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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 51  |  Issue : 6  |  Page : 219-222

Acute pancreatitis and primary hyperparathyroidism: Effect of parathyroidectomy


Department of General Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India

Date of Submission06-Oct-2017
Date of Decision19-Jan-2018
Date of Acceptance04-May-2018
Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Riju Ramachandran
Department of General Surgery, Amrita Institute of Medical Sciences, Amrita University, AG1, Sterling Sarovar, Kosseri Lane, Edapally, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_158_17

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  Abstract 

Background: The association between primary hyperparathyroidism (PHPT) and acute pancreatitis (AP) is well known. However, the causal association is disputed.
Aims: The present cohort study of PHPT patients was done: (1) to assess the prevalence of AP and (2) to assess the effect of successful parathyroidectomy in preventing further recurrence.
Materials and Methods: Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone. Review of records of patients who were successfully operated for PHPT was done. Records of patients treated with confirmed diagnosis of AP during the study period were reviewed. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05).
Results: There were 13 (7.5%) patients with confirmed diagnosis of AP and serum calcium level significantly elevated in this group. There was a linear association of serum calcium with AP. Successful parathyroidectomy prevented further episodes in 11 (84.6%) of patients. There was 2% prevalence of PHPT among 558 patients with AP.
Conclusions: Hypercalcemia in PHPT patients was significantly associated with AP and early parathyroidectomy prevented further recurrence.

Keywords: Acute pancreatitis, hypercalcemia, primary hyperparathyroidism


How to cite this article:
Ramachandran R, Nair GC, Babu MJ, Jacob P. Acute pancreatitis and primary hyperparathyroidism: Effect of parathyroidectomy. Formos J Surg 2018;51:219-22

How to cite this URL:
Ramachandran R, Nair GC, Babu MJ, Jacob P. Acute pancreatitis and primary hyperparathyroidism: Effect of parathyroidectomy. Formos J Surg [serial online] 2018 [cited 2019 Jan 18];51:219-22. Available from: http://www.e-fjs.org/text.asp?2018/51/6/219/247307


  Introduction Top


Conventionally, 80% of acute pancreatitis (AP) is related to alcohol abuse and biliary stone disease and <10% have metabolic causes as etiology.[1],[2] Ever since the association between AP and primary hyperparathyroidism (PHPT) was reported in 1940 by Smith and Cook,[3] many case series have appeared in the literature recording varying prevalence from 1.5% to 15%.[4],[5],[6] However, the causal association of PHPT with AP was always debated. Population-based survey did not reveal significant difference in the prevalence of AP in PHPT patients and general population.[4] A recent systematic review emphasized the association between PHPT and AP and implicated hypercalcemia as causal association.[7] However, many case series failed to exclude other concurrent potential causes of AP such as alcohol abuse and biliary stones, and hence, the causal association was doubted.

We also analyzed the case records of patients admitted with confirmed diagnosis of AP during the study period for clinical and biochemical features indicative of PHPT. The aim of the study was to assess the prevalence of AP in PHPT patients and to determine the effect of parathyroidectomy in preventing recurrence.


  Materials and Methods Top


Study design

Patients operated for PHPT during January 2005 and December 2014 were included in the study. Patients with evidence of multiple endocrine neoplasia type 1 were excluded since associated pancreatic tumors could be an etiology. AP patients with other possible etiological features such as alcohol abuse, biliary stones, and elevated serum triglycerides (50.0–150.0 mg/dl) were excluded from the study.

Diagnosis of AP was based on the history of acute abdominal pain with serum lipase level more than 200 U/L (21–67). Contrast-enhanced helical computed tomography (CT) was reviewed for confirmation. A diagnosis of recurrent AP was made if the patient had more than one episode of AP.

