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ORIGINAL ARTICLE
Year : 2017  |  Volume : 11  |  Issue : 1  |  Page : 17-21

Prevalence and characteristics of the metabolic syndrome in patients with chronic pancreatitis


1 Department of Endocrinology, Army Hospital (R and R), New Delhi, India
2 Department of Gastroenterology, Army Hospital (R and R), New Delhi, India

Date of Web Publication15-Feb-2018

Correspondence Address:
K V. S Hari Kumar
Department of Endocrinology, Army Hospital (R and R), New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/anm.anm_7_17

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   Abstract 


Objective: Chronic pancreatitis (CP) and metabolic syndrome (MS) share a bidirectional cause and effect relation. We investigated the prevalence and characteristics of MS in patients with CP and compared the same between alcoholic CP and tropical CP (TCP). Materials and Methods: In this cross-sectional, observational study, we included serial patients of CP presented to our hospital. We excluded CP patients with other known systemic disorders, long-term intake of drugs that could affect the lipids and also excluded patients with features of exocrine deficiency. The study population is grouped as alcoholic CP (Group 1; n = 65) and TCP (Group 2; n = 37). A fasting blood sample was checked for all the biochemical parameters, and MS was defined as per the Asian modification of the National Cholesterol Education Program Adult Treatment Panel III definition. The results were analyzed by appropriate statistical methods. Results: The study participants (85 male and 17 female) had a mean age 40.8 ± 12.6 years, CP duration 3.7 ± 4.7 year, and body mass index of 22.5 ± 3.2 kg/m2. A total of 27 (26%) out of 102 patients had the presence of the MS, which was similar in frequency between both the groups (P = 0.0991). Hyperglycemia and low high-density lipoprotein cholesterol (HDL-C) were the common features in alcoholic CP, whereas TCP patents showed hyperglycemia, abdominal obesity, and low HDL-C. None of the participants had all the five components, and seven patients had no features of the MS. Conclusion: MS is seen in a quarter of patients with CP, and the prevalence is same irrespective of the underlying etiology.

Keywords: Alcohol, chronic pancreatitis, diabetes, hypertension, metabolic syndrome


How to cite this article:
Hari Kumar K V, Manrai M, Sood A K. Prevalence and characteristics of the metabolic syndrome in patients with chronic pancreatitis. Ann Nigerian Med 2017;11:17-21

How to cite this URL:
Hari Kumar K V, Manrai M, Sood A K. Prevalence and characteristics of the metabolic syndrome in patients with chronic pancreatitis. Ann Nigerian Med [serial online] 2017 [cited 2018 Dec 13];11:17-21. Available from: http://www.anmjournal.com/text.asp?2017/11/1/17/225613




   Introduction Top


Chronic pancreatitis (CP) is a common gastrointestinal disorder that has significant morbidity. The common etiological factors for the CP include alcohol consumption, gallstone disease, and tropical CP (TCP) variety.[1] Loss of pancreatic exocrine function leads to malabsorption syndrome, and patients are in poor general health. CP may occasionally remain asymptomatic and is discovered incidentally during the evaluation of diabetes mellitus with pancreatic calcification.[2] Metabolic syndrome (MS) comprises a combination of abdominal obesity, dyslipidemia, hyperglycemia, and hypertension.[3] The prevalence of MS is increasing in the last few decades due to the urbanization and changing lifestyle.[4] CP is characterized by the atrophy of the gland and the loss of insulin-producing beta cell mass culminating into diabetes, which is also known as pancreatogenic diabetes or type 3c diabetes. The amount of the beta cell loss is the major determining factor for the development of diabetes, which could also be aggravated by the presence of coexisting MS.[5] The delineation of the exact etiology of diabetes in a patient with CP is often difficult due to the involvement of multiple risk factors.

CP and MS have a bidirectional relationship in their etiopathogenesis. Hypertriglyceridemia is a diagnostic component of MS, which increases the risk of pancreatitis.[6] Hypertriglyceridemia is also a marker of underlying insulin resistance, which predisposes to diabetes mellitus.[7] Patients with obesity and diabetes have a higher risk of developing pancreatitis, in comparison to normal population.[8] Incretin modulators that are used in the management of diabetes have been shown to increase the risk of pancreatitis.[9] The poor nourishment, debility, and lack of physical exercise in CP could reduce the high-density lipoprotein cholesterol (HDL-C), which is another diagnostic component of MS.[10] The previous studies on the clinical profile of CP patients did not evaluate the prevalence of the MS in these patients.[11],[12] Moreover, there is no study that assessed the differences between the alcoholic and TCP. Hence, we conducted this study to assess the prevalence and characteristics of the MS in patients with CP.


   Materials and Methods Top


Study population

We conducted this cross-sectional, observational study at a tertiary level armed forces referral hospital in India. All patients with a known diagnosis of CP (aged 18–70) of any duration under follow-up at our hospital were included in the study. We excluded patients with other known systemic disorders (chronic liver disease, chronic kidney disease, thyroid disease) long-term intake of drugs that could affect the obesity and lipid panel (glucocorticoids, statins, thyroxine, and oral contraceptive pills). We also excluded patients with features to suggest exocrine deficiency (steatorrhea and signs of fat-soluble vitamin deficiency). The patients were divided into two groups based on the etiology for the comparison: Group 1 (Alcoholic CP) and Group 2 (TCP). All the patients were managed as per the clinical condition by the treating physician.

Study measures

A detailed history regarding the profile of CP was obtained from all the participants. The physical examination includes measurements that are relevant for the identification of the MS. Body weight was measured with light clothing and without footwear to the nearest 0.1 kg. Standing height was measured with a wall-mounted stadiometer to the nearest 0.1 cm. The body mass index (BMI) was calculated as the weight in kilograms divided by the square of the height in meters. Waist circumference was measured on bare skin as the narrowest circumference between the lower costal margin and the iliac crest in centimeters. After a resting period of 30 min, systolic and diastolic blood pressure was measured from the right arm using an automated monitor. Blood pressure was obtained thrice from the same individual 30 min apart, and the average was taken.

Study sampling

A fasting venous blood sample after an overnight fast for more than 12 h was collected from each participant at 0800 h. The serum was analyzed for hematological and biochemical parameters including total cholesterol, triglycerides (TG), HDL-C, low density lipoprotein cholesterol (LDL-C), and liver function tests. Fasting plasma glucose and lipid panel except LDL-C were analyzed using enzymatic methods with reagents supplied by Roche Diagnostics and Hitachi 911 analyzer (Roche Diagnostics). LDL-C was calculated using the Friedewald equation in samples with TG <400 mg/dL.[13]

Study definitions

MS was defined according to the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines which have been modified for the Asian Indians.[14] Briefly, they include the presence of diabetes, hypertension, increased abdominal circumference (more than 90 cm for males and 80 cm for females), elevated TG (>150 mg/dL), and low HDL-C (<40 mg/dL for males and <50 mg/dL for females). CP was diagnosed based on the clinical and imaging criteria.[15] Typically, patients have chronic abdominal pain along with either presence of pancreatic calcification/atrophy on the ultrasound or the presence of ductal changes on the computed tomography or magnetic resonance imaging.

Statistics

Data are presented as mean ± standard deviation, and a comparison between the groups was done using nonparametric (Mann–Whitney U-test) and Fisher's exact tests. Spearman's correlation test was used for correlation between numerical variables and P < 0.05 was considered statistically significant. The statistical analysis and graph generation were done using the Graph Pad Prism Software, Version 6 (Graph Pad Software, San Deigo, CA, USA).


   Results Top


The study participants (85 male and 17 female) had a mean age of 40.8 ± 12.6 years, mean CP duration of 3.7 ± 4.7 years, body weight of 63.3 ± 10.8 kg, and mean BMI of 22.5 ± 3.2 kg/m 2. A total of 67 patients had alcoholic CP and the remaining 35 had TCP. Type 3c diabetes mellitus was seen in 54 patients with average glycosylated hemoglobin of 7.5 ± 1.6%. A total of 27 (26%) out of 102 patients had the presence of the MS. The comparison between the two groups is given in [Table 1]. Alcoholic CP (14/67) and TCP (13/35) showed comparable prevalence of the MS (P = 0.0991). Alcoholic CP had higher glycosylated hemoglobin in comparison to the TCP patients. The majority of the participants had 3 components of the MS and none of the participants had all the five components. Hyperglycemia and low HDL-C were the common features in alcoholic CP, whereas TCP patents showed equal presence of hyperglycemia, abdominal obesity, and low HDL-C. Seven participants had none of the positive features of the MS as shown in the [Figure 1]. Patients with TCP had a higher percentage positivity of three components as shown in [Figure 2]. The majority of the patients with alcoholic CP showed the presence of two components of the MS.
Figure 1: Metabolic syndrome parameters as per the etiology of chronic pancreatitis

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Figure 2: Percentage of patients with metabolic syndrome and individual components

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Table 1: Comparison of parameters between the two groups of chronic pancreatitis

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   Discussion Top


Our study showed that MS is seen in only a quarter of the patients with the MS. The previous reports suggest that the MS was seen in 52% of the patients with CP.[16] The low prevalence in our data could be due to the racial differences as the previous report was from a Caucasian population. The previous research on CP showed that the patients had a very low BMI irrespective of the presence of underlying diabetes or not.[17] The mean BMI in their study was 18.4 kg/m 2 whereas our patients had 22.5 kg/m 2. Our exclusion of patients with exocrine dysfunction could explain the high BMI in our study. Pancreatic exocrine dysfunction is a very late phenomenon in the course of the disease and is seen only after about 90% of the pancreatic tissue is destroyed. The literature is not available regarding the prevalence of the MS in the CP patients based on the etiology. Alcohol and TCP did not show any significant changes in the prevalence of the MS. The prevalence of MS is seen varying between 15% and 25% of the population from our country, similar to that described in our study.[18] Indian population have unique clinical and biochemical features including high body fat, visceral fat, and insulin resistance described as the Asian Indian Phenotype, which could have affected the prevalence rate in our study.[19]

Recent reports have suggested significant changes in the lipid profile of patients with CP. A study from China showed that patients with CP had low HDL-C and elevated glucose level in comparison to healthy controls.[20] These authors have shown a positive correlation between the lipids and the urinary amylase level. We did not check for the urinary amylase in our study precluding any comparison. Another study showed that CP patients had no significant difference in the HDL-C level.[21] CP is a disorder of significant oxidative stress and is identified by the oxidized fatty acid levels in the serum.[22] The lipids may also serve as the potential biomarkers for the severity of the disease in acute pancreatitis. The previous reports suggest that the low HDL and high TG have been seen to have a direct correlation with the Ranson's score.[23]

Our data showed interesting trends regarding the individual component positivity of the MS. Majority of the alcoholic CP patients had hyperglycemia whereas, the TCP patients had an equal prevalence of the hyperglycemia, abdominal obesity, and low HDL-C. This could be due to a direct toxic effect of the alcohol on the beta cells, leading to the beta cell damage.[24] However, the prevalence of the diabetes is the same between both the groups. Another interesting feature is the presence of two risk factors in almost half of the study population as shown in [Figure 2]. This suggests that the majority of the patients with CP have underlying subclinical inflammatory state and is exposed to the consequences of the MS as well.[25] It is essential to screen for the complications and educate these individuals about the healthy lifestyle measures to reduce the burden of the cardiovascular disease.

Obesity and MS are proinflammatory conditions, and CP is mediated by the same.[26] Few authors have even studied the role of anti-inflammatory molecules in minimizing the damage and progression of acute pancreatitis.[27] The role of inflammation has been established in the pathogenesis of acute pancreatitis, but the same has not been established conclusively in CP.[28] The strength of our study includes the assessment of the MS in a reasonable number of patients with CP, and no such study has been conducted earlier from our country. The limitations of our study include the cross-sectional design, lack of significant correlation between the established parameters and the sampling done only once during the study. Another limitation of the cross-sectional design is the inability to derive a cause and effect relation between the CP and MS. We did not present the data according to the severity of the CP or MS due to the small sample size.


   Conclusion Top


MS is common in patients with CP and is seen in a quarter of patients. The majority of the participants had three components, and hyperglycemia is the common component in the CP. The prevalence of MS is not different between the alcoholic CP and TCP. Further large-scale studies with more number of patients are required to confirm the findings observed in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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