Die chronische Pankreatitis (CP) ist eine wiederkehrende, entzündliche Erkrankung des Pankreas. In den letzten Jahren wurden mehrere Kandidatengene, die zur Entstehung einer CP prädisponieren, identifiziert. Zu diesen Genen gehören PRSS1, PRSS2, SPINK1, CFTR und CTRC. Der Pathogenese der genetisch bedingten CP scheint dabei eine frühzeitige, intrapankreatische Aktivierung von Trypsin zugrunde zu liegen. Cathepsin B (CTSB), eine in Lysosomen vorkommenden Protease, ist in der Lage Trypsinogen zu aktivieren. Genetisch zeigte sich eine Assoziation der p.L26V Variante bei tropisch-kalzifizierender CP, welche bei idiopathischer CP nicht bestätigt wurde. Neben CTSB ist CTSL die am zweithäufigsten vorkommende lysosomale Protease. Funktionelle Untersuchungen zeigten, dass CTSL ein inaktives Trypsin freisetzt. Im Mausmodell zeigten sich bei Ctsl-/- Tieren bei experimentell induzierter Pankreatitis zwei Effekte. Zum einen war die Trypsinaktivität erhöht, zum anderen verlief die Pankreatitis milder, da vermehrt Apoptose anstelle von Nekrose der Azinuszellen auftrat. In dieser Studie wurde mittels uni-direktionaler DNA-Sequenzierung das gesamte CTSL1 untersucht. Dabei fanden wir insgesamt drei seltene nicht-synonyme Varianten. Die Variante c.5A>C (p.N2T, rs112682750) fanden wir bei einem Patienten, wobei diese Variante bereits bei Kontrollen beschrieben wurde. Die Varianten c.126+1G>A und c.915A>C (p.E305D) lagen bei jeweils einer Kontrolle vor. Sowohl seltene als auch häufige Varianten und die berechneten Haplotypen zeigten keinen signifikanten Verteilungsunterschied zwischen Patienten und Kontrollen. Demnach besteht keine Assoziation von Varianten des CTSL1 und CP.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20794号 / 医博第4294号 / 新制||医||1025(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 妹尾 浩, 教授 浅野 雅秀, 教授 川口 義弥 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Chronic pancreatitis is considered a risk factor for pancreatic cancer. An exact mechanism how chronic inflammation of the pancreas leads to pancreatic cancer is not yet understood; the possibility of a shared genetic predisposition for both diseases is also assumed. A similar association in patients with AIP has not yet been demonstrated. The aim of our work was to expand the knowledge about relationship between chronic pancreatitis and pancreatic cancer. We studied the association of the diseases in two synchronous projects. In the first one, we examined the occurrence of pancreatic cancer in patients with autoimmune pancreatitis. In the second project, we investigated the presence of genetics variants associated with chronic pancreatitis in patients with pancreatic cancer. In the retrospective study of our cohort of patients, we were one of the very first in the world to show occurrence of pancreatic cancer in patients with autoimmune pancreatitis, and as the only one, we have defined the characteristics of such patients. To assess the association of the diseases, we performed a systematic review where we identified all reported cases of coincidence of pancreatic cancer and autoimmune pancreatitis; the incidence of cancer in patients with autoimmune pancreatitis was similar to that of patients...

