Exocrine Pancreatic Insufficiency In Patients Research Articles

Deficiencies in specific nutrients and micronutrients in patients with exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a known complication of upper gastrointestinal surgery and has recently been associated with bariatric surgery. Our objectives were to determine the incidence of EPI in patients who underwent bariatric surgery and to identify the type of bariatric procedure most associated with EPI.This retrospective cohort analysis included patients age ≥18 years who underwent bariatric surgery at Mayo Clinic between 2010 and 2020. Patients with a history of other gastrointestinal or hepatobiliary resection, revision of bariatric surgery, EPI prior to surgery, and surgery greater than >10 years earlier were excluded from the study. Characteristics were compared between two groups based on type of bariatric surgery including Roux-en-Y gastric bypass (RYGB) or gastric sleeve (GS). Characteristics were also analyzed between patients with RYGB who developed post-operative steatorrhea and those who did not.Of 150 patients, 126 underwent RYGB while 24 patients had GS. Thirty-one (20.6%) patients developed post-operative steatorrhea and 14 (9.3%) were diagnosed with EPI. Mean pancreatic elastase level was 287 ± 156 mcg/g and fecal fat level 31 ± 22 g/d. There was a significantly higher proportion of post-operative steatorrhea in patients who underwent RYGB compared to gastric sleeve surgery (p = 0.029).The incidence of EPI after bariatric surgery in our cohort was 9.3%. Overall, patients who underwent RYGB had higher rates of EPI (10.3%) than those who had GS (4.2%). Clinicians should be aware of EPI as a cause for steatorrhea in patients who underwent bariatric surgery and consider treatment with enzyme replacement therapy.

Potential for Screening for Pancreatic Exocrine Insufficiency Using the Fecal Elastase-1 Test

The early diagnosis of pancreatic exocrine insufficiency (PEI) is hindered because many of the functional diagnostic techniques used are expensive and require specialized facilities, which prevent their widespread availability. We have reviewed current evidence in order to compare the utility of these functional diagnostic techniques with the fecal elastase-1 (FE-1) test in the following three scenarios: screening for PEI in patients presenting with symptoms suggestive of pancreatic disease, such as abdominal pain or diarrhea; determining the presence of PEI in patients with an established diagnosis of pancreatic disease, such as chronic pancreatitis or cystic fibrosis; determining exocrine status in disorders not commonly tested for PEI, but which have a known association with this disorder. Evidence suggests the FE-1 test is reliable for the evaluation of pancreatic function in many pancreatic and non-pancreatic disorders. It is non-invasive, is less time-consuming, and is unaffected by pancreatic enzyme replacement therapy. Although it cannot be considered the gold-standard method for the functional diagnosis of PEI, the advantages of the FE-1 test make it a very appropriate test for screening patients who may be at risk of this disorder.

Pancreatic Insufficiency Secondary to Tobacco Exposure: A Controlled Cross-Sectional Evaluation.

Tobacco exposure is an established risk factor for pancreatic cancer and chronic pancreatitis; however, its role in pancreatic insufficiency is not clear. This controlled, cross-sectional study examined smokers and nonsmokers with no history of pancreatic disease. Histories and validated inventories of alcohol and tobacco use were obtained, and pancreatic insufficiency was assessed using the fecal elastase-1 assay. Of 7854 patients approached, 226 were interviewed and 200 enrolled. The rates of pancreatic insufficiency [18% (18/100)] and severe pancreatic insufficiency [10% (10/100)] were significantly higher in smokers than in controls [6% (6/100), P = 0.009 and 1% (1/100), P = 0.010, respectively]. On multivariate logistic regression, the risk of pancreatic insufficiency in smokers was significantly increased [odds ratio, 4.34 (1.37-13.75); P = 0.012], controlling for alcohol use and relevant covariates. Tobacco exposure was associated with the highest odds ratio for pancreatic insufficiency. Alcohol consumption was strongly associated with tobacco exposure (P < 0.001), but not with pancreatic insufficiency by multivariate analysis (P = 0.792). This study suggests that tobacco exposure is independently associated with pancreatic exocrine insufficiency in patients without a prior diagnosis of pancreatic disease. Tobacco exposure seems to have greater detrimental effects on pancreatic function than alcohol in this population.

