Form Of Chronic Pancreatitis Research Articles

Chronic pancreatitis: a changing etiology or a gap in technological medicine

Alcohol is considered the most important risk factor for the development of chronic pancreatitis. The possibility of evaluating CFTR mutations and the discovery of other gene mutations has led to a better evaluation of the familiar/hereditary forms of chronic pancreatitis and the identification of autoimmune pancreatitis has further improved our knowledge of the disease. However, recent studies on chronic pancreatitis on a worldwide level reveal an increase in the idiopathic forms of the disease. Clinicians must pay greater attention to identifying the factors associated with chronic pancreatitis.

Severe obstructive jaundice in a young patient with IgG4-negative autoimmun pancreatitis – treatment without invasive procedures

Introduction: Autoimmun pancreatitis should be a differenzial diagnosis from other form of chronic pancreatitis and pancreas malignancies in jaundice, abdominal pain, weight loss with pancreas enlargement, narrowing of the bile duct and abnormal immunserological tests. Here we report a 28-year-old previously healthy male with ANA, IgG4- negative autoimmun pancreatitis according to the findings of serum biochemistry, CT and ERCP. Our patient presented with a 1 month history of obstructive jaundice, epigastrial pain, weight loss after using itraconazol for skin mycosis. His serum bilirubin and ALP were highly elevated on admission. The transaminase levels were only mildly elevated and serum amylase was in normal range. Abdominal US showed a dilated common bile duct (CBD) and intrahepatic biliary radicals, the head and body of the pancreas was bulky. There were no gallstones, CBD stones or any mass lesions in the CBD. The CT scan of the abdomen showed the enlargement of the head and body with dilated intra-and extrahepatic bile ducts. Hypergammaglobulinaemia, autoantibodies and elevated serum IgG4 levels were not detected. CA 19–9, CEA were in normal range. Fine needle aspiration of the pancreas was done, malignancy was not observed. During ERCP diffuse narrowing of pancreatic duct and intrapancreatic part of the CBD were found, papillotomy and biliary drainage were not performed. Biopsy was taken from the papilla of Vateri, IgG4 positive cells were not detected. Diabetes mellitus appeared, needing just diet. Oral prednisolon therapy was started. After a few weeks, the diffuse enlargement of the pancreas on CT reverted to normal. Dilation of the bile ducts and elevated liver enzymes normalized. Paralelly clinical improvement was observed, abdominal pain, weigt loss and jaundice resolved, serum blood glucose levels normalized on diet. Conclusion: AIP was diagnosed based on clinical symptoms and ERCP pictures. Early initiation of corticostreoid therapy may prevent invasive endoscopic procedures in the management of obstructive jaundice.

Pancreatitis del surco y su diagnóstico diferencial con el adenocarcinoma de páncreas

We analyzed the clinical, radiographic and histologic characteristics, as well as the difficulties that arose in the differential diagnosis between groove pancreatitis (a benign entity consisting of a segmental form of chronic pancreatitis occurring as a sheet-like scar in the area of pancreatoduodenal groove) and adenocarcinoma of the pancreas. To this end, four cases with abnormalities in the groove area were retrospectively reviewed, three with groove pancreatitis, and one with adenocarcinoma of the pancreas. The important role of imaging techniques is highlighted, with emphasis on magnetic resonance imaging of the pancreas and magnetic resonance cholangiography, which reveal certain differentiating characteristics between these two entities. However, distinguishing between these entities is often difficult, and sometimes impossible. Consequently, cyto-histological study is always required.

