Una actualización de pancreatitis crónica: artículo de revisión / Update on chronic pancreatitis: review article

La pancreatitis crónica es una enfermedad fibro-inflamatoria progresiva del páncreas caracterizada por la fibrosis irreversible de la glándula con el eventual fallo de las funciones exocrinas y endocrinas. Las características distintivas de la enfermedad son el dolor abdominal, la malabsorción, la desnutrición, la diabetes mellitus y las calcificaciones pancreáticas. En muchos pacientes el origen de esta enfermedad se debe a una compleja mezcla de factores ambientales (por ejemplo, alcohol, cigarrillos y productos químicos en el trabajo), factores genéticos y en algunos casos origen hereditario o autoinmune. El manejo incluye enfoques médico, endoscópico y quirúrgico con la necesidad de la interacción entre diversas especialidades para dar un enfoque multidisciplinario coordinado. Esta revisión ofrece una visión general de los estudios recientes resumiendo la epidemiología, etiología, fisiopatología, manifestaciones clínicas, diagnóstico y tratamiento de la enfermedad.

Chronic pancreatitis is a progressive fibro-inflammatory disease of the pancreas characterized by irreversible fibrosis of the gland with eventual failure of exocrine and endocrine functions and hallmark features of abdominal pain, malabsorption, malnutrition, diabetes mellitus and pancreatic calcifications. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals), genetic factors and a few patients with hereditary or autoimmune disease. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. This review provides the reader with a comprehensive overview of the studies summarizing the epidemiology, etiology, physiopatology, clinical manifestation, diagnosis and treatments of the disease.

Pancreatitis y pancreatopatía crónica: evaluación fisiopatogénica, clínica y funcional: (basada en 1.300 casos en más de tres décadas en el Hospital de Clínicas de Bs. As.) / Chronic pancreatitis and chronic pancreatopathy: physiopathogenic, clinical and funcitonal evaluation. experience with 1,300 cases during three decades

Siguiendo a una experiencia de 33 años, de orden clínico y funcional (test de secretina), se intenta, por una parte, precisar los conceptos de pancreatitis crónica (PC) y de pancretopatía crónica (Pt.p.Cr.). Por otra, de consignar los índices de incidencia y de sus peculiaridades clínicas de expresión. El término de PC se propone cuando: "Las alteraciones estructurales del páncreas, con las eventuales modificaciones de los órganos y elementos anatómicos que con él se vinculan, y/o el déficit funcional de su componente exocrino ("pancreón") constituyen la fuente de la expresión clínica que predomina, de manera ostensible, en el complejo sindromático que exhibe el paciente en evaluación". Se estima como no ajustada a la realidad la noción clásica que considera a la PC como una afección de curso progresivo inexorable. Se enfatiza, por el contrario, la noción de que la PC cuando es adecuadamente tratada puede detener su evolución e, incluso, mostrar evidencias clínico-funcionales de su capacidad regenerativa. La denominación de pancreatopatía crónica (Pt.p.Cr.) es propuesta para aquellas condiciones en las que: "Los signos y/o síntomas originados por eventuales alteraciones anátomos-estructurales del páncreas y/o por modificaciones funcionales de su componenete secretorio exocrino se hallan disimuladamente inmersos dentro de un complejo sindromático que tiene génesis extra-pancreonal". De los 1.300 tests de secretina efectuados, 100 fueron dedicados a perfilar la respuesta secretoria exocrina normal. Y ello tanto en el hombre como en la mujer, discriminando, además, en ambos sexos, los resultados obtenidos por encima y por debajo de una edad crítica límite trazada a los 45 años. En 368 casos, la evaluación conjunta clínica-funcional permitió incluir a los pacientes dentro de la categoría de las PC. Dentro de esta entidad nosológica, se hizo el distingo entre la PC calcificante (alcohólica e idiopática), la autoinmune y la obstructiva. Como PC alchólica fueron.

Following a clinical evaluation and an exocrine pancreatic secretion exploration with the secretin test for more than three decades, we have tried to delineate the concepts of chronic pancreatitis (CP) and chronic pancreatopathy (Chr. Ptp). Besides, the rate of incidence of these two clinical entities in the Clinicas Hospital of Bs. As. was analyzed and discussed. The term CP was accepted when: "The anatomo-structural changes of the pancreatic gland and/or the exocrine functional component impairment constitute the patient's dominant clinical expresion". It is considered as erroneous and misleading the assumption that considers CP as a disease of an inexorable progressive course. On the contrary, the authors empehasize their conviction, based on experimental and clinical experiences, that CP is susceptible, when appropriately treated, of stopping its evolution and even disclose clinical-functional imporovements testifyng the inherent regenerative capacity of the gland. In contrast to the above, the denomination of Chr.Ptp. should be restricted when: "The signs and/or symptoms induced by the anatomo-structural changes of the pancretic gland and/or the functional derangement of the exocrine component remain disguised in the clinical syndrome of other diseases". Out of the 1,300 secretin tests performed, 100 were done on healthy controls. This study allowed establishing the normal statistical values of the different parameters. Besides, of showing the differences between men and women, especially above the critical age of 45. This clinical-functional evaluation allowed classifying 368 cases as CP. The folowing sub-groups were delineated: Calcifyiung "CP" (alcoholic, 240 cases and idiopathic, 119 cases); autoimmune CP (n=7) and Obstructive "CP" (n=11). In the Chr.Ptp. entity were classified 171 cases. As it is implied in the definition, this type of chronic inflammation of the pancreatic gland remained immersed in other disease entities.

Expression of sonic hedgehog signaling pathways in a rat model of chronic pancreatitis

To establish a rat model of chronic pancreatitis, and to prove the activation of sonic hedgehog [SHH] signaling pathways in chronic pancreatitis. This study was conducted between January and July 2008 in the Department of General Surgery, Wuhan General Hospital, Guangzhou Military Command, Wuhan, China. Thirty Wistar rats were randomly divided into 3 groups: control group [A], experimental control group [B], and model group [C] [10 rats in each group]. Trinitrobenzene sulfonic acid was infused into the pancreatic duct to induce chronic pancreatitis in the model group rats. In the experimental control group, we opened the abdominal cavity and infused with 0.9% sodium chloride solution. Serum levels of bilirubin and amylase were determined by radioimmunoassay. Histopathological alterations were studied using the optical microscopy. Expression of patched-1 [PTCH-1], smoothened [SMO], and SHH were detected by immunohistochemistry. Compared with the control group [A], the serum bilirubin and amylase in the model group increased significantly after 7 days of treatment, and fibrotic proliferation of pancreatic tissues were found after 35 days; the expression of PTCH-1, SMO, and SHH in the pancreatic tissue increased significantly in the model group. Trinitrobeneze sulfonic acid can induce chronic pancreatitis in rat. The SHH signaling pathway is activated in rats with chronic pancreatitis

Curso Terapêutica em Gastroenterologia: aula 8: Pancreatite crônica / Course Therapeutics in Gastroenterologia: class 8: Chronic pancreatitis

A pancreatite crônica (PC) é um processo inflamatório crônico do pâncreas, no qual há destruição irreversível do tecido pancreático endócrino e exócrino. A principal forma é a PC calcificante, causada na imensa maioria dos pacientes pelo alcoolismo. A terapêutica visa então abstinência alcoólica, controle da dor abdominal e das insuficiências endócrina (diabetes) e exócrina (esteatorréia). O médico deve estar atento também para possíveis complicações, a exemplo do pseudocisto pancreático.

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.