Chronic pancreatitis:Pain and computed tomography/magnetic resonance imaging findings

Chronic pancreatitis(CP)is a fibroinflammatory disease characterized by irreversible destruction of pancreatic tissue.With the development of the disease,it may lead to exocrine and/or endocrine insufficiency.CP is one of the common diseases that cause abdominal pain,which will not get permanent spontaneous relief as the disease evolves.The American College of Gastroenterology clinical guidelines recommend computed tomography or magnetic resonance imaging as the first-line examination for the diagnosis of CP.CP common imaging findings include pancreatic atrophy,irregular dilatation of the pancreatic duct,calcification of pancreatic parenchyma,pancreatic duct stones,etc.In clinical practice,whether any correlations between CP-induced abdominal pain patterns(no pain/constant/intermittent pain)and corresponding imaging findings present are not well known.Therefore,this review aims to comprehensively sort out and analyze the relevant information by collecting lots of literature on this field,so as to construct a cross-bridge between the clinical manifestations and imaging manifestations of CP patients.Also,it provides an imaging basis and foundation for the classification and diagnosis of abdominal pain types in clinical CP patients.

Dietary Green Tea Extract and Antioxidants Improve Insulin Secretory Functions of Pancreatic β-Cells in Mild and Severe Experimental Rodent Model of Chronic Pancreatitis

Chronic pancreatitis (CP) is a progressive inflammatory disorder of the pancreas. It is predominantly idiopathic (with an unknown cause) in India and mostly due to alcohol in the West. Diabetes that occur secondary to chronic pancreatitis (T3c Diabetes) is often brittle, and is difficult to attain normoglycemia with conventional treatment requiring multiple doses of insulin. Mild and severe model of CP was induced in mice by repeated intraperitoneal injections of cerulein and L-arginine respectively with an intent to study islet dysfunction and develop therapeutic strategy in animal models of CP. Dietary intervention of epigallocatechin-3-gallate (EGCG) was tested in both the models of CP for its beneficial effects on insulin secretory functions. Pancreata collected upon euthanasia were used to study alterations in the morphology of pancreatic parenchyma and inflammation by staining with H&E and fibrotic changes by Masson’s trichrome and picrosirius staining. Insulin secretory functions of islets were evaluated to test the efficacy of the dietary intervention on β-cell functions. Intraperitoneal glucose tolerance test was performed to monitor the glucose homeostasis before and after the dietary intervention. Both the models resulted in CP with dispersed acini, inflammation and fibrosis. The loss of acini and extent of fibrosis was more in L-arginine model. 2-fold improvement in glucose-stimulated insulin secretory functions of islets was observed with 0.5% EGCG dietary intervention in cerulein model of CP and 1.6-fold in L-arginine model of CP. A further improvement in insulin secretion by 3.2-fold was observed with additional dietary supplements like N-acetyl cysteine, curcumin in combination with EGCG. Our results thus demonstrate and highlight the therapeutic potential of dietary green tea (EGCG) supplementation in reversing islet dysfunction and improving glucose homeostasis in experimental chronic pancreatitis in mice.

A Deep Learning Framework for Mass-Forming Chronic Pancreatitis and Pancreatic Ductal Adenocarcinoma Classification Based on Magnetic Resonance Imaging

Pancreatic diseases, including mass-forming chronic pancreatitis (MFCP) and pancreatic ductal adenocarcinoma(PDAC), present with similar imaging features, leading to diagnostic complexities. Deep Learning (DL) methodshave been shown to perform well on diagnostic tasks. Existing DL pancreatic lesion diagnosis studies basedon Magnetic Resonance Imaging (MRI) utilize the prior information to guide models to focus on the lesionregion. However, over-reliance on prior information may ignore the background information that is helpful fordiagnosis. This study verifies the diagnostic significance of the background information using a clinical dataset.Consequently, the Prior Difference Guidance Network (PDGNet) is proposed, merging decoupled lesion andbackground information via the Prior Normalization Fusion (PNF) strategy and the Feature Difference Guidance(FDG) module, to direct the model to concentrate on beneficial regions for diagnosis. Extensive experiments inthe clinical dataset demonstrate that the proposed method achieves promising diagnosis performance: PDGNetsbased on conventional networks record an ACC (Accuracy) and AUC (Area Under the Curve) of 87.50% and89.98%, marking improvements of 8.19% and 7.64% over the prior-free benchmark. Compared to lesion-focusedbenchmarks, the uplift is 6.14% and 6.02%. PDGNets based on advanced networks reach an ACC and AUC of89.77% and 92.80%. The study underscores the potential of harnessing background information in medical imagediagnosis, suggesting a more holistic view for future research.

