Exocrine pancreatic insufficiency in type 1 and type 2 diabetes mellitus: do we need to treat it? A systematic review.

The exocrine and endocrine pancreata are very closely linked both anatomically and physiologically. Abdominal symptoms such as nausea, bloating, diarrhea, steatorrhea, and weight loss can often occur in diabetic patients. Impairments of the exocrine pancreatic function seem to be a frequent complication of diabetes mellitus; however, they are largely overlooked. The aim of this paper is to provide an overview of the current concepts of exocrine pancreatic insufficiency (PEI) in diabetes mellitus. The prevalence and symptoms of PEI in diabetes mellitus, the pathomechanism, and difficulties of diagnosis and therapy of PEI are summarized in this systematic review.

New-onset type 2 diabetes mellitus--A high-risk group suitable for the screening of pancreatic cancer?

BACKGROUND: Type 2 diabetes mellitus is widely considered to be associated with pancreatic cancer. OBJECTIVE: To determine the incidence of pancreatic cancer in new-onset type 2 diabetic patients by measuring the serum level of CA 19-9 and performing abdominal ultrasonography (US). PATIENTS AND METHODS: Consecutive type 2 diabetic patients in whom diabetes was diagnosed within 36 months were included in this prospective study. Serum CA 19-9 measurement and US were performed in all patients. If any of two was positive, abdominal computer tomography (CT) was carried out. Endoscopic ultrasound-guided fine needle aspiration or direct surgical referral was performed on patients with CT-identified lesions. RESULTS: A total of 115 patients were enrolled. CA 19-9 was elevated in 10 patients but pancreatic cancer diagnosed in neither of them. Pancreatic cancer was revealed by morphological means in three patients without elevated CA 19-9 level. The sensitivity, specificity, positive-, negative predictive values and validity were 0%, 90.4%, 0%, 97.9% and 87.9% for CA 19-9, 66.7%, 100%, 100%, 99% and 99% for US, respectively. The value of the Standardized Incidence Ratio for pancreatic cancer in new-onset type-2 diabetic patients was 198.6 (95% CI = 6.25-46.9). CONCLUSIONS: The prevalence of pancreatic cancer in patients with new-onset type-2 diabetes is significantly higher than that in the general population and screening is beneficial for detecting PaC in this patient population. CA 19-9 and US is not reliable screening modality for pancreatic cancer screening in this population.

Prevalence of exocrine pancreatic insufficiency in type 2 diabetes mellitus with poor glycemic control.

OBJECTIVES: To evaluate the relationship between exocrine pancreatic insufficiency and the level of glycemic control in diabetes (DM). METHODS: Patients with type 2 DM treated in our clinic were prospectively recruited into the study. Pancreatic diabetes was excluded. Cases with HbA1c ≥7% formed Group A (n = 59), and with HbA1c <7% Group B (n = 42). The fecal level of pancreatic elastase (PE-1) was measured and morphological examinations of the pancreas were performed. RESULTS: The PE-1 level was significantly lower in Group A than in Group B (385.9 ± 171.1 µg/g, vs. 454.6 ± 147.3 µg/g, p = 0.038). The PE-1 level was not correlated with HbA1c (r = -0.132, p = 0.187), the duration of DM (r = -0.046, p = 0.65), age (r = 0.010, p = 0.921), BMI (r = 0.203, p = 0.059), or pancreatic steatosis (r = 0.117, p = 0.244). The size of the pancreas did not differ significantly between Groups A and B. CONCLUSIONS: An exocrine pancreatic insufficiency demonstrated by fecal PE-1 determination is more frequent in type 2 DM patients with poor glycemic control. The impaired exocrine pancreatic function cannot be explained by an alteration in the size of the pancreas or by pancreatic steatosis.

Sepsis and hepatitis together with herpes simplex esophagitis in an immunocompetent adult.

Herpes simplex virus (HSV)-induced sepsis affects immunocompromised patients. We report here the case of an immunocompetent adult with sepsis, hepatitis, renal failure and esophagitis. The possibility of HSV should be considered in cases of sepsis without any evident cause, even in immunocompetent patients. The characteristic endoscopic and histological findings of the associated esophagitis may assist the etiology of sepsis.

