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Pancreatogenic (type 3c) Diabetes

Type 3c (pancreatogenic) Diabetes Mellitus Secondary To Chronic Pancreatitis And Pancreatic Cancer

Type 3c (pancreatogenic) Diabetes Mellitus Secondary To Chronic Pancreatitis And Pancreatic Cancer

Diabetes mellitus is a group of diseases defined by persistent hyperglycaemia. Type 2 diabetes, the most prevalent form, is characterised initially by impaired insulin sensitivity and subsequently by an inadequate compensatory insulin response. Diabetes can also develop as a direct consequence of other diseases, including diseases of the exocrine pancreas. Historically, diabetes due to diseases of the exocrine pancreas was described as pancreatogenic or pancreatogenous diabetes mellitus, but recent literature refers to it as type 3c diabetes. It is important to note that type 3c diabetes is not a single entity; it occurs because of a variety of exocrine pancreatic diseases with varying mechanisms of hyperglycaemia. The most commonly identified causes of type 3c diabetes are chronic pancreatitis, pancreatic ductal adenocarcinoma, haemochromatosis, cystic fibrosis, and previous pancreatic surgery. In this Review, we discuss the epidemiology, pathogenesis, and clinical relevance of type 3c diabetes secondary to chronic pancreatitis and pancreatic ductal adenocarcinoma, and highlight several important knowledge gaps. Continue reading >>

Pancreatogenic Diabetes: Special Considerations For Management

Pancreatogenic Diabetes: Special Considerations For Management

Volume 11, Issue 3 , September 2011, Pages 279-294 Pancreatogenic Diabetes: Special Considerations for Management Author links open overlay panel YunFengCuiab Dana K.Andersena1 Get rights and content Background/Aims: Pancreatogenic, or type 3c, diabetes (T3cDM) occurs due to inherited or acquired pancreatic disease or resection. Although similar to the more prevalent type 1 and type 2 diabetes, pancreatogenic diabetes has a unique pattern of hormonal and metabolic characteristics and a high incidence of pancreatic carcinoma in the majority of patients with T3cDM. Despite these differences, no guidelines for therapy have been described. Methods: Published studies on the prevalence, pathophysiology, and cancer associations of T3cDM were reviewed. The recent studies on the protective role and mechanism of metformin therapy as both an anti-diabetic and anti-neoplastic agent were reviewed, and studies on the cancer risk of other anti-diabetic drugs were surveyed. Results: T3cDM accounts for 510% of Western diabetic populations and is associated with mild to severe disease. Hepatic insulin resistance is characteristic of T3cDM and is caused by deficiencies of both insulin and pancreatic polypeptide. 75% of T3cDM is due to chronic pancreatitis, which carries a high risk for pancreatic carcinoma. Insulin and insulin secretagogue treatment increases the risk of malignancy, whereas metformin therapy reduces it. Pancreatic exocrine insufficiency associated with T3cDM contributes to nutritional deficiencies and the development of metabolic bone disease. Conclusions: Until consensus recommendations are reached, the glycemic treatment of T3cDM should avoid insulin and insulin secretagogues if possible. Metformin should be the first line of therapy, and continued if insulin treatment Continue reading >>

Pancreatogenic (type 3c) Diabetes

Pancreatogenic (type 3c) Diabetes

1. Definition Pancreatogenic diabetes is a form of secondary diabetes, specifically that associated with disease of the exocrine pancreas. The most common disease of the exocrine pancreas associated with the development of diabetes is chronic pancreatitis. Analogous to chronic pancreatitis-associated diabetes is cystic fibrosis-related diabetes (CFRD), in which pancreatic exocrine insufficiency pre-dates the pancreatic endocrine insufficiency responsible for the development of diabetes. Because diabetes in cystic fibrosis is associated with worse nutritional status, more severe inflammatory lung disease, and greater mortality from respiratory failure, CFRD has long been recognized as a distinct form of diabetes requiring a specified approach to evaluation and treatment (30) now recognized by the American Diabetes Association (28). While the distinct pathogenesis of diabetes in chronic pancreatitis has also long been appreciated, only recently have guidelines been developed supporting a specified diagnostic and therapeutic algorithm (37). Finally, other less common forms of pancreatogenic diabetes exist, such as that due to pancreatic cancer (18), as well as post-pancreatectomy diabetes, with each requiring individualized approaches to care. 2. Classification Pancreatogenic diabetes is classified by the American Diabetes Association and by the World Health Organization as type 3c diabetes mellitus (T3cDM) and refers to diabetes due to impairment in pancreatic endocrine function related to pancreatic exocrine damage due to acute, relapsing and chronic pancreatitis (of any etiology), cystic fibrosis, hemochromatosis, pancreatic cancer, and pancreatectomy, and as well rare causes such as neonatal diabetes due to pancreatic agenesis (1). Prevalence data on T3cDM are scarce b Continue reading >>

Payperview: Pancreatogenic Diabetes: Special Considerations For Management - Karger Publishers

Payperview: Pancreatogenic Diabetes: Special Considerations For Management - Karger Publishers

I have read the Karger Terms and Conditions and agree. Background/Aims: Pancreatogenic, or type 3c, diabetes (T3cDM) occurs due to inherited or acquired pancreatic disease or resection. Although similar to the more prevalent type 1 and type 2 diabetes, pancreatogenic diabetes has a unique pattern of hormonal and metabolic characteristics and a high incidence of pancreatic carcinoma in the majority of patients with T3cDM. Despite these differences, no guidelines for therapy have been described. Methods: Published studies on the prevalence, pathophysiology, and cancer associations of T3cDM were reviewed. The recent studies on the protective role and mechanism of metformin therapy as both an anti-diabetic and anti-neoplastic agent were reviewed, and studies on the cancer risk of other anti-diabetic drugs were surveyed. Results: T3cDM accounts for 510% of Western diabetic populations and is associated with mild to severe disease. Hepatic insulin resistance is characteristic of T3cDM and is caused by deficiencies of both insulin and pancreatic polypeptide. 75% of T3cDM is due to chronic pancreatitis, which carries a high risk for pancreatic carcinoma. Insulin and insulin secretagogue treatment increases the risk of malignancy, whereas metformin therapy reduces it. Pancreatic exocrine insufficiency associated with T3cDM contributes to nutritional deficiencies and the development of metabolic bone disease. Conclusions: Until consensus recommendations are reached, the glycemic treatment of T3cDM should avoid insulin and insulin secretagogues if possible. Metformin should be the first line of therapy, and continued if insulin treatment must be added for adequate glucose control. Pancreatic enzyme therapy should be added to prevent secondary nutritional and metabolic complicatio Continue reading >>

What Is Type 3c Diabetes?

What Is Type 3c Diabetes?

2nd November 3027 -- Most people have heard of type 1 and type 2 diabetes but now concerns are being raised about under-diagnosis of a newly identified form of the condition - known as type 3c. According to researchers from the University of Surrey, the failure of doctors to recognise this form of diabetes is putting patients' health at risk. What is type 3c diabetes? Type 3c diabetes occurs as a result of pancreatic disease or injury sometimes many years prior to a diabetes diagnosis, which affects the body's ability to produce insulin. It is also sometimes called 'pancreatogenic diabetes' or 'diabetes of the exocrine pancreas'. Type 3c diabetes is associated with poor glycaemic control and early insulin therapy. In type 1 diabetes the immune system mistakenly attacks healthy body tissue in the pancreas preventing the creation of insulin. It always needs insulin treatment. Type 2 diabetes, the most common form of diabetes, is associated with obesity and occurs when the body doesn't produce enough insulin to function properly, or the body's cells don't react to insulin correctly. Patients with this form of diabetes may be treated with diet and medication but may eventually need insulin injections. New study and findings In the first ever study of its kind, researchers from the University of Surrey, examined the anonymised GP records of more than 2 million people, looking at the frequency of different types of diabetes and the accuracy of diagnosis. They discovered that up to 97.3% of people who have previously experienced pancreatic disease are misdiagnosed, typically with type 2 diabetes, rather than the correct condition type 3c. Researchers also discovered that adults were more likely to develop type 3c diabetes than type 1 diabetes making it more common than previou Continue reading >>

How To Treat Pancreatogenic Diabetes?

How To Treat Pancreatogenic Diabetes?

On one side, having an unsuppressed glucose production from the liver, he will continuously have high glycemia levels excursions. On the other side, glucagon in not produced anymore and the peripheral insulin sensitivity is increased due to lack of insulin. Therefore it is very easy to suffer hypoglycemia events. I must admit that insulin treatment will be problematic, but you have to stick to it. He needs small doses of course, because his insulin sensitivity is increasing. A1c is high not only because of nonmanagement of hyperglycemia, but also because of the the effects of the anti-insulin hormones, excluding glucagone in this case. Metformin may do more harm than good in this case. It will slow down the hepatic gluconeogenesis but also it will increase the glycolysis in the peripheral tissues, which is a bad idea in cases with frequent hypoglycemia. Do not forget that metformin also decreases levels of glucagon that could be given exogenously in severe cases of hypoglicemia, making it more difficult to deal with. 1. Avoid hypoglycemia (No skipping meals; Frequent small meals; Continuous glicemia measurements, especially after physical activity; No alcohol; Keeping glucagone with him always; Instruct a family member how to use glucagon) 3. Last but not least, pay attention to malnutrition. Because of the lack of exocrine pancreatic enzymes, your patient will have lots of malnutrition related problems. These problems can also reflect themselves in the hypo-hyper levels of glycemia he is suffering from. Continue reading >>

Awareness Of Type 3c Diabetes And Why It Is Misdiagnosed

Awareness Of Type 3c Diabetes And Why It Is Misdiagnosed

Diabetes has long been divided into type 1 and type 2. But a third type has entered the mix — and we aren’t diagnosing it correctly. Type 1 diabetes occurs when the pancreas doesn’t produce insulin and is usually diagnosed at a young age. Type 2 diabetes shows up later in life when the pancreas can’t make enough insulin to keep up with the body. This new third type, Type 3c, starts with a damaged pancreas. The researchers say that pancreatitis is leading to misdiagnoses of type 2 diabetes in people who actually have type 3c diabetes. A new study involving two million people has found 97.3% of those who had previously suffered from pancreatic disease (acute pancreatitis or chronic pancreatic disease) had been wrongly diagnosed with type 2 diabetes when, in fact, they actually had type 3c diabetes, despite a sevenfold increased insulin requirement within 5 years, by which time 45.8% of patients with diabetes following chronic pancreatic disease are using insulin. Type 3c diabetes, also known as pancreatogenic diabetes, is not as well known compared to type 1 and type 2 diabetes. It develops when the pancreas becomes inflamed, or part of it is removed and eventually stops producing insulin. A recent study from the American Diabetes Association found only 3 percent of people with type 3c have actually received a correct diagnosis. These misdiagnoses mean people with type 3c might not be getting effective treatments. People diagnosed with type 3c require insulin, but may also benefit from taking digestive enzyme tablets, one of the study’s researchers wrote. That alternative treatment option is what sets type 3c apart from the other types. Correctly identifying the type of diabetes is important as it helps the selection of the correct treatment. Several drugs used Continue reading >>

Management Of Pancreatogenic Diabetes: Challenges And Solutions

Management Of Pancreatogenic Diabetes: Challenges And Solutions

Go to: Introduction Pancreatogenic diabetes is a form of secondary diabetes, classified by the American Diabetes Association (ADA) and the World Health Organization as type 3c diabetes mellitus (T3cDM).1,2 It refers to diabetes due to diseases of the exocrine pancreas: pancreatitis (acute, relapsing, or chronic pancreatitis of any etiology), pancreatectomy/trauma, neoplasia, cystic fibrosis, hemochromatosis, and fibrocalculous pancreatopathy.3 With the exception of cancer, damage to the pancreas must be extensive enough for diabetes to occur.1,2 Rather scarce data on T3cDM suggest that most cases result from chronic pancreatitis, as this condition was identified as the underlying disease in 78.5% of all patients with T3cDM.4 In Western populations, T3cDM is estimated to occur in 5%–10% of all diabetic patients, mostly due to chronic pancreatitis.4–6 True prevalence of T3cDM is unknown – data are scarce, mostly due to challenges with accurate diabetes classification in clinical practice.4,7–9 Many T3cDM patients are initially misclassified due to underrecognized contribution of pancreatic disease to the development of diabetes. In order to improve diagnosis, diagnostic criteria for T3cDM have been proposed by Ewald and Bretzel which include 1) the presence of pancreatic exocrine insufficiency, 2) evidence of pathological pancreatic imaging, and 3) the absence of type 1 diabetes mellitus (T1DM)-associated autoantibodies.6 They may be further supported by additional minor criteria, such as an absent pancreatic polypeptide (PP) response to mixed-nutrient ingestion.6 These criteria may be more reliably applied at the presentation of diabetes due to a degree of overlap in established insulin deficiency (related to pancreatic atrophy and exocrine insufficiency). It is Continue reading >>

Is Pancreatic Diabetes (type 3c Diabetes) Underdiagnosed And Misdiagnosed?

Is Pancreatic Diabetes (type 3c Diabetes) Underdiagnosed And Misdiagnosed?

Exocrine pancreatic insufficiency is frequently associated with diabetes, with high prevalence in both insulin-dependent or insulin-independent patients. Exocrine pancreatic failure has often been perceived as a complication of diabetes. In contrast, recent clinical observations lead to the notion that nonendocrine pancreatic disease is a critical factor for development rather than a sequel to diabetes. The incidence of diabetes caused by exocrine pancreatic disease appears to be underestimated and may comprise 8% or more of the general diabetic patient population. Nonendocrine pancreas disease can cause diabetes by multiple mechanisms. Genetic defects have been characterized, resulting in a syndrome of both exocrine and endocrine failure. Regulation of β-cell mass and physiological incretin secretion are directly dependent on normal exocrine function. Algorithms for diagnosis and therapy of diabetes should therefore address both endocrine and exocrine pancreatic function. PREVALENCE OF PANCREATIC EXOCRINE INSUFFICIENCY IN PATIENTS WITH DIABETES— In recent years, the evaluation of exocrine pancreatic function has been greatly facilitated by newly available noninvasive stool tests allowing screening of large patient populations. Measurement of fecal elastase-1 concentrations (FECs) by enzyme-linked immunosorbent assay based on monoclonal human specific antibodies has become a standard diagnostic parameter with good correlation to direct tests of pancreatic exocrine function (12) and morphological pancreas alterations (13), albeit limited sensitivity in mild pancreatic exocrine insufficiency. Exocrine pancreatic function using FEC assessment has been extensively studied in patients with diabetes. Normal exocrine function (FEC >200 μg/g) was observed in ∼58% of patie Continue reading >>

Type 3c (pancreatogenic) Diabetes

Type 3c (pancreatogenic) Diabetes

Type 3c diabetes (also known as Pancreatogenic diabetes) is a form of diabetes that is being researched. It involves the exocrine and digestive functions of the pancreas. Out of all the diabetics, 5–10% may actually be type 3c diabetics. In 80% of people who suffer from this condition, chronic pancreatitis seems to be the cause.[1] Presentation[edit] Complications[edit] The same complications that occur for other types of diabetics (type 1 and type 2) may occur for type 3c diabetics. These include retinopathy, nephropathy, neuropathy, and cardiovascular disease. Patients with this condition are advised to follow the same risk-reduction guidelines as the other diabetics do and keep blood sugars as normal as possible to minimize any complications. Cause[edit] There are multiple causes. Some of which identified are: Pancreatic disease Pancreatic resection Chronic pancreatitis (caused by exocrine insufficiency, maldigestion, and malnutrition).[2] Lacking genes in the E2F group.[3] More possible causes are being researched. Diagnosis[edit] Diagnostic Criteria for T3cDM Major criteria (all must be fulfilled): Presence of exocrine pancreatic insufficiency (according to monoclonal fecal elastase-1 or direct function tests. Pathological pancreatic imaging: (by endoscopic ultrasound, MRI, or CT) Absence of T1DM-associated autoimmune markers (autoantibodies). Minor Criteria: Imparied β-cell function No excessive insulin resistance (e.g. as measured by HOMA-IR). Impaired incretin (e.g. GIP) or pancreatic polypeptide secretion. Low serum levels of lipid (fat) soluble vitamins (A, D, E, or K). Management[edit] The condition can be managed by many factors. Lifestyle Modifications[edit] Avoiding toxins to the body such as alcohol and smoking reduce pancreatic inflammation. Also, eat Continue reading >>

I Have Type 3c Diabetes – What Is That All About?

I Have Type 3c Diabetes – What Is That All About?

This week is #NationalDiabetesWeek and social media has been full of interesting facts and hints and tips on how to manage either Type 1 or Type 2 diabetes. What I have noticed though is that no-one has, thus far, mentioned Type 3 diabetes. This hasn’t come as a surprise. A year before I was diagnosed with operable pancreatic cancer, I was told that I may have Type 2 diabetes. However, I wasn’t overweight, nor did I have a family history of the disease. We now know that it was probably the cancer causing the blood sugar level elevations and this link between new-onset diabetes without weight gain (which can occur 1-3 years before a pancreatic cancer diagnosis) is something that we at Pancreatic Cancer Action are investigating in our research programmes. For all of these years (nearly 9) I have believed that I have Type 2 diabetes. However, at a recent consultation with my new Diabetologist, I discovered that I have in fact got Type 3c Diabetes. This I had never heard of before and so went about trying to find out more. I looked at some informed websites including Diabetes UK and found nothing. Not even a mention. And not all of the medical profession has heard of this type of diabetes either – unless they are specialists in this field. Never being one to give up, I kept on researching. I have since found out that, of all diabetes cases Type 3c makes up about 8%1 – not a lot, but not insignificant either. Type 3c Diabetes is usually characterised by the fact that the patient has had all or part of their pancreas resected due to cancer or cystic lesions or other diseases of the pancreas such as pancreatitis and cystic fybrosis.2 Patients often have Pancreatic Exocrine Insufficiency (malabsorption) and are on Pancreatic Enzyme Therapy (PERT) to help them get their Continue reading >>

There’s A Third Type Of Diabetes—and Doctors Are Misdiagnosing It As Type 2

There’s A Third Type Of Diabetes—and Doctors Are Misdiagnosing It As Type 2

Syda Productions/Shutterstock There are many surprising facts about type 2 diabetes, including the fact that sometimes it’s actually something else. Say hello to a new form of diabetes. It’s called type 3c diabetes and may be commonly mistaken for type 2 diabetes, the form of the disease most closely linked to obesity, a new study suggests. As a result, many people with type 3c diabetes may not be getting the care they need to keep the eventual consequences of diabetes, such as eye, nerve, and kidney damage, at bay, the researchers warn in Diabetes Care. Type 3c diabetes follows disease of the pancreas and is also called pancreatogenic diabetes, explains study author Simon de Lusignan, BSc, MB BS, MSc, MD(Res), professor of primary care and clinical informatics, the chair in health care management, and head of the department of clinical and cxperimental medicine at University of Surrey in Guildford, UK. “After pancreas disease, it is possible to develop diabetes. The people who do should be labeled type 3c. This is often not thought about, and they are instead labeled as type 2.” Some 88 percent of people who had type 3c diabetes in the study were misdiagnosed as having type 2 over a 10-year period. Put another way: Just 3 percent of the people in the study were correctly identified as having type 3c diabetes. The pancreas is intricately involved in all forms of diabetes. Located behind the lower part of the stomach, this organ is charged with producing insulin, the hormone that helps the body use glucose (blood sugar) in foods for energy. It plays a crucial role in the differences between type 1 and type 2: In type 1 diabetes, the pancreas stops producing insulin altogether. In type 2 diabetes, your body does not use insulin properly. In these cases, the pancre Continue reading >>

Pancreatogenic Diabetes

Pancreatogenic Diabetes

Endocrine Abstracts (2015) 37 EP338 | DOI: 10.1530/endoabs.37.EP338 Author affiliations View ePoster Download ePoster Nottingham University Hospital, Nottinghamshire, UK. Aims: Diabetes mellitus secondary to pancreatic disease and pancreatic surgery (pancreatogenic; type 3c) is a discrete entity to common types of diabetes and there are no well established guidelines for its management. At Nottingham University Hospitals, we have set up a multidisciplinary pancreatogenic diabetes clinic since 2008. The aim of this study is to look at the outcome of the clinic since its been established. Methods: Case notes and hospital database of all 51 patients (32 male, 19 female) attending the clinic between 2008 and April 2014 were reviewed retrospectively. Their mean duration of diabetes was 5+0.76 years. Results: Mean HbA1c on first attendance was 70.4 ( 21.2). Mean weight at 1 year showed an increase from 75.2+3.1 kg to 83+4.1 kg. BMI increased from 26.0 to 29.8 kg/m2. During the first year in the clinic, 15 patients had their medications reviewed and changed and there were only four patients admitted; three had problem with glycaemic control with DKA and one had multiple admissions due to hypoglycaemia. Conclusions: There was improvement in HbA1c of the patients at 1 year. Mean BMI showed that patients were initially overweight and their BMIs have increased at 1 year. Attendance rates at the clinic are generally good; 80% of appointments have been attended. This showed that there is positive outcome of the pancreatogenic diabetes clinic. Therefore, patients with pancreatogenic diabetes should be managed in such clinic rather than usual diabetes clinics. Continue reading >>

Type 3c (pancreatogenic) Diabetes

Type 3c (pancreatogenic) Diabetes

Pancreatogenic diabetes or type 3c diabetes is a form of secondary diabetes, associated with a primary disorder of the exocrine portion of the pancreas. What is Type 3c (Pancreatogenic) Diabetes? Pancreas - Overview of Structure and Function Types of Diabetes Mellitus What are the Causes of Type 3c (Pancreatogenic) Diabetes? What are the Symptoms of Type 3c (Pancreatogenic) Diabetes? How do you Diagnose Type 3c (Pancreatogenic) Diabetes? How do you Treat Type 3c (Pancreatogenic) Diabetes? How do you Prevent Type 3c (Pancreatogenic) Diabetes? Frequently Asked Questions Glossary References What is Type 3c (Pancreatogenic) Diabetes? Pancreatogenic or type 3c diabetes mellitus is a form of secondary diabetes wherein the primary disease is in the exocrine portion of the pancreas and predates the development of diabetes. It is suggested that between 5-10% of all diabetics may have pancreatogenic diabetes. Interestingly nearly 80 percent of pancreatogenic diabetes is caused by chronic pancreatitis. The exact figures are not known as data remains scarce and frequently patients with pancreatic diabetes are misclassified. Only recently have diagnostic criteria been proposed for pancreatogenic diabetes, enabling accurate diagnosis and appropriate management of the condition. Pancreas - Overview of Structure and Function The pancreas is an important organ found in the abdominal cavity. It is elongated and tapering and is situated behind the stomach. The pancreas is structurally divided into four parts namely head, neck body and tail. Functionally, it is divided into two portions, the exocrine portion and the endocrine portion. The exocrine portion occurs predominantly in the head, neck and body and consists of glands that secrete digestive juices which travel to the small intestin Continue reading >>

Type 3c (pancreatogenic) Diabetes Mellitus Secondary To Chronic Pancreatitis And Pancreatic Cancer

Type 3c (pancreatogenic) Diabetes Mellitus Secondary To Chronic Pancreatitis And Pancreatic Cancer

Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer JavaScript is disabled for your browser. Some features of this site may not work without it. Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer Keywords: Diabetes mellitus ; Type 2 diabetes ; Chronic pancreatitis ; Pancreatic ductal adenocarcinoma ; Type 3c diabetes Cite As:Hart, P. A., Bellin, M. D., Andersen, D. K., Bradley, D., Cruz-Monserrate, Z., Forsmark, C. E., Chari, S. T. (2016). Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer. The Lancet. Gastroenterology & Hepatology, 1(3), 226237. Diabetes mellitus is a group of diseases defined by persistent hyperglycaemia. Type 2 diabetes, the most prevalent form, is characterised initially by impaired insulin sensitivity and subsequently by an inadequate compensatory insulin response. Diabetes can also develop as a direct consequence of other diseases, including diseases of the exocrine pancreas. Historically, diabetes due to diseases of the exocrine pancreas was described as pancreatogenic or pancreatogenous diabetes mellitus, but recent literature refers to it as type 3c diabetes. It is important to note that type 3c diabetes is not a single entity; it occurs because of a variety of exocrine pancreatic diseases with varying mechanisms of hyperglycaemia. The most commonly identified causes of type 3c diabetes are chronic pancreatitis, pancreatic ductal adenocarcinoma, haemochromatosis, cystic fibrosis, and previous pancreatic surgery. In this Review, we discuss the epidemiology, pathogenesis, and clinical relevance of type 3c diabetes secondary to chronic pancreatitis and pancreatic ductal adenocarcinoma, and highlight severa Continue reading >>

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