Risk Factors For Pancreatitis Research Articles

Risk factors for pancreatitis in older women: the Iowa Women's Health Study

PurposePancreatitis—an inflammation of pancreas—is a severe and costly disease. Although many risk factors for pancreatitis are known, many pancreatitis cases, especially in elderly women, are of unknown etiology. MethodsRisk factors for acute pancreatitis (AP) and chronic pancreatitis (CP) were assessed in a prospective cohort (n = 36,436 women, aged ≥ 65 years). Exposures were self-reported at baseline. Pancreatitis was ascertained by linkage to Medicare claims (1986–2004) categorized by a physician as follows: “AP”, one AP episode (n = 511) or “CP”, 2+ AP or 1+ CP episodes (n = 149). ResultsMultivariable odds ratios (ORs) and 95% confidence intervals for AP and CP were calculated using multinomial logistic regression. Alcohol use was not associated with AP or CP. Heavy smoking (40+ vs. 0 pack-years) was associated with a twofold increased OR for CP. For body mass index greater than or equal to 30 versus less than 25 kg/m2, the ORs were 1.35 (1.07–1.70) for AP (P trend = .009) and 0.59 (0.37–0.94) for CP (P trend = .01). ORs for AP and CP were increased for hormone replacement therapy use, heart disease, and hypertension. There were positive significant associations between protein and total fat intake for CP and AP. ConclusionsWe identified factors associated with AP and CP that may be specific to older women.

Acute Pancreatitis-Induced by Platinum Compounds in Patients with Cancer: A Review of Literature

The purpose of this review of the literature was to describe the relationship between use of platinum-based antineoplastics and development of acute pancreatitis in patients with cancer. A literature search was conducted using PubMed, Science Direct and Google scholar databases for articles published from 1985 to 2014. The headings and/or text words (platinum compounds), (acute pancreatitis-induced by platinum compounds), and (cisplatin, carboplatin, and oxaliplatin) were entered, and the search was limited to articles describing case reports in adults with cancer. A total of 12 cases were reported between 1985 and 2012; including three platinum compounds; cisplatin, carboplatin, and oxaliplatin. In conclusion, it is highly recommended to include baseline assessment for acute pancreatitis risk factors and to consider acute pancreatitis in the differential diagnosis of abdominal pain in patients who have received platinum-based chemotherapy.

Smoking, drinking, and pancreatitis: a population-based cohort study in Taiwan.

In Western population, smoking is a dose-dependent risk factor for pancreatitis, whereas a threshold of 5 drinks per day may exist for alcohol to increase pancreatitis risk. Given ethnic differences in tobacco and alcohol metabolism, we examined the associations between smoking, alcohol, and pancreatitis in Asians. A population-based cohort was assembled using participants of the National Health Interview Survey in Taiwan. Information on drinking and smoking was collected by in-person interview at baseline. Incident cases of pancreatitis were identified through data linkage with National Health Insurance claims database. During 94,601 person-years of follow-up, 66 incident cases of pancreatitis occurred. Neither current nor ever smoking was associated with the incidence of pancreatitis (adjusted hazard ratio [aHR] 1.13; 95% confidence interval [CI], 0.62-2.06; and aHR, 1.14; 95% CI, 0.63-2.06, respectively). Dose-response analysis also showed no association between smoking and pancreatitis. By contrast, regular (aHR, 3.09; 95% CI, 1.51-6.30) and heavy alcohol drinking (aHR, 6.46; 95% CI, 3.07-13.60) were associated with an increased incidence of pancreatitis compared with abstinence. In this Asian population-based cohort, alcohol was associated with pancreatitis in a dose-dependent way, but smoking was not associated with pancreatitis. These results support for ethnic differences in susceptibility to smoking- and alcohol-related pancreatitis.

Incidence of pancreatitis and pancreatic cancer in a randomized controlled multicenter trial (SAVOR-TIMI 53) of the dipeptidyl peptidase-4 inhibitor saxagliptin.