Secretin-stimulated MRI assessment of exocrine pancreatic function in patients with cystic fibrosis and healthy controls.

Secretin-stimulated magnetic resonance imaging (s-MRI) and pancreatic diffusion weighted imaging (DWI) are novel non-invasive imaging techniques for assessment of exocrine pancreatic insufficiency (EPI). The aim was to validate s-MRI assessed pancreatic secreted volume using novel semi-automatic quantification software, and to assess the ability of s-MRI with DWI to diagnose EPI in patients with cystic fibrosis (CF). s-MRI and DWI was performed in 19 patients with CF (median age 21years; range 16-56; eight men) and in 10 healthy controls (HC) (median age 46years; range 20-65; four men). Sequential coronal T2-weighted images covering the duodenum and small bowel and axial DWI were acquired before and 1, 5, 9, and 13min after secretin stimulation. A short endoscopic secretin test was used as reference method for EPI. CF patients with EPI had lower apparent diffusion coefficient before secretin in the pancreatic head (P<0.001) and lower secreted bowel fluid volumes (P=0.035) compared to HC and CF patients without EPI. ROC curve analyses identified that secreted fluid volume after 13min yielded the highest diagnostic accuracy for diagnosing EPI (AUC 0.93; 95% CI [0.80-1.00]). Pancreatic s-MRI is useful for the assessment of exocrine pancreatic function with high diagnostic accuracy for the diagnosis of EPI in CF.

Pancreatic exocrine insufficiency: Comparingfecal elastase 1 with 72-h stool for fecal fat estimation.

Identification of pancreatic exocrine insufficiency (PEI) is important in the management of chronic pancreatitis. The 72-h stool for fecal fat estimation (FFE) has long been considered a gold standard indirect test for the diagnosis of PEI. However, the test is cumbersome for both patients and laboratory personnel alike. In this study, we aimed to assess fecal elastase 1 (FE1) as an alternate to FFE for the diagnosis of PEI. In all, 87 consecutive patients diagnosed with chronic pancreatitis were included in this study. FFE and FE1 estimation was done for all the patients. For FE1, two cutoffs (<100 and <200μg) were selected to define pancreatic exocrine insufficiency. The sensitivity, specificity, and positive and negative predictive values for the two cutoffs were estimated. Kappa statistics was used to assess degree of agreement between both tests. All patients completed the study and were included in the analysis. The sensitivity, specificity, and positive and negative predictive value and PABAK (prevalence and bias adjusted kappa) for FE1 <100μg was 84.9, 47.6, 83.6, 50, and 0.52, respectively. For FE1 <200μg, it was 90.9, 9.5, 75.95, 25, and 0.43, respectively. FE1 is a sensitive test; however, it does not have a good agreement with FFE. FE1 may be used as screening test for PEI in patients with chronic pancreatitis.

Sarcopenia is closely associated with pancreatic exocrine insufficiency in patients with pancreatic disease

Background/ObjectivesThe loss of skeletal muscle mass (sarcopenia) is associated with the poor prognosis of pancreatic cancer. It has been reported pancreatic exocrine insufficiency (PEI) is associated with serum nutritional markers in chronic pancreatitis. However, there has been no report about the relationship between sarcopenia and PEI. The aim of this study is to determine whether body composition, including skeletal muscle (SM), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), intramuscular adipose tissue content (IMAC), and serum nutritional markers are associated with pancreatic exocrine function in patients with pancreatic disease. MethodsData were collected prospectively on 132 patients with pancreatic disease. SM, SAT, VAT and IMAC were assessed by computed tomography. Patients underwent a 13C-labeled mixed triglyceride breath test to measure pancreatic exocrine function. Serum nutritional markers were measured at the same time of 13C-labeled mixed triglyceride breath test. Patients were stratified by quartiles according to each body component, and for each component the lowest group was defined as the lowest quartile, treating men and women separately. The lowest group for SM was defined as sarcopenia. PEI was defined as a percentage 13CO2 cumulative dose at 7 h below 5%. ResultsSarcopenia was associated with PEI in both men (P < 0.001) and women (P = 0.012). Serum albumin was associated with PEI in men only (P = 0.005). Among all patients, sarcopenia (P = 0.001) and serum albumin (P = 0.058) were associated with PEI. On multivariate analysis, only sarcopenia remained independently associated with PEI (P < 0.001). ConclusionsSarcopenia is independently associated with PEI in patients with pancreatic disease.