Type 1 Diabetes versus Type 2 Diabetes with Onset in Persons Younger than 20 Years of Age

Type 1 diabetes (T1D) is the most common form of diabetes in children in Western countries. There have been no large studies of childhood diabetes from India. We undertook the MEDI study (Multicenter Survey of Early Onset Diabetes in India) to assess the proportion of various subtypes of diabetes among the young subjects presenting to the endocrinology divisions of seven large teaching hospitals in different regions of India. In addition, we compared the clinical features of T1D and type 2 diabetes (T2D) in Indian subjects. Patients with onset of disease at younger than 20 years of age were included in this study. Six hundred and three subjects (603) were studied of whom 535 subjects (89%) had T1D, 36 (6%) had T2D, 18 (3%) had diabetes related to tropical pancreatitis or other forms of chronic pancreatitis, while other subtypes accounted for the rest. Compared to those with T2D, subjects with T1D were younger, had a lower C-peptide level, higher prevalence of ketosis, lower prevalence of acanthosis nigricans, and lower LDL and triglyceride levels. When compared with that of T2D, a higher proportion of patients with T1D were positive for GAD-65 and IA-2 antibodies, and this difference was statistically significant for GAD-65 antibodies. Overall, this large multicenter study showed that T1D is the commonest form of diabetes in childhood. T2D is the next most common kind, while chronic pancreatitis-related diabetes is uncommon.

ONSET OF EXOCRINE AND ENDOCRINE INSUFFICIENCY IN THE FOLLOW UP OF PATIENTS SUFFERING FROM AUTOIMMUNE PANCREATITIS (AIP)

Background: Autoimmune pancreatitis (AIP) is particular form of pancreatitis where an immune-mediated mechanism has been postulated. Few data are available from the literature for the long-term outcome of the disease. Aim: To investigate the onset of exocrine and endocrine insufficiency in patients suffering from AIP compared to patients suffering from other forms of chronic pancreatitis (CP). Patients and Methods: Patients suffering from AIP, from CP associated with daily alcohol intake higher than 80 g/day for at least 5 yrs (ACP), and from idiopathic CP (ICP) were enrolled. Inclusion criteria were: admission from 1996 to 2006; clinical onset of the disease within 1 year from the admission; no previous diagnosis of chronic pancreatitis. Definitive diagnosis of CP based on the basis of clinical history, radiological investigations, pancreatic function tests, histology, surgical evidence. All patients were therefore followed at least every two years. Exocrine pancreatic insufficiency was diagnosed on the basis of faecal fat output >7 g/day or faecal elastase-1 lower than 100 μg/g of stool. Endocrine pancreatic insufficiency (diabetes) was diagnosed on the basis of fasting serum glucose levels higher than 127 mg/L or abnormal oral glucose tolerance test (OGTT). Results: 70 AIP patients (46 M and 29 F, mean age 43.1 ± 15.4 yrs), 57 ACP (54 M and 3 F, mean age 43.9 ± 9.7 yrs) and 40 ICP (18 M and 22 F, mean age 43.6 ± 13 yrs) were studied. The survival curve for the onset of pancreatic exocrine and endocrine insufficiency was similar in AIP compared to ACP and ICP. Exocrine pancreatic insufficiency, but not endocrine, was significantly correlated with pancreatic surgery in AIP but not in non AIP-CP groups (p < 0.0001). Conclusions: The onset of exocrine and endocrine insufficiency in AIP is similar to that observed in ACP and ICP. This indicates that the inflammatory process in AIP is chronic, with a progressive destruction of pancreatic parenchyma, even in the absence of clinical signs and symptoms.

A case series of autoimmune pancreatitis: how can we avoid unnecessary surgery?

Background: Autoimmune pancreatitis (AIP) is a special form of chronic pancreatitis that can be treated with steroids. Jaundice is one of the main presentations of this condition which mimics pancreatico-biliary malignancy. Many physicians are not fully aware of this condition, and do not realize some typical features that can help the diagnosis before sending patients for unnecessary surgery. Objective: To report a case series of AIP in which surgery could have been avoided. Methods: We studied 4 autoimmune pancreatitis patients who presented either unexplained obstructive jaundice or pancreatic head mass. Results: Of the 4 patients, two underwent surgery and unfortunately one died post operatively. The other 2 patients were diagnosed using typical cholangiopancreatograms and surgery was avoidable. All 4 had elevated immunoglobulin isotype 4 (IgG4) level, and 3 had typical pancreatograms suggestive of autoimmune pancreatitis. Conclusion: Patients who present unexplained obstructive jaundice or pancreatic head mass should be subjected to helpful imaging studies and laboratory features on the possibility of autoimmune pancreatitis before sending them to surgery.