To determine the incidence of pancreatitis and pancreatic cancer in the SAVOR-TIMI 53 trial. A total of 16,492 type 2 diabetic patients ≥40 years old with established cardiovascular (CV) disease or CV risk factors were randomized to saxagliptin or placebo and followed for 2.1 years. Outcome measures were investigator reported with blinded expert adjudication of total pancreatitis (acute and chronic) and reported cases of pancreatic cancer. Trial investigators reported 35 events of pancreatitis in each treatment arm in 63 patients (33 [0.40%] in the saxagliptin arm and 30 [0.37%] in control arm), with a hazard ratio (HR) of 1.09 (95% CI 0.66-1.79, P = 0.80). Adjudication confirmed pancreatitis in 24 patients (26 events) in the saxagliptin arm (0.29%) and 21 patients (25 events) in placebo arm (0.26%), with an HR of 1.13 (0.63-2.06, P = 0.77). Cases of definite acute pancreatitis were confirmed in 17 (0.2%) vs. 9 (0.1%) (HR 1.88 [0.86-4.41], P = 0.17), definite plus possible pancreatitis in 22 vs. 16 (HR 1.36 [0.72-2.64], P = 0.42), and chronic pancreatitis in 2 vs. 6 (HR 0.33 [0.05-1.44], P = 0.18) in the saxagliptin and placebo arms, respectively. No differences in time to event onset, concomitant risk factors for pancreatitis, investigator-reported causality from study medication or disease severity, and outcome were found between treatment arms. The investigators reported 5 and 12 cases of pancreatic cancer in the saxagliptin and placebo arms, respectively (HR 0.42 [0.13-1.12], P = 0.09). In the SAVOR-TIMI 53 trial, within 2.1 years of follow-up, risk for pancreatitis in type 2 diabetic patients treated with saxagliptin was low and apparently similar to placebo, with no sign of increased risk for pancreatic cancer. Further studies are needed to completely resolve the pancreatic safety issues with incretin-based therapy.

Endoscopic Papillary Large Balloon Dilation for Treatment of Large Bile Duct Stones Does Not Increase the Risk of Post-procedure Pancreatitis

Endoscopic sphincterotomy (ES) and endoscopic papillary large balloon dilation (EPLBD) are well-known procedures for the treatment of common duct stones. There was no statistically significant difference in post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis rates between ES and EPLBD in most studies. The aims of this study were to evaluate whether EPLBD increases the risk of post-ERCP pancreatitis and to identify the risk factors influencing post-ERCP pancreatitis. A review of 341 patients who underwent ERCP for treatment of common duct stones larger than 1 cm in diameter from January 2006 to December 2011 was conducted retrospectively. Patients were divided into three groups: ES group (n = 207), EPLBD + ES group (n = 99), and EPLBD with previous history of ES group (n = 35). Of 341 patients, overall incidence of post-ERCP pancreatitis was 2.6% (n = 9). Incidence of post-ERCP pancreatitis was 3.4, 2.0, and 0% in the ES group, EPLBD + ES group, and EPLBD with previous history of ES group, respectively. No significant difference in the incidence of post-ERCP pancreatitis was observed among the three groups (p = 0.47). Endoscopic biliary stenting was the independent risk factor for pancreatitis according to univariate (p = 0.046) and multivariate analyses (p = 0.036, OR 4.211, 95% CI 1.095-16.199). Age, sex, stone size, mechanical lithotripsy, common bile duct diameter, balloon size, and duration of balloon dilation were not significantly related to post-ERCP pancreatitis. EPLBD with antecedent limited ES or previous ES state does not increase the risk of post-ERCP pancreatitis in patients with large bile duct stones. Endoscopic biliary stenting seems to be the independent risk factor of post-ERCP pancreatitis.

Chemotherapy-induced fulminant acute pancreatitis in pancreatic carcinoma: A case report.

Cases of chemotherapy-induced pancreatitis are rarely reported and among those diagnosed, the majority are mild and self-limiting. However, no previous cases of fulminant acute pancreatitis (FAP) induced by chemotherapeutic agents have been reported. The current study presents a case of FAP in a 62-year-old female on gemcitabine and capecitabine therapy. The patient was admitted to the China-Japan Friendship Hospital (Beijing, China) with the symptoms of acute pancreatitis two days after the completion of the first cycle of chemotherapy. Shock, hypoxemia and acute renal failure supervened, which resulted in mortality. As the common etiologies of pancreatitis were eliminated, a correlation between the incidence of FAP, and pancreatic cancer or chemotherapy, or both was suspected. Clinicians should be aware of this potential adverse effect when prescribing chemotherapeutic agents, particularly in patients with pre-existing risk factors for pancreatitis.

Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years.