Pain management in chronic pancreatitis

Pain in chronic pancreatitis(CP)is difficult to manage.Many patients suffer from inadequate pain relief,completely incapacitating them in their daily activities.Historically,despite their well-known adverse effects,opioids have been the pillar of treatment regimens in painful CP.The management is now gradually evolving with a better understanding of the underlying pathophysiology of CP-related pain.Clinicians should follow a holistic approach to the management of CPassociated pain,which must involve lifestyle changes that are coupled with analgesic medications and other pain-relieving interventions.Furthermore,there is no easy cure for vanquishing CP-associated pain.Each patient must be evaluated on a case-by-case basis by a multidisciplinary team to decide which treatment option is best suited for that individual.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life.Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention.Traditionally surgery is reserved for patients who do not improve with other interventions.However,recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function.Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders,minimally invasive surgery for chronic pancreatitis is slow to evolve.Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis.With this background,the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis.A Pub Med search of all relevant articles was performed using the appropriate keywords,parentheses,and Boolean operators.Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy,considered an adequate procedure only in a small proportion of patients.The pancreatic head is the pacemaker of pain,so adequate decompression is critical for long-term pain relief.Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection.With improvements in laparoscopic instrumentation and technological advances,minimally invasive surgery for chronic pancreatitis is gaining momentum.However,more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Pancreatic cancer,autoimmune or chronic pancreatitis,beyond tissue diagnosis:Collateral imaging and clinical characteristics may differentiate them

Pancreatic ductal adenocarcinoma(PDAC)is one of the most lethal malignancies and is developing into the 2nd leading cause of cancer-related death.Often,the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses,such as autoimmune pancreatitis(AIP)and massforming chronic pancreatitis(MFCP),making its diagnosis challenging.Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications.Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses;however,the diagnostic accuracy is imperfect.Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis.It is not unusual that after a thorough diagnostic evaluation,the clinician is confronted with a pancreatic mass with uncertain diagnosis.In those cases,a re-evaluation must be entertained,preferably by an experienced multispecialty team including radiologists,pathologists,gastroenterologists,and surgeons,looking for disease-specific clinical,imaging,and histological hallmarks or collateral evidence that could favor a specific diagnosis.Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP,PDAC,and MFCP and to highlight those disease-specific clinical,radiological,serological,and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.

Incidence,prevalence,and comorbidities of chronic pancreatitis:A 7-year population-based study

BACKGROUND Chronic pancreatitis(CP)is a fibroinflammatory syndrome leading to reduced quality of life and shortened life expectancy.Population-based estimates of the incidence,prevalence,and comorbidities of CP in China are scarce.AIM To characterize the incidence,prevalence,and comorbidities of CP in Sichuan Province,China,with population-based data.METHODS Data on CP from 2015 to 2021 were obtained from the Health Information Center of Sichuan Province.During the study period,a total of 38090 individuals were diagnosed with CP in Sichuan Province.The yearly incidence rate and point prevalence rate(December 31,2021)of CP were calculated.The prevalence of comorbid conditions in CP patients was estimated.The annual number of CPrelated hospitalizations,hospital length of stay,and hospitalization costs for CP were evaluated.Yearly incidence rates were standardized for age by the direct method using the permanent population of Sichuan Province in the 2020 census as the standard population.An analysis of variance test for the linearity of scaled variables and the Cochran-Armitage trend test for categorical data were performed to investigate the yearly trends,and a two-sided test with P<0.05 was considered statistically significant.RESULTS The 38090 CP patients comprised 23280 males and 14810 females.The mean age of patients at CP diagnosis was 57.83 years,with male patients(55.87 years)being younger than female patients(60.11 years)(P<0.001).The mean incidence rate of CP during the study period was 6.81 per 100000 person-years,and the incidence of CP increased each year,from 4.03 per 100000 person-years in 2015 to 8.27 per 100000 person-years in 2021(P<0.001).The point prevalence rate of CP in 2021 was 45.52 per 100000 individuals for the total population,with rates of 55.04 per 100000 individuals for men and 35.78 per 100000 individuals for women(P<0.001).Individuals aged 65 years or older had the highest prevalence of CP(113.38 per 100000 individuals)(P<0.001).Diabetes(26.32%)was the most common comorbidity in CP patients.The number of CP-related hospitalizations increased from 3739 in 2015 to 11009 in 2021.The total costs for CP-related hospitalizations for CP patients over the study period were 667.96 million yuan,with an average of 17538 yuan per patient.CONCLUSION The yearly incidence of CP is increasing,and the overall CP hospitalization cost has increased by 1.4 times during the last 7 years,indicating that CP remains a heavy health burden.