Tropical Pancreatitis

Purpose: Case Presentation: A 29 year old female immigrant from India presented with a 5 month history of recurrent abdominal pain. Past medical history was significant for vitamin B12 deficiency, iron deficiency anemia and acute pancreatitis. History was negative for smoking, alcohol, drug use, gallstone disease, constitutional symptoms and medication use. Lab work was unremarkable. Abdominal CT showed extensive calcification within the head, body and tail of the pancreas and dilated pancreatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) showed a pancreatic duct stricture in the neck of the pancreas. Stent placement did not relieve pain. Repeat ERCP showed multiple calcified stones with a large stone in the head of the pancreas causing obstruction. Endoscopic shock wave lithotripsy (ESWL) and ERCP were attempted for stone removal but were unsuccessful. Surgical decompression (lateral pancreaticojejunostomy) was effective in achieving pain relief. The patient was diagnosed with Tropical Pancreatitis (TP). Discussion: TP is a form of chronic pancreatitis (CP) found in people residing within 30 degrees of the equator (Asia, Africa, South America). It is the most common type of CP in India, accounting for approximately 70% of patients with CP. The etiology of TP is unknown. Environmental factors and decreased inhibitory capacity within the pancreas (SPINK1 mutation) have been implicated. Characteristic features of TP include young age at onset, residence in the tropics, absence of alcohol use, no other cause of CP, large duct disease with ductal dilatation, large pancreatic calculi (predominantly in the head) and chronic abdominal pain. Patients can develop nutritional deficiencies and insulin-requiring diabetes. They are at high risk of pancreatic cancer. Management is directed towards pain relief, and control of diabetes and steatorrhea. ERCP coupled with ESWL has been used for stone fragmentation and removal in patients unresponsive to medical therapy. Recently, surgical decompression and drainage have been shown to be more effective than endoscopic treatment in patients with obstruction of the pancreatic duct. TP is an important diagnosis to consider in an immigrant patient from the tropics with chronic abdominal pain and pancreatic calcification.

Tropical Pancreatitis: an unusual case of chronic pancreatitis in juveniles

Immigration from tropical areas increases the incidence of illnesses not common in developed countries. We present a patient with tropical chronic pancreatitis (TCP), a juvenile form of chronic pancreatitis found predominantly in developing countries in tropical regions of the world.

Refractory Autoimmune Pancreatitis: Azathioprine or Steroid Pulse Therapy

TO THE EDITOR: We read with interest the article by Church et al. (1) on autoimmune pancreatitis (AIP) in the first series from the United Kingdom. They diagnosed 11 patients with AIP and treated them with oral steroid. Altough initial response to steroid therapy was excellent in all patients, six patients (55%) relapsed on steroid reduction or withdrawal, and four of them responded to azathioprine and increased steroid. Because azathioprine therapy may cause acute pancreatitis and requires frequent blood tests for early detection of side effects (2–4), a safe and simple alternative for refractory AIP is needed. AIP is a recently described unique form of chronic pancreatitis characterized by sausage-like diffuse swelling of the pancreas, a diffusely irregular narrowing of the main pancreatic duct, a high serum IgG4 concentration, and a response to oral steroid therapy (5, 6). In unresponsive patients with the biliary stenosis caused by AIP, surgery may be necessary for the relief of symptoms and for differentiation from malignancy (5). Because oral steroid therapy requires a long period for the drug tapering, the biliary stenosis suspected to be caused by AIP but cannot be distinguished from malignancy is not indicated for the therapy (5, 6). Steroid pulse therapy is a well-recognized alternative for refractory autoimmune disorders without steroid tapering. We, therefore, applied the therapy for refractory AIP, resulting in dramatic response for a short period (5, 6). Azathioprine is an effective drug as a maintenance and steroid-sparing agent in autoimmune disorders and organ transplants (2–4). Although azathioprine is widely used in Crohn’s disease, a major drawback is the frequent occurrence of side effects, especially acute pancreatitis(2). A large population-based case-control study found an eight-fold increased relative risk of acute pancreatitis in all users of azathioprine (3). In animal models, azathioprine involves activation of circulating vasoactive mediators, formation of microthrombi, or direct injury of the capillary endothelium, and then deteriorates pancreatic microcirculation, thereby increasing ischemia and acinar cell injury (4). Altough further comparative studies are needed, we believe that azathioprine therapy should be avoided in pancreatic diseases such as AIP, whereas steroid pulse therapy is a more effective alternative for refractory AIP.