Surgical cure of hyperparathyroidism was ensured by intraoperative parathyroid hormone monitoring (Miami criterion) and regular follow-up to exclude recurrent hypercalcemia. All patients were reviewed at 6 monthly intervals. Ultrasonography or CT of the abdomen, serum amylase, and lipase levels was done based on clinical findings. Data regarding clinical features and laboratory values were retrieved from the prospective database maintained in the surgical endocrinology division of the Institution. The details regarding prior treatment were reviewed.

Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone.

Statistics

The cohort was further divided into two subgroups based on the association of AP. For the comparison of categorical variables among the different groups, Chi-square test was used. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied because the laboratory parameters values did not follow the parametric assumption. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05). SPSS version 11 (SPSS Inc., Chicago) was employed for statistical analysis.


  Results Top


During the study period, 186 patients were operated for PHPT. Nine patients with clinical and biochemical evidence of MEN-1 syndrome were excluded from the study. Of the remaining 177 patients, 12 patients (6.6%) were asymptomatic and others presented with symptoms related to the skeletal system, kidneys, gastrointestinal system, and metabolic disturbances. There were 16 (8.6%) patients with AP and 9 (4.8%) with chronic calcific pancreatitis (CCP), and hence, a total of 13.4% had complications related to the pancreas. Of the 16 patients with AP, three were excluded in view of associated alcohol abuse (n = 2) and obesity with increased serum level of triglycerides (body mass index [BMI] – 33.4lg/m2 and serum triglycerides level – 491 mg/dl). All the 13 patients had recurrent AP since they had more than one episode of AP.

We analyzed the data of 174 patients with the mean age of 45.66 years (standard deviation [SD]: 14.24) and the mean BMI of 24.6 Kg/m2 (SD: 4.123). The cohort included 59% (n = 103) females. Coincident hypertension was present in 59 (33.3%) and diabetes mellitus in 40 (22%) patients when PHPT was diagnosed. The mean value of creatinine clearance (modification of diet in renal disease study equation) was 78.24 mL/min/1.73 m2 (SD: 35.213) and 20 (12%) had eGFR <40 ml. The profile of cohort is shown in [Table 1].
Table 1: Profile of the group

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The cohort that included 13 (7.5%) patients who had recurrent episodes of AP was grouped to analyze clinicopathological features and is noted in [Table 2]. The mean age of the group was 45.24 years included 7 (54%) females. The serum level of calcium was significantly high in patients who developed AP compared to those who did not.
Table 2: Characteristics of patients with acute pancreatitis

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Successful parathyroidectomy was done in all patients, and the mean weight of excised parathyroid lesion was 5.784 g (SD: 6.05). The histology showed adenoma in 135 (77.6%), atypical adenoma in 7 (4%), carcinoma in 13 (7.5%), and hyperplasia in 19 (11%). The patients were followed for a mean duration of 61.46 months (24–132). Of the 13 with AP, 11 (84.6%) were free of further episodes, but 2 developed CCP during follow-up.

We analyzed 558 patients admitted with AP during the same study period (male 416 and female 142) with mean age of 42.71 years (SD: 18.829). Of these, 11 (2%) had confirmed PHPT. The mean serum calcium level was 8.1 mg/dl (SD: 1.342) and 61.2% had values below reference level. The serum calcium levels of patients with PHPT were above normal reference level during hospitalization (mean: 10.32 mg/dl). All PHPT patients underwent successful parathyroidectomy and did not develop further episodes of AP.


  Discussion Top


In this group, 95% of participants were symptomatic and the serum levels of calcium and PTH were high. We observed 7.5% prevalence of AP in PHPT patients after adjusting to other potential etiologies.