BackgroundPost- endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most severe complication associated with diagnostic and therapeutic ERCP. A multivariate analysis of risk factors for PEP is essential for identifying patients at high risk and subsequently choosing other suitable diagnoses.MethodsPertinent publications were identified through systematic searches of MEDLINE, Elsevier, and Springer; we performed a systematic review of 12 clinical studies published in the past ten years, selected out of 451 reviewed articles, in which risk factors for pancreatitis were identified. Seven probable risk factors were evaluated, and outcomes expressed in the case of dichotomous variables, as an odds ratio (OR) (with a 95% confidence interval, 95% CI).ResultsWhen the risk factors were analyzed, the OR for female gender was 1.40 (95% CI 1.24 to 1.58); the OR for previous PEP was 3.23 (95% CI 2.48 to 4.22); the OR for previous pancreatitis was 2.00 (95% CI 1.72 to 2.33); the OR for endoscopic sphincterotomy was 1.42 (95% CI 1.14 to 1.78); the OR for precut sphincterotomy was 2.11 (95% CI 1.72 to 2.59); the OR for Sphincter of Oddi dysfunction was 4.37 (95% CI 3.75 to 5.09); and the OR for non-prophylactic pancreatic duct stent was 2.10 (95% CI 1.63 to 2.69).ConclusionsIt appears that female gender, previous PEP, previous pancreatitis, endoscopic sphincterotomy, precut sphincterotomy, Sphincter of Oddi dysfunction, and non-prophylactic pancreatic duct stent are the risk factors for post-ERCP pancreatitis.

Su1686 Pancreatic Interventions in ERCP: Pancreatitis Rates and Riskfactors in a National Population-Based Cohort Study

Pancreatic interventions in ERCP are less frequent than bile duct procedures and little is known about the complications. In this nation-wide population-based cohort study we analyse the risk factors for pancreatitis in ERCPs targeted towards pancreas.

A Two-institution study of risk factors for pancreatitis after endoscopic retrograde cholangiopancreatography for transpapillary biliary stent placement in patients with malignant biliary obstruction

A Two-institution study of risk factors for pancreatitis after endoscopic retrograde cholangiopancreatography for transpapillary biliary stent placement in patients with malignant biliary obstruction

Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study.

Background/AimsWe investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy.MethodsThis retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis.ResultsThere was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection.ConclusionsOur data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Old age is associated with increased severity of complications in endoscopic biliary stone removal.

Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Effect of magnesium supplementation and depletion on the onset and course of acute experimental pancreatitis

Background and objectiveHigh calcium concentrations are an established risk factor for pancreatitis. We have investigated whether increasing magnesium concentrations affect pathological calcium signals and premature protease activation in pancreatic acini,...

Risk Factors For Acute Pancreatitis In Patients With Acute Lymphoblastic Leukemia

