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Duodenal Acidity May Increase the Risk of Pancreatic Cancer in the Course of Chronic Pancreatitis: an Etiopathogenetic Hypothesis

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Duodenal Acidity May Increase the Risk of Pancreatic Cancer in the Course of Chronic Pancreatitis: an Etiopathogenetic Hypothesis JOP. J Pancreas (Online) 2005; 6(2):122-127. EDITORIAL Duodenal Acidity May Increase the Risk of Pancreatic Cancer in the Course of Chronic Pancreatitis: An Etiopathogenetic Hypothesis Giorgio Talamini Gastroenterology and Endoscopy Service, University of Verona. Verona, Italy Summary duodenum. Patients undergoing a Whipple procedure or side-to-side pancreaticojejuno- Chronic pancreatitis patients have an stomy are probably less critically affected increased risk of developing pancreatic because secretions transit, at least in part, via cancer. The cause of this increase has yet to the papilla. be fully explained but smoking and If the duodenal acidity hypothesis proves inflammation may play an important role. To correct, then, in addition to stopping smoking, these, we must now add a new potential risk reduction of duodenal acid load in patients factor, namely duodenal acidity. Patients with with pancreatic insufficiency may help chronic pancreatitis very often present decrease the risk of pancreatic cancer. pancreatic exocrine insufficiency combined with a persistently low duodenal pH in the postprandial period. The duodenal mucosa in Chronic pancreatitis (CP) patients have an chronic pancreas patients with pancreatic increased risk of developing pancreatic cancer insufficiency has a normal concentration of s- [1, 2]. The cause of this increase has yet to be cells and, therefore, the production of secretin fully explained and various hypotheses are is preserved. Pancreatic ductal cells are being explored [3, 4, 5, 6, 7]. Nevertheless, largely responsible for the amount of smoking unquestionably plays an important bicarbonate and water secretion in response to role [4, 8, 9] because the great majority of CP secretin stimulation. When gastric acid in the patients have smoked a large number of duodenum is not well-balanced by alkaline cigarettes for a long period of time [10]. pancreatic secretions, it may induce a Excluding patients with a diagnosis of prolonged secretin stimulus which interacts pancreatic cancer formulated within only a with the pancreatic ductal cells resulting in an few years of the onset of symptoms (probably increased rate of ductular cell activity and cases of misdiagnosis of chronic pancreatitis) turnover. N-Nitroso compounds from tobacco, [11], we have documented that at least one- identified in human pancreatic juice and third of pancreatic cancer risk in CP is due to known to be important carcinogens, may then smoking while the remaining two-thirds may act on these active cells, thereby increasing be due to the interaction of smoking with the risk of cancer. Duodenal acidity is inflammation and/or other factors [10]. We probably of particular concern in patients who have tried to identify these other risk factors. have undergone a duodenum-preserving In the general population, in very large series, pancreatic head resection, since, in this cholecystectomy, gastrectomy and diabetes anatomic situation, pancreatic juice transits mellitus have been identified as weak risk directly via the jejunal loop, bypassing the factors for pancreatic cancer [12]; however, in JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 2 – March 2005. [ISSN 1590-8577] 122 JOP. J Pancreas (Online) 2005; 6(2):122-127. our patients with CP, these factors would The centroacinar and ductal cells are largely appear not to be associated with any increased responsible for a considerable amount of - risk of pancreatic cancer [13]. HCO3 and water secretion in response to Inflammation probably has a significant secretin stimulation [24]. The maximum - impact [14, 15]; illnesses such as a Barrett concentration of HCO3 is 150 mMol/L. These esophagus, atrophic gastritis, celiac disease, cells present high levels of activity of Crohn’s or ulcerative colitis, and cirrhosis carbonic anhydrase. Secretin receptors increase the risk of cancer in the respective increase the concentration of cyclic adenosine organs. Mechanisms involving DNA monophosphate (c-AMP) which activates Cl- modifications take many years and are not channels resulting in an exchange of CL- for - clearly understood [14, 15, 16]. The HCO3 at the luminal membrane with a interaction between smoking and subsequent cascade of events. inflammation may also be very important in Duodenal pH is the most important regulator CP and may modify the host response to of secretin release and pancreatic bicarbonate smoking in a chronic condition having a secretion; the threshold value is 4.5 pH in the higher risk of cancer [7, 9, 17, 18, 19]. duodenum. Below this value, the secretin- releasing peptide in the intestinal mucosa Duodenal Acidity (probably a phospholipase A2 [25]) releases secretin into the plasma [24]. When seeking to understand pancreatic The secretin-stimulated pancreatic exocrine carcinogenesis in CP, it may now be secretion is profoundly inhibited by atropine, necessary to consider a new potential source suggesting