Burden of bone disease in chronic pancreatitis:A systematic review and meta-analysis

BACKGROUND Bone disease is an under-recognized cause of morbidity in chronic pancreatitis(CP).Over the past decade,publications of original studies on bone disease in CP has warranted synthesis of the evidence to ascertain the true burden of the problem.AIM To quantify the prevalence of osteopenia,osteoporosis,and fragility fractures in CP patients and investigate the associated clinical features and outcomes.METHODS A systematic search identified studies investigating bone disease in CP patients from Cochrane Library,Embase,Google Scholar,Ovid Medline,PubMed,Scopus,and Web of Science,from inception until October 2022.The outcomes included prevalence of osteopenia,osteoporosis,and fragility fractures,which were metaanalyzed using a random-effects model and underwent metaregression to delineate association with baseline clinical features.RESULTS Twenty-one studies were included for systematic review and 18 studies were included for meta-analysis.The pooled prevalence of osteopenia and osteoporosis in CP patients was 41.2%(95%CI:35.2%-47.3%)and 20.9%(95%CI:14.9%-27.6%),respectively.The pooled prevalence of fragility fractures described among CP was 5.9%(95%CI:3.9%-8.4%).Metaregression revealed significant association of pancreatic enzyme replacement therapy(PERT)use with prevalence of osteoporosis[coefficient:1.7(95%CI:0.6-2.8);P<0.0001].We observed no associations with mean age,sex distribution,body mass index,alcohol or smoking exposure,diabetes with prevalence of osteopenia,osteoporosis or fragility fractures.Paucity of data on systemic inflammation,CP severity,and bone mineralization parameters precluded a formal metaanalysis.CONCLUSION This meta-analysis confirms significant bone disease in patients with CP.Other than PERT use,we observed no patient or study-specific factor to be significantly associated with CP-related bone disease.Further studies are needed to identify confounders,at-risk population,and to understand the mechanisms of CP-related bone disease and the implications of treatment response.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas,resulting in recurrent abdominal pain,diabetes mellitus,and malnutrition.It may lead to various other complications such as pseudocyst formation,benign biliary stricture,gastric outlet obstruction;and vascular complications like venous thrombosis,variceal and pseudoaneurysmal bleed.Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy.Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration,or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations.Procedure-related bleed is usually venous and mostly managed conservatively.Procedure-related arterial bleed,however,may require radiological interventions.

Non-pharmacological pain palliation methods in chronic pancreatitis

Chronic pancreatitis(CP)is a condition characterized by persistent and often severe pain resulting from the inflammatory disease of the pancreas.While pharmacological treatments play a significant role in palliative pain management,some patients require non-pharmacological methods.This review article focuses on non-pharmacological approaches used to alleviate pain in CP.The article examines non-pharmacological palliation options,including surgery,endoscopic approaches,neurostimulation techniques,acupuncture,and other alternative medicine methods.The effectiveness of each method is evaluated,taking into consideration patient compliance and side effects.Additionally,this article emphasizes the importance of personalized pain management in CP and underscores the need for a multidisciplinary approach.It aims to summarize the existing knowledge on the use of non-pharmacological palliation methods to improve the quality of life for patients with CP.

Coexistent alcohol-related cirrhosis and chronic pancreatitis have a comparable phenotype to either disease alone:A comparative retrospective analysis