Autoimmune pancreatitis: negotiating the labyrinth of terminology, diagnosis and differential diagnosis

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that typically affects adults with a male predilection. Jaundice, weight loss, anorexia and abdominal pain are the most common presenting symptoms. Serum IgG and IgG4 are frequently elevated. Imaging studies show diffuse enlargement of the pancreas with diffuse or segmental narrowing of the main pancreatic duct. When pancreatic involvement is focal, it can mimic adenocarcinoma on imaging. Histologically, the disease is characterized by a duct-centric fibroinflammatory process, dense lymphoplasmacytic infiltrates and phlebitis. High numbers of IgG4-positive plasma cells are frequently present. The absence of duct dilatation, pseudocyst, fat necrosis or calcification aids in the distinction from alcoholic pancreatitis. AIP can involve other sites in the pancreaticobilairy tree and is frequently associated with other autoimmune and fibrosclerosing diseases. This has led to the concept that AIP is the pancreatic manifestation of systemic IgG4-related immunological disease. The prognosis is generally favourable with an excellent response to steroids.

Surgical Treatment of Alcohol-Associated Chronic Pancreatitis: The Challenges and Pitfalls

Long-term excessive alcohol consumption is the most common risk factor for the development of chronic pancreatitis. Management of patients with alcohol-associated chronic pancreatitis can be complicated by problems associated with dependency, psychosocial burden, and physical changes like malnutrition and hepatic insufficiency. The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 184), pancreatoduodenectomy (PD, n = 97), or distal pancreatectomy (DP, n = 91) for chronic pancreatitis were retrospectively analyzed. Long-term outcome was assessed by patient survey with a median follow up of 5.5 +/- 0.2 years. Of 372 patients, 171 underwent surgery for alcohol-associated chronic pancreatitis. According to patient questioning, the prevalence of alcohol cessation before surgery in the 171 patients was 81 per cent. Operative morbidity in the 171 patients was 20 per cent, 50 per cent, and 26 per cent after LPJ, PD, and DP, respectively, with an overall perioperative mortality rate of 2 per cent. None of the patients developed delirium tremens using an alcohol withdrawal protocol. Continued alcohol abuse before surgery did not affect perioperative morbidity (P > 0.05). Follow up was available for a total of 229 patients, of which 39 per cent with alcohol-associated chronic pancreatitis had died compared with 16 per cent in the nonalcohol group (P < 0.001). Of the remaining 171 patients, 45 per cent with alcohol-associated chronic pancreatitis had good pain control compared with 49 per cent of the remainder (P > 0.05). Continuation of alcohol abuse after operation did not affect success for pain control at follow up (P > 0.05). Surgical treatment of alcohol-associated chronic pancreatitis can be performed with similar morbidity and mortality compared with other forms of chronic pancreatitis. Alcohol cessation is preferred but not mandated to achieve good operative long-term outcome. Caution needs to be taken to prevent postoperative alcohol withdrawal. Long-term follow up with psychosocial support and management of co-existing addictions is important.