a mediated muscarinic cholinergic of risk in addition to the above-mentioned pathway involving the vagus nerve [26]. factors, namely duodenal acidity [20]. Moreover, smoking reduces the pancreatic In CP patients, who very often present fluid and bicarbonate secretion in men for 60- pancreatic exocrine insufficiency [21], 90 min [27]. duodenal pH may be persistently low. In When gastric acid in the duodenum is not fasting conditions gastric and duodenal pH adequately buffered by alkaline pancreatic are normal, whereas, in the postprandial secretions, it may induce a prolonged secretin period there is increased, prolonged acidity in stimulus which interacts with pancreatic both the stomach and the duodenum [22]. The ductal cells with a subsequent increased rate increased acidification of the duodenum of ductular cell activity and turnover. releases secretin from duodenal s-cells to the blood, probably in normal (or higher) Tobacco Smoking concentrations for a prolonged period of time. Thus, the area under secretin curve after a N-Nitroso compounds from tobacco, which meal should be increased. The duodenal are known to be important carcinogens [28] mucosa in chronic pancreas patients with and have been identified in human pancreatic pancreatic insufficiency has a normal juice and rat acinar cells [29], may also act on concentration of s-cells and, therefore, the the active ductal cells [30]. production of secretin is preserved [23]. A cigarette contains up to 30 mg of nicotine, a Of the total pancreatic mass, the acini account volatile alkaloid rapidly absorbed by for about 85% whereas the ductal and membranes, with a half life of 30-60 minutes. centroacinar cells (also called principal cells) Peak arterial and venous nicotine levels after make up only about 5% of the glandular cell smoking reach 80 ng/mL and 5-15 ng/mL, mass [24]. Even without conclusive evidence repectively [31, 32]. In the saliva of smokers, regarding the type of cell of origin, we know bearing in mind that the salivary gland that phenotypic ductal pancreatic presents characteristics similar to the adenocarcinomas constitute about 80% of pancreas, nicotine levels are much higher than pancreatic cancers. in the blood, i.e. 1,300 ng/mL [33]. Nicotine, JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 2 – March 2005. [ISSN 1590-8577] 123 JOP. J Pancreas (Online) 2005; 6(2):122-127. one of the main components of smoking, is a very often wine drinkers even between meals, relatively inert chemical in carcinogenesis. It and so duodenal acidity during the day may is metabolized to cotinine (mutagenic). prove persistently low. Cigarette smoke, moreover, contains a large When patients have been diagnosed as having number of other more potent carcinogens (e.g. pancreatic insufficiency, many doctors advise 4-(N-methylnitrosamino)-1-(3-pyridyl)- them to reduce their alcohol intake and butanone (NNK) and N-nitrosonornicotine increase the number of meals in order to (NNN) [28, 30]). obtain better digestion. The increase in the Benzopyrene induces a specific type of G:C- number of postprandial periods may induce a >T:A mutation found in K-ras and p53 genes more prolonged acidic pH in the duodenum. in lung tumors [34, 35], and loss of A few years after the onset of symptoms, heterozygosity of the FHIT locus (located on pancreatic insufficiency usually increases [21] chromosome 3p14.2) occurs in lung cancer and thus the production of bicarbonate in the and in 60% of pancreatic cancers [36]. In the postprandial period proves increasingly pancreatic juice of CP patients, K-p53 and insufficient to neutralize the duodenal acidity. p53 mutation have been found with a high We can postulate more frequent or prolonged prevalence [37, 38]. s-secretin cell production from the duodenum, Smoking may modify vascular reactivity [39], and more intense stimulation of the ductal and interaction with alcohol may increase cells. pancreatic damage [40]. Harvey A Risch [20] claims that, in normal Effect of Surgery on Anatomy and subjects, the low duodenal pH due to Physiology Helicobacter pylori (HP) infection may account for the persistent stimulation of The low duodenal pH hypothesis is probably pancreatic ductal cells by secretin. A number of particular concern in CP with a duodenum- of epidemiological studies support this preserving pancreatic head resection (e.g. hypothesis [41, 42]. Chronic pancreatitis Beger’s operation, consisting in a partial patients, and even those with a prevalence of resection of the head with a Roux-en-Y about 20% of duodenal ulcers [43, 44] would pancreaticojejunostomy), since, in this not seem to be at high risk of HP infection anatomic situation, the pancreatic juice [45]. transits directly via the jejunal loop, Unfortunately, in our series, we have few data bypassing the duodenum. From this point of concerning HP and we do not know whether view, patients undergoing patients with CP and pancreatic cancer are HP pancreaticoduodenectomy (e.g. the Whipple positive; consequently, we cannot evaluate procedure) or anastomotic surgery (e.g. side- the hypothetical increased risk of pancreatic to-side pancreaticojejunostomy) should cancer. We have also been unable to find any probably be less critically affected.
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