Pancreatic exocrine insufficiency after pancreaticoduodenectomy is more prevalent with pancreaticogastrostomy than with pancreaticojejunostomy. A retrospective multicentre observational cohort study

ObjectiveRecently, pancreaticogastrostomy (PG) has attracted renewed interest as a reconstruction technique after pancreaticoduodenectomy (PD), as it may imply a lower risk of clinical pancreatic fistula than reconstruction by pancreaticojejunostomy (PJ). We hypothesise that pancreatic exocrine insufficiency (PEI) is more common during clinical follow-up after PG than it is after PJ. Research design and methodsThis study compares the prevalence of PEI in patients undergoing PD for malignancy with reconstruction by PG versus reconstruction by PJ. PEI during the first year of follow-up was defined as the intake of pancreatic enzyme replacement therapy (PERT) within one year postoperatively and/or an abnormal exocrine function test. ResultsA total of 186 patients, having undergone surgery at two university hospitals, were included in the study. PEI during the first year postoperatively was present in 75.0% of the patients with PG, compared to 45.7% with PJ (p < 0.001). Intake of PERT within one year after surgery was found to be more prevalent in the PG group, i.e. 75.8% versus 38.5% (p < 0.001). There was a trend towards more disturbed exocrine function tests after PG (p = 0.061). ConclusionsPEI is more common with PG reconstruction than with PJ reconstruction after pancreaticoduodenectomy for malignancy.

Prevalence of symptomatic pancreatic exocrine insufficiency in patients with pancreatic malignancy: nutritional intervention may improve survival

Prevalence of symptomatic pancreatic exocrine insufficiency in patients with pancreatic malignancy: nutritional intervention may improve survival

Últimos avances en pancreatitis crónica

This article summarizes some of the recent and clinically relevant advances in chronic pancreatitis. These advances mainly concern the definition of the disease, the etiological diagnosis of idiopathic disease, the correlation between fibrosis degree and pancreatic secretion in the early stages of chronic pancreatitis, the treatment of the disease and of pain, the clinical relevance of pancreatic exocrine insufficiency, and the diagnosis of autoimmune pancreatitis. A new mechanistic definition of chronic pancreatitis has been proposed. Genetic testing is mainly of help in patients with relapsing idiopathic pancreatitis. A significant correlation has been shown between the degree of pancreatic fibrosis as evaluated by elastography and pancreatic secretion of bicarbonate. New data supports the efficacy of antioxidants and simvastatin for the therapy of chronic pancreatitis. The pancreatoscopy-guided intraductal lithotripsy is an effective alternative to extracorporeal shock wave lithotripsy in patients with chronic calcifying pancreatitis. The presence of pancreatic exocrine insufficiency in patients with chronic pancreatitis is associated with a significant risk of cardiovascular events. Fine needle biopsy and contrast enhanced harmonic endoscopic ultrasonography are of help for the diagnosis of autoimmune pancreatitis and its differential diagnosis with pancreatic cancer.

PWE-155 Should Patients with Human Immunodeficiency Virus and Gastrointestinal Symptoms be Routinely Tested for Pancreatic Exocrine Insufficiency?

