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Pancreatitis-Diabetes and Pancreatic Cancer.

The pancreatic islets are suspended in a sea of acinar cells and are therefore susceptible to stress and injury from CP. Only a subset (~40%) of patients with CP develop diabetes mellitus (T3cDM), which is assumed to be due to destruction of the islets of Langerhans. T3cDM may comprise up to 10% of all diabetes cases but may go unrecognized by diabetologists or internists. Recognition of T3cDM is very important for multiple reasons. First, primary treatment should be directed at preventing pancreatitis rather than controlling peripheral glucose levels. Second, unrecognized pancreatic insufficiency is associated with maldigestion, vitamin deficiencies, and asynchrony between nutrient intake and absorption. Third, destruction of the islets in T3cDM results in loss of counter-regulatory hormones (glucagon and PP), making the patient susceptible to life-threatening episodes of hypoglycemia, especially associated with insulin therapy. Fourth, T3cDM may be associated with high incretin levels linked with maldigestion, making expensive incretin treatment (GLP-1 analogues or DPP-4 inhibitors) marginally useful or dangerous.  Fifth, T3cDM appears to be associated with a high risk of pancreatic cancer.  We currently do not understand the variability in islet cell injury, loss, and/or regeneration in CP. We also lack biomarkers of early T3cDM and the means to distinguish T3cDM from type 1 and type 2 DM.  These issues continue to be the focus of PancreasFest, and a recent NIDDK Workshop.   (See also Summary Report, Pancreas. PMID 24152948)

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