Management Of Pancreatic Exocrine Insufficiency Research Articles

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.

Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician.

SummaryAimsIn exocrine pancreatic insufficiency (EPI), the quantity and/or activity of pancreatic digestive enzymes are below the levels required for normal digestion, leading to maldigestion and malabsorption. Diagnosis of EPI is often challenging because the characteristic signs and symptoms overlap with those of other gastrointestinal conditions. Additionally, there is no single convenient, or specific diagnostic test for EPI. The aim of this review is to provide a framework for differential diagnosis of EPI vs other malabsorptive conditions.MethodsThis is a non‐systematic narrative review summarising information pertaining to the aetiology, diagnosis and management of EPI.ResultsExocrine pancreatic insufficiency may be caused by pancreatic disorders, including chronic pancreatitis, cystic fibrosis, pancreatic resection and pancreatic cancer. EPI may also result from extra‐pancreatic conditions, including coeliac disease, Zollinger‐Ellison syndrome and gastric surgery. Timely and accurate diagnosis of EPI is important, as delays in treatment prolong maldigestion and malabsorption, with potentially serious consequences for malnutrition, overall health and quality of life. Symptoms of EPI are non‐specific; therefore, a high index of clinical suspicion is required to make a correct diagnosis.

Diagnosis and management of pancreatic exocrine insufficiency.

In 2015, the Australasian Pancreatic Club (APC) published the Australasian guidelines for the management of pancreatic exocrine insufficiency (http://pancreas.org.au/2016/01/pancreatic-exocrine-insufficiency-guidelines). Pancreatic exocrine insufficiency (PEI) occurs when normal digestion cannot be sustained due to insufficient pancreatic digestive enzyme activity. This may be related to a breakdown, at any point, in the pancreatic digestive chain: pancreatic stimulation; synthesis, release or transportation of pancreatic enzymes; or synchronisation of secretions to mix with ingested food. Main recommendations: The guidelines provide advice on diagnosis and management of PEI, noting the following: A high prevalence of PEI is seen in certain diseases and conditions, such as cystic fibrosis, acute and chronic pancreatitis, pancreatic cancer and pancreatic surgery. The main symptoms of PEI are steatorrhoea or diarrhoea, abdominal pain, bloating and weight loss. These symptoms are non-specific and often go undetected and untreated. PEI diagnosis is predominantly based on clinical findings and the presence of underlying disease. The likelihood of PEI in suspected patients has been categorised into three groups: definite, possible and unlikely. If left untreated, PEI may lead to complications related to fat malabsorption and malnutrition, and have an impact on quality of life. Pancreatic enzyme replacement therapy (PERT) remains the mainstay of PEI treatment with the recommended adult initial enzyme dose being 25 000-40 000 units of lipase per meal, titrating up to a maximum of 75 000-80 000 units of lipase per meal. Adjunct acid-suppressing therapy may be useful when patients still experience symptoms of PEI on high dose PERT. Nutritional management by an experienced dietitian is essential. Changes in management as a result of these guidelines: These are the first guidelines to classify PEI as being definite, possible or unlikely, and provide a diagnostic algorithm to facilitate the early diagnosis of PEI and appropriate use of PERT.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery.

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

MON-P055: A Retrospective Study of the Management of Pancreatic Exocrine Insufficiency at University College London Hospital (UCLH)

MON-P055: A Retrospective Study of the Management of Pancreatic Exocrine Insufficiency at University College London Hospital (UCLH)

Exocrine Pancreatic Insufficiency: A Literature Review

Exocrine pancreatic insufficiency (EPI) is a clinical entity that manifests as a mal absorption syndrome. Its relationship with multiple worldwide-highly prevalent pancreatic and extra pancreatic affections constitutes a major health problem due to high morbidity and mortality rates. The underlying disease requires an exhaustive assessment to identify possible nutritional deficiencies so as to prevent future complications. An impaired hydro electrolytic balance and low levels of serum nutritional markers indicate or predict EPI in high risk subjects. Unfortunately, pancreatic exocrine function test available so far do not diagnose early stages of the disease but they are quite effective in advanced EPI. Imaging studies are essential in the overall management of EPI as they may provide information regarding the etiology and structural pancreatic modifications. ERCP, despite post-procedure complications, is considered the gold standard due to its diagnostic and therapeutic properties. Treatment is based on pancreatic enzyme replacement therapy (PERT) along with nutritional supplements intake and good control of the underlying disease.

Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency

Because of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI). A working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category. Recent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the 'unlikely' PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000-40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy.