Acute pancreatitis is a life-threatening complication of acute lymphoblastic leukemia (ALL) treatment. Previous studies have reported that intensive chemotherapy (especially asparaginase) and older age may predispose patients to pancreatitis (Samarasinghe et al. Br J Haematol 2013, Kearney et al. Pediatr Blood Cancer 2009;53:162 and Knoderer et al. Pediatr Blood Cancer 2007;49:634); however only a few large trials and case series have been reported. We studied 5185 ALL patients (age 0 to 30 years) enrolled between 1994 and 2012 on six front-line protocols for childhood ALL (St. Jude Total XIIIB and Total XV; COG P9904/P9905/P9906 and AALL0232) at St. Jude Children's Research Hospital and in the Children's Oncology Group. Pancreatitis was diagnosed in 117 (2.3%) patients by clinical symptoms, elevation in the serum amylase or lipase levels and abnormal radiographic or surgical findings according to NCI CTCAE version 2.0 (grade 3-4) or 3.0 (grade 2-4). The first episode of pancreatitis developed during remission induction in 24 of 117 (20.5%) patients and during the first year of therapy (including remission induction) in 104 of 117 (88.9%) patients.We investigated whether age, gender, race, immunophenotype, cumulative asparaginase dose and formulation (native E. coli-asparaginase [Elspar] vs PEG-asparaginase [Oncaspar]) were associated with the development of pancreatitis. Race was categorized as white, black, Hispanic, Asian and other based on inferred genetic ancestry (European, African, Native American and Asian) using STRUCTURE (Yang et al. Nat Genet 2011;43:237-241). Patients with pancreatitis were significantly older than those without the complication (median age, 11.7 years vs 7.3 years; P = 2.2 × 10-9). Hispanics (46 of 1177, 3.9%) and blacks (11 of 350, 3.1%) had a higher risk of pancreatitis than did whites (46 of 3069, 1.5%) and Asians (1 of 99, 1.0%; P = 1.6 × 10-5). Patients treated on protocols featuring higher cumulative dose of asparaginase (Total XV, COG P9906 and AALL0232) developed more pancreatitis than those on the protocols with lower dose of asparaginase (Total XIIIB and COG P9904/P9905) (103 of 3358, 3.1% vs 14 of 1827, 0.8%; P = 1.2 × 10-8; Figure 1). Gender, immunophenotype and asparaginase formulation were not associated with the development of pancreatitis. In a multivariate model, Native American ancestry (hazard ratio = 1.20 for every 10% increase; P = 8.4 × 10-8), older age (hazard ratio = 1.08 for every 1 year increase; P = 1.2 × 10-5) and higher cumulative dose of asparaginase (hazard ratio = 3.27 for those receiving native E.coli-asparaginase [or PEG-asparaginase equivalent] ≥ 240,000 U/m2 vs< 240,000 U/m2; P = 1.1 × 10-4) remained independent risk factors for pancreatitis, while African ancestry was only marginally significant (hazard ratio = 1.08 for every 10% increase; P = 0.053). In summary, older age, Native American ancestry and higher asparaginase exposure independently predict the development of pancreatitis in children treated for ALL. [Display omitted] Disclosures:Evans:St. Jude: In accordance with institutional policy, St. Jude allocates a portion of the income it receives from licensing inventions and tangible research materials to those researchers responsible for creating this intellectual property., In accordance with institutional policy, St. Jude allocates a portion of the income it receives from licensing inventions and tangible research materials to those researchers responsible for creating this intellectual property. Patents & Royalties, Under this policy, I and/or my spouse have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics. Other. Hunger:Jazz Pharmaceuticals: I receive funding for investigator-initiated research of asparaginase from Jazz Pharmaceuticals., I receive funding for investigator-initiated research of asparaginase from Jazz Pharmaceuticals. Other; Sigma-Tau Pharmaceuticals: I receive funding for investigator-initiated research of asparaginase from Sigma-Tau Pharmaceuticals. Other. Relling:Sigma-Tau Pharmaceuticals: I receive funding for investigator-initiated research on the pharmacology of asparaginase from Sigma-Tau Pharmaceuticals., I receive funding for investigator-initiated research on the pharmacology of asparaginase from Sigma-Tau Pharmaceuticals. Other; St. Jude Children's Research Hospital : I have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics., I have in the past received a portion of the income St. Jude receives from licensing patent rights related to TPMT polymorphisms as clinical diagnostics. Patents & Royalties.

The potential risks of pancreatitis and pancreatic cancer with GLP‐1‐based therapies are far outweighed by the proven and potential (cardiovascular) benefits

Recent suggestions that glucagon-like peptide-1 (GLP-1)-based therapies could cause pancreatitis, and even pancreatic cancer, are based on: The worrying histological changes are not reproduced in all studies and are unexpectedly variable with different GLP-1-based therapies. Singh's findings that pancreatitis is doubled with GLP-1-based therapies could relate to their use in obese patients who are prone to pancreatitis risk factors--gallstones and hypertriglyceridaemia. The other observational studies do not find an association between GLP-1-based therapies and pancreatitis. The increased reports of pancreatitis and pancreatic cancer are likely to be attributable to 'notoriety bias'. Butler's findings for those on GLP-1-based therapies vs. those not, could have other explanations. Meanwhile: META ANALYSIS: Randomized control trials with GLP-1-based therapies do not find increased pancreatitis risk. Meta-analysis of 53 randomized controlled trials including 20 212 dipeptidyl peptidase-4 inhibitor-treated patients found a significantly reduced risk of major adverse cardiovascular events [odds ratio 0.689 (0.528-0.899), P = 0.006] for dipeptidyl peptidase-4 inhibitors compared with control subjects. The evidence suggests that there is more than a possibility that some of the GLP-1 receptor agonists, and possibly also some dipeptidyl peptidase-4 inhibitors, may be associated with reduced cardiovascular events. Eight ongoing long-term cardiovascular randomized controlled trials will report from September 2013 onwards. These trials should resolve the issue of pancreatitis risk and substantiate the extent of benefit. Whilst we should remain vigilant, currently the balance of evidence is strongly in support of GLP-1-based therapy, with benefits far outweighing potential risks.

Chronic pancreatitis.

