WBR0729

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathology
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 47-year-old man, with a history of chronic alcohol consumption, presents to the physician's office for recurrent abdominal pain that radiates to the back. The patient's past medical history is significant for cholecystectomy and several episodes of pancreatitis for the past 10 years. Upon further questioning, the patient also notes he has stools that are difficult to flush and has been recently diagnosed with diabetes mellitus. Following appropriate work-up, a wedge biopsy of the pancreas is performed, and the diagnosis of alcoholic chronic pancreatitis is made. Which of the following statements is true about alcoholic chronic pancreatitis?]]
Answer A	AnswerA::Caucasians are at increased risk of alcoholic chronic pancreatitis compared to African-Americans
Answer A Explanation	AnswerAExp::African-Americans are at increased risk of alcoholic chronic pancreatitis.
Answer B	AnswerB::Chronic pancreatitis is due to inefficient ethanol processing within the pancreas
Answer B Explanation	AnswerBExp::Although ethanol is efficiently metabolized by the pancreas, its metabolites activate stellate cells and damage pancreatic acinar cells.
Answer C	AnswerC::Ethanol metabolites activate pancreatic stellate cells
Answer C Explanation	AnswerCExp::Ethanol metabolites damage acinar cells and activate stellate cells, resulting in fibrosis and chronic pancreatitis.
Answer D	AnswerD::Excessive alcohol consumption is the predominant factor among the majority of cases of chronic pancreatitis
Answer D Explanation	[[AnswerDExp::Chronic pancreatitis is associated with alcohol consumption, but excessive consumption is observed in only 30-35% of the cases. Hence, it is believed that other factors, in addition to the amount of consumed alcohol, also play a significant role in the development of chronic pancreatitis.]]
Answer E	AnswerE::Alcoholic chronic pancreatitis is less common than infectious etiologies of pancreatitis among adults.
Answer E Explanation	AnswerEExp::Alcoholic chronic pancreatitis is a much more common cause of chronic pancreatitis. In the adult population, infectious etiology is considered rare.
Right Answer	RightAnswer::C
Explanation	[[Explanation::Alcoholic chronic pancreatitis is the most common cause of chronic pancreatitis among adults in otherwise healthy patients. It is more common among the African-American population compared to other ethnicities. Alcoholic chronic pancreatitis is not believed to be significantly associated with the amount of excessive alcohol consumption, since excess consumption is responsible for only 30% of cases of alcoholic chronic pancreatitis. Also, pancreatic injury from alcohol may occur using very small doses; thus there may be no real threshold for the amount needed to induce chronic pancreatitis. Despite the efficient ethanol processing, alcohol metabolites damage pancreatic acinar cells and activate stellate cells, resulting in fibrosis and chronic pancreatitis, with reduced exocrine and endocrine pancreatic functions (such as steatorrhea and diabetes mellitus in this patient). Stellate cells of the pancreas are special cells found in pancreatic regions that contain exocrine activity. They are cells that resemble myofibroblasts. They are activated during tissue damage, which causes their proliferation and migration into injured sites for reparation of tissue by phagocytosing and synthesizing new extracellular matrix structures. Chronic activation of pancreatic stellate cells is associated with fibrotic changes, chronic pancreatitis, and pancreatic cancer. Educational Objective: Alcoholic chronic pancreatitis is associated with the activation of pancreatic stellate cells by ethanol metabolites. Chronic stellate cell activation leads to fibrosis, chronic pancreatitis, and pancreatic cancer. References: Braganza JM, Lee SH, McCloy RF, McMahon MJ. Chronic pancreatitis. Lancet. 2011;377:1184-97. Omary MB, Lugea A, Lowe AW, Pandol SJ. J Clin Invest. 2007;117(1):50-59. First Aid 2014 page 368 and 515]]
Approved	Approved::Yes
Keyword	WBRKeyword::Chronic, WBRKeyword::Pancreatitis, WBRKeyword::Stellate, WBRKeyword::Cells, WBRKeyword::Alcoholic, WBRKeyword::Abdominal, WBRKeyword::pain, WBRKeyword::Steatorrhea, WBRKeyword::Diabetes, WBRKeyword::Mellitus, WBRKeyword::Wedge, WBRKeyword::Biopsy, WBRKeyword::Fibrosis, WBRKeyword::Ethanol, WBRKeyword::Alcohol
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