review of literature on clinical pancreatology - The Pancreapedia

Hal<strong>of</strong>uginone did not affect TGF-beta levels in cerulein-treated mice but inhibited serumresponse factor synthesis and Smad3 phosphorylation. In culture, hal<strong>of</strong>uginone inhibitedpancreatic stellate cell proliferation and TGF-beta-dependent increase in Cygb/STAP andtransgelin synthesis and metalloproteinase 2 activity. Hal<strong>of</strong>uginone increased c-Jun N-terminal kinase phosphorylation in pancreatic stellate cells derived from cerulein-treatedmice. Hal<strong>of</strong>uginone prevented the increase in acinar cell proliferation and further increasedthe cerulein-dependent PAP-1 synthesis. It was concluded that hal<strong>of</strong>uginone inhibits Smad3phosphorylation and increases c-Jun N-terminal kinase phosphorylation, leading to theinhibition <strong>of</strong> pancreatic stellate cell activation and consequent prevention <strong>of</strong> fibrosis.Hal<strong>of</strong>uginone increased the synthesis <strong>of</strong> PAP-1, which further reduces pancreas fibrosis.Thus, hal<strong>of</strong>uginone might serve as a novel therapy for pancreas fibrosis [285].Pancreatopleural fistulaePancreaticopleural fistula (PPF) is an unusual complication <strong>of</strong> chronic pancreatitis. Itsdiagnosis is obscured by predominance <strong>of</strong> pulmonary symptoms. A <strong>review</strong> <strong>of</strong> clinicalpresentation, etiology, diagnostic, and treatment modalities is presented in context <strong>of</strong> twocases from one institution. Case reports and case series <strong>of</strong> PPFs in the English <strong>literature</strong>from 1960 to 2007 were identified in the PubMed, OVID, and EMBASE search engines. Fiftytwocases <strong>of</strong> pancreaticopleural fistula were identified. Common presenting complaint wasdyspnea (65 %) followed by abdominal pain (29 %), cough (27 %) and chest pain (23 %).Computed tomography scanning diagnosed PPF in 8 (47 %) <strong>of</strong> 17 patients, endoscopicretrograde cholangiopancreatography diagnosed PPF in 25 (78 %) <strong>of</strong> 32 patients, andmagnetic resonance cholangiopancreatography diagnosed PPF in 8 (80 %) <strong>of</strong> 10 patients.Twenty-one patients (65 %) improved with conservative management alone. Interventionaltherapy (5 endoscopic and 6 surgical interventions) was eventually needed in 35 percent <strong>of</strong>the patients after failing conservative management. Magnetic resonancecholangiopancreatography is the better initial choice for being a noninvasive procedure andfor better demonstration <strong>of</strong> complete main pancreatic duct obstruction. Restoring anatomiccontinuity is important if conservative approach fails [286].Maldigestion and nutritionVitaminsThe main clinical manifestations <strong>of</strong> exocrine pancreatic insufficiency are fat malabsorption,known as steatorrhea, which consists <strong>of</strong> fecal excretion <strong>of</strong> more than 6 g <strong>of</strong> fat per day,weight loss, abdominal discomfort and abdominal swelling sensation. Fat malabsorption alsoresults in a deficit <strong>of</strong> fat-soluble vitamins (A, D, E and K) with consequent clinicalmanifestations. The relationships between pancreatic maldigestion, intestinal ecology andintestinal inflammation have not received particular attention, even if in clinical practice thesemechanisms may be responsible for the low efficacy <strong>of</strong> pancreatic extracts in abolishingsteatorrhea in some patients. The best treatments for pancreatic maldigestion should be reevaluated,taking into account not only the correction <strong>of</strong> pancreatic insufficiency usingpancreatic extracts and the best duodenal pH to permit optimal efficacy <strong>of</strong> these extracts, butwe also need to consider other therapeutic approaches including the decontamination <strong>of</strong>intestinal lumen, supplementation <strong>of</strong> bile acids and, probably, the use <strong>of</strong> probiotics whichmay attenuate intestinal inflammation in chronic pancreatitis patients [287].Nutritional support