We review selected important clinical observations reported in 2012. 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. Analysis of endoscopic ultrasonography (EUS) images with an artificial neural network (ANN) program may improve chronic pancreatitis diagnosis compared with clinical interpretation of images. In a multicenter, randomized controlled trial of chronic pancreatitis patients, 90 000 USP U of pancreatin with meals decreased fat malabsorption compared with placebo. Detection of visceral pain in chronic pancreatitis predicts pain relief from various treatments, but nonvisceral pain due to altered central pain processing may respond to agents such as pregabalin. Predictors of surgical pain relief include onset of symptoms less than 3 years and preoperatively no opioid use and less than five endoscopic procedures. Total pancreatectomy for presumed painful chronic pancreatitis remains controversial. Celiacs are at risk for pancreatitis. The diagnosis of chronic pancreatitis may be enhanced by ANN analysis of EUS imaging. Treatment of fat malabsorption requires 90,000 USP U of lipase with meals. Relief of pain from organ directed treatment of chronic pancreatitis may depend upon timing of interventions and whether pain is visceral or nonvisceral.

Endoscopic biliary stenting and pancreatitis.

Endoscopic biliary stenting across the duodenal papilla can obstruct the adjacent pancreatic orifice and disturb the flow of pancreatic juice, which may result in pancreatitis. However, the relationship of endoscopic biliary stenting to post-procedure pancreatitis has not been thoroughly examined. Therefore, we have reviewed the published literature on this issue. Although biliary stenting, especially with large-bore and self-expandable metallic stents (SEMSs), has been considered a possible additional risk factor for pancreatitis following biliary stenting, most studies have not provided convincing supporting evidence; this failure may be due to inadequate study design or insufficient numbers of subjects. It also remains unclear whether endoscopic sphincterotomy (EST) performed prior to biliary stenting decreases the incidence of post-stenting pancreatitis; some recent studies have claimed that EST is not necessary before biliary stenting, even with placement of SEMSs. Well-designed studies with a large number of subjects will be needed to clarify these issues.

Chronic Pancreatitis

Chronic pancreatitis has an annual incidence of 23 per 100 000 population in Germany, where it accounts for about 10 000 hospital admissions per year. The disease shortens the life expectancy of its sufferers by an average of 23%. It most commonly affects men aged 20 to 40. A systematic search for pertinent literature retrieved 19 569 publications, 485 of which were considered in the creation of this guideline, including 67 randomized controlled trials (RCTs). A consensus conference reached agreement on a total of 156 definitions and recommendations. The identification of genetic risk factors for pancreatitis is now well established. The diagnosis is made mainly with ultrasonography of the pancreas; if the findings are uncertain, further studies can be performed, including endosonography and endosonographically assisted fine-needle puncture for the examination of small foci of disease. Computed tomography and MRI/magnetic resonance cholangiopancreatography are supplementary diagnostic methods. Endoscopic retrograde cholangiopancreatography is now used almost exclusively for treatment, rather than for diagnosis. 30% to 60% of patients develop complications of chronic pancreatitis, including pseudocysts, bile-duct stenosis, or medically intractable pain, which can be treated with an endoscopic or surgical intervention. Patients with steatorrhea, a pathological pancreatic function test, or clinical evidence of malabsorption should be given pancreatin supplementation. The head of the pancreas should be resected if it contains an inflammatory pseudotumor. The management of patients with chronic pancreatitis requires close interdisciplinary collaboration, as it can be treated medically and endoscopically as well as surgically.

Effects of a mitochondria-targeted antioxidant (MitoQ) in murine experimental acute pancreatitis

Effects of a mitochondria-targeted antioxidant (MitoQ) in murine experimental acute pancreatitis

Mo1459 Post ERCP Pancreatitis Risk Factors and Prognosis in Elderly

Mo1459 Post ERCP Pancreatitis Risk Factors and Prognosis in Elderly

Inflammation, Autophagy, and Obesity: Common Features in the Pathogenesis of Pancreatitis and Pancreatic Cancer

Inflammation and autophagy are cellular defense mechanisms. When these processes are deregulated (deficient or overactivated) they produce pathologic effects, such as oxidative stress, metabolic impairments, and cell death. Unresolved inflammation and disrupted regulation of autophagy are common features of pancreatitis and pancreatic cancer. Furthermore, obesity, a risk factor for pancreatitis and pancreatic cancer, promotes inflammation and inhibits or deregulates autophagy, creating an environment that facilitates the induction and progression of pancreatic diseases. However, little is known about how inflammation, autophagy, and obesity interact to promote exocrine pancreatic disorders. We review the roles of inflammation and autophagy, and their deregulation by obesity, in pancreatic diseases. We discuss the connections among disordered pathways and important areas for future research.