Introduction Diarrhoea and gastrointestinal (GI) symptoms are common symptom in patients with human immunodeficiency virus (HIV). Malabsorption secondary to pancreatic exocrine insufficiency (PEI) has been reported in patients with HIV. Treatment with pancreatic enzyme replacement therapy (PERT) improves symptoms and reduces complications of PEI (malnutrition and osteoporosis). We aimed to calculate the prevalence of PEI in patients with HIV referred to gastroenterology secondary care clinics for persistent GI symptoms. Methods All patients tested for PEI between 2010 and 2014 were identified. Presenting symptoms and presence of HIV were noted. Faecal elastase (FEL-1) was used to assess pancreatic function with FEL-1 Results 84 patents were identified during the period. 21 were identified with HIV (mean age 47.5, SD 9.8, 85.7% male). 12/21 (57.1%) HIV patients with GI symptoms had low FEL-1 compared to 8/63 (12.7%) patients with GI symptoms without HIV (p = 10/12 (83.3%) HIV patients with low FEL-1 had abdominal imaging. Pancreatic abnormalities were detected in 2/10 cases (20%). 7/8 (87.5%) controls with low FEL-1 had imaging, 3/7 (42.9%) had pancreatic abnormalities. In both groups pancreatic calcification and atrophy were detected. No malignancy was identified. 9/12 (72.5%) HIV patients and 5/8 (62.5%) controls were treated with PERT. 9/9 (100%) HIV patients reported symptomatic improvement; 4/5 (80%) controls derived benefit. Doses prescribed varied from 60,000–140,000 units/day across both groups. Conclusion Given its significantly high yield and response to treatment FEL-1 should be performed to check for PEI in patients with HIV presenting with gastrointestinal symptoms or weight loss. Disclosure of Interest None Declared

Prevalence of exocrine pancreatic insufficiency in patients with chronic pancreatitis without follow-up: Nutritional status and quality of life. PANCR-EVOL study

Prevalence of exocrine pancreatic insufficiency in patients with chronic pancreatitis without follow-up: Nutritional status and quality of life. PANCR-EVOL study

Pancreatic Exocrine Insufficiency in Patients With Pancreatic or Periampullary Cancer: A Systematic Review.

The aim of this study was to determine the prevalence of pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer, both before and after resection. Systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA guidelines). We included studies reporting on pancreatic exocrine insufficiency in patients with pancreatic or periampullary cancer. Data on patient demographics, type of pancreatic resection, diagnostic test, and occurrence of pancreatic exocrine insufficiency were extracted. Prevalence of pancreatic exocrine insufficiency was calculated before and after pancreatic resections and in patients with locally advanced pancreatic cancer. Nine observational cohort studies with 693 patients were included. Median preoperative prevalence of pancreatic exocrine insufficiency was 44% (range, 42%-47%) before pancreatoduodenectomy, 20% (range, 16%-67%) before distal pancreatectomy, 63% before total pancreatectomy, and 25% to 50% in patients with locally advanced pancreatic cancer. The median prevalence of pancreatic exocrine insufficiency at least 6 months after pancreatoduodenectomy was 74% (range, 36%-100%) and 67% to 80% after distal pancreatectomy. Pancreatic exocrine insufficiency is diagnosed in approximately half of all patients scheduled to undergo resection for pancreatic or periampullary cancer. The prevalence increases markedly after resection. These data highlight the need of pancreatic enzyme suppletion in these patients.

Development and Diagnostic Accuracy of a Breath Test for Pancreatic Exocrine Insufficiency in Chronic Pancreatitis.

To develop a ¹³C-labeled substrate breath test by defining the optimal ¹³C-labeled substrate, substrate dose, test meal, and duration of the test and evaluating its accuracy for the diagnosis of pancreatic exocrine insufficiency (PEI) in chronic pancreatitis (CP). Five consecutive prospective comparative studies in patients with known advanced CP and healthy controls were performed to develop the optimal breath test. Coefficient of fat absorption was used as the reference method. The diagnostic accuracy of the optimized breath test was prospectively further evaluated in patients with advanced CP using coefficient of fat absorption as the reference method. The optimal breath test protocol was that using 250 mg of ¹³C-mixed triglyceride as substrate together with a test meal containing 16 g of fat. Coefficient of fat absorption and breath test results correlated significantly (r = 0.736, P < 0.001). The test has sensitivity, specificity, and overall accuracy of 92.9%, 91.7%, and 92.3%, respectively, for the diagnosis of PEI. The optimized ¹³C-mixed triglyceride breath test is an accurate and simple breath test for the diagnosis of PEI in patients with CP, easily applicable to the clinical routine.