[Pancreatic cancer or autoimmune pancreatitis: endosonography as a diagnostic reviser]. / Pancreastumor vagy autoimmun pancreatitis: az endoszonográf mint diagnosztikus revizor.

Conventional radiologic imaging (abdominal ultrasound, computer tomography) used in the differential diagnosis of post-hepatic jaundice can frequently provide inaccurate diagnosis. Inflammatory lesions may mimic neoplastic processes and malignancy may be accompanied by perifocal inflammation resulting in histological misdiagnosis. Furthermore, chronic and autoimmune pancreatitis are associated with an increased risk for pancreatic cancer. Radial endosonography has become a markedly important method in the imaging of the pancreas. It has a crucial role in the diagnosis and staging of pancreatic cancer. The authors present three cases where the diagnosis of pancreatic cancer determined by conventional imaging techniques (abdominal ultrasound, computer tomography, endoscopic retrograde cholangiopancreatography) was excluded or confirmed by the radial endosonography. The authors conclude that radial endosonography is an essential complementary method among imaging techniques of the pancreas and in tumor staging. Application of that may prevent unnecessary surgeries, which is obviously useful for patients and cost effective for health care providers.

Association between autoimmune pancreatitis and systemic autoimmune diseases.

AIM: To investigate the association between autoimmune pancreatitis (AIP) and systemic autoimmune diseases (SAIDs) by measurement of serum immunoglobulin G4 (IgG4). METHODS: The serum level of IgG4 was measured in 61 patients with SAIDs of different types who had not yet participated in glucocorticosteroid treatment. Patients with an elevated IgG4 level were examined by abdominal ultrasonography (US) and, in some cases, by computer tomography (CT). RESULTS: Elevated serum IgG4 levels (919 ± 996 mg/L) were detected in 17 (28%) of the 61 SAID patients. 10 patients had Sjögren's syndrome (SS) (IgG4: 590 ± 232 mg/L), 2 of them in association with Hashimoto's thyroiditis, and 7 patients (IgG4: 1388 ± 985.5 mg/L) had systemic lupus erythematosus (SLE). The IgG4 level in the SLE patients and that in patients with SS were not significantly different from that in AIP patients (783 ± 522 mg/L). Abdominal US and CT did not reveal any characteristic features of AIP among the SAID patients with an elevated IgG4 level. CONCLUSION: The serum IgG4 level may be elevated in SAIDs without the presence of AIP. The determination of serum IgG4 does not seem to be suitable for the differentiation between IgG4-related diseases and SAIDs.

Improved glycemic control in pancreatic diabetes through intensive conservative insulin therapy.

OBJECTIVE: The aim of this study was to evaluate the effectivity and safety of insulin therapy in patients with DM secondary to underlying chronic pancreatitis with initially inappropriate glycemic control. METHODS: Pancreatic DM patients treated with oral antidiabetics (OAD) or pre-mixed insulin (PMI) with HbA1c ≥7.0% were recruited. Intensive conservative insulin treatment (ICT) (Group A, n = 16) or PMI (Group B, n = 8) was introduced instead of OAD, or the initial PMI therapy was switched to ICT (Group C, n = 10). The changes in HbA1c, fasting plasma glucose, body weight and hypoglycemic events from baseline to 2 years were followed. RESULTS: The patients in Group A and B had been treated with oral antidiabetics for 55 ± 68 months before switching to insulin therapy. The level of HbA1c had worsened from 8.3 ± 1.5% to 9.8 ± 1.7% during this period. The ICT had reduced HbA1c significantly from 9.7 ± 1.8% to 7.6 ± 1.4% after 12 weeks, in Group A, and five patients had HbA1c<7.0%. The introduction of PMI in Group B reduced HbA1c from 10.0 ± 1.4% to 9.0 ± 0.6% by 12 weeks. None of the patients had HbA1c<7.0%. By 12 weeks, the introduction of ICT in Group C had reduced the level of HbA1c from 8.8 ± 1.7% to 7.7 ± 1.2%. Two patients reached HbA1c<7.0%. There were two severe hypoglycemic episodes during the 2 years, one-one case in Group A and B. CONCLUSIONS: Oral medication becomes insufficient early in pancreatic DM. Long-term improvement of glycemic control can be achieved through intensified insulin therapy and in selected cases through PMI with a low risk of hypoglycemia.