BACKGROUND Alcohol use disorder is a prevalent disease in the United States.It is a well-demonstrated cause of recurrent and long-standing liver and pancreatic injury which can lead to alcohol-related liver cirrhosis(ALC)and chronic pancreatitis(ACP).ALC and ACP are associated with significant healthcare utilization,cost burden,and mortality.The prevalence of coexistent disease(CD)ranges widely in the literature and the intersection between ALC and ACP is inconsistently charac-terized.As such,the clinical profile of coexistent ALC and ACP remains poorly understood.We hypothesized that patients with CD have a worse phenotype when compared to single organ disease.AIM To compare the clinical profile and outcomes of patients with CD from those with ALC or ACP Only.METHODS In this retrospective comparative analysis,we reviewed international classi-fication of disease 9/10 codes and electronic health records of adult patients with verified ALC Only(n=135),ACP Only(n=87),and CD(n=133)who received care at UPMC Presbyterian-Shadyside Hospital.ALC was defined by histology,imaging or clinical evidence of cirrhosis or hepatic decompensation.ACP was defined by imaging findings of pancreatic calcifications,moderate-severe pancreatic duct dilatation,irregularity or atrophy.We compared demographics,pertinent clinical variables,healthcare utilization,and mortality for patients with CD with those who had single organ disease.RESULTS Compared to CD or ACP Only,patients with ALC Only were more likely to be older,Caucasian,have higher body mass index,and Hepatitis B or C infection.CD patients(vs ALC Only)were less likely to have imaging evidence of cirrhosis and portal hypertension despite possessing similar MELD-Na and Child C scores at the most recent contact.CD patients(vs ACP Only)were less likely to have acute or recurrent acute pancreatitis,diabetes mellitus,insulin use,oral pancreatic enzyme therapy,and need for endoscopic therapy or pancreatic surgery.The number of hospitalizations in patients with CD were similar to ACP Only but significantly higher than ALC Only.The overall mortality in patients with CD was similar to ALC Only but trended to be higher than ACP Only(P=0.10).CONCLUSION CD does not have a worse phenotype compared with single organ disease.The dominant phenotype in CD is similar to ALC Only which should be the focus in longitudinal follow-up.

Dietary intake in patients with chronic pancreatitis:A systematic review and meta-analysis

BACKGROUND A progressive reduction in the secretion of pancreatic enzymes in patients with chronic pancreatitis(CP)results in malabsorption and ultimate malnutrition.However,the pathogenesis of malnutrition is multifactorial and other factors such as chronic inflammation,alcohol excess and poor dietary intake all contribute.Patients may restrict their dietary intake due to poor appetite or to avoid gastrointestinal symptoms and abdominal pain.Whilst up to half of patients with chronic pancreatitis are reportedly malnourished,the dietary intake of patients with CP is relatively understudied and has not been systematically reviewed to date.AIM To perform a systematic review and meta-analysis of the dietary intakes of patients with CP compared to healthy controls,and to compare the dietary intake of patients with alcohol-related CP and non-alcohol-related CP.METHODS A systematic literature search was performed using EMBASE,MEDLINE,and Cochrane review on studies published between 1946 and August 30th,2019.Adult subjects with a diagnosis of CP who had undergone dietary assessment were included in the systematic review(qualitative analysis).Studies on patients with other pancreatic diseases or who had undergone pancreatic surgery were not included.Studies comparing the dietary intake of patients with CP to that of healthy controls were included in the meta-analysis(quantitative analysis).Metaanalysis was performed using Review Manager 5.3.Newcastle Ottawa Scale(NOS)was used to assess quality of studies.RESULTS Of 6715 studies retrieved in the search,23 were eligible for qualitative analysis while 12 were eligible for quantitative analysis.In the meta-analysis,the total energy(calorie)intake of patients with CP was similar to that of healthy controls[mean difference(MD):171.3;95%confidence interval(CI):-226.01,568.5;P=0.4],however patients with CP consumed significantly fewer non-alcohol calories than controls[MD:-694.1;95%CI:-1256.1,(-132.1);P=0.02].CP patients consumed more protein,but carbohydrate and fat intakes did not differ significantly.Those with alcohol-related CP consumed more mean(standard deviation)calories than CP patients with a non-alcohol aetiology[2642(1090)kcal and 1372(394)kcal,respectively,P=0.046],as well as more protein,fat,but not carbohydrate.CONCLUSION Although patients with CP had similar calorie intake to controls,studies that analysed the contribution of alcohol to energy intake showed that patients with CP consumed fewer non-alcohol calories than healthy controls.A high calorie intake,made up to a large degree by alcohol,may in part contribute to poor nutritional status in CP.