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INTRODUÇÃO: O comprometimento pancreático em pacientes com Doença de Crohn (DC) é objeto de poucos estudos, porém as poucas séries sobre o assunto indicam um acometimento de uma parcela significativa dos pacientes, variando de 1,2% a 58%. O ultra-som endoscópico (EUS) apresenta a vantagem de apresentar uma sensibilidade muito maior que o ultra-som abdominal e a tomografia computadorizada. Quando comparado à colangiopancreatografia retrógrada endoscópica, este possui, além de uma maior sensibilidade, um índice de complicações significativamente menor. OBJETIVOS: Avaliar a incidência de alterações pancreáticas ao ultra-som endoscópico em pacientes com Doença de Crohn, correlacionando com fatores clínicos, bioquímicos e endoscópicos. MÉTODOS: Cinqüenta e um pacientes com DC, com idade entre 18 e 60 anos (média de 38 anos), sem história prévia de doença pancreática, diabetes mellitus ou alcoolismo, foram submetidos ao exame de EUS. O grupo controle foi formado por 20 pacientes submetidos ao EUS e que não apresentavam história de doença pancreato-biliar ou de Crohn. Dados clínicos, endoscópicos e laboratoriais foram coletados para posterior correlação. Onze variáveis ecoendoscópicas foram analisadas, tanto ductais quanto parenquimatosas. Os pacientes com três ou mais alterações foram submetidos à colangiorressonância magnética (CRNM). Para análise da função pancreática, foi realizado dosagens de elastase fecal em 39 pacientes. RESULTADOS: Dos pacientes analisados, 56% pertenciam ao sexo feminino, com tempo médio de diagnóstico da enfermidade de 7 anos e índice de atividade da doença (CDAI) médio de 102. Dois pacientes, (3,9%) apresentaram quatro alterações ecoendoscópicas, três pacientes, (5,9%) possuíram três alterações, 11 pacientes, (21,5%) tiveram duas alterações e 13 pacientes, (25,5%) apresentaram apenas uma alteração ao EUS. As alterações parenquimatosas totalizaram 39 achados, contra 11 alterações ductais. Apenas três pacientes (16%) do grupo controle apresentaram uma alteração ecoendoscópica (p<0,001). Os pacientes com três ou mais alterações ao EUS realizaram a CRNM, que não mostrou alterações em nenhum dos casos. Quatro pacientes, (10%) apresentaram dosagens de elastase fecal compatíveis com insuficiência pancreática exócrina, sem apresentar correlação com a ecoendoscopia. O único fator preditivo correlacionado com o número de alterações ao EUS foi doença ileal exclusiva. CONCLUSÕES: Os pacientes com DC possuíram uma alta incidência de anormalidades na morfologia pancreática (aproximadamente 10% com três ou mais alterações no EUS). Estas alterações foram localizadas predominantemente em parênquima, o que pode justificar a falta de correlação com a CRNM / BACKGROUND: Pancreas injury usually is not mentioned as an extra-intestinal manifestation of Crohns disease, but the few available series suggest pancreatic injury in a significant proportion of these patients, ranging from 1.2% to 58% in this series. Endoscopic ultrasound (EUS) presents the advantage of having a much higher sensitivity than the abdominal ultrasound or computadorized tomography in evaluating pancreas abnormalities. Compared to the endoscopic retrograde cholangiopancreatography, EUS has at least an equal sensitivity, with a lower complication rate. AIMS: To evaluate the incidence of pancreatic alterations by means of the EUS in Crohns disease, correlating them with clinical, endoscopic and biochemical data. METHODS: Fifty one patients with Crohns disease, age between 18 and 60 years-old (mean = 38), without previous history of pancreatic disease, diabetes mellitus or alcoholism, were submitted to EUS. The control-group was formed by 20 patients submitted to EUS with no previous history of pancreatic or Crohns disease. Clinical, endoscopic and biochemical data were collected in order to determine possible predictive factors. Eleven variables were analyzed, both in pancreatic parenchyma and ducts. The patients with 3 or more alterations were submitted to magnetic resonance. Pancreatic function was determined using fecal elastase assay in 39 patients. RESULTS: Of the 51 analyzed patients, 56% were female, with mean diagnosis time of seven years (1-25) and Crohns disease Activity Index (CDAI) of 102 (20-419). Two patients (3.9%) presented 4 alterations in the EUS exam, 3 (5.9%) presented 3 alterations, 11 (21.5%) had 2 alterations and 13 (25.5%) had 1 alteration in the EUS, which were statistically significant when compared to the control-group, in whom only 16% presented 1 exam alteration (p<0.001). The parenchymal abnormalities were more common, totalizing 39 findings when compared to 11 ductal abnormalities. The patients with 3 or more alterations in the exam were submitted to magnetic resonance; however, pancreatic lesions were not detected. Four patients (10%) had low fecal elastase measurement, suggestive of exocrine pancreatic insufficiency. None of these patients had significant pancreatic alterations in EUS. The only predictive factor that correlated with the number of alterations in EUS was isolated ileal disease. CONCLUSIONS: Patients with Crohns disease had a higher incidence of pancreatic abnormalities (10% with 3 or more alterations in endoscopic ultrasound) in comparison to the control-group. These alterations were found most frequently in the pancreatic parenchyma, which might explain the lack of correlation with the magnetic resonance, which is more prone to detect duct abnormalities. The only predictive factor to these alterations on EUS was ileal disease

