The importance of the pancreas in 2023

A belated happy new year, and as we return in 2023, we focus on a new topic not commonly covered in this blog- the pancreas. As always, there are a fantastic range of articles published in BMJOG within the last month and these can all be accessed free-of-charge on the website. A particular favourite is the article by Waddingham et al, focused on the recognition, assessment and management of complications of diagnostic upper Gastrointestinal endoscopy, which we will cover with a sister article in the coming months.

In the first article this month Awadelkarim and colleagues discuss immunoglobulin G4-related disease, specifically in relation to the pancreatic vs head and neck presentations. IgG4-related diseases are a group of immune-mediated fibrotic and inflammatory conditions which commonly have either a pancreaticobiliary (PB) and head and neck (HN) presentation, leading to pancreatic/biliary or lacrimal/salivary/thyroid issues, respectively. The clinical presentation, management implications and response to treatment remains uncertain and the team aimed to assess differences in the PB and HN presentation in a cohort of patients from Newcastle. Utilising a cohort of 60 patient, the team retrospectively analysed the clinical features and treatments of patients. PB disease was more common in older patients, compared to HN disease (64 vs 51 years). Additionally, PB disease had higher serum IgG4 levels and more patients with >1 organ involved (68% vs 33%). HN disease patients received more second-line therapy (71% versus 36%) but persistently high serum IgG4 (after therapy) was more common in PB disease. This study starts to shed some light on the this uncommon, and difficult to diagnose/treat disease. The authors conclude that there appear to be distinct clinical subtypes of disease, but more prospective characterisation is needed to understand the presentation and optimal management strategies.

Published in Gut, Glaubitz et al take a highly scientific approach to address a relatively common issue in acute pancreatitis- bacterial translocation and subsequent infection of the necrotic tissue. The underlying drivers behind this are uncertain, but presence of infection is a poor prognostic sign. The team determined that there was a key role for Treg/Th17 balance in maintaining the duodenal barrier function in a murine model. The authors found that in acute pancreatitis, Treg-activation, which protects against a systemic inflammatory process, causes disturbance of the intestinal barrier function within the duodenum, allowing for commensal bacteria to enter areas of pancreatic necrosis. Specific overgrowth of pathogenic taxa including Escherichia/Shigella were associated with more severe disease. The authors conclude that Tregs may be a useful target for therapy in acute pancreatitis, preventing progression to severe disease.

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