Autoimmune pancreatitis

Autoimmune pancreatitis is a rare form of chronic pancreatitis. Its clinical relevance, however, cannot be dismissed, as it can be difficult to distinguish autoimmune pancreatitis from malignant pancreatic cancer and in contrast with the majority of chronic pancreatitis forms it can be efficiently treated, even complete remission can be achieved on steroid therapy. The clinical picture of autoimmune pancreatitis is not characteristic, obstructive jaundice, abdominal pain, weight loss are frequently observed. Imaging studies often show diffuse pancreas enlargement and irregular narrowing of the main pancreatic duct. Elevated serum IgG4 immunoglobulin concentrations, some autoantibodies and the presence of IgG4 positive immune cells were observed in addition to other histological features. Apart from pancreatic manifestations, other organs may also be affected, thus associations with sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, Riedel thyroiditis and inflammatory bowel diseases have been described. Based on these findings, autoimmune pancreatitis should be regarded as a systemic disease, as a manifestation of systemic IgG4-related sclerosing disease.

Novel mutations in the calcium sensing receptor gene in tropical chronic pancreatitis in India

Objective. Tropical chronic pancreatitis (TCP) is a form of chronic pancreatitis seen in many tropical countries in young non-alcoholic subjects who are often malnourished. Nutritional deficiencies, either at the macro or micro level, and food toxins have been implicated in its causation, although there is no final proof to confirm this suggestion. Mutations of SPINK1 and CFTR genes have been proposed as disease modifiers, or as determinants of phenotypes. Mutations involving the calcium sensing receptor (CASR) have been suggested to increase the risk of chronic pancreatitis (CP), since high intracellular levels of calcium activate trypsinogen within the acinar cells. A combination of CASR and SPINK1 gene mutations has been proposed to predispose to idiopathic CP. The purpose of this study was to report on novel mutations in CASR, identified in TCP patients. Material and methods. We screened our TCP patients for mutations in CASR and SPINK1 genes. In a cohort of 35 patients and an equivalent number of controls, genomic DNA was screened for mutations in CASR and SPINK1 by direct DNA sequencing. Results. Four new mutations were found in the CASR gene. A combination of both SPINK1 (N34S) and CASR mutations was seen in 6% of the patients, while 22% harbored a single mutation. Conclusions. Our study suggests, for the first time, that CASR mutation may be a risk for TCP, and that this risk may be further increased if there is an associated SPINK1 mutation.

Pancréatite auto-immune

Chronic autoimmune pancreatitis is an entity distinct from all other forms of chronic pancreatitis. It is expressed by signs of acute or chronic pancreatitis, sometimes associated with cholestatic jaundice. In imaging, it may appear as diffuse (duct destructive) or pseudotumoral lesions. These 2 aspects are probably different clinical forms of chronic autoimmune pancreatitis. Some autoimmune diseases are associated with chronic autoimmune pancreatitis, but not consistently. One such disease involves a bile disorder very similar to primary sclerosing cholangitis but responsive to corticosteroid treatment. Pancreatitis may be a sign of intestinal inflammatory diseases (and vice versa): testing for Crohn's disease and ulcerative rectocolitis is justified in patients with idiopathic pancreatitis. Chronic autoimmune pancreatitis must be routinely considered in patients with a pancreatic tumor that is for a clinical, epidemiologic, serologic or imaging reason not completely consistent with pancreatic adenocarcinoma. A short corticosteroid therapy (< 4 weeks) is probably less harmful in a patient with pancreatic adenocarcinoma than pancreatectomy (or chemotherapy) in patients with chronic autoimmune pancreatitis. Diagnosis depends on a body of clinical and radiologic evidence. The diagnostic value of serologic markers and especially of autoantibodies must be clarified in the future.

