Evidence Of Pancreatic Insufficiency Research Articles

Impact of calcifications on diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration for pancreatic ductal adenocarcinoma.

Chronic calcific pancreatitis (CCP) is a major risk factor for pancreatic ductal adenocarcinoma (PDAC) and is common in southern India. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is useful for tissue acquisition in patients with solid pancreatic lesions. Multiple factors may affect the diagnostic yield ofFNA samples. The present study was performed to assess the impact of pancreatic calcifications on the diagnostic yield of EUS-FNA in PDAC. All patients with confirmed PDAC from January 2013 to December 2017 were included. CCP was diagnosed based on typicalimaging characteristics with or without evidence of pancreatic insufficiency along with surgical histopathology reports showing features of chronic pancreatitis. The diagnostic yield and adequacy of cellularity were assessed by a pathologist who was blinded and were compared between the two groups: group 1: PDAC patients with no evidence of CCP and, group 2: PDAC patients with CCP. A total of 122 patients were included in the study. The diagnostic yield was lower in patients in group 2 (n= 42, 25 [59.52%]) as compared to those in group 1 (n= 80, 63 [78.75%]) (p-value = 0.01). On multivariate analysis, only the presence of calcifications was found to have an independent association with diagnostic yield (odds ratio 3.83 [95% confidence interval 1.22-11.9]). CCP had a significant impact on the diagnostic yield of EUS-FNA for pancreatic adenocarcinoma. Novel techniques and newer technology that may mitigate the negative effect of calcification on diagnostic yield of EUS-FNA in patients withCCP.

Pancreatic Solid Pseudopapillary Tumor Presenting With Elevated DHEA and Testosterone

Solid pseudopapillary neoplasms (SPN) of the pancreas are extremely rare epithelial tumor with low malignant potential, account for 1-2% of exocrine pancreatic tumors. When symptomatic, these tumors come to light due to mass affect on neighboring structures. Peculiarly, we encountered a healthy 34-year-old female who was found to have an elevated dehydroepiandrosterone (DHEA) and testosterone level during evaluation of irregular menstrual cycles. She subsequently underwent a CT scan with no abnormalities of the adrenal glands; however, an indeterminate pancreatic tail mass was seen. MRI of abdomen further characterized the lesion as an enhancing pancreatic tail mass measuring up to 2.7 cm, that was concerning for pancreatic neoplasm. The patient underwent upper endoscopic ultrasound which confirmed a hypoechoic mass in the pancreatic tail, measuring 2.3 by 1.7 cm. An intact interface was seen between the mass and adjacent structures, suggesting a lack of invasion. Fine needle biopsy was performed and cytology revealed solid pseudopapillary tumor (Figures 1&2). The patient was advised to undergo distal pancreatectomy. Although there does to be a female predilection of SPNs, the underlying role of sex hormones (ie: estrogen and progesterone) in neoplasm growth or histogenesis remains unclear. One retrospective study, spanning 15 years, noted the clinical presentation was generally nonspecific. Abdominal or vague pain was seen in ˜70% of their patients and was followed by symptoms of tumor mass effects. SPNs are generally inactive on screening modalities such as tumor markers (ie: AFP, CEA, CA 19-9 and CA 125). Histochemically there is no evidence of pancreatic insufficiency, pancreatic parenchymal injury, abnormal liver function, or cholestasis. To our knowledge this is the first documented presentation with elevated DHEA and Testosterone level in an asymptomatic woman. Extensive workup reveled no secondary (including adrenal) etiology for her hormonal dysregulation. We recommend further review and investigation into this potential correlative relationship in an effort to guide future management of this unusual neoplasm.1319_A.tif Figure 1: No Caption available.1319_B.tif Figure 2: No Caption available.

Evaluation of pro-carboxypeptidase A and carboxypeptidase A as serologic markers for adenocarcinoma of the pancreas

Background: A serological marker for pancreatic cancer may allow for early detection and potentially more effective treatments. Pro-carboxypeptidase A (pro-CPA) is produced exclusively in the pancreas and converted to its active form, CPA, in the intestinal lumen. We hypothesized that alterations in serum pro-CPA and/or CPA may be useful as a diagnostic test for pancreatic cancer. Patients and methods: Serum samples obtained from 34 patients with pancreatic adenocarcinoma prior to surgical intervention and 64 control patients were assayed for pro-CPA and CPA. A variety of statistical methods was used to evaluate the utility of these measurements individually and in combination to classify the samples with respect to the presence or absence of pancreatic adenocarcinoma. Results: Because of positive skewing of the data in some populations, transformation of the data to natural logarithmic scales was used and resulted in normal distributions. All pancreatic cancer patients had ln(CPA) levels within or below the normal range defined as two standard deviations from the control group mean (−2.714±0.413). Ln(pro-CPA) levels in 24 of 34 cancer patients were outside the normal range of the control group (0.306±0.33). Pancreatic cancer patients with ln pro-CPA values within the control range had low ln CPA, advanced stage and/or evidence of pancreatic insufficiency. While each of these individual values (ln pro-CPA or ln CPA) does not adequately separate all control from cancer patients, a bivariate classification rule is presented that uses both ln pro-CPA and ln CPA simultaneously to predict the presence of pancreatic cancer with a sensitivity of 91% and a specificity of 95%. Conclusions: The data presented suggest that abnormalities in serum pro-CPA and CPA levels are associated with the presence of pancreatic cancer.

Pancreatic exocrine insufficiency in HIV‐positive patients

We describe the management of a cohort of eight HIV-positive patients on antiretroviral medication with evidence of pancreatic insufficiency consisting of chronic diarrhoea and a low faecal elastase measurement. Twenty-two patients with chronic diarrhoea for whom a faecal elastase measurement was available were identified retrospectively. We compared baseline demographic characteristics, antiretroviral treatment and symptoms of steatorrhea between patients with evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement of <200 microg/g (cases), and patients with evidence of normal pancreatic function, i.e. a normal faecal elastase measurement of >200 microg/g (controls). We describe the management of the patients with evidence of pancreatic insufficiency. Of the 22 patients, eight had evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement. Comparing cases with controls, cases were more likely to have symptoms of steatorrhea (P=0.03) or to have lost weight (P=0.02). Cases were also significantly more likely to have taken didanosine (ddI) as part of their antiretroviral treatment when their symptoms started. Seven cases were treated with oral pancreatic supplements and all had symptomatic improvement of their diarrhoea. One patient stopped treatment with oral pancreatic supplements because of side effects without a relapse of symptoms; he had also stopped zalcitabine (ddC). We believe that measurement of faecal elastase to detect pancreatic insufficiency should be part of the standard investigation of HIV-positive patients with chronic diarrhoea alongside assessment for other causes of diarrhoea. Faecal elastase measurements should be requested, in particular, in all patients with diarrhoea and weight loss, or symptoms of steatorrhea, and in those on treatment with an antiretroviral regime containing ddI. If the faecal elastase level is low, a switch of antiretroviral medication to a nonddI/ddC-containing regime should be considered and treatment with oral pancreatic enzyme therapy should be instituted.

Intraductal pancreatic calculi in patients with choledochal cyst

Summary Intraductal pancreatic calculi are a rare association in patients with choledochal cyst (CC). Reported herein is a retrospective analysis of the data on pancreatic calculi in 37 patients (10 children and 27 adults) who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CC over a period of 15 years. Five patients (one child and four adults) were identified as having intraductal pancreatic calculi. Three had type I and two had type IV CC. Four underwent cyst excision. No intervention was carried out for the pancreatic calculi. There was no evidence of pancreatic insufficiency on follow up and none had recurrence of abdominal pain. One patient died of cholangitis, which was the initial presenting problem. Intraductal pancreatic calculi associated with CC, although uncommon, are not rare and are not always symptomatic.

Central pancreatectomy with pancreaticogastrostomy for benign pancreatic pathology.

Benign lesions of the neck and proximal body of the pancreas pose an interesting surgical challenge. If the lesions are not amenable to simple enucleation, surgeons may be faced with the choice of performing a right-sided resection (pancreaticoduodenectomy) or a left-sided resection (distal pancreatectomy) to include the lesion, resulting in resection of a substantial amount of normal pancreatic parenchyma. Central pancreatic resection has been reported with Roux-en-Y pancreaticojejunostomy reconstruction; however, this interrupts small bowel continuity and obligates an additional anastomosis. We have reviewed our experience with central pancreatectomy with pancreaticogastrostomy (PG) for benign central pancreatic pathology. Between January 1999 and December 2002, 14 central pancreatectomies were performed with PG reconstruction. There were 7 women and 7 men with a mean age of 60.9 years. Five resections were performed for islet cell tumors, three were performed for noninvasive intraductal papillary mucinous neoplasms, two were performed for serous cystadenoma, and one each was performed for a simple cyst, pseudocyst, mucinous metaplasia, and focal chronic pancreatitis. Seven out of 14 patients experienced a total of 10 complications. Pancreatic fistulae manifested by drainage of amylase-rich fluid from the operatively placed drains developed in 5 patients (36%). Reoperation or interventional radiologic procedures were not required in any patient with a fistula. Postoperative follow-up demonstrated 13 out of 14 patients to be alive and well without evidence of pancreatic insufficiency. One patient died at home on postoperative day 57 of cardiac pathology. Central pancreatectomy with PG is a safe and effective procedure that allows for preservation of pancreatic endocrine and exocrine function without disruption of enteric continuity. The complication of pancreatic fistula was managed conservatively via maintenance of operatively placed drains.

Nutritional challenges of infants with cystic fibrosis.

Nutrition plays an essential role in the management of cystic fibrosis (CF), particularly in infants with their high energy requirement due to rapid growth. Most infants are already malnourished at the time of clinical diagnosis due to an energy imbalance with increased losses and needs not compensated by energy intake. Even in very young asymptomatic CF patients diagnosed by neonatal screening programs, nutritional deficits can be detected in a high proportion of infants, since about half of all CF patients have evidence of pancreatic insufficiency at the time of birth. This review provides recommendations for assessment of the nutritional status at diagnosis and nutritional management including supplementation with pancreatic enzymes during the first year of life.

Chronic diarrhea and neutropenia not associated with pancreatic insufficiency: a non-Shwachman-Diamond entity.

Six children with chronic diarrhea and neutropenia, initially referred for evaluation of Shwachman-Diamond syndrome, were found to have no evidence of pancreatic insufficiency. All presented in the spring with a prodromal respiratory illness. Hematologic evaluation was normal except for iron deficiency anemia and neutropenia. Small intestinal biopsies of all children showed inflammation, consistent with chronic enteritis. The children were followed until growth returned to previous percentiles. Diarrhea and neutropenia resolved by 6-month follow-up, and there was no recurrence of the neutropenia at 1 year.

Chronic Diarrhea and Neutropenia Not Associated with Pancreatic Insufficiency

Summary:Six children with chronic diarrhea and neutropenia, initially referred for evaluation of Shwachman‐Diamond syndrome, were found to have no evidence of pancreatic insufficiency. All presented in the spring with a prodromal respiratory illness. Hematologic evaluation was normal except for iron deficiency anemia and neutropenia. Small intestinal biopsies of all children showed inflammation, consistent with chronic enteritis. The children were followed until growth returned to previous percentiles. Diarrhea and neutropenia resolved by 6‐month follow‐up, and there was no recurrence of the neutropenia at 1 year.

The Ageing Gut: A Study of Intestinal Absorption in Relation to Nutrition in the Elderly

This study was designed to assess the functional efficiency of the ageing small intestine and the possible role of malabsorption in old people with nutritional deficiencies. Fifty subjects aged 65 to 92 years were studied, of whom 33 presented with anaemia, chronic diarrhoea or bone pains, and 17 were apparently healthy 'controls' with no relevant symptoms. Tests of intestinal function included blood xylose and iron absorption curves, a double isotope Schilling test, faecal fat, urinary indican and small bowel radiology, with duodenal aspiration and jejunal biopsy in some cases. On the basis either of steatorrhoea or at least two other abnormal parameters of absorption, there were 15 cases of malabsorption. Thirteen of these had symptoms but two were 'controls'. Four of these had duodenal diverticulosis, two had the post-gastrectomy syndrome, and one had calcific pancreatitis. Malabsorption in the remaining eight cases was not fully explained. The age range of this last group was 72--86 years; one of them had a contaminated small bowel and two showed some evidence of pancreatic insufficiency. Malabsorption emerged as a significant cause of low levels of serum iron, haemoglobin and calcium. The blood xylose test is a useful screening procedure for intestinal malabsorption in old age, but full evaluation calls for investigation of pancreatic function.

Cystic Fibrosis in Adolescents and Adults

Forty-five patients (25 male and 20 female) over 12 years of age with cystic fibrosis have been studied clinically, radiologically and physiologically. Their mean age at the first visit was 17 years; they were followed for a mean period of 4 years and attended at least every six months. The first symptom which developed before the age of five in 42 of the 45 patients was respiratory. Thirty-two of the 45 patients had severe lung disease (Group III) at the start of the study of the seven patients died during the study. Cough and sputum were almost universal, 23 had haemoptyses and eight pneumothoraces. Staphylococcus pyogenes, Haemophilus influenzae and Pseudomonas aeruginosa were the common pathogens isolated from sputum and the increasing prevalence of the latter was again confirmed. Acquisition of the mucoid strain of pseudomonas signified poor prognosis. Established infection was never eradicated. Forty-three patients had evidence of pancreatic insufficiency; in all but one patient the symptoms were mild and five patients abandoned dietary restriction and pancreatin without ill effect. Seven patients had symptoms of partial bowel obstruction (meconium ileus equivalent) but only one required surgical relief. The liver was enlarged in seven patients and the spleen was felt in three. Three patients had diabetes mellitus. The influence of cystic fibrosis on growth and development is reported--the growth spurt is late in the majority but growth failure is not confined to those with severe lung infection or malabsorption and in these circumstances remains unexplained. Mean weight was low in relation to height and puberty was delayed in both sexes.