Management Of Pancreatic Exocrine Insufficiency Research Articles

Pancreatitis crónica

Chronic pancreatitis (CP) is a disease in which, due to different causes, the pancreatic tissue is replaced by fibrous tissue. This results in loss of both endocrine and exocrine function. This may happen due to different causes, often involving various risk factors. Investigating these causes is important due to their different therapeutic and prognostic implications, which are listed in the TIGAR-O classification. The clinical manifestations of CP occur when most of the organ's function has been lost. They include chronic abdominal pain, exocrine pancreatic insufficiency, and endocrine pancreatic insufficiency. There is no gold standard test for diagnosing CP that can provide a definitive diagnosis, but epidemiological, clinical, radiological (mainly endoscopic ultrasound and magnetic resonance cholangiopancreatography), and analytical tests (stool elastase test, complete nutritional study, and, if available, a 13C-labeled mixed triglyceride breath test) must be jointly evaluated. It is not necessary to obtain a histological specimen. Treatment is focused on pain management with medical, endoscopic, or surgical treatment in the most refractory cases; management of exocrine pancreatic insufficiency with lipase enzyme supplementation if available; management of endocrine pancreatic insufficiency (antidiabetics and insulin); and control of risk factors (tobacco use and alcohol use disorder).

Real-World Patient Experience With Pancreatic Enzyme Replacement Therapy in the Treatment of Exocrine Pancreatic Insufficiency.

This study aimed to provide patients insights on the management of exocrine pancreatic insufficiency (EPI) with pancreatic enzyme replacement therapy (PERT). A survey of 75 members of Inspire's Pancreatitis or Pancreatic Cancer Support communities was conducted. Eligibility included having EPI secondary to chronic pancreatitis, pancreatic cancer, pancreatic surgery, or acute pancreatitis, and current/past PERT experience. Patients were 73% female, 57% aged 50 to 69 years, and 85% White, with PERT prescribed by a gastroenterologist/pancreatologist for 64%. Only approximately half of respondents agreed that their healthcare provider provided detailed information about EPI (54%) or how PERT works to treat EPI (56%). Most respondents (83%) reported searching for information about EPI, 56% were taking PERT solely before or after eating, 36% reported taking suboptimal PERT doses, and 39% reported no follow-up. In addition, 24% decreased their PERT dosage without consulting their physician, and 21% reported purposely skipping PERT. This study reveals potential barriers to effective treatment of EPI with PERT, including lack of patient education, mainly how and when to take PERT, gaps in appropriate dosing, and lack of patient follow-up. Continued focus on patient and provider education is essential to address these gaps and optimize the treatment of EPI.

BS O02 Pancreatic Exocrine Insufficiency after Bariatric Metabolic Surgery: Results from a Systematic Review and Meta-Analysis

Abstract Background Disruptive gastrointestinal symptoms and malnutrition are common following bariatric metabolic surgery (BMS), and pancreatic exocrine insufficiency (PEI) is a sparsely considered cause of such. Untreated PEI results in substantial patient harm and should be managed with pancreatic enzyme replacement therapy (PERT). The incidence of PEI, its diagnosis and management, is unclear after BMS. The aim of this review was to assimilate the literature on incidence, diagnosis, and management of PEI in patients following BMS. Methods A systematic review of PUBMED and Embase databases identified studies investigating PEI following BMS. A pooled analysis was performed to determine prevalence of PEI in each cohort, and benefit of PERT. Meta-analyses were performed using the software package Revman 5.4, in accordance with the recommendation of the Cochrane Collaboration. Results 12 studies were included in the quantitative synthesis of PEI rate after BMS. The rate of PEI after any BMS was 23.0% (95% CI:14.6% - 32.6%) amongst 1157 patients, and most common after biliopancreatic diversion with duodenal switch (44.0% (95%CI: 9.2-82.1%)). The most common diagnostic test used was faecal-elastase-1 (FE-1) (10/12 studies) reporting <200 µg/g as diagnostic of PEI. Five studies considered management of PEI with 81.7% (95% CI: 73.8% - 88.6%) of patient’s responding positively to PERT when prescribed. One study specifically reported improved Vitamin D, quality of life and FE-1 following PERT, with no effect on weight loss. Conclusions PEI is common following BMS, particularly following bypass procedures, and may be a substantial contributor to post-operative malnutrition in these patients. With over 4/5th patients experiencing symptomatic benefit of PERT, and evidence suggesting it does not prohibit weight loss, future research must further illuminate the role of PERT in the post-operative story of BMS patients.