The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease

Several classification systems of chronic pancreatitis have been proposed to provide a basis for treatment and research. All of these previous classifications were designed at the height of pancreatic research of their respective times; thus, each represented the most current knowledge available to pancreatologists at the time. However, none of these classifications provide simultaneously a simple standardized system for the clinical classification of chronic pancreatitis according to etiology, clinical stage, and severity of the disease, nor are they consistently useful for directing clinical practice and comparing interinstitutional data. Thus, we aimed to develop a new classification system of chronic pancreatitis to provide a framework for studying the interaction of various risk factors on the course of the disease. We reviewed the literature on the clinical course of all different forms of chronic pancreatitis, and we reviewed all previous classification systems of the disease. This approach provided a basis for the development of a new and unifying classification of chronic pancreatitis. We established the M-ANNHEIM multiple risk factor classification system based on the current knowledge of acute and chronic pancreatitis. This classification allows patients to be categorized according to the etiology, clinical stage, and severity of their disease. The severity of pancreatic inflammation was assessed using a scoring system that takes into account the clinical symptoms and treatment options of chronic pancreatitis. Finally, four hypothetical patients were categorized according to the M-ANNHEIM classification system to provide examples of its applicability in clinical practice. The M-ANNHEIM multiple risk factor classification system is simple, objective, accurate, and relatively noninvasive, and it incorporates etiology, different stages of the disease, and various degrees of clinical severity. This new classification system will be helpful for investigating the impact and interaction of various risk factors on the course of the disease and will facilitate the comparison and combination of interinstitutional data.

Immunoglobulin G4 associated cholangitis: Description of an emerging clinical entity based on review of the literature

During the last decade, patients with steroid responsive sclerosing cholangitis have been described in a number of case reports and a few cases series. These patients meet diagnostic criteria for primary sclerosing cholangitis (PSC) but seem to have a better prognosis and are often, but not always, associated with autoimmune pancreatitis (AIP). Unlike biliary strictures in PSC, most PSC-like biliary strictures seen in association with AIP respond well to steroids and some have been shown to resolve after immunosuppressive treatment during prolonged follow-up. In addition, steroid-responsive dominant bile duct lesions, sometimes mimicking infiltrating hilar cholangiocarcinoma, without pancreatic abnormalities have also been reported. Here we review the literature on this emerging clinical entity and suggest that this condition of steroid responsive biliary strictures be named Immunoglobulin G4 (IgG4) Associated Cholangitis (IAC). We performed an electronic database search of MEDLINE for case reports and case series of sclerosing cholangitis with pancreatitis and/or pancreatic mass (1960–July 2006). Articles were limited to English and these case reports and cases series were reviewed and all references on the combination of sclerosing cholangitis and pancreatitis as well as IgG4 positive cholangitis without pancreatic involvement not identified by our original search were obtained. Terminology and Definition

Long-term Follow-up in Small Duct Chronic Pancreatitis

A pancreatic duct diameter (PDD) ranging from 4 to 5 mm is regarded as "normal." The "large duct" form of chronic pancreatitis (CP) with a PDD >7 mm is considered a classic indication for drainage procedures. In contrast, in patients with so-called "small duct chronic pancreatitis" (SDP) with a PDD <3 mm extended resectional procedures and even, in terms of an "ultima ratio," total pancreatectomy are suggested. Between 1992 and 2004, a total of 644 patients were operated on for CP. Forty-one prospectively evaluated patients with SDP underwent a new surgical technique aiming at drainage of the entire major PD (longitudinal "V-shaped excision" of the anterior aspect of the pancreas). Preoperative workup for imaging ductal anatomy included ERCP/MRCP, visualizing the PD throughout the entire gland. The interval between symptoms and therapeutic intervention varied from 12 to 120 months. Median follow-up was 83 months (range, 39-117 months). A pain score as well as a multidimensional psychometric quality-of-life questionnaire was used. Hospital mortality was 0%. The perioperative (30 days) morbidity was 19.6%. Postoperative, radiologic imaging showed an excellent drainage of the entire gland and the PD in all but 1 patient. Global quality-of-life index increased in median by 54% (range, 37.5%-80%). Median pain score decreased by 95%. Twenty-seven patients (73%) had complete pain relief. Sixteen patients (43%) developed diabetes, while the exocrine pancreatic function was well preserved in 29 patients (78%). "V-shaped excision" of the anterior aspect of the pancreas is a secure and effective approach for SDP, achieving significant improvement in quality of life and pain relief, hereby sparing patients from unnecessary, extended resectional procedures. The deterioration of exocrine and endocrine pancreatic functions is comparable with that observed during the natural course of the disease.

