Painless Tropical Chronic Pancreatitis with Extensive Calcification.

Chronic pancreatitis (CP) is caused by a wide variety of causes such as alcohol, biliary diseases, trauma, infections, autoimmune diseases, and hereditary disorders. Patients with CP present with disabling abdominal pain, weight loss, exocrine insufficiency, and diabetes and are at risk for malignant transformation. Pancreatic calcification narrows down the diagnosis of CP. Uncommon causes of calcific pancreatitis include autoimmune pancreatitis, hereditary pancreatitis, tropical pancreatitis, groove pancreatitis, and pancreatitis associated with cystic fibrosis, Ascaris, and ectopic pancreatic tissue. Calcific pancreatitis in young diabetics of tropical countries could be either due to alcohol or tropical pancreatitis. We report a young man with weight loss and steatorrhea, but without abdominal pain whose evaluation led to a diagnosis of tropical CP and diabetes.

Assessment of cassava toxicity in patients with tropical chronic pancreatitis.

Background and aim: There have been conflicting reports on the role of cassava ingestion in tropical pancreatitis (TCP). In this study we aimed to estimate cyanogens detoxifying enzyme rhodanese, thiocyanate and sulfur containing amino acids in cassava consumer as well as cassava non-consumer TCP patients and healthy controls and compare the same. Methods: Eighty-six TCP patients and 90 healthy controls were recruited. Serum rhodanese, thiocyanate, plasma amino acids, urinary inorganic sulfate/creatinine were measured. Results: There was significant reduction in serum rhodanese activity in both cassava consumer- and non-consumer TCP patients as compared to controls but no significant difference between cassava consumer- and non-consumer TCP patients was observed. Serum thiocyanate was significantly lower in cassava consumer TCP patients as compared to cassava consumer controls but not significantly different from cassava non-consumer TCP patients. Plasma methionine, cysteine and urinary inorganic sulfate / creatinine ratio was significantly lower in both cassava consumer and non-consumer TCP patients as compared to controls but were comparable among cassava consumers and non-consumers. Conclusions: Significant reduction in rhodanese activity with concomitant decrease in sulfur containing amino acids and antioxidants such as glutathione suggests that TCP patients are at higher risk of defective detoxification of cyanogens. However there was no difference between cassava consumers and non-consumers. Low levels of sulfur amino acids may contribute to the development of pancreatitis.

Anthropometric, biochemical, clinical and dietary assessment for malnutrition in South Indian patients with chronic pancreatitis.

Background and aim: Recent surveys suggest a change in nutritional status of population in Kerala along with a steep rise in alcoholism. We aimed to conduct a comprehensive assessment of anthropometric, biochemical, clinical and dietary parameters and study the association of nutritional status with dietary intake. Methods: We compared the nutrient intake of a cohort of patients with chronic pancreatitis with a recent population survey. We also sought to compare the prevalent nutritional status of patients with previous series. Results: Chronic pancreatitis patients had poor intake of most nutrients. However, severe malnutrition is present only in a small minority (4%) as compared to previous series. Fat intake in patients with tropical chronic pancreatitis was significantly lower in alcoholic chronic pancreatitis patients (27.5g/d vs. 43g/d). Conclusions: Malnutrition remains an important problem in chronic pancreatitis; however severe malnutrition is rare as compared to previous series. Energy (calorie) deprivation and micronutrient deficiency are major nutritional issues. Use of additional anthropometric parameters, especially triceps skin fold thickness, in conjunction with body mass index, is helpful. Subjective global assessment is a useful method for assessment for nutritional status in chronic pancreatitis patients.

Malnutrition is not an etiological factor in the development of tropical pancreatitis – A case-control study of Southern Indian patients.

Background and Aim: Malnutrition is implicated as an etiological factor in tropical pancreatitis (TP). The aim of the present study was to elucidate whether malnutrition is the cause or the result of TP. Methods: Consecutive recently diagnosed patients with TP were evaluated for their nutritional status and dietary patterns before and after the onset of TP. The nutritional status of patients before the onset of TP was compared with that of healthy controls to demonstrate the role of malnutrition as an etiological factor for TP. Results: Of 256 consecutive patients with chronic pancreatitis, 89 were diagnosed as TP patients with disease duration of less than 1 year (mean age 32.14 ± 14 years; 60 % males) and comprised the study group. The nutritional status before the onset of TP was comparable with that of controls (n=101) with 15% of patients and 12% of the controls being malnourished (BMI <18.5kg/m2). However, after the onset of TP, 52% (n=46) of patients lost weight and the percentage of malnourished patients increased from 15% to 38% (p=<0.001) indicating that there was significant weight loss after the disease onset. When the causes of weight loss were evaluated, it was found that low calorie intake significantly contributed to weight loss (p=0.001). Conclusion: Malnutrition is not an etiological factor of TP and weight loss occurred as a result of low calorie intake after the onset of TP.

Pancreatic diabetes.

Pancreatic endocrine insufficiency secondary to destruction of acinar cells is a well known complication of chronic pancreatitis (CP). Of all patients with diabetes mellitus, 0.5-1% is secondary to CP. The frequency of occurrence of diabetes in CP is about 40-60%. This figure varies according to the aetiology, extent of calcification, and duration of the disease. Pancreatic diabetes is more commonly associated with alcoholic and tropical calcific pancreatitis of long duration. The pathophysiology of pancreatic diabetes is related to beta cell failure and reduced insulin secretory capacity. The development of pancreatic diabetes calls for careful evaluation and management to prevent long term complications. Pancreatic cancer is a known complication of chronic pancreatitis and sometimes manifests with new onset diabetes. As destruction of pancreatic tissue in CP leads to depletion of both insulin and glucagonproducing cells of the islets of Langherhans, pancreatic diabetics are usually not prone to ketoacidosis. A trial of oral hypoglycemic agents followed by insulin therapy when the need arises has been the line of management thus far in these patients. This review focuses on the prevalence, unique pathophysiological aspects, clinical features and special issues in the management of diabetes secondary to chronic pancreatitis.