Online CME Participation by Gastroenterologists Improves Management of Exocrine Pancreatic Insufficiency

Introduction: Management of exocrine pancreatic insufficiency (EPI) can be challenging for gastroenterologists. This study assessed the effect of online continuing medical education (CME) on clinical decision-making among participating gastroenterologists compared to non-participating matched peers. Methods: The American Gastroenterological Association Institute and Medscape, LLC identified performance gaps in management of EPI. An enduring online video-based CME expert roundtable discussion was hosted on Medscape from February 28th, 2013. Clinical case vignettes with assessment questions were administered to CME participants following the CME activity and final data for outcomes was collected by May 30th, 2013. A control group of non-participants that matched the participants' characteristics (e.g., specialty, number of EPI patients treated) was randomly selected and administered the same set of questions. The difference in responses to survey questions between the two groups were analyzed using chi-square tests (P < .05), and educational effect size was calculated using Cohen's d formula, which represented the degree of nonoverlap in answers between the CME participants and non-participants. Results: Gastroenterologist CME participants (n=100) were 37.2% more likely to make evidence-based practice choices than non-participants (n=100) (moderate educational effect size of d=0.58) in the following areas: - 28% more participants ordered a fecal elastase test to confirm EPI (75% participants vs 47% non-participants, P<0.001). - 12% more participants ruled out small bowel bacteria overgrowth in poor responders to enzyme replacement therapy (90% participants vs 78% non-participants, P=.02). - 16% more participants ordered a Vitamin D level for a patient with a history of diarrhea due to EPI (93% participants vs 77% non-participants, P=.002). - 12% more participants accurately counselled patients beginning EPI therapy (88% participants vs 76% non-participants, P=.03). - Most participants (88%) and non-participants (90%) recognized that efficacy of pancreatic enzyme supplementation is influenced by timing of consumption. Conclusion: CME participation in an online video roundtable discussion impacted clinical decisionmaking in gastroenterologists treating EPI, which may translate to improved outcomes in patients. Future education should focus on testing to confirm EPI and patient-clinician communication on treatment adherence and disease management.

Prescription patterns of enzyme-containing products in South Africa over a 2-year period

Enzymes are traded in five categories, namely medical (intervention), diagnostic (detection and quantification), molecular biology, biofuel and industrial. Therapeutic enzymes have been investigated for different uses, for example, for the treatment of genetic disorders, blood clotting disorders, cancer and infectious diseases and for burn debridement. No studies on the prescription of enzyme-containing products in South Africa could be found. Enzymes are classified in the Monthly Index of Medical Specialities under digestants, enzymes and fibrinolytics. The primary aim of this study was to investigate the prescription patterns and cost of enzyme-containing products in South Africa. A private health-care medicines claims database for 2010 and 2011 of approximately 4.5 million records was analysed retrospectively. Enzyme-containing products constituted a small percentage of medical insurance claims (only 0.02% of approximately 4.5 million claims for products and procedures), yet they were relatively expensive. A total of 906 products was prescribed at a cost of almost ZAR2 million over the 2 years. Hyaluronidase was the most frequently prescribed (60.04%), followed by pancreatin-containing products (34.66%). Pancreatin (lipase/ protease/amylase) is primarily used in the management of pancreatic exocrine insufficiency. The average cost per hyaluronidase prescription paid by the medical insurance schemes was ZAR280. Other enzyme-containing products prescribed were imiglucerase, alteplase and tenecteplase. Imiglucerase was overall the most expensive. Alteplase, tenecteplase and streptokinase are antithrombotic enzymes that are used in the treatment of acute myocardial infarction or ischaemic stroke. Streptokinase, regarded as the most affordable antithrombotic enzyme, was not prescribed during the period under study. With the growing opportunities for enzymes for therapeutics, the use of enzyme-containing products which are comparatively expensive require cost-effectiveness studies.

13C-mixed triglyceride breath test in management of exocrine pancreatic insufficiency

13C-mixed triglyceride breath test in management of exocrine pancreatic insufficiency

Diagnosis and management of pancreatic exocrine insufficiency

AbstractManaging pancreatic exocrine insufficiency effectively is challenging for both specialist and primary‐care physicians. This review summarises current methods employed to diagnose and treat PEI effectively and prevent complications.