Autoimmune pancreatitis in Hungary: a multicenter nationwide study.

BACKGROUND: To date, most cases of autoimmune pancreatitis (AIP) have been reported from Japan. The aim of the present study was to assess the clinical features and management of AIP cases in Hungary. METHODS: The demographics, clinical presentation, laboratory and imaging findings, extrapancreatic involvement, treatment response and recurrence were evaluated in the first 17 patients diagnosed with AIP in Hungary. RESULTS: The mean age at presentation was 42.7 years (range: 16-74); 47% of the patients were women. New-onset mild abdominal pain (76%), weight loss (41%) and jaundice (41%) were the most common symptoms, with inflammatory bowel disease being the most frequent (36%) extrapancreatic manifestation. Diffuse pancreatic swelling was seen in 7 patients (41%) and a focal pancreatic mass in 8 (47%). Endoscopic retrograde cholangiopancreatography revealed pancreatic duct strictures in all study patients. The serum IgG4 level at presentation was elevated in 62% of the 8 patients in whom it was measured. All the percutaneous core biopsies (5 patients) and surgical specimens (2 patients), and 2 of the 4 biopsies of the papilla of Vater revealed the typical characteristic findings of AIP: a diffuse lymphoplasmacytic infiltration, marked interstitial fibrosis and obliterative phlebitis. Immunostaining indicated IgG4-positive plasma cells in 62% of the 8 patients in whom it was performed. Granulocytic epithelial lesions (GEL) were present in 3 patients. The patients without GELs were older (mean age 59 years), while those with GEL were younger (mean age 34 years), and 2 of 3 were female and had ulcerative colitis. A complete response to steroid treatment was achieved in all 15 patients. Because of the suspicion of a pancreatic tumor, 2 patients with focal AIP underwent partial pancreatectomy. One patient relapsed, but responded to azathioprine. CONCLUSIONS: This first Hungarian series has confirmed several previously reported findings on AIP. AIP with GEL was relatively frequent among our patients: these patients tended to be younger than in earlier studies and displayed a female preponderance with a high coincidence of ulcerative colitis. Performance of a percutaneous biopsy is strongly recommended. The response to immunosuppressive therapy was excellent. and IAP.

[Acute pancreatitis caused by hypertriglyceridemia]. / Hypertriglyceridaemia okozta akut pancreatitis sajátosságai beteganyagunkban.

UNLABELLED: Hypertriglyceridemia is reported to cause 1-7% of the cases of acute pancreatitis. AIM: The aim of the present study was to assess the clinical features and management of pancreatitis with hypertriglyceridemia in our tertiary center. METHODS: Between 1 January 2007 and 31 December 2009, patients with a diagnosis of hypertriglyceridemia-induced acute pancreatitis were reviewed. Patients with pancreatitis and serum triglyceride levels greater than 11.3 mmol/l (≈1000 mg/dl) were included. Acute pancreatitis with other etiologies was excluded. RESULTS: 26 patients (2 women, 24 men; median age at presentation 42 years; range: 22-70) were diagnosed with hypertriglyceridemia­induced acute pancreatitis; 3 patients had altogether 7 relapses. The total number of cases was 33, which accounted for 4.71% of the total number of acute pancreatitis cases in the examined period. There was a failure in diet in 30.3% and a history of regular alcohol abuse in 57.6% of the cases. A history of diabetes mellitus was present in 38.1%, and gallstones in 9.1% of the cases. Lactescent serum was described on admission in 27.3%. Mean triglyceride level was 47.24 mmol/l (≈4181 mg/dl; 12.4-103.8 mmol/l). Amylase level was elevated to three times the normal in 54.5%, and that of lipase to three times the normal in 58.8%. Necrotizing acute pancreatitis was diagnosed in 7 patients (26.9%), and pseudocyst in 8 patients (30.7%). Administration of insulin, heparin, plasmapheresis and fibrates lowered the triglyceride to 3.71 mmol/l (≈328 mg/dl). CONCLUSION: The clinical course of acute pancreatitis with hypertriglyceridemia does not differ from acute pancreatitis of other causes. Interestingly, levels of serum pancreatic enzymes may be normal or only minimally elevated. Insulin, heparin, plasmapheresis and fibrates effectively reduce lipid levels and relieve symptoms. A low triglyceride level is necessary to prevent relapses.