1. Advances in the etiology of chronic pancreatitis
European Postgraduate School
in Gastroenterology
Prague, April 2010
550 Jahre Universität Greifswald
Medizinische Klinik der königlichen
Universität Greifswald
1456
1859
Markus M. Lerch
Department of Medicine A
Ernst-Moritz-Arndt Universität Greifswald

2. Chronic Pancreatitis - Etiology
Reasons to discriminate between different etiologies:
Specific treatment options
Inherent co-morbidities
Different cancer surveillance strategies
Alcohol Idiopathic Metabolic Anatomical Hereditary Autoimmune

3. Layer et al, Gastroenterology 1994;107:1481- 87
Chronic Pancreatitis – Alcohol Cessation
Non-Alcoholic CP
Incidence of calcifications
Propabililty in %
Alcoholic-CP
Time after onset of symptoms
Layer et al, Gastroenterology 1994;107:

4. Chronic Pancreatitis - Alcohol Cessation
Strum et al, 1971
Stop Alcohol
Gastard et al, 1973
Leger et al, 1974
Prinz et al, 1974
Bornman et al, 1980
Marks et al, 1980
Miyaka et al, 1987
Hayakawa et al, 1989
Strum et al, 1995 20 40 60 80
100
Patients with pain [%]

5. Chronic Pancreatitis – Cessation of Smoking
Maisoneuve P, Gut 2005; 54:
100 80 60 40 20
Log rank p<0.0001
Smokers
OR 2.0 [CI ]
Cumulative Incidence of calcifications, %
Non-Smokers
years after diagnosis of chronic alcoholic pancreatitis

6. Hereditary Pancreatitis
Hereditary pancreatitis is clinically indistinguishable from
other forms and varities of pancreatitis.
14 year old girl with chronic pancreatitis
and R122H-mutation
48 year old women with chronic pancreatitis
and R122H-mutation

7. Hereditary pancreatitis in Germany
1952, first description of
hereditary pancreatitis
(autosomal dominant trait).
1996 Discovery of the first
mutation associated with
hereditary pancreatitis in the
cationic trypsinogen gene
(PRSS1) by Whitcomb et al.
Greifswald
Münster
Weiss F.U. Am J Gastroenterol. 2008;103:
Haplotype-Analysis of 10 unrelated families with
a R122H mutation from an area of 100 km
resulted in 7 different haplotypes.
This precludes
a Founder-Effect
Block A (17 kb)
Block B (62 kb)
Chr. 7: 142, ,183 kb
PRSS1
PRSS2

8. Cationic trypsin D22G K23R R116C K92N E79K G83E R122H/C V123M P36R
N29I/T
D100H
L104P
C139F
Activation site
Cationic trypsin

9. Clinical course of Hereditary Pancreatitis
Cumulative incidence of diabetes, %
age, years 10 20 30 40 50 60 70 80 90
100
male
female
100 90 80 70 60
Alcoholic CP
Cumulative age at onset, % 50 40 30 20 10 10 20 30 40 50 60
age, years
R122H
negativ
N29I
A16V
Howes N, Lerch MM et al Clinical Gastroenterology and Hepatology 2004; 2:

10. cumulative pancreatic
Pancreatic Cancer in Hereditary Pancreatitis
50-70% increased risk
for pancreatic cancer in
patients with hereditary
pancreatitis.
40% cumulative risk
until 70. years of age.
Elimination/Treatment
of causal factors:
Smoking, Alcohol
Hyperlipidemia,
Hypercalcemia,
Gallstones,
Duct stricture,
Drugs and Medications
cumulative pancreatic
cancer risk, %
age at diagnosis of pancreatic cancer 80 70 60 50 40 30 20
Non-smokers smokers
p < 0.01 60 50 40 30 20 10 20 40 60
age, years
Howes N, Lerch MM et al Clinical Gastroenterology and Hepatology 2004; 2: ;
Lowenfels AB, JAMA 2001; 286:

11. Indications for Genetic Hereditary Pancreatitis testing
 Recurrent (2 or more) episodes of acute Pancreatitis without
identifyable cause or etiology or
 Idiopathic chronic Pancreatitis - especially in children and young
adults under the age of 25 years
 Pancreatitis in a patients with a positive family
history of Pancreatitis (one or more first or second
degree relatives)
I. Ellis, M.M. Lerch, D.C. Whitcomb: Pancreatology 2001:1:

12. Pathophysiological role of two mutant trypsinogens:
Decreased autoactivation
PRSS1
PRSS2
100 80
Wild-Type 80 60
Wild-Type 60
Trypsin activity (%)
Trypsin activity (%) 40 40 20 20
R122C
G191R
0.5 1
1.5 2 5 10 15 20 25 30
Time (h)
Time (min)
pH 8.0, 5 mM Ca2+
Simon et al. J. Biol. Chem. 2002; 277:
Witt et al Nature Genetics 2006; 38:

13. insertion of a new cleavagewt
R122C
reducing
non-reducing 60 42 30 22 17
kDa
Simon P. et al. J. Biol. Chem. 2002; 277: SH I
CH2 C H
=COO-
H3N+-
PRSS1
Trypsinogen
Wild type G191R
min
Trypsin
insertion of a new cleavage
site EGGKD / ERGKD
PRSS2
Witt et al Nature Genetics 2006; 38:
Cystein

14. The phenotype of two novel trypsinogen mutations
II:1
II:4
II:2
62y
II:3
54y
III:6
12y
III:5
17y
III:4
24y
III:3
25y
III:2
30y
III:1
31y
II:5
52y
II:6
II:7
45y
I:1
87y
69y diab.
Symbole
o. A.
Pancreatitis
test for R122C
carrier
PRSS1
Simon P. et al. J. Biol. Chem. 2002; 277:
Screening of Exon 4
for G191R mutations:
ICP/HP 17/1414 (1.2%)
ACP 4/405 (1.0%)
CONTROL 157/4581 (3.5%)
PRSS2
Witt et al Nature Genetics 2006; 38:

15. R116C Trypsin – Retention and ER StressII
III IV
63y
62y
48y
44y
40y
38y
36y
17y
15y
100
R116C
Wild type 80 60
Trypsin Activity (%) 40 35 25
Homogenate
Pellet
Supernatant
kDa wt
R116C
Expression in 293T cells 20
pH 8.0, 5 mM Ca2+
0.5 1
1.5 2
time (h)
100 70
BiP (78 kDa) wt
R116A
R116C
Kereszturi et al. Hum Mutation 2009; 30:

16. Cathepsin B-ind. activation
PRSS-Mutations: „gain or loss of function“ ?
Autoactivation
Autolysis
Cathepsin B-ind. activation
A16V ?
D19A ▲
D22G
K23R
N29I ◄►
E79K ▼
R122C
R122H
XXX
R116C
G191R
▼ intracellular
processing
▼ intracellular
processing

17. Sporadic point mutations in the PRSS1- Gen in idiopathic chronic Pancreatitis
In 5 of 50 Patients with idiopathic Pancreatitis (10%) mutations in
the cationic Trypsinogen gene were found.
10%
65%
90%
Affected Patients represented 35%
of all patients under 25 years.
Simon P, Weiss F.U. et al JAMA. 2002;288:2122
35%

18. Sporadic point mutations in the PRSS1- The French Cohort
Rebours V Am J Gastroenterol 2008; 103: , Rebours AJG 2009; 104: 2312
Masson E et al Clin Gastroenterol Hepatol 2008; 6: 82-88
In 78 families with hereditary pancreatitis and 200 individuals
(6673 patients years) PRSS1 mutations were detected in 68%.
R122H: 78%, N29I: 12% and others 10%.
Cumulative risk of pancreatic cancer was 11% at the age of 50 and 49% at the age of 75.
Smoking and diabetes mellitus are the main risk factors.
Trypsinogen copy number variations are present in 6% of idiopathic chronic pancreatitis cases but are unrelated to familial chronic or tropical calcifying pancreatitis.

