The Enigma of Type 3c Diabetes in Chronic Pancreatitis

Abstract

Pancreatogenic or Type 3c diabetes (T3cDM) is relatively a new entry in the complex world of diabetes study. While the general population and physicians are well aware of type 1 and type 2 diabetes mellitus, as evidenced by numerous study groups and the reams of guidelines on diagnosis and treatment of type 1 and type 2 diabetes mellitus, relatively much less is known, considered and documented about diabetes mellitus that occurs secondary to pancreatic diseases. A casual search of Pubmed reveals less than 100 entries on type 3c diabetes. This may be because physicians earlier considered type 3c diabetes to be of rare occurrence and thus a condition rarely considered in everyday practice. Yet, recent data on type 3c diabetes (T3cDM) showed that it might be more common than generally thought. Studies also propose that this clinically important condition might be consistently under and misdiagnosed in routine clinical practice. 1 The World Health Organization (WHO) and American Diabetes Association (ADA) have categorized diabetes occurring as a result of benign and malignant disease to exocrine pancreas, such as chronic pancreatitis, hemochromatosis, cystic fibrosis, fibrocalculous pancreatopathy, pancreatic trauma, pancreatic cancer and pancreatectomy as Pancreaticogenic diabetes (T3cDM). 2,3 It is estimated that about 78.5% of T3cDM patients are with chronic pancreatitis and 8% of T3cDM are suffering from pancreatic cancer. 4 Globally about 10% of the total diabetic population has been diagnosed for Chronic Pancreatitis (CP), which is characterized by progressive fibrosis, irreversible exocrine and early onset endocrine dysfunction of pancreas. Recurrent and intractable abdominal pain is the dominant clinical hallmark that mandates aggressive treatment. An initial population-based study in Kerala (1996), confirmed later by questionnaire based studies in the Asia Pacific region, has recorded the prevalence of CP to be 114-200/100,000 populations in southern India, which is markedly higher than that in western industrialized nations (10-15/100,000). 5 Importantly, patients report initially with diabetes and then diagnosed for CP with the mean age of diagnosing CP being less than 30 years. However, it is noted that about 30% of patients with CP have diabetes and more than 50% of these individuals will develop diabetes before 40 years of age. In comparison to the western countries wherein it takes about 10 years for diabetes to manifest in diagnosed CP patients, it is within 2 years between onset of CP and diagnosis of diabetes in Indian patients, indicating the rapid loss of endocrine functions in these individuals.Although pathogenesis of diabetes in chronic pancreatitis has long been recognized, only recently it is classified as a distinct entity and guidelines have been developed supporting a specified diagnostic and therapeutic algorithm. 6 T3C DM is distinct from Type 1 and Type 2 DM as it arises due to chronic inflammation and has unique clinical and laboratory parameters and is associated with high incidence...

Chronic Calcific Pancreatitis and Its Association With Secondary Diabetes Mellitus

“…Diabetes develops in CP mostly as a result of pancreatic inflammation destroying islet cells. Malnutrition also impairs incretin production, leading to decreased insulin production from the surviving β cells [40].…”

Missed case of pancreatogenic diabetes diagnosed using ultrasound

“…[ 7 ] On the other side, it has been observed that 38% of patients suffering from CP develop diabetes within the next 1–2 years. [ 8 ] Hence, it becomes essential to diagnose cases of CP at the earliest to alter the natural course of the disease. However, biochemical studies are not helpful in definitive diagnosis during early stages.…”

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

“…While early and periodic screening for DM with CP is recommended, the same is also critical for non-diabetic patients with CP as they are strongly predisposed to T3cDM [6]. Patients diagnosed with CP without DM exhibit an extended glucose tolerance curve, and once diagnosed with CP, 40% of patients exhibit early-onset DM [108]. Another study also showed that a two-hour oral glucose tolerance test helped in early detection of glycemic alteration even when fasting blood glucose and HbA1c were normal, indicating that an appropriate management could help prevent CP severity [109].…”