Serum calcium level was significantly high in AP patients, but the PTH level was not. The regression model showed a linear association with serum calcium level with no definite cutoff point. There were no other possible etiologies associated with them and hence we assume that hypercalcemia was an independent triggering factor in the development of AP. AP was noted as the first manifestation in patients with hypercalcemia related to malignancy and sarcoidosis.[8],[9],[10] Experimental hypercalcemia by calcium infusion was found to induce trypsinogen activation and pancreatic cellular damage in rats.[11] Hypercalcemia induces pancreatic damage through secretary block, accumulation of secretory products, and activation of proteases.[12] Experimental evidence link elevated acinar cell calcium levels with AP in association with premature trypsinogen activation to trypsin.[12],[13]

Successful parathyroidectomy prevented further episodes in 84.5% (n = 11) patients. Approximately 10% AP patient's progress to chronic pancreatitis and the significant predictors are continued alcohol abuse and smoking.[14] The progression to chronic form is mostly due to the persistence of the primary etiology. Two patients who had progression of disease suffered more than four episodes of AP requiring hospitalization before the diagnosis of PHPT. The patients with CCP gave multiple episodes of AP in the past.

Of the 558 patients with AP admitted during the study period, 2% patients had confirmed PHPT. All these patients underwent successful parathyroidectomy. The serum calcium levels of all these patients were above normal reference level during the acute phase of the disease. Awareness of this rare combination among the treating physician helps to make an early diagnosis of PHPT and thus preventing progression of the disease to chronic disease.

However, hypercalcemia does not have a temporal relation with AP. Despite having high serum calcium levels, <15% PHPT patients develop AP. Few genetic variables have been identified that increase the susceptibility to develop AP, namely, polymorphisms in serine protease inhibitor Kazal type 1 (SPINK1), polymorphisms in cationic trypsinogen (PRSS1) and chymotrypsinogen C (CTRC) genes in the acinar cells and cystic fibrosis transmembrane conductance regulator (CFTR), and calcium-sensing receptor (CASR genes in the ductal cells).[15] SPINK1 gene governs pancreatic secretory trypsin inhibitor and mutations in SPINK1 N34S allele is associated with acute and chronic pancreatitis, but only <1% carriers develop pancreatitis during their lifetime.[16],[17] SPINK1 mutations are seen in approximately 2% of population and were considered to lower the threshold for pancreatitis from other genetic or environmental factors, but by themselves does not cause disease.[18],[19],[20]

Extracellular calcium-sensing receptors were first cloned from bovine parathyroid glands in 1993[21] and later Rácz et al. documented evidence indicating the presence of CASR in human exocrine pancreas.[22] Recent studies from Germany and India have reported high prevalence of CASR and SPINK1 N34S missense mutation either alone or in combination.[23],[24] Felderbauer et al. found significantly high prevalence of the N34S missense mutation in the SPINK1 gene among PHPT patients with AP.[19] The higher disease severity indices of PHPT and increased incidences of SPINK1 gene mutation can explain significantly high prevalence of AP in PHPT patients in Indian subcontinent.


  Conclusions Top


Significantly, high prevalence of AP was present among patients with PHPT. Approximately 2% of AP could be related to PHPT. These patients had high serum calcium levels during the acute phase of pancreatitis and awareness of this rare combination increases chances of early diagnosis. Surgical cure of hyperparathyroidism effectively prevents further recurrence of AP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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2.
Chen Y, Zak Y, Hernandez-Boussard T, Park W, Visser BC. The epidemiology of idiopathic acute pancreatitis, analysis of the nationwide inpatient sample from 1998 to 2007. Pancreas 2013;42:1-5.  Back to cited text no. 2
    
3.
Smith FB, Cook RT. Acute fatal hyperparathyroidism. Lancet 1940;2:650.  Back to cited text no. 3
    
4.
Khoo TK, Vege SS, Abu-Lebdeh HS, Ryu E, Nadeem S, Wermers RA, et al. Acute pancreatitis in primary hyperparathyroidism: A population-based study. J Clin Endocrinol Metab 2009;94:2115-8.  Back to cited text no. 4
    