Pancreatic Exocrine Insufficiency (PEI) in chronic pancreatitis (CP) and cystic fibrosis (CF) patients: Combining clinician insights and existing literature to develop a conceptual model to aid in the identification and management of PEI

Pancreatic Exocrine Insufficiency (PEI) in chronic pancreatitis (CP) and cystic fibrosis (CF) patients: Combining clinician insights and existing literature to develop a conceptual model to aid in the identification and management of PEI

Management of Pancreatic Exocrine Insufficiency

A 56-year-old obese Caucasian woman named M.B. reported experiencing anorexia and early satiety in the prior two months. She has lost 10 pounds in two weeks. No changes had been made to her type 2 diabetes medications, she took no other medications, and her exercise habits were unchanged. M.B. made an appointment with her primary care physician (PCP) and her physical examination was inconclusive. The complete blood count and chemistry panel were normal; however, a computed tomography scan of the abdomen showed a 3 cm abnormality in her pancreas with a question of involvement of her superior mesenteric artery. Her PCP suggested that she see a gastroenterologist for an endoscopy. The gastroenterologist performed an endoscopic ultrasound (EUS) and blood work was conducted, including the cancer antigen 19-9 (CA 19-9) and carcinoembryonic antigen tumor marker tests. M.B.’s CA 19-9 was slightly elevated at 88 mg/dl, and the EUS procedure obtained several tissue specimens that were consistent with adenocarcinoma of the pancreas with no involvement of lymph nodes. She then saw an oncologic gastrointestinal surgeon who ordered a positron-emission tomography (PET) scan; the scan showed the tumor in the head of the pancreas involving major blood vessels. Based on these findings, her pancreatic cancer was determined to be locally advanced and unresectable. M.B. was referred to a medical oncologist and reported several additional symptoms that she started to experience, including more frequent and very foul smelling stools as well as bloating with flatulence. She was continuing to lose weight because eating was so uncomfortable. Her oncologist asked a registered dietitian to consult with her. An initial diet history revealed that M.B. was eating a diet consisting of three Management of Pancreatic Exocrine Insufficiency

Pancreatic cancer and supportive care—pancreatic exocrine insufficiency negatively impacts on quality of life

Pancreatic cancer is a fatal cancer with a median survival from diagnosis of around 5 months Speer et al. (Med J Aust 196(8):511-515, 2012). Given the short survival time for people with pancreatic cancer, effective supportive care is imperative to enable best quality of life. This article presents an unexpected finding from research into the psychosocial supportive care needs of people affected by pancreatic cancer that management of pancreatic exocrine insufficiency is an area of unmet need that severely impacts on quality of life and increases carer burden in people affected by pancreatic cancer. A qualitative inquiry framework was used to explore participants' perspectives and experience. Two groups of participants (N = 35) were recruited across Australia from people accessing the Cancer Helpline or direct referral from clinicians/nurses: patients diagnosed with pancreatic cancer (N = 12) and carers/family (N = 23) including a subgroup of bereaved participants (N = 14). Sampling continued until saturation. A thematic content analysis was conducted. The findings revealed that the major quality of life theme was difficulty in managing gut symptoms and complex dietary issues. Issues were related to lack of information about malabsorption and managing symptoms of pancreatic exocrine insufficiency. This was compounded by a lack of routine dietary consultation: perceived reluctance of clinicians to prescribe enzyme supplements and poor understanding of dose to diet guidelines. Participants expressed distress relating to the effects of pancreatic exocrine insufficiency. Pancreatic enzyme supplement therapy with clear dosage guidelines and associated dietary advice could resolve symptoms of malabsorption and markedly improve quality of life. For people affected by pancreatic cancer, this is an essential supportive care.

Cost-effectiveness analysis of pancreatin minimicrospheres in patients with pancreatic exocrine insufficiency due to chronic pancreatitis

Objective:Chronic pancreatitis (CP) is the most common cause of pancreatic exocrine insufficiency (PEI). Management of PEI due to CP is achieved through lifelong treatment with pancreatic enzyme replacement therapy (PERT). To the authors’ knowledge, no cost-effectiveness analysis on the benefit of PERT in CP patients with PEI has been performed to date. The objective of this analysis was to examine the cost-effectiveness of Creon (pancreatin minimicrospheres [MMS]), one of the main PERTs available in Poland, in treating patients with CP-related PEI.Methods:The cost-effectiveness of pancreatin MMS in the treatment of patients with CP-related PEI vs no PERT treatment was estimated using a decision analysis based on clinical data from relevant studies. The model horizon was 20 years. Main outcomes included the percentage of patients with controlled PEI, survival, total medical costs, number of quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). All costs were analysed from the Polish payer perspective.Results:The model included clinical data from 176 patients treated in five pancreatin MMS randomized trials. Treatment with pancreatin MMS resulted in a considerably higher proportion of patients with controlled PEI compared to those not treated with any PERT. Over a horizon of 20 years, the total treatment cost and the ICER for pancreatin MMS was €8223 and €6312 per QALY, respectively.Limitations:Important limitations include the lack of long-term and comparative clinical data available. The use of ‘no PERT treatment’ as a comparator against pancreatin MMS treatment may not accurately reflect current practice in Poland.Conclusions:Treatment of CP-related PEI with pancreatin MMS is cost-effective from a Polish payer perspective, with an ICER below the accepted ‘willingness to pay’ threshold of 3-times gross domestic product (GDP) per capita. These results are likely to apply to other European countries.