Impact of surgery for chronic pancreatitis on the risk of pancreatic cancer:Untying the Gordian knot

Pancreatic ductal adenocarcinoma is an aggressive tumor with poor long-term outcomes.Chronic pancreatitis(CP)is considered a risk factor for the development of pancreatic cancer(PC).Persistent pancreatic inflammation and activation of pancreatic stellate cells play a crucial role in the pathogenesis of CPrelated PC by activating the oncogene pathway.While genetic mutations increase the possibility of recurrent and persistent pancreatic inflammation,they are not directly associated with the development of PC.Recent studies suggest that early surgical intervention for CP might have a protective role in the development of CP-related PC.Hence,the physician faces the clinical question of whether early surgical intervention should be recommended in patients with CP to prevent the development of PC.However,the varying relative risk of PC in different subsets of CP underlines the complex gene-environment interactions in the disease pathogenesis.Hence,it is essential to stratify the risk of PC in each individual patient.This review focuses on the complex relationship between CP and PC and the impact of surgical intervention on PC risk.The proposed risk stratification based on the genetic and environmental factors could guide future research and select patients for prophylactic surgery.

Antioxidant therapy in acute,chronic and post-endoscopic retrograde cholangiopancreatography pancreatitis:An updated systematic review and meta-analysis

AIM:To investigate the efficacy and adverse effects of antioxidant therapy in acute pancreatitis(AP),chronic pancreatitis(CP) and post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP).METHODS:Pub Med,Scopus,Google Scholar,Cochrane library database,and Evidence-based medicine/clinical trials published before August 2014 were searched. Clinical and laboratory outcomes of randomized trials of antioxidant therapy in patients with AP,CP and PEP were included. The methodological quality of the trials was assessed by the Jadad score based on the description of randomization,blinding,and dropouts(withdrawals). The results of the studies were pooled and meta-analyzed to provide estimates of the efficacy of antioxidant therapy.RESULTS:Thirty four trials out of 1069 potentially relevant studies with data for 4898 patients wereeligible for inclusion. Antioxidant therapy significantly reduced the length of hospital stay in AP patients {mean difference-2.59 d(95%CI:-4.25-(-0.93)],P = 0.002}. Although,antioxidant therapy had no significant effect on serum C reactive protein(CRP) after 5-7 d in AP patients [mean difference-9.57(95%CI:-40.61-21.48,P = 0.55],it significantly reduced serum CRP after 10 d {mean difference-45.16 [95%CI:-89.99-(-0.33)],P = 0.048}. In addition,antioxidant therapy had no significant effect on CP-induced pain [mean difference-2.13(95%CI:-5.87-1.6),P = 0.26]. Antioxidant therapy had no significant effects on the incidence of all types of PEP [mean difference 1.05(95%CI:0.74-1.5),P = 0.78],severe PEP [mean difference 0.92(95%CI:0.43-1.97),P = 0.83],moderate PEP [mean difference 0.82(95%CI:0.54-1.23),P = 0.33],and mild PEP [mean difference 1.33(95%CI:0.99-1.78),P = 0.06]. Furthermore,while antioxidant therapy had no significant effect on serum amylase after less than 8 h sampling [mean difference-20.61(95%CI:-143.61-102.39),P = 0.74],it significantly reduced serum amylase close to 24-h sampling {mean difference-16.13 [95%CI:-22.98-(-9.28)],P < 0.0001}.CONCLUSION:While there is some evidence to support antioxidant therapy in AP,its effect on CP and PEP is still controversial.

Serum Mac-2 binding protein is a novel biomarker for chronic pancreatitis

AIM: To determine the efficacy of Mac-2 binding protein(Mac-2bp) for diagnosis of chronic pancreatitis.METHODS: Fifty-nine healthy volunteers(HV), 162 patients with chronic pancreatitis(CP), and 94 patients with pancreatic ductal adenocarcinoma(PDAC) were enrolled in this study. We measured serum Mac-2bp using our developed enzyme-linked immunosorbent assay kit. Additional biochemical variables were measured using an automated analyzer(including aminotransferase, alanine aminotransferase, γ-glutamyltransferase, alkaline phosphatase, triglyceride, C-reactive protein, and amylase levels) or chemiluminescent enzyme immunoassay(carbohydrate antigen 19-9 and carcinoembryonic antigen). The ability of Mac-2bp to predict CP diagnosis accurately was assessed using receiver operating characteristic(ROC) analyses.RESULTS: Serum Mac-2bp levels were significantly increased in CP patients compared to HV(P < 0.0001) and PDAC patients(P < 0.0001). Area under the ROC curve values of Mac-2bp for the discrimination of CP from HV and PDAC were 0.727 and 0.784, respectively. Multivariate analyses demonstrated that serum Mac-2bp levels were independent determinants for CP diagnosis from HV and PDAC patients. Immunohistological staining showed that Mac-2bp was expressed faintly in the pancreas tissues of both CP and PDAC patients. Serum aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, alkaline phosphatase, and triglyceride levels were significantly higher in patients with CP or PDAC. Serum Mac-2bp levels were highly correlated with protein levels of alanine aminotransferase, γ-glutamyltransferase, and C-reactive protein, but not amylase, suggesting that the damaged liver produces Mac-2bp. CONCLUSION: Measurement of serum Mac-2bp may be a novel and useful biomarker for CP diagnosis as well as liver fibrosis in the general population.

