Bone Disease in Chronic Pancreatitis: A Complex Phenomenon
Bone Disease in Chronic Pancreatitis: A Complex Phenomenon
The purpose of this study is to define the prevalence of low bone density
 (osteopenia/osteoporosis) in patients with chronic pancreatitis. Secondary aims include
 investigating the prevalence of hypogonadism (low sex hormones) in patients with chronic
 pancreatitis and determining if hypogonadism and/or use of narcotic pain medications are risk
 factors for low bone density in this patient population.

 1. Hypothesis:

 Patients with chronic pancreatitis are at increased risk of low bone density
 (osteopenia/osteoporosis), and hypogonadism (low sex hormone levels) and narcotic pain
 medication use are independent risk factors for the development of low bone density in
 this patient population.

 2. The outcome measures include:

 i) Prevalence of low bone density (osteopenia/osteoporosis) in patients with chronic
 pancreatitis (as determined by DXA scan and fracture history).

 ii) Prevalence of hypogonadism (low sex hormones) in patients with chronic pancreatitis
 (as determined by sex hormone levels and clinical history).

 iii) Identification of hypogonadism and/or opioid use as risk factors for low bone
 density in patients with chronic pancreatitis (as determined by univariate and
 multivariate analysis of multiple risk factors).

 3. After obtaining written consent from potential subjects, a questionnaire will be
 performed outlining risk factors for low bone density. Dual X-ray absorptiometry (DXA
 scan) will be performed to evaluate for low bone density and a blood test will be
 performed to evaluate for low sex hormones, low levels of vitamin D, and other risk
 factors for low bone density.
Chronic pancreatitis is defined as a continuing inflammatory disease of the pancreas
 characterized by irreversible morphologic changes that typically cause pain and/or permanent
 loss of function. The annual incidence of chronic pancreatitis in the Unites States is 5-12
 per 100,000 and prevalence of 50 per 100,000 persons though the incidence is rising over time
 . The most common symptoms related to chronic pancreatitis include steatorrhea and abdominal
 pain. Pain with chronic pancreatitis can be severe and debilitating and opioid pain
 medications are frequently utilized in the management of these symptoms .

 A number of chronic malabsorptive disorders, including Crohn's disease, celiac disease, and
 cystic fibrosis are known to be associated with decreased bone mineral density. Similarly,
 there is increasing data supporting low bone mineral density (osteopenia and osteoporosis) in
 patients with chronic pancreatitis, though the exact mechanisms remain unclear.

 A meta-analysis of 11 observational studies of chronic pancreatitis reported the prevalence
 of osteopenia to be 39.8% and osteoporosis 23.4%, with the cumulative prevalence of low bone
 density (osteopenia and osteoporosis) being almost 65%. Interestingly, out of the eleven
 studies in this meta-analysis, eight were performed in Europe, two in India, and one in South
 America.

 Some studies in chronic pancreatitis have described a link between Vitamin D deficiency and
 risk for low bone density. Other proposed risk factors for low bone density in this patient
 population include age, gender, malnutrition, alcohol use, smoking, and variation and
 duration of pancreatitis. However, other potential novel risk factors for low bone density
 exist in patients with chronic pancreatitis. These factors include chronic use of opioid
 medications and hypogonadism.

 Opioid use is prominent in patients with chronic pancreatitis. At least 85% of patients
 suffering from chronic pancreatitis will develop pain and despite many different treatment
 methods, many patients with chronic pancreatitis do not get respite from their pain, even
 after several years. Therefore, up to 50% or more of all patients with chronic pancreatitis
 will utilize opioid medications as part of their pain management strategy. Opioid medication
 use has been shown to be a risk factor for low bone density. The exact mechanism behind
 opioid-induced low bone density is not known but is likely multi-factorial.

 To date, the prevalence of hypogonadism in patients with chronic pancreatitis is unknown but
 would be expected to be higher than the general population due to the risk factors of opioid
 use, chronic illness, and potentially malnutrition. This warrants further investigation as a
 higher prevalence of hypogonadism could directly impact bone health in this cohort, not to
 mention potential effects of hypogonadism on quality of life and fertility.

 This research project will utilize Dual X-ray absorptiometry (DXA scan) and clinical history
 to determine the prevalence of low bone density (osteopenia/osteoporosis) in our cohort;
 blood draw, clinical history, and questionnaire to determine prevalence of hypogonadism in
 our cohort; and blood draw, clinical history, and questionnaire to examine specific risk
 factors for low bone density in our cohort.

 After obtaining written consent from potential subjects, a questionnaire will be performed
 outlining smoking history, alcohol use history, fracture history, signs/symptoms of
 hypogonadism, exercise patterns, and opioid medication use history. A one-time Dual X-ray
 absorptiometry (DXA scan) will be performed on each subject. A one-time blood draw will be
 performed on each subject, with the following lab tests being performed on each subject:

 -  25-hydroxy Vitamin D

 -  Comprehensive Metabolic Panel

 -  Total Testosterone (males)

 -  Estradiol (females)

 -  Lutenizing hormone (LH)

 -  Follicle-stimulating hormone (FSH)

 -  Steroid hormone binding globulin (SHBG)

 -  Prolactin
Inclusion Criteria:

 -  Age 19-75 years

 -  Diagnosis of Chronic Pancreatitis, as defined by specific clinical criteria

 Exclusion Criteria:

 -  Refusal to complete the consent process in it's entirety.

 -  Pregnancy