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Felderbauer P, Karakas E, Fendrich V, Lebert R, Bartsch DK, Bulut K, et al. Multifactorial genesis of pancreatitis in primary hyperparathyroidism: Evidence for “protective” (PRSS2) and “destructive” (CTRC) genetic factors. Exp Clin Endocrinol Diabetes 2011;119:26-9.  Back to cited text no. 5
    
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McIntosh J, Lauer J, Gunatilake R, Knudtson E. Multiple myeloma presenting as hypercalcemic pancreatitis during pregnancy. Obstet Gynecol 2014;124:461-3.  Back to cited text no. 9
    
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11.
Mithöfer K, Fernández-del Castillo C, Frick TW, Lewandrowski KB, Rattner DW, Warshaw AL, et al. Acute hypercalcemia causes acute pancreatitis and ectopic trypsinogen activation in the rat. Gastroenterology 1995;109:239-46.  Back to cited text no. 11
    
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Frick TW, Mithöfer K, Fernández-del Castillo C, Rattner DW, Warshaw AL. Hypercalcemia causes acute pancreatitis by pancreatic secretory block, intracellular zymogen accumulation, and acinar cell injury. Am J Surg 1995;169:167-72.  Back to cited text no. 12
    
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Ward JB, Petersen OH, Jenkins SA, Sutton R. Is an elevated concentration of acinar cytosolic free ionised calcium the trigger for acute pancreatitis? Lancet 1995;346:1016-9.  Back to cited text no. 13
    
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Sankaran SJ, Xiao AY, Wu LM, Windsor JA, Forsmark CE, Petrov MS, et al. Frequency of progression from acute to chronic pancreatitis and risk factors: A meta-analysis. Gastroenterology 2015;149:1490-5000.  Back to cited text no. 14
    
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Krüger B, Albrecht E, Lerch MM. The role of intracellular calcium signaling in premature protease activation and the onset of pancreatitis. Am J Pathol 2000;157:43-50.  Back to cited text no. 16
    
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Chen JM, Mercier B, Audrezet MP, Ferec C. Mutational analysis of the human pancreatic secretory trypsin inhibitor (PSTI) gene in hereditary and sporadic chronic pancreatitis. J Med Genet 2000;37:67-9.  Back to cited text no. 17
    
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Pfützer RH, Barmada MM, Brunskill AP, Finch R, Hart PS, Neoptolemos J, et al. SPINK1/PSTI polymorphisms act as disease modifiers in familial and idiopathic chronic pancreatitis. Gastroenterology 2000;119:615-23.  Back to cited text no. 18
    
19.
Felderbauer P, Hoffmann P, Einwächter H, Bulut K, Ansorge N, Schmitz F, et al. Anovel mutation of the calcium sensing receptor gene is associated with chronic pancreatitis in a family with heterozygous SPINK1 mutations. BMC Gastroenterol 2003;3:34.  Back to cited text no. 19
    
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Whitcomb DC. Mechanisms of disease: Advances in understanding the mechanisms leading to chronic pancreatitis. Nat Clin Pract Gastroenterol Hepatol 2004;1:46-52.  Back to cited text no. 20
    
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Brown EM, Gamba G, Riccardi D, Lombardi M, Butters R, Kifor O, et al. Cloning and characterization of an extracellular Ca (2+)-sensing receptor from bovine parathyroid. Nature 1993;366:575-80.  Back to cited text no. 21
    
22.
Rácz GZ, Kittel A, Riccardi D, Case RM, Elliott AC, Varga G, et al. Extracellular calcium sensing receptor in human pancreatic cells. Gut 2002;51:705-11.  Back to cited text no. 22
    
23.
Felderbauer P, Karakas E, Fendrich V, Bulut K, Horn T, Lebert R, et al. Pancreatitis risk in primary hyperparathyroidism: Relation to mutations in the SPINK1 trypsin inhibitor (N34S) and the cystic fibrosis gene. Am J Gastroenterol 2008;103:368-74.  Back to cited text no. 23
    
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