OGC P16 Pancreatic Exocrine Insufficiency after Oesophagogastric Resection: Results from a Systematic Review and Meta-Analysis

Abstract Background Unpleasant gastrointestinal complications can affect 9/10 patients after oesophagogastric resection (OGR), and malnutrition is recognised in this cohort. Untreated pancreatic exocrine insufficiency (PEI) results in substantial patient harm and is recognised as a contributor to such symptoms. The incidence of post-operative PEI is unclear, however and the benefit of management with pancreatic enzyme replacement therapy (PERT), rarely discussed. The aim of this study was to assimilate the literature on incidence, diagnosis, and management of PEI in patients following OGR. Methods A systematic review of PUBMED and Embase databases identified studies investigating PEI following OG resection. A pooled analysis was performed to determine prevalence of PEI in each cohort, and benefit of PERT. Meta-analyses were performed using the software package Revman 5.4, in accordance with the recommendation of the Cochrane Collaboration. Results Twelve studies were included in the quantitative synthesis of PEI rate after OGR surgery. The rate of PEI after any OGR was 50.4% (95% CI: 38.3% - 62.6%) amongst 463 patients. PEI was most prevalent after total gastrectomy at 66.2% (95% CI: 44.9% - 84.9%) followed by subtotal, 46.9% (95% CI: 33.3% - 60.9%) and oesophagectomy 31.0% (95% CI: 17.0% - 46.9%) The most common diagnostic test used was faecal-elastase-1 (FE-1) (4/12 studies) reporting <200 µg/g as diagnostic of PEI. Four studies reported the effect of PERT, with symptomatic benefit seen in 75.2% (95% CI: 66.9% - 82.7%). Conclusions PEI is common following OGR, with over half of patients developing PEI. The presence of PEI reduces quality of life, contributes to malnutrition and long-term poor health, but can be managed effectively with PERT. Future work must further define the role of PERT after OGR, considering not only nutritive and qualitative benefit, but also whether a survival advantage is conferred.

Perioperative management of pancreatic exocrine insufficiency - evidence-based proposal for a paradigm shift in pancreatic surgery

Perioperative management of pancreatic exocrine insufficiency - evidence-based proposal for a paradigm shift in pancreatic surgery

S27 Impact of an Exocrine Pancreatic Insufficiency Order Set on Adequacy of Management of Exocrine Pancreatic Insufficiency and Related Complications

S27 Impact of an Exocrine Pancreatic Insufficiency Order Set on Adequacy of Management of Exocrine Pancreatic Insufficiency and Related Complications

Prescription patterns of pancreatic enzyme replacement therapy for patients with pancreatic cancer in the United States.

Exocrine pancreatic insufficiency (EPI) is frequently seen in patients with pancreatic cancer (PDAC) and is thought to contribute to nutritional complications. While EPI can be pharmacologically temporized with pancreatic enzyme replacement therapy (PERT), there is lack of clear evidence informing its use in PDAC. Here we aim to survey pancreatic surgeons regarding their utilization of PERT in the management of EPI for PDAC. An online survey was distributed to the members of The Americas Hepato-Pancreato-Biliary Association (AHPBA) and The Pancreas Club. 86.5% (180/208) of surgeons prescribe PERT for at least some resectable/borderline resectable PDAC cases. Only a minority of surgeons order investigations to confirm EPI before starting PERT (28.1%) or test for adequacy of therapy (28.3%). Few surgeons believe that PERT has an effect on overall survival (19.7%) or disease-free survival (6.25%) in PDAC. PERT is widely prescribed in patients with resectable/borderline resectable PDAC, but investigations establishing EPI and assessing PERT adequacy are underutilized. A substantial proportion of surgeons are unclear as to the effect of PERT on survival outcomes in PDAC. These data call for prospective studies to establish guidelines for optimal use of PERT and its effects on survival outcomes in PDAC.

Training 1,200 dietitians: An evaluation of a training course for non-specialist dietitians on the management of pancreatic exocrine insufficiency

<h2>Summary</h2><h3>Background</h3> Concurrent with its evolution as medical and surgical sub-speciality, pancreatic disease is now recognised as a speciality within dietetics. Recent national guidelines have highlighted the importance of nutritional assessment and intervention in both pancreatic cancer and pancreatitis, but there is a lack of timely and appropriate nutritional support for many patients with pancreatic disease. <h3>Methods</h3> The Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland developed a training course for non-specialist dietitians in 2014. Improvement in knowledge was assessed using questionnaires carried out before and after the training course, and results assessed against pre-agreed targets. Comprehensive evaluation of each aspect of the course was collated. <h3>Results</h3> Over four years, 1,215 dietitians attended the course in 32 different locations throughout the United Kingdom. Eight three percent completed knowledge questionnaires before and after the course. There was a significant improvement in test scores (22.2 ± 5.3 <i>vs</i>. 35.8 ± 4.0, <i>P</i><0.0001), with 94% of delegates achieving the target score for non-specialists. The course was well evaluated with 98% of all markers graded as ‘good' or ‘excellent'. <h3>Conclusions</h3> Targeted educational initiatives delivered outside of normal working hours are an effective means of training and educating a large number of health care professionals over a large geographical area within a short timeframe.

Diagnosis and treatment of exocrine pancreatic insufficiency in chronic pancreatitis: An international expert survey and case vignette study

IntroductionDespite evidence-based guidelines, exocrine pancreatic insufficiency is frequently underdiagnosed and undertreated in patients with chronic pancreatitis. Therefore, the aim of this study is to provide insight into the current opinion and clinical decision-making of international pancreatologists regarding the management of exocrine pancreatic insufficiency. MethodsAn online survey and case vignette study was sent to experts in chronic pancreatitis and members of various pancreatic associations: EPC, E-AHPBA and DPSG. Experts were selected based on publication record from the past 5 years. ResultsOverall, 252 pancreatologists participated of whom 44% had ≥ 15 years of experience and 35% treated ≥ 50 patients with chronic pancreatitis per year. Screening for exocrine pancreatic insufficiency as part of the diagnostic work-up for chronic pancreatitis is performed by 69% and repeated annually by 21%. About 74% considers nutritional assessment to be part of the standard work-up. Patients are most frequently screened for deficiencies of calcium (47%), iron (42%), vitamin D (61%) and albumin (59%). In case of clinically steatorrhea, 71% prescribes enzyme supplementation. Of all pancreatologists, 40% refers more than half of their patients to a dietician. Despite existing guidelines, 97% supports the need for more specific and tailored instructions regarding the management of exocrine pancreatic insufficiency. ConclusionThis survey identified a lack of consensus and substantial practice variation among international pancreatologists regarding guidelines pertaining the management of exocrine pancreatic insufficiency. These results highlight the need for further adaptation of these guidelines according to current expert opinion and the level of available scientific evidence.

Diagnosis and Treatment of Exocrine Pancreatic Insufficiency in Chronic Pancreatitis: An International Expert Survey and Case Vignette Study

Introduction: Despite evidence-based guidelines, exocrine pancreatic insufficiency is frequently underdiagnosed and undertreated in patients with chronic pancreatitis. Therefore, the aim of this study is to provide insight into the current opinion and clinical decision-making of international pancreatologists regarding the management of exocrine pancreatic insufficiency.

Provider Differences in Monitoring and Management of Exocrine Pancreatic Insufficiency in Chronic Pancreatitis.

Chronic pancreatitis (CP) is a common cause of exocrine pancreatic insufficiency (EPI). Regular monitoring and treatment are recommended to decrease morbidity. This study evaluates whether provider type impacts EPI monitoring and management in CP. Fecal elastase 1 (FE-1) testing and pancreatic enzyme replacement therapy (PERT) utilization were retrospectively compared between primary care providers (PCPs), gastroenterologists and pancreas specialists using pairwise comparisons. Multivariate analysis was conducted to study the association between adequate PERT and age, sex, race, insurance status, provider type, and etiology. Among 256 patients, FE-1 was measured in 115 (44.9%) and of 143 (55.9%) patients who received PERT, 100 (69.9%) received adequate dosage. Fecal elastase 1 testing was performed in 7/57 (12.3%) by PCP, 11/38 (28.9%) by gastroenterologists, and 97/161 (60.2%) by pancreas specialists (P < 0.0001). Adequate PERT was prescribed in 7/24 (29.2%) patients by PCPs, 11/20 (55.0%) by gastroenterologists, and 82/99 (82.8%) by pancreas specialists (P < 0.0001). On multivariate analysis, pancreas specialists were significantly more likely to prescribe adequate PERT compared with PCP (odds ratio, 11.3; 95% confidence interval, 3.3-38.2; P < 0.001). Many patients with CP receive inadequate surveillance and EPI treatment. Pancreas specialists are more likely to surveil and treat EPI adequately.

Clinical and pharmacological approaches to the management of exocrine pancreatic insufficiency in chronic pancreatitis

Chronic pancreatitis is a multifactorial disease in which repeated episodes of inflammation of the pancreas contribute to the development of fibrous tissue, leading to chronic pain, as well as exocrine and endocrine insufficiency. The incidence and prevalence of chronic pancreatitis in the world are growing, as evidenced by current statistics. In addition, the annual costs associated with the treatment of exocrine and endocrine insufficiency are also increasing. In the United States alone, the annual cost of treating these complications is $ 75.1 million. Exocrine insufficiency is one of the most frequent complications, which is characterized by a deficiency of pancreatic enzymes, leading to the development of malabsorption syndrome (impaired absorption of nutrients, vitamins and minerals). Due to the increased incidence and deterioration of the quality of life associated with this condition, the goal of treatment is to compensate for the deficiency of exocrine enzymes with oral pancreatic enzyme replacement therapy. The core of this therapy is to deliver activated, unbroken enzymes directly to the small intestine during a meal. Many studies have shown that prescribing enzyme replacement therapy improves symptoms associated with exocrine insufficiency, reduces the progression of osteopenia, and improves survival in such patients. The use of pancreatin contributes to the correction of exocrine insufficiency in patients with chronic pancreatitis. The data presented in the article indicate that the drug is a safe and effective agent, meets all modern standards and requirements, and can be used to correct enzymatic pancreatic insufficiency.

Adherence to European guidelines in treatment and management of pancreatic exocrine insufficiency in chronic pancreatitis patients

Adherence to European guidelines in treatment and management of pancreatic exocrine insufficiency in chronic pancreatitis patients

Adherence to European Guidelines for Treatment and Management of Pancreatic Exocrine Insufficiency in Chronic Pancreatitis Patients.

European evidence-based guidelines for the treatment and management of chronic pancreatitis (CP) have been made available following the harmonizing diagnosis and treatment of CP across Europe (HaPanEU) initiative by the United European Gastroenterology (UEG). The aim of this study was to evaluate adherence to the guideline recommendations in the management of patients with pancreatic exocrine insufficiency (PEI) at Karolinska University Hospital in Stockholm. UEG guideline recommendations were evaluated and categorized into 55 different quality indicators (QIs). Data from a retrospective cohort of CP patients being treated at Karolinska University Hospital were evaluated with regard to overall adherence as well as adherence to specific QIs. A total number of 118 patients out of 956 patients diagnosed with CP were eligible for inclusion with mean overall adherence of 61.9% to the defined QIs. A significant difference in mean overall adherence was shown between patients diagnosed with CP prior to 1 January 2016 and following 1 January 2016 (59.3% and 67.7% respectively, p = 0.004), with linear regression analysis also demonstrating improvement correlating to date of diagnosis (p = 0.002). In conclusion, diagnosis and treatment of PEI improved after the HaPanEU guidelines became available and is continuously improving; however, there is room for further improvement.

