Authors' reply

Glob. Health Epidemiol.

Narayana

2016

Self Cite

BackgroundThe idiopathic variety of chronic pancreatitis (CP) in India particularly in Kerala state was earlier called ‘tropical pancreatitis’ with peculiar features: early age of onset, severe malnutrition, diabetes and poor prognosis. A change in disease phenotype and behaviour has been observed recently.ObjectiveTo review the changing profile of CP in India and examine its relationship with environmental influences and socio-economic development.MethodsRelevant studies on CP in India were reviewed along with social and economic parameters in Kerala over the past 4 decades.ResultsThere has been a definite change in the phenotype of CP in India with onset in mid twenties, better nutritional status, and a much better prognosis compared with the reports in 1970s. Genetic susceptibility due to genetic mutations particularly in SPINK1, CFTR, CTRC, and CLDN2/MORC4 genes is the most important factor and not malnutrition or dietary toxins for idiopathic CP suggesting the term ‘tropical pancreatitis’ is a misnomer. We observed a close relationship between socio-economic development and rising income in Kerala with late onset of disease, nutritional status, and better prognosis of CP.ConclusionChanging profile of CP in India and better understanding of risk factors provide evidence for gene–environmental interactions in its pathobiology.

Section: Negative Influence Of Rising Incomes: Alcohol Consumption Asmentioning

confidence: 99%

Changing phenotype and disease behaviour of chronic pancreatitis in India: evidence for gene–environment interactions

Glob. Health Epidemiol.

Narayana

2016

Self Cite

“…In such a scenario, sticking to an old terminology i.e. 'tropical' is an oddity especially since there is nothing to suggest any influence of geographic location either on its pathogenesis, phenotype or disease behaviour [22].…”

mentioning

confidence: 99%

Chronic pancreatitis in India: untying the nutritional knot

2011

Indian J Gastroenterol

Nutrition is central to human existence from sustenance of cellular life to powering its myriad functions. Contrasting images of Haitian or Ugandan malnourished children and Westerner obese kids mirror not only the economic reality of a nation but also the propensity to diseases albeit of opposite polarity from Kwashiorkor/Marasmus to metabolic syndrome with equal implications for health outcomes. In addition to specific nutritional deficiency states such as scurvy and rickets, indirect effects of nutrition on human health are of greater importance.In this context, astute clinical observations in 1960s brought attention to a rather typical form of chronic pancreatitis (CP) in Kerala [1]. The picture of a young malnourished patient with chronic calcific pancreatitis and diabetes evoked much interest. Since one of its most peculiar features was malnutrition (undernutrition), it was soon implicated in its etiopathogenesis. At a time when the basic structure of DNA was just about making the headlines, genetic mutation as the cause of disease was not even on the agenda outside of Mendelian disorders. Malnutrition thus made the cut being the striking clinical feature. Since the disease was reported mainly from tropical countries, which ironically were much poorer and undernourished than their temperate counterparts, the term 'tropical pancreatitis' (TP) was coined for want of a more defining terminology.Protein deficient and high carbohydrate diet was thus implicated in the etiopathogenesis of the thus coined TP. Sandhyamani et al. [2] showed that high carbohydrate and low protein diet, either comprising of cornstarch or cassava, resulted in ductal changes with mucoid metaplasia and parenchymal atrophy in an animal model of bonnet monkey. However, pancreatic changes were rather different from those typically seen in CP and the animals predominantly developed vascular and cardiac changes-features not observed in CP patients. Furthermore, severe malnutrition has been shown to result in pancreatic atrophy and insufficiency and not CP thus disproving the nutritional hypothesis [3]. Since cassava was a staple diet in Kerala, it gained the status of a co-culprit as a logical extension of the nutritional hypothesis. The cassava hypothesis has also been discarded because: (i) cassava consumption was not found as a risk factor in case-control studies including one from Kerala [4], (ii) patients with the TP were reported from areas where cassava was not consumed [5], and (iii) long-term cassava consumption did not produce diabetes or pancreatitis in a rat model [6].Even though the association of malnutrition with CP was consistent, not many clinical studies examined the cause and effect relationship. Our group first showed that malnutrition was an effect and not a cause of CP. In a prospective study of 120 patients with idiopathic CP, only 20.6% were underweight before the onset of the disease while 67% lost weight following the disease suggesting that malnutrition was an effect and not a cause of CP [5]. A recent study by Sathi...

Chronic Pancreatitis in India and Asia

2012

Curr Gastroenterol Rep

Chronic pancreatitis (CP) is widely prevalent in Asian countries much more so in India and Japan. The phenotype of CP is somewhat similar to that reported from western countries. The prevalent types of CP are mainly idiopathic and alcohol related. Current evidence suggests that the term "tropical pancreatitis" used for idiopathic CP from India is a misnomer. Gallstones' association with CP reported from China remains controversial. There has been ample evidence that mutations in the SPNIK1 and CFTR genes are strongly associated with idiopathic CP in patients from different ethnic backgrounds. Oxidative stress is important in the pathophysiology and antioxidants have been shown to result in significant pain relief with CP. Home-made balanced diet is effective for treating malnutrition in patients with CP. Endoscopic therapy combined with ESWL may provide significant relief in patients with pancreatic ductal calculi/stricture. Surgery is quite effective in CP and may be better than endotherapy.