Long-term Outcome and Prevention of Recurrences after Acute Alcoholic Pancreatitis

Acute pancreatitis (AP) is one of the most common reasons for immediate gastrointestinal hospital admissions. Two of the most common etiologies are excessive alcohol consumption and gallstones. Biliary pancreatitis rarely relapses when gallstone disease is treated appropriately. However, in acute alcoholic pancreatitis (AAP), relapses of the disease are common and recurrent acute pancreatitis (RAP) develops in 33-46% of patients, and further chronic pancreatitis (CP) in 12-16%. The data on the development of pancreatic dysfunction after an initial episode of AP are controversial, however, and it is not clear what kind of consequences a single episode of AP may have for later pancreatic function and morphology. The aim of this dissertation was to assess the incidence and risk factors for pancreatic dysfunction and chronic morphological changes after AAP and to explore ways to prevent RAP. The effects of a single episode of AAP on pancreatic dysfunction were studied in 77 patients in a prospective long-term follow-up lasting for 10.5 years in median. Pancreatic function was assessed at 1 to 2-year intervals. Endocrine dysfunction (prediabetes or diabetes) developed in half of the patients and exocrine dysfunction (persistently low fecal elastase-1) in one fourth. RAP was a major risk factor for endocrine dysfunction. Pancreatogenic diabetes mellitus developed in 20% of the patients and only in patients with RAP. Morphological changes seen in the pancreas were evaluated with secretin stimulated magnetic resonance cholangiopancreatography (S-MRCP). In a followup extending for up to nine years, chronic changes were observed in 47% of the patients and were more prevalent in patients with RAP and non-mild first AAP. Pancreatic dysfunction was associated with chronic changes. The impact of abstinence from alcohol on recurrence of AAP was studied using a prospective study design. Abstinence protected against RAP and also against developing new-onset diabetes. The current status of brief interventions (BIs) and substance abuse treatment in patients with AAP was assessed in patients treated in Pirkanmaa Hospital District, Finland in 2010 – 2012. Abstinence as the goal for substance abuse treatment was mentioned in only one third of these patients’ discharge summaries. In-hospital BI seemed not to have been provided for about one third of patients. On the other hand, in-hospital BI itself did not appear to reduce the later occurrence of RAP. In addition, young age at presentation of first AAP and higher Alcohol Use Disorders Identification Test (AUDIT) points were significant risk factors for RAP. The conclusion of this thesis is that pancreatic insufficiency is likely to develop in patients who have recovered from their first AAP episode. RAP is the most important risk factor for the development of pancreatic endocrine insufficiency, pancreatogenic diabetes and chronic morphological pancreatic changes. Pancreatic function should be actively monitored after AAP and especially in patients with RAP. Alcohol abstinence protects against RAP and should thus be recommended to all AAP patients. Identification of the drinking problem and more effective means to organize the follow-up care for routine intervention are needed in order to effectively prevent recurrent attacks.