Practical approaches to diagnostic and treatment of exocrine pancreatic insufficiency in patients with diabetes mellitus

In the review the state-of-the-art practical approaches to diagnostics and treatment of exocrine pancreatic insufficiency in patients with diabetes mellitus are discussed. It has underlined potencial pathogenetic mechanisms of development of exocrine pancreatic insufficiency and its frequency in patients with diabetes mellitus, recognized using modern diagnostic methods, such as determination of fecal elastase 1 level and 13С-triglyceride breath test. In details it has discussed the principles of correction of exocrine pancreatic insufficiency, use of modern drugs and the main causes of failure of pancreatic enzyme replacement therapy in patients with diabetes mellitus.

Últimos avances en pancreatitis crónica

This article summarizes some of the recent and clinically relevant advances in chronic pancreatitis. These advances mainly concern the early diagnosis of the disease, the treatment of symptoms and complications, mainly pain and pancreatic exocrine insufficiency, and the diagnosis and therapy of autoimmune pancreatitis. The multimodal dynamic endoscopic ultrasound-guided secretin-stimulated evaluation of the pancreas provides relevant morphological and functional information for the diagnosis of chronic pancreatitis at early stages. Extracorporeal shock wave lithotripsy in patients with calcifying pancreatitis and endoscopic pancreatic stent placement are effective alternatives for pain therapy in patients with chronic pancreatitis. Presence of pancreatic exocrine insufficiency in patients with chronic pancreatitis is associated with a significantly increase of mortality rate. Despite that, pancreatic enzyme replacement therapy is not prescribed in the majority of patients with pancreatic exocrine insufficiency, or it is prescribed at a low dose. The newly developed and commercialized needles for endoscopic ultrasound-guided pancreatic biopsy are effective in retrieving appropriate tissue samples for the histological diagnosis of autoimmune pancreatitis. Maintenance therapy with azathioprine is effective and safe to prevent relapses in patients with autoimmune pancreatitis.

240 A randomized, double-blind, multicentre, multinational crossover comparison of the pancreatic enzyme product (PEP) APT-1008 (ZENPEP®) to KREON® in the treatment of exocrine pancreatic insufficiency (EPI) associated with cystic fibrosis (CF) in patients ≥12 years of age

Objectives An investigational PEP (APT-1008, to be marketed in Europe as ENZEPI®) was compared to KREON® in the treatment of EPI associated with CF. Methods This was a randomized, double-blind, active-controlled, 2-arm crossover, multinational, multicentre study comparing APT-1008 (APT) to KREON in the treatment of EPI in patients ≥12 years of age with CF. Patients were stabilized on their current PEP treatment during screening followed by randomization to APT or KREON for 28 days; then switched without washout to the opposite treatment with the same treatment schedule. The primary efficacy endpoint was the coefficient of fat absorption over 72 hours (CFA-72h) at the end of each period. Secondary endpoints included the coefficient of nitrogen absorption over 72 hours, clinical signs and symptoms of EPI, and quality of life. Safety assessments included adverse events (AE), laboratory tests and vital signs. Results 96 patients were randomized into 2 treatment sequences (APT/KREON or KREON/APT) with 83 completers comprising the efficacy population. APT demonstrated both non-inferiority and equivalence to KREON in fat absorption (LS mean CFA-72h: APT 84.08% [SE 1.109] vs. KREON 85.33% [SE 1.109]). Efficacy results of APT and KREON were generally similar for the secondary endpoints. The most frequent AEs were gastrointestinal, in 8.7% and 11.1% of patients on APT and KREON, respectively; no treatment-related serious AEs occurred. APT demonstrated safety and tolerability similar to KREON. Conclusions This study demonstrated that APT has comparable efficacy and safety to KREON in the treatment of adolescents and adult patients with EPI associated with CF.

A Look Inside the Pancreas: The Endocrine-Exocrine Cross-talk?