ERCP and CT diagnosis of pancreas divisum and its relation to etiology of chronic pancreatitis

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Endoscopic ultrasound features of autoimmune pancreatitis: The typical findings and chronic pancreatitis changes

BACKGROUND Few studies have fully described endoscopic ultrasound(EUS)features of newly diagnosed autoimmune pancreatitis(AIP)involving both typical findings and chronic pancreatitis(CP)features.The typical EUS findings are prevalent in the diffuse type AIP but may not be as common for the focal type,and the differences between the diffuse and focal AIP need to be specified.AIM To demonstrate the EUS features of newly diagnosed AIP and the difference between diffuse and focal AIP.METHODS This retrospective single center study included 285 patients of newly diagnosed type 1 AIP following the international consensus diagnostic criteria,with the EUS procedures accomplished before corticosteroid initiation.We explored the EUS features and compared the typical AIP and CP features between the diffuse and focal AIP cases.The Rosemont criteria were employed for CP features definition and CP change level comparison.RESULTS For the typical AIP features,there were significantly more patients in the diffuse group with bile duct wall thickening(158 of 214 cases,73.4%vs 37 of 71 cases,52.1%,P=0.001)and peripancreatic hypoechoic margin(76 of 214 cases,35.5%vs 5 of 71 cases,7.0%,P<0.001).For the CP features,there were significantly more patients in the focal group with main pancreatic duct dilation(30 of 214 cases,14.0%vs 18 of 71 cases,25.3%,P=0.03).The cholangitis-like changes were more prevalent in the focal cases with pancreatic head involvement.The CP change level was relatively limited for newly diagnosed AIP cases in both groups.CONCLUSION This study demonstrated the difference in the typical AIP and CP features between diffuse and focal AIP and indicated the limited CP change level in newly diagnosed AIP.

Pain management in chronic pancreatitis incorporating safe opioid practices: Challenge accepted

Patients with chronic pancreatitis often experience severe,unrelenting abdominal pain,which can significantly impact their quality of life.Pain control,therefore,remains central to the overall management of chronic pancreatitis.Most of the strategies aimed at treating the pain of chronic pancreatitis are based on expert opinion and vary from one institution to another,as there are no uniform guidelines to direct a stepwise approach towards achieving this goal.In this editorial,we comment on best practice strategies targeted towards pain control in chronic pancreatitis,specifically highlighting the use of opioid medications in this patient population.We discuss various safe and efficacious prescription monitoring practices in this article.

An experimental study in etiologic effect of pancreas divisum on chronic pancreatitis and its pathogenesis

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Idiopathic chronic pancreatitis:Beyond antioxidants

Chronic pancreatitis(CP)is a complex disease associated with gene-gene or geneenvironment interactions.The incidence of idiopathic CP has shown an increasing trend,withits phenotypeshaving changed considerably in the last two decades.The diseaseitself can be regulated before it reaches the stage of established CP;however,the etiopathogenesis underlying idiopathic CP remains to be established,making the condition difficult to cure.Unfortunately,there also remains a lack of consensus regarding the beneficial effects of antioxidant therapiesfor CP.It is known that antioxidant therapy does not reduce inflammatory and fibrotic cytokines,making it unlikely that they could modulate the disease process.Although antioxidants are safe,very few studies to date have reported the long-term beneficial effects in patients with CP.Thus,studies are being performed to identify drugs that can improve symptoms and alter the natural history of CP.Statins,with their numerous pleiotropic effects,may play a role in the treatment of CP,butin 2006,their use was found to be associated with the undesirable side effect of promoting pancreatitis.Latter studies showed favourable effects of statins in CP,highlighting the particular benefits of lipophilic statins,such as lovastatin and simvastatin,over the hydrophilic statins,such as rosuvastatin.Ultimately,studies to repurpose N-acetylcysteine as a CP therapy areyielding very promising results.