La insuficiencia pancreática exocrina: estado actual de su conocimiento entre los profesionales de Argentina

Background. Exocrine pancreatic insufficiency is defined as the inability to maintain pancreatic secretion or maintain normal food digestion. It is an underdiagnosed entity. Objective. To collect information from the health professionals of different specialties in our country on the current state of knowledge of exocrine pancreatic insufficiency. Material and method. During the period comprising from August to November 2018, an anonymous survey was conducted. The survey was sent by e-mail. 447 professionals responded from a total of 2054 surveys sent. Results. We observed that a significant proportion of professionals did not relate exocrine pancreatic insufficiency with various etiologies that may cause it. Typical exocrine pancreatic insufficiency symptoms such as diarrhea-steatorrhea (96.2%) and the weight loss (85%) were the most chosen. Regarding diagnostic methods, digestive symptoms (60.6%) and the fecal elastase test (59.5%) were the most selected options. Regarding treatment, most chose to indicate the intake of the PERT capsules during food ingestion (61.3%). Only the 37.4% chose the initial dose recommended by most guidelines. A varied diet without fat restriction was indicated by the 40% of the respondents. In relation to the control of response to treatment, the improvement of symptoms (87.5%) and anthropometry (59.7) were the most used parameters. Most professionals do not use clinical guidelines for the management of these patients and only 22% used the guidelines. Conclusion. Based on the data obtained in this survey, we observed that a significant proportion of professionals do not know the relevant aspects in relation to the etiology, the clinical manifestations, the diagnosis, and the nutritional and pharmacological management of exocrine pancreatic insufficiency.

The investigation and management of pancreatic exocrine insufficiency: A retrospective cohort study

Pancreatic exocrine insufficiency (PEI) is associated with significant gastrointestinal symptoms, but is readily treated by pancreatic enzyme replacement therapy (PERT). We reviewed our current practice and examined the factors that predict repeating a positive faecal elastase-1 (FE1; <200 μg/g), the repeat FE1 being normal, initiation of PERT and clinical response to treatment. A single-centre retrospective cohort study was conducted. Outpatients with FE1 <200 μg/g between 2012 and 2018 were included. Logistic regression was used to explore the associations with each outcome, with statistical adjustment for confounders. Two-hundred and ten patients were included; 28.1% of patients had their FE1 repeated, 47.5% of whom had a normal repeat result. Patients with initial FE1 <15 μg/g were unlikely to be reclassified on repeat testing. Patients with a confirmatory low FE1, abnormal pancreatic imaging or abnormal nutrition blood tests were more likely to be started on PERT (all p<0.05). Patients with abnormal pancreatic imaging were 10 times more likely to respond to PERT (odds ratio 10.70; 95% confidence interval 1.62-70.70; p=0.01). Augmenting clinical judgement with pancreatic imaging and repeat FE1 testing could improve the rate of PERT prescription and inform the approach to non-response, particularly in cases where there is diagnostic doubt.

Update on the diagnosis and management of exocrine pancreatic insufficiency.

Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine, resulting in malabsorption. Clinical manifestations of EPI are often nonspecific and can lead to lack of timely recognition and diagnosis. Central to this clinical dilemma is the lack of highly accurate or specific testing which leads to misdiagnosis and suboptimal treatment. Identification of high-risk patients is key in the diagnosis of EPI and this includes patients with pancreatic parenchyma disorders such as chronic pancreatitis, pancreatic malignancy, cystic fibrosis, and those undergoing pancreatic resection for benign and malignant disease. Less recognized are the number of additional conditions which may also have EPI as a consequence. Owing to an increase in morbidity and impaired quality of life associated with this condition, goals of treatment have been aimed at repleting exocrine enzyme deficiency by oral pancreatic enzyme replacement therapy (PERT). The basis of PERT is to provide activated digestive enzymes to the small bowel during the prandial period, mainly, leading to sufficient absorption of fat and fat-soluble vitamins. The benefits of PERT have been shown to go beyond the improvement in signs and symptoms associated with EPI and include decreasing prevalence of osteopathy and improving survival outcomes in subsets of patients with this condition. However, despite the overall benefits in treatment, the diagnosis and management of EPI are suboptimal. Current literature suggests patients at high risk of developing EPI are not tested and those who are diagnosed are not treated with adequate dosages. In this review, we highlight patients who are at high risk for the development of EPI, analyze consequences and treatment of this disorder, review rationale for enzyme replacement therapy, and examine current evidence for treatment optimization.

Management of Exocrine Pancreatic Insufficiency in Children.

The diagnosis of exocrine pancreatic insufficiency (EPI) can be difficult, as symptoms may be nonspecific. A delayed diagnosis of EPI can negatively impact health through poor weight gain, impaired growth, and malabsorption of nutrients. Because of active growth and development, children are more vulnerable to the consequences of untreated EPI. Pancreatic enzyme replacement therapy is the cornerstone of management and offers both symptomatic relief and improvement in clinical outcomes. Additionally, a high-energy diet with unrestricted fat and supplementation with fat-soluble vitamins is often required to optimize growth and prevent nutrition deficiencies. Cystic fibrosis (CF) is the most common condition in children that causes EPI, and improvement in nutrition management is associated with improved pulmonary function and increased survival. Currently, the management of other conditions leading to EPI in children is not well studied, and inferences from the CF literature are often necessary in caring for these patients.

Management of pancreatic exocrine insufficiency.

Pancreatic exocrine insufficiency (PEI) is one of the well known causes of malabsorption syndrome. An insufficient secretion of pancreatic enzymes and bicarbonate secondary to different pancreatic diseases and upper gastrointestinal and pancreatic surgery leads to maldigestion and malabsorption of nutrients. Patients with PEI may present with symptoms of malabsorption and different nutritional deficiencies. Recent data support the high clinical relevance of PEI and its treatment. Deficiencies of fat-soluble vitamins, proteins, micronutrients and antioxidants in patients with PEI are associated not only with an increased risk of osteoporosis and sarcopenia but also of cardiovascular events and mortality. Pancreatic enzyme replacement therapy (PERT) allows improving fat and protein digestion, relieving maldigestion-related symptoms, normalizing the nutritional status, and improving quality of life of patients with PEI. Recent data support the efficacy of PERT on survival in patients with pancreatic cancer. Dose of oral pancreatic enzymes should be adequate to normalize the nutritional status of PEI patients. Increasing evidence supports the relevance of PEI management by dietary advice and appropriate PERT. Well designed and powered randomized, placebo-controlled clinical trials are needed to further evaluate the clinical impact of PEI and its treatment in clinical practice.

Diagnosis and Management of Exocrine Pancreatic Insufficiency.

Recent studies have documented that many patients with pancreatic exocrine insufficiency (EPI) are not identified and are not treated with appropriate dosages of pancreatic enzyme replacement therapy. This review will summarize the approach to diagnosis, treatment, and monitoring for treatment effect and complications in patients with exocrine insufficiency. While chronic pancreatitis is the most commonly identified cause of EPI, pancreatic cancer and pancreatic surgery are increasingly important. The diagnosis of EPI remains challenging, but fecal elastase is the most clinically useful test. Treatment requires an understanding of the appropriate dosage and timing of enzyme replacement, but recent studies show that clinicians often do not have this understanding. Monitoring and prevention of complications of EPI is increasingly important, particularly osteopenia and osteoporosis. In those that fail to respond, coexistent small intestinal bacterial overgrowth should be considered. Many clinicians do not consider EPI in the differential diagnosis, and patients with EPI are routinely undertreated in the USA. Appropriate identification of those at risk and use of appropriate enzyme therapy, along with monitoring for metabolic complications of EPI, are essential to provide effective care for these patients.