Though the pancreas has traditionally been considered a combination of two separate organ systems, both the exocrine and endocrine portions are structurally and functionally interrelated. Disease processes diffusely involving the pancreas can give rise to both endocrine and exocrine dysfunctions and pancreatic diseases account for less than 0.5% of all cases of diabetes. Chronic pancreatitis and fibrocalculous pancreatic diabetes are the two most common diseases of the exocrine pancreas which can give rise to beta cell dysfunction and diabetes. On the contrary, prominent changes in the structure and functions of the exocrine pancreas have been identified in a significant number of the commonly encountered forms of diabetes, where exocrine insufficiency is unexpected otherwise. A number of hypotheses have been put forward by different workers at different time frames to explain the mechanisms of exocrine pancreatic insufficiency in patients with primary pancreatic endocrine dysfunction. Though the frequency of exocrine insufficiency seems quite high in the literature, paucity of data exists on the beneficial effect of enzyme supplementation in diabetes patients with/without exocrine abnormality.

EUS elastography to predict pancreatic exocrine insufficiency in patients with chronic pancreatitis

Diagnosis of pancreatic exocrine insufficiency (PEI) is hindered by methodological difficulties of pancreatic function tests. The probability of PEI in chronic pancreatitis (CP) increases as pancreatic fibrosis develops. Pancreatic fibrosis in CP may be quantified by EUS elastography. To evaluate whether EUS-elastography can predict PEI in patients with CP. Prospective, observational study. Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain. Patients diagnosed with CP based on EUS and magnetic resonance imaging and MRCP findings. Diagnosis of PEI was based on the (13)C-mixed triglyceride breath test. EUS-elastography was performed with PENTAX echoendoscopes and Hitachi-Preirus US platform. Two areas were selected for elastographic evaluation: area A corresponds to the pancreatic parenchyma and area B to a soft peripancreatic reference area. The quotient B/A (strain ratio [SR]) was considered the elastographic result. Pancreatic SR in CP patients with and without PEI. A total of 115 patients with CP (mean age, 50.2 years, range, 21-81; 92 male) of different etiologies were included; 35 patients (30.4%) had PEI. Pancreatic SR was higher in patients with PEI (4.89; 95% confidence interval, 4.36-5.41) than in those with a normal breath test result (2.99; 95% confidence interval, 2.82-3.16) (P < .001). A direct relationship was found between the SR and the probability of PEI, which increases from 4.2% in patients with an SR less than 2.5 to 92.8% in those with an SR greater than >5.5. Single-center study. The degree of pancreatic fibrosis as measured by EUS-guided elastography allows quantification of the probability of PEI in patients with CP.

Exocrine pancreatic insufficiency in patients with pancreatic or peri-ampullary cancer: A systematic review

Exocrine pancreatic insufficiency in patients with pancreatic or peri-ampullary cancer: A systematic review

Exocrine Pancreatic Insufficiency, as Assessed by Fecal Elastase-1 Levels, in Diabetic Patients: An Estimate of Prevalence in Prospective Studies

Objective: To assess the prevalence of pancreatic exocrine insufficiency (PEI) inpatients with diabetes mellitus (DM). Design: Meta-analysis of prospective, observational studies that used fecal elastase-1 estimation to determine PEI in patients with DM. Data extraction: A total of 11 studies out of 1156 retrieved references, published between 2000 and 2013, fulfilled the inclusion criteria. The primary outcome measure was proportions of patients with DM and PEI. Results: Of the 2891 patients enrolled, 921 (31.8%) showed abnormal (i.e, 100 but <200 μg/g) in elastase-1 excretion. In 921 patients with type-1 DM, the weighted rate of PEI was 37.7% (CI 27.2-49.5), and 26.2% (CI 19.4-34.3) in 1970 type-2 diabetic patients, a difference of 11.5% (p=0.09). Of patients with abnormal (<200 μg/g) fecal elastase-1 concentrations, severe PEI was present in 53.4% (CI 45.2-61.4) of type-1, and in 50.3% (CI 40.7-59.9) of type-2 diabetic patients. Limitation: Some variables, which may influence fecal elastase-1 excretion, could not be controlled due to missing data. Conclusions: When explored by fecal elastase-1 testing, one in three patients with DM showed signs of impaired exocrine function. The results suggest that testing for PEI should be part of the diagnostic work-up of patients with DM.