect that this mediator acts locally via autocrine mechanisms. [ABSTRACT FROM AUTHOR]

The article presents views and insights of the author concerning the compliance with guidelines for the management of acute pancreatitis. Guidelines in acute pancreatitis have been produced by national societies, by international societies, and simply by groups of interested pancreatologists. According to the author, guidelines should be commissioned by existing societies and be based on as high a level of evidence as possible, with grade of recommendation stated clearly.

The article focuses on a study regarding gastrointestinal motility in acute pancreatitis. It mentions that the study reveals the high prevalence of dysmotility-related symptoms in patients with acute pancreatitis with the help of Gastroparesis Cardinal Symptom Index (GCSI). It also mentions that gastrointestinal symptoms are limited and similar in character in acute or chronic states of dysmotility.