A blinded randomised controlled trial to determine the effect of enteric coating on enzyme treatment for canine exocrine pancreatic insufficiency

BackgroundEnzyme treatment is the mainstay for management of exocrine pancreatic insufficiency (EPI) in dogs. ‘Enteric-coated’ preparations have been developed to protect the enzyme from degradation in the stomach, but their efficacy has not been critically evaluated. The hypothesis of the current study was that enteric coating would have no effect on the efficacy of pancreatic enzyme treatment for dogs with EPI.Thirty-eight client-owned dogs with naturally occurring EPI were included in this multicentre, blinded, randomised controlled trial. Dogs received either an enteric-coated enzyme preparation (test treatment) or an identical preparation without the enteric coating (control treatment) over a period of 56 days.ResultsThere were no significant differences in either signalment or cobalamin status (where cobalamin deficient or not) between the dogs on the test and control treatments. Body weight and body condition score increased in both groups during the trial (P<0.001) but the magnitude of increase was greater for the test treatment compared with the control treatment (P<0.001). By day 56, mean body weight increase was 17% (95% confidence interval 11-23%) in the test treatment group and 9% (95% confidence interval 4-15%) in the control treatment group. The dose of enzyme required increased over time (P<0.001) but there was no significant difference between treatments at any time point (P=0.225). Clinical disease severity score decreased over time for both groups (P=0.011) and no difference was noted between groups (P=0.869). No significant adverse effects were reported, for either treatment, for the duration of the trial.ConclusionsEnteric coating a pancreatic enzyme treatment improves response in canine EPI.

Management of pancreatic exocrine insufficiency: Australasian Pancreatic Club recommendations

Pancreatic exocrine insufficiency (PEI) occurs when the amounts of enzymes secreted into the duodenum in response to a meal are insufficient to maintain normal digestive processes. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function is commonly assessed by conducting a 3-day faecal fat test and by measuring levels of faecal elastase-1 and serum trypsinogen. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. In adults, the initial recommended dose of pancreatic enzymes is 25,000 units of lipase per meal, titrating up to a maximum of 80,000 units of lipase per meal. In infants and children, the initial recommended dose of pancreatic enzymes is 500 units of lipase per gram of dietary fat; the maximum daily dose should not exceed 10,000 units of lipase per kilogram of bodyweight. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid-suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high-dose enzyme therapy. A dietitian experienced in treating PEI should be involved in patient management. Dietary fat restriction is not recommended for patients with PEI. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Medium-chain triglycerides do not provide any clear nutritional advantage over long-chain triglycerides, but can be trialled in patients who fail to gain or to maintain adequate bodyweight in order to increase energy intake.

The effectiveness of enzymatic replacement therapy measured by turbidimetry and the lipaemic index in exocrine pancreatic insufficient young, growing pigs, fed a high-fat diet

Conventionally, the management of exocrine pancreatic insufficiency (EPI) involves the consumption of a specific diet as well as the replacement of pancreatic enzymes, the effectiveness of which is usually measured by a classical method of blood analyses of non-esterified fatty acids (NEFA) and triglycerides (TG). Dietary supplementation with a pancreatic enzyme preparation (PEP), in conjunction with a high-fat diet, on growth performance, digestibility and absorption (analysed using turbidimetry) of dietary fat in pigs with EPI was investigated. EPI was developed by surgical ligation of the pancreatic duct of six male pigs, 6 weeks of age. The pigs were fed a high fat diet (twice daily). A PEP containing 1800 mg entero-coated pancreatin was included in the high fat meals. Blood, urine and faecal samples were collected. The urine and faeces were analysed for dry matter, crude protein and fat content. The lipaemic index and plasma lipid profiles were assessed. EPI completely stopped growth of the pigs. Treatment with PEP significantly increased (P<0.05) growth and body mass as well as the digestibility of dry matter and crude protein. PEP significantly improved the co-efficient of fat absorption, the lipaemic index (measured by turbidimetry methods) and caused significant changes in plasma nonesterified fatty acids and triglyceride concentrations. The short term enzymatic replacement therapy together with a high fat meal has immediate beneficial effects on diet digestibility and on the growth retardation observed in EPI pigs. The turbidimetry method used to measure lipaemic index is a reliable, quick and efficient technique in measuring plasma lipid profiles and thus a good tool for assessing fat absorption.