THE M-ANNHEIM CLASSIFICATION OF CHRONIC PANCREATITIS - A NEW CLASSIFICATION SYSTEM ACCORDING TO ETIOLOGY, CLINICAL STAGES AND SEVERITY OF THE DISEASE

Introduction: Several classification systems of chronic pancreatitis have been proposed to provide a basis for treatment and research. All of these previous classifications were at the height of their respective time and represented the available knowledge in pancreatology at that time. However, none of these classifications provided, at the same time, a simple standardized system for clinical classification of chronic pancreatitis according to etiology, clinical course and severity of the disease, or was consistently useful in directing clinical practice and comparing interinstitutional data. We aimed to develop a new classification system of chronic pancreatitis to provide a framework to study the interaction of various risk factors on the course of the disease. Methods: We reviewed the literature on descriptions of the clinical course of all different forms of chronic pancreatitis, and we reviewed all previous classification systems of the disease. Patients with chronic pancreatitis (n = 25 consecutive patients from clinical practice) were recruited. Results: Based on the current knowledge of acute and chronic pancreatitis, we established the M-ANNHEIM multiple risk factor classification system. The severity of pancreatic inflammation was assessed with a scoring system that includes clinical symptoms and treatment options of chronic pancreatitis. Finally, the new classification system successfully categorized our cohort of patients with chronic pancreatitis according to the disease etiology, the stages and the severity of the disease. Conclusions: The M-ANNHEIM multiple risk factor classification system is simple, objective, accurate and relatively noninvasive and incorporates etiology, different stages of the disease and various degrees of clinical severity. This new classification will be helpful in investigating the impact and interaction of various risk factors on the course of the disease. This system will also facilitate the comparison and combination of interinstitutional data.

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Der betagte Patientmit chronischer Pankreatitis/Pankreaskarzinom

Chronic pancreatitis is mostly caused by heavy alcohol consumption and is characterized by the onset of symptoms in the fourth and fifth decade. Beginning in patients older than 65 years of age is rare. Leading symptom is recurrent or persisting abdominal pain which is missed only in approximately 5% of the cases. Chronic pancreatitis is classified as idiopathic if there is no anamnesis of alcohol abuse or some rare specific causes. The Idiopathic Chronic Senile Pancreatitis (ICSP) is a subset of the non-alcoholic pancreatitis and is characterized by advanced age at the time of first manifestation. Although life expectancy especially in chronic alcoholic pancreatitis is reduced, there are many patients who reach older age. The natural history in all forms of chronic pancreatitis shows a decrease in pain and the manifestation of exocrine and endocrine insufficiency as late complications. Especially in the elderly loss of weight may occur with steatorrhea and pancreatic diabetes mellitus as the dominating clinical problem of chronic pancreatitis. If pain persists treatment is symptomatically with analgesics. The possibility of causal surgery or the indication for endoscopic treatment of painful chronic pancreatitis should be proven in every single case. Standard pancreatin treatment consisting of large amounts of enzymes will abolish maldigestion. Pancreatic diabetes requires often insulin, there is a tendency to hypoglycaemia. In contrast to chronic pancreatitis cancer of the pancreas is a typical and frequent disease of the elderly. The prognosis is bad and one year life expectancy is just about 11%. One of the reasons is, that the diagnosis is found lately because early symptoms are missing. Specific symptoms like pain, weight loss or jaundice occur lately. In suspicion of pancreatic cancer a lot of methods of morphological diagnostic are available such as CT, MRCP, ultrasound, ERCP and PET, in addition the specific tumor markers CA 19-9 and CEA. After diagnostic is completed, curative resection is possible in only a low percentage of all cases. Old age is no contraindication for surgery, prognosis and the risk of surgery don't differ to other age groups. In most cases palliative therapy is the only possible option because of an advanced tumor stage. Sufficient pain therapy, endoscopic stenting in case of obstructive jaundice or gastroenterostomy in case of duodenal are useful interventions.