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Pancreatic Morphological Changes in Long-Term Follow-Up after Initial Episode of Acute Alcoholic Pancreatitis

  • SSAT Plenary
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Objective

The long-term morphological changes induced by a single episode of alcoholic pancreatitis are not known. Our aim was to study these morphological changes in secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) after the first episode of alcohol-associated acute pancreatitis and to evaluate the risk factors and possible protective factors potentially associated with later chronic findings. We have previously reported 2-year follow-up results in pancreatic morphology. This study extends the follow-up to 9 years.

Patients and Methods

In this prospective follow-up study, S-MRCP imaging was performed for 44 (41 M, 3 F; mean age, 46 (25–68) years) patients after their first episode of alcohol-associated pancreatitis. Pancreatic morphology was evaluated at 3 months and at 2, 7, and 9 years after hospitalization. Recurrent attacks of pancreatitis were studied and pancreatic function was monitored by laboratory tests. Patients’ alcohol consumption was evaluated with questionnaires, laboratory markers, and self-estimated alcohol consumption via interview. Smoking and body mass index were annually recorded.

Results

At 3 months, 32 % of the patients had normal findings in S-MRCP, 52 % had acute, and 16 % had chronic changes. At 7 years, S-MRCP was performed on 36 patients with normal findings in 53 %, the rest (47 %) having chronic findings. Pancreatic cyst was present in 36 %, parenchymal changes in 28 %, and atrophy in 28 % of the cases. There were no new changes in the pancreas in the attending patients between 7 and 9 years (18 patients). Of the patients with only acute findings at 3 months, 60 % resolved to normal in 7 years, but the rest (40 %) showed chronic changes later on. The initial attack was mild in 65 %, moderate in 25 %, and severe in 10 % of the patients. Patients with mild first attack had fewer chronic changes at 7 years compared to patients with moderate or moderate and severe together (p = 0.03, p = 0.01). Of the patients in the seventh year of S-MRCP, 22 % had suffered a recurrent episode of acute pancreatitis (mean, 22 (2–60) months) and 11 % had a clinical diagnosis of chronic pancreatitis. At 7 years, 88 % of the patients with recurrences had chronic findings in S-MRCP versus 36 % with nonrecurrent pancreatitis (p = 0.02). Six (17 %) patients abstained from alcohol throughout follow-up (mean, 8.7 (7–9.1) years), but even one of these developed pancreatic atrophy. Out of the non-abstinent patients who did not suffer recurrences, 4/22 (18 %) had developed new findings during at follow-up S-MRCP (NS). In univariate analysis, heavy smoking showed no correlation with increased chronic changes compared to nonsmoking.

Conclusions

Morphological pancreatic changes increase with recurrent episodes of acute pancreatitis. Patients with mild first attack have fewer chronic changes in the pancreas in the long term. However, even a single episode of acute alcoholic pancreatitis may induce chronic morphological changes in long-term follow-up.

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Authors and Affiliations

  1. School of Medicine, University of Tampere, Tampere, Finland

    Jussi Nikkola, Sari Räty, Johanna Laukkarinen, Isto Nordback & Juhani Sand

  2. Department of Radiology, Tampere University Hospital, Tampere, Finland

    Irina Rinta-Kiikka

  3. Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland

    Sari Räty, Johanna Laukkarinen, Riitta Lappalainen-Lehto, Satu Järvinen, Hanna Seppänen, Isto Nordback & Juhani Sand

  4. Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Teiskontie 35, 33521, Tampere, Finland

    Juhani Sand

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  1. Jussi Nikkola
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Correspondence to Juhani Sand.

Additional information

Discussant

Dr. Nicholas Zyromski (Indianapolis, Indiana): Pancreatic morphological changes in a long-term follow-up after first episode of acute alcoholic pancreatitis.

Nikkola, et al.

These Finnish authors provide a strong contribution to our knowledge of acute alcoholic pancreatitis natural history. The major strength of this study lies in the diligent, long-term (9 years!) follow-up of an extremely challenging patient population. The authors found that a primary episode of severe pancreatitis (as opposed to mild or moderate severity) was accompanied by recurrent pancreatitis episodes and pancreatic morphologic changes.

Questions:

1. Did morphologic changes seen on secretin-stimulated MRCP correlate with clinical exocrine and endocrine insufficiency rates?

How does this knowledge influence clinical practice (are you more likely to offer decompression of pseudocyst prior to symptom development)?

Closing Discussant

Dr. Jussi Nikkola: Patients who had normal pancreatic morphology at seven years had not developed chronic pancreatitis in follow-up, while 24 % (4/17) of patients with chronic changes at seven years had developed clinically significant pancreatic exocrine insufficiency (p = 0.04). These patients had all gone through a recurrent episode or episodes of pancreatitis.

Seventen percent (3/18) of patients who had normal morphology at seven years had developed new diabetes. Among patients with chronic findings at seven years 42 % (5/12) had a new diagnose of diabetes during follow-up (NS) (patients with diabetes diagnosed before or during hospitalization excluded). One patient who had chronic pancreatitis didn’t develop diabetes but the rest three did.

Pseudocyst at two years was noted as a risk factor for recurrences as Pelli et al. previously reported. Occurrence of persistent pseudocyst, even asymptomatic, should thus probably favor active drainage. No additional risk factors were found in this study. We managed to report important observations of long-term changes in pancreatic morphology during natural course of acute alcoholic pancreatitis. Main findings were that recurrent episodes are connected to increased pancreatic damage and patients with mild first attack have less chronic changes during follow-up. Attention should be paid to decrease recurrences in alcoholic pancreatitis. Nordback et al. have demonstrated that active interventions with six-months intervals decrease recurrences effectively.

This study has been selected for the following plenary sessions: 21.11.2012 Operatiiviset päivät 2012 (National Surgical Meeting), Helsinki, Finland. 19.5.2013 Digestive Disease Week 2013, Orlando, FL, USA

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Nikkola, J., Rinta-Kiikka, I., Räty, S. et al. Pancreatic Morphological Changes in Long-Term Follow-Up after Initial Episode of Acute Alcoholic Pancreatitis. J Gastrointest Surg 18, 164–171 (2014). https://doi.org/10.1007/s11605-013-2279-1

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