19. Chymotrypsin C (CTRC) variants that diminish
activity or secretion are associated with chronic pancreatitis Rosendahl et al Nature Genetics 2008; 40: 78-82
Chymotrypsin C is a trypsin-degrading enzyme.
Alterations in the CTRC Gene at position p.R254W and p.K247_R254del are present in 30 out of 901 (3.3%) pancreatitis individuals but only in 21 of 2804 controls (0.7%).
Functional analysis showed impaired activity or reduced secretion indicating that loss of function alterations in CTRC predispose to pancreatitis.

20. Pancreatic secretory Trypsin Inhibitor (PSTI, SPINK-1)
Witt et al, (Nat. Genet., 2000)
Mutations in 23% of children with
idiopathic chronic Pancreatitis
 autosomal-recessive disorder
Pfützer et al, (Gastroenterology, 2000)
Mutations in idiopathic chronic Pancreatitis (25%), hereditary Pancreatitis and in
the healthy population (2%).
 Modifier - Gene, risk of pancreatitis < 1%
Bhatia et al, Schneider et al,
(Gastroenterology, 2002)
Mutations in tropical calcifying pancreatitis
(up to 44%) and in ‘Fibrocalculous Pancreatic Diabetes mellitus‘ (55%).
 Risk factor for tropical Pancreatitis and
Diabetes mellitus
Model by A. Brunskil & W. F. Furey

21. SPINK1-Mutations in Patients with Hereditary Pancreatitis
IV:1 8
IV:2 5
I:1 54
I:2 81
II:1 64
II:3 61
II:5 60
III:2 36
II:2
II:4 69
II:7 50
III:5 16
II:6 68
III:6 13
II:8 46
III:3 35
III:1
III:4
Symbols
Empty symbol
chronic Pancreatitis
positiv for PRSS1 Mutation
positiv for N34S Mutation
Asymptomatic carrier wt I.
II.
I:2 45
II:1
I:1
I:1
I:2 87
II:2 59
II:3
II:4 62
III:4 32
II:1 50
III:1 28
III:2 26
III:3 30
III.
SPINK1 Mutations (N34S) are found among
Pancreatitis patients as well as among healthy carriers
of Trypsinogen mutations.
Weiss F.U. et al. J. Med. Gen. 2003;40:e40,1-5

22. SPINK1 Mutations in Hereditary Pancreatitis
Cumulative Incidence of Pancreatitis
100
100
100 80 80 80 60 60 60
Phenotype, % of total 40 40 40
PRSS1,
SPINK wt
SPINK N34S
mild
Pancreatitis No
Diabetes 20 20 20
severe
Pancreatitis
Diabetes 10 20 30 40 50 60 10 20 30 40 50 60 10 20 30 40 50 60
Age at disease onset, years
SPINK1 Mutations have no influence on the severity of clinical disease course
of hereditary pancreatitis Weiss F.U. et al. J. Med. Gen. 2003;40:e40,1-5

23. Association of CTSB Polymorphisms with Tropical Calcific Pancreatitis
Hyderabad Calicut Total
Patients/Controls Patients/Controls Patients/Controls
(n=140) (n=155) (n=166) (n=175) (n=306) (n=330)
Leu26Val * 0.29*
* p= 0.013
Ser53Gly * 0.04*
* p= 0.152
His110
His111
E64d
N34S positive N34S negative Controls (n=134) (n=172) (n=330)
Leu26Val
ethnic origin: Dravidian
Mahurkar et al. Gut :

24. CTSB Val26 mutation in German ICP Patients
C/C
C/G
G/G pG
(Mahurkar)
Patients 64 23 31 10
0,398 (51/128)
0,46
Controls
100 30 44 26
0,480 (96/200)
0,29
X2 p-Value
0,428
0,578
0,117
0,147
0,013 OR
0,764
0,836
1,897
0,718
2,09
95% CI
0, ,569
0, ,648
0, ,621
0,45 - 1,15
1,55 - 2,81
Weiss et al. Gut (9):