Die Hämoxygenase-1 (HO-1) ist das geschwindigkeitsbestimmende Enzym des Hämabbaus und ist wichtiger Regulator inflammatorischer Prozesse. Der Verlauf einer experimentellen akuten Pankreatitis (AP) konnte im Tiermodell durch HO-1 Induktion abgemildert werden. Die Aktivierung und Proliferation pankreatischer Stellatum Zellen (PSC) wird durch eine experimentelle HO-1 Induktion inhibiert und kann so möglicherweise vor der Fibrosierung des Pankreasparenchyms bei chronischer Pankreatitis (CP) schützen. Die Transkription der HO-1 wird durch einen GT-Repeat beeinflusst, der im Promoter lokalisiert ist. Diese Arbeit untersuchte, ob Varianten des GT-Repeat oder weitere genetische Varianten der HO-1 mit verschiedenen Pankreatitisformen assoziiert sind. Der GT-Repeat und der SNP rs2071746 wurden mit fluoreszensmarkierten Primern bzw. mit Schmelzkurvenanalyse bei 285 Patienten mit AP, bei 208 Patienten mit alkoholischer CP (ACP), bei 207 mit idiopathischer/hereditärer CP (ICP/HCP), 147 Patienten mit Alkoholischer Leberzirrhose (ALZ) und bei 289 Kontrollen untersucht. Bei den ACP Patienten wurde die GT-Repeat Analyse auf insgesamt 446 Patienten erhöht. Zusätzlich wurden die kodierenden HO-1 Abschnitte mittels DNA-Sequenzierung bei 145 Patienten mit ACP, 138 Patienten mit ICP/HCP, 147 Patienten mit ALZ und bei 151 Kontrollen analysiert. Das Exon 3 wurde darüber hinaus bei zusätzlichen ICP/HP Patienten und Kontrollen untersucht. Die Längenverteilungen des GT-Repeat, die Allelverteilung des SNP rs2071746 und die Verteilung der bei der DNA-Sequenzierung gefundenen synonymen und nicht synonymen Varianten waren bei allen untersuchten Gruppen nicht signifikant unterschiedlich. Obwohl die funktionellen Daten einen Einfluss von HO-1 Varianten auf die Pathogenese der verschiedenen Pankreatitis-Formen nahelegen, konnte unsere umfangreiche genetische Analyse keine Assoziation nachweisen. Genetische Varianten der HO-1 haben keinen Einfluss auf die Entwicklung einer AP, ACP, ICP/HCP und ALZ.

Dvylikapirštę žarną išsauganti kasos rezekcija Frey būdu yra standartinė operacija gydant sergančiuosius komplikuotu lėtiniu pankreatitu. Kasos ir plonosios žarnos jungtis įprastai atliekama dviejų aukštų siūlėmis. Disertacinio darbo tikslas – palyginti Frey operacijos, naudojant vieno arba dviejų aukštų kasos – tuščiosios žarnos siūlę, rezultatatus, taip pat įvertinti operuotų pacientų gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos. Perspektyviniame atsitiktinių imčių klinikiniame tyrime dalyvavo aštuoniasdešimt pacientų. Tiriamieji prieš operaciją atsitiktine tvarka suskirstyti į dvi grupes: pirmos grupės pacientams atlikta operacija, formuojant kasos – tuščiosios žarnos jungtį vieno aukšto ištisine siūle; antros grupės pacientams, kasos – tuščiosios žarnos jungtis suformuota dviejų aukštų pavienėmis siūlėmis. Tyrime nustatėme, kad bendras operacijos laikas (208±46 min ir 255±58 min), bei pankreojejunoanastomozės siuvimo laikas (19±6 min. ir 51±18 min.) buvo statistiškai reikšmingai mažesnis „vieno aušto siūlės“ grupėje nei „dviejų aukštų pavienių siūlių“ grupėje. Pooperacinės komplikacijos, kasos fistulės dažnis, pooperacinė hospitalizavimo trukmė abiejose grupėse nesiskyrė. Vertinant gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos, nustatytas statistiškai reikšmingas gyvenimo kokybės pagerėjimas abiejose pacientų grupėse. / The duodenum-preserving pancreatic resection according to Frey is a standard operation for patients with complicated chronic pancreatitis. The pancreatojejunostomy is usually performed using two layer suture. The aim of doctoral dissertation was to compare single- and two-layer suture in pancreatojejunostomy performed in duodenum-preserving pancreatic resection according to Frey modification and to assess the changes of the quality of life 12 months after operation. A total of 80 patients were enrolled in the prospective randomized clinical. They were randomly allocated into two groups. In the first group of patients, pancreatojejunostomy was constructed by using single-layer continuous suture. In the second group of patients, pancreatojejunostomy was constructed by using two-layer interrupted suture. Overall time of the operation (208 ± 46 min. and 255 ± 58 min.) and the suturing time (19 ± 6 min. and 51 ± 18 min.) were significantly shorter in the single layer anastomosis group. Postoperative complications, the prevalence of pancreatic fistula, the length of stay did not differ in both groups. There was a statistically significant improvement of the quality of life 12 months after operation in the both groups of patients.

The duodenum-preserving pancreatic resection according to Frey is a standard operation for patients with complicated chronic pancreatitis. The pancreatojejunostomy is usually performed using two layer suture. The aim of doctoral dissertation was to compare single- and two-layer suture in pancreatojejunostomy performed in duodenum-preserving pancreatic resection according to Frey modification and to assess the changes of the quality of life 12 months after operation. A total of 80 patients were enrolled in the prospective randomized clinical. They were randomly allocated into two groups. In the first group of patients, pancreatojejunostomy was constructed by using single-layer continuous suture. In the second group of patients, pancreatojejunostomy was constructed by using two-layer interrupted suture. Overall time of the operation (208 ± 46 min. and 255 ± 58 min.) and the suturing time (19 ± 6 min. and 51 ± 18 min.) were significantly shorter in the single layer anastomosis group. Postoperative complications, the prevalence of pancreatic fistula, the length of stay did not differ in both groups. There was a statistically significant improvement of the quality of life 12 months after operation in the both groups of patients. / Dvylikapirštę žarną išsauganti kasos rezekcija Frey būdu yra standartinė operacija gydant sergančiuosius komplikuotu lėtiniu pankreatitu. Kasos ir plonosios žarnos jungtis įprastai atliekama dviejų aukštų siūlėmis. Disertacinio darbo tikslas – palyginti Frey operacijos, naudojant vieno arba dviejų aukštų kasos – tuščiosios žarnos siūlę, rezultatatus, taip pat įvertinti operuotų pacientų gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos. Perspektyviniame atsitiktinių imčių klinikiniame tyrime dalyvavo aštuoniasdešimt pacientų. Tiriamieji prieš operaciją atsitiktine tvarka suskirstyti į dvi grupes: pirmos grupės pacientams atlikta operacija, formuojant kasos – tuščiosios žarnos jungtį vieno aukšto ištisine siūle; antros grupės pacientams, kasos – tuščiosios žarnos jungtis suformuota dviejų aukštų pavienėmis siūlėmis. Tyrime nustatėme, kad bendras operacijos laikas (208±46 min ir 255±58 min), bei pankreojejunoanastomozės siuvimo laikas (19±6 min. ir 51±18 min.) buvo statistiškai reikšmingai mažesnis „vieno aušto siūlės“ grupėje nei „dviejų aukštų pavienių siūlių“ grupėje. Pooperacinės komplikacijos, kasos fistulės dažnis, pooperacinė hospitalizavimo trukmė abiejose grupėse nesiskyrė. Vertinant gyvenimo kokybės pokyčius, praėjus 12 mėn. po operacijos, nustatytas statistiškai reikšmingas gyvenimo kokybės pagerėjimas abiejose pacientų grupėse.

INTRODUÇÃO: O comprometimento pancreático em pacientes com Doença de Crohn (DC) é objeto de poucos estudos, porém as poucas séries sobre o assunto indicam um acometimento de uma parcela significativa dos pacientes, variando de 1,2% a 58%. O ultra-som endoscópico (EUS) apresenta a vantagem de apresentar uma sensibilidade muito maior que o ultra-som abdominal e a tomografia computadorizada. Quando comparado à colangiopancreatografia retrógrada endoscópica, este possui, além de uma maior sensibilidade, um índice de complicações significativamente menor. OBJETIVOS: Avaliar a incidência de alterações pancreáticas ao ultra-som endoscópico em pacientes com Doença de Crohn, correlacionando com fatores clínicos, bioquímicos e endoscópicos. MÉTODOS: Cinqüenta e um pacientes com DC, com idade entre 18 e 60 anos (média de 38 anos), sem história prévia de doença pancreática, diabetes mellitus ou alcoolismo, foram submetidos ao exame de EUS. O grupo controle foi formado por 20 pacientes submetidos ao EUS e que não apresentavam história de doença pancreato-biliar ou de Crohn. Dados clínicos, endoscópicos e laboratoriais foram coletados para posterior correlação. Onze variáveis ecoendoscópicas foram analisadas, tanto ductais quanto parenquimatosas. Os pacientes com três ou mais alterações foram submetidos à colangiorressonância magnética (CRNM). Para análise da função pancreática, foi realizado dosagens de elastase fecal em 39 pacientes. RESULTADOS: Dos pacientes analisados, 56% pertenciam ao sexo feminino, com tempo médio de diagnóstico da enfermidade de 7 anos e índice de atividade da doença (CDAI) médio de 102. Dois pacientes, (3,9%) apresentaram quatro alterações ecoendoscópicas, três pacientes, (5,9%) possuíram três alterações, 11 pacientes, (21,5%) tiveram duas alterações e 13 pacientes, (25,5%) apresentaram apenas uma alteração ao EUS. As alterações parenquimatosas totalizaram 39 achados, contra 11 alterações ductais. Apenas três pacientes (16%) do grupo controle apresentaram uma alteração ecoendoscópica (p<0,001). Os pacientes com três ou mais alterações ao EUS realizaram a CRNM, que não mostrou alterações em nenhum dos casos. Quatro pacientes, (10%) apresentaram dosagens de elastase fecal compatíveis com insuficiência pancreática exócrina, sem apresentar correlação com a ecoendoscopia. O único fator preditivo correlacionado com o número de alterações ao EUS foi doença ileal exclusiva. CONCLUSÕES: Os pacientes com DC possuíram uma alta incidência de anormalidades na morfologia pancreática (aproximadamente 10% com três ou mais alterações no EUS). Estas alterações foram localizadas predominantemente em parênquima, o que pode justificar a falta de correlação com a CRNM / BACKGROUND: Pancreas injury usually is not mentioned as an extra-intestinal manifestation of Crohns disease, but the few available series suggest pancreatic injury in a significant proportion of these patients, ranging from 1.2% to 58% in this series. Endoscopic ultrasound (EUS) presents the advantage of having a much higher sensitivity than the abdominal ultrasound or computadorized tomography in evaluating pancreas abnormalities. Compared to the endoscopic retrograde cholangiopancreatography, EUS has at least an equal sensitivity, with a lower complication rate. AIMS: To evaluate the incidence of pancreatic alterations by means of the EUS in Crohns disease, correlating them with clinical, endoscopic and biochemical data. METHODS: Fifty one patients with Crohns disease, age between 18 and 60 years-old (mean = 38), without previous history of pancreatic disease, diabetes mellitus or alcoholism, were submitted to EUS. The control-group was formed by 20 patients submitted to EUS with no previous history of pancreatic or Crohns disease. Clinical, endoscopic and biochemical data were collected in order to determine possible predictive factors. Eleven variables were analyzed, both in pancreatic parenchyma and ducts. The patients with 3 or more alterations were submitted to magnetic resonance. Pancreatic function was determined using fecal elastase assay in 39 patients. RESULTS: Of the 51 analyzed patients, 56% were female, with mean diagnosis time of seven years (1-25) and Crohns disease Activity Index (CDAI) of 102 (20-419). Two patients (3.9%) presented 4 alterations in the EUS exam, 3 (5.9%) presented 3 alterations, 11 (21.5%) had 2 alterations and 13 (25.5%) had 1 alteration in the EUS, which were statistically significant when compared to the control-group, in whom only 16% presented 1 exam alteration (p<0.001). The parenchymal abnormalities were more common, totalizing 39 findings when compared to 11 ductal abnormalities. The patients with 3 or more alterations in the exam were submitted to magnetic resonance; however, pancreatic lesions were not detected. Four patients (10%) had low fecal elastase measurement, suggestive of exocrine pancreatic insufficiency. None of these patients had significant pancreatic alterations in EUS. The only predictive factor that correlated with the number of alterations in EUS was isolated ileal disease. CONCLUSIONS: Patients with Crohns disease had a higher incidence of pancreatic abnormalities (10% with 3 or more alterations in endoscopic ultrasound) in comparison to the control-group. These alterations were found most frequently in the pancreatic parenchyma, which might explain the lack of correlation with the magnetic resonance, which is more prone to detect duct abnormalities. The only predictive factor to these alterations on EUS was ileal disease

© 2017, © 2017 American Federation for Medical Research. A middle-aged man presents with acute pancreatitis of unknown etiology and is found to have a presentation consistent with the diagnosis of type 2 autoimmune pancreatitis (AIP). AIP is a group of rare heterogeneous diseases that are challenging to diagnose. There are 2 types of AIP. Type 1 disease is the more common worldwide than type 2 AIP. While type 1 AIP is associated with IgG4-positive antibodies, type 2 AIP is IgG4 antibody negative. Both types of AIP are responsive to corticosteroid treatment. Although type 1 AIP has more extrapancreatic manifestations and more commonly relapses, this is a case of a patient with type 2 AIP with inflammatory bowel disease and relapsing course.