25. Cathepsin B mutation Leu26Val in pancreatitis
Mahurkar et al.
Gut :1270-5
N34S positive N34S negative Controls
(n=134) (n=172) (n=330)
Leu26Val
Population
Ethnic origin
(n)
pG (Val26)
CEPH
Mixed Caucasian 92
0,320
Pooled_CEPH
Caucasian 94
0,323
HapMap-CEU
European 55
0,355
SC_95_C 45
0,367
HapMap-YRI
Sub-Saharan African 52
0,394
TSC_42_C 41
0,430
JBIC-allele
Japanese
732
0,493
HapMap-JPT
Asian 44
0,523
HapMap-HCB 43
0,547
1198
0,452 ± 0,042
Weiss et al. Gut :1322-3
see refSNP ID: rs12338 at /SNP/snp_ref.cgi?rs=12338

26. Chronic Pancreatitis and CFTR Mutations
One third of patients (n=27) with idiopathic pancreatitis carry CFTR-Mutations (Risk x 80).
J. Cohn et al. New Engl J Med 1998;339:653-58
CFTR Mutations represent a risk factor for chronic pancreatitis in patients without a history of alcohol abuse (19% of n = 60), but not for those with alcoholic pancreatitis (8.5% of n = 72).N. Sharer et al. New Engl J Med 1998;339:645-52
Kerem et al. Science
1989; 245:
F 508 Mutation
Weiss FU Gut 2005; 54:
CFTR allele
frequency
12/66 Patients
with CFTR
Mutations,
8/66 Patients
with T5 Allels

27. Prevalence of gene mutations in chronic pancreatitis
Chymotrypsin C mutations
10%
Idiopathic pancreatitis
45.5%
Trypsinogen mutations
10%
SPINK-1 mutations
15.2%
T5 Allels
12.1%
CFTR mutations
18.2%

28. Metabolic Chronic Pancreatitis – Causal treatment
Hyperlipidemia
(apoCII deficiency, lipoprotein lipase deficiency)
Serum triglyercide levels > 1000 mg/dl
Incidence extremely low
Treatment which maintains TG below 500 mg/dl leads to resolution of symptoms.
Toskes PP, Gastroenterol Clin North Am 1990; 19:
Hyperparathyroidism:
Hyperthyreoidims leads to increased serum calcium levels, what is associated with an increased risk of pancreatitis.
The incidence of chronic pancreatitis is between %.
Early parathyreoidectomy leads to resolution of symptoms.
Bess MA JAMA 1980; 243: ; Russel CF Br. J. Surg ; 69: ;

29. Summary and Conclusion
Hereditary chronic and idiopathic chronic pancreatitis are associated with mutations in the trypsinogen gene, the SPINK-1 Gene, the chymotrypsin C gene and the CFTR gene.
More genes will surely be identified.
The pathophysiological impact of these gene mutations are not completety understood and further experiments are warranted.
Etiologies of pancreatitis already treatable (such as autoimmune pancreatitis etc. ) need to be distinguished from pancreatitis varieties that are not yet treatable – but may become so.
In hereditary pancreatitis (trypsin mutations) smoking cessation may reduce the risk of pancreatic cancer. Other surveillance strategies are, however, urgently needed.

30. www.pancreas.de Julia Mayerle Uli Weiss Peter Simon Ali Aghdassi
Gabriele Sauter

31. Chronic Pancreatitis - Alcohol Cessation
100
Stop Alcohol
Alcohol 80 60
Output in % of initial 40 20
n= 18 vs. 14 pt ∆ 4-11 years p<0.01
Bicarbonate
Lipase
Chymotrypsin
Gullo et al, Gastroenterology 1988;95:

32. Diagnosis and Screening for Hereditary Pancreatitis
Today, restriction enzyme
digest with BstU I represents the most extensive initial screening test for hereditary pancreatitis.
A C G C C N G C G T G T
C T
type
type
Control
R122H
R122C
Control
R122H
R122C
Wild
Wild
Sequence in Exon 3
Arg
RSS1 wt AAC-GCC-CGC-GTG-T
Cys
R-122-C AAC-GCC-TGC-GTG-T
Afl
III
BstU I
P. Simon, F.U. Weiss et al. J
Biol
Chem. 2002;277:

33. Natural Course of Alcoholic Chronic Pancreatitis -
Stage 1 (early)
Stage 2
Stage 3
Pain
Serum Enzyme Elevation
Exocrine Pancreatic Function 5 10
15 years
Modified according to R Ammann, Schweiz Rundsch Med Prax. 1970; 59: