Pancreatic Function Test Research Articles

Correlation of MRCP quantification (MRCPQ) with conventional non-invasive pancreatic exocrine function tests

To correlate MRCP quantification (MRCPQ) of pancreatic fluid output following secretin with steatorrhoea, urinary pancreo-lauryl (PL) or fecal elastase 1 (FE1) tests. Sixty-one patients, 36 male, median age 51 years (23-78) with known or suspected pancreatic disease who had undergone both MRCPQ and FE1 or PL were included. Twenty-nine patients had chronic pancreatitis, five acute pancreatitis, seven normal, five pancreas divisum, four pancreatic atrophy, three pancreatic duct obstruction, two post-surgical and six miscellaneous diagnoses. Clinical assessment of steatorrhoea was available in 29. MRCP was performed before and at 2 min intervals after 0.1 ml/kg IV Secretin. Changes in signal intensity in the imaging volume were plotted against time and the flow rate derived from the gradient. Scatter plots, Pearson correlation coefficient, and the Fisher Exact test were performed. MRCPQ was significantly different (p = 0.012) between those with/without steatorrhoea; mean +/- SD (95% CI) were 4.0 +/- 1.5 (3.1:4.9, n = 16) and 6.3 +/- 2.9 (4.7:7.8, n = 13). Fifty-one paired FE1-MRCPQ and 24 PL-MRCPQ data sets were analysed. Both the Pearson correlation coefficient (FE1 p = 0.001 and %TK p = 0.003) and the Fisher Exact test were significant (FE1 p = 0.016 and %T/K 0.03). MRCPQ correlated with steatorrhoea, PL and FE1.

Endoscopic Cystostomy for Posttraumatic Pseudocyst in Children

Endoscopic Cystostomy for Posttraumatic Pseudocyst in Children

Physiological Evaluation of the Severity of Pancreatic Exocrine Dysfunction During Endoscopy

Despite the advances in pancreatic imaging, there continues to be a need to measure exocrine function to determine which patient requires enzyme supplementation. To evaluate the potential use of a rapid endoscopic test that can be conducted by nonacademic centers, we investigated whether concentration of trypsin in food-stimulated secretion is related to trypsin synthesis and secretion. Subjects include 22 chronic pancreatitis patients (10 mild, 5 moderate, and 7 severe radiological disease) and 11 healthy controls. During upper gastrointestinal endoscopy, pancreatic secretion was stimulated by a single 30-mL duodenal injection of an enteral diet, followed 5 minutes later by periampullary juice aspiration (endoscopic pancreatic function test [ePFT]). This was followed by a conventional 2-hour marker-perfusion diet-stimulated pancreatic trypsin secretion and synthesis study (2-hour PFT [2hPFT]). Severity of radiological disease was associated with a progressive loss of enzyme secretion measured by the 2hPFT. The endoscopic PFT correlated positively with 2hPFT (r2 = 0.48; P < 0.0001) and an activity of less than 5% of the average normal had a 96% specificity and 75% sensitivity for the detection of pancreatic insufficiency as defined by a loss of greater than 90% of pancreatic secretion. The diagnostic power of endoscopy may be enhanced by the collection of a pancreatic juice sample after enteral feed stimulation because measurement of the trypsin content will identify chronic pancreatitis patients who will be benefited by enzyme supplementation.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for diagnosis of chronic pancreatitis

The diagnosis of chronic pancreatitis is based on altered pancreatic morphology and function. A spectrum of disease exists, and milder forms of disease may be missed by CT but demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). The accuracy of ERCP and EUS for diagnosis of "minimal change" or "early" chronic pancreatitis is controversial, particularly when the results from these imaging procedures are discordant with each other or with tests of pancreatic function; in some cases ERCP and EUS should be considered indeterminate for diagnosis. This review discusses recent data concerning the accuracy of ERCP and EUS for diagnosis of chronic pancreatitis, the use of EUS fine-needle aspiration for differential diagnosis of pancreatic masses, and the use of EUS and EUS-guided TruCut biopsy for diagnosis of autoimmune pancreatitis.

Nutritional management of cystic fibrosis patients

We critique recent advances in nutritional care of patients with cystic fibrosis focusing on our understanding of the role of fecal elastase as a pancreatic function test, enzyme replacement therapy and bone health. Fecal elastase measured by the monoclonal antibody method is a useful screening test for delineating cystic fibrosis patients with pancreatic insufficiency (needing enzyme replacement therapy) from those with pancreatic sufficiency. Cutoff levels, however, have not been clearly defined, particularly in infancy. Newer enzyme products that attempt to improve the intralumenal intestinal pH with bicarbonate or using a combination of unprotected and enteric coated products fail to completely correct nutrient maldigestion. Compromised bone health in cystic fibrosis patients may be due to multiple factors including calcium, vitamin D, and vitamin K deficiencies and lung inflammation. Current recommendations for treatment of bone health in cystic fibrosis are not evidence-based. Fecal elastase is a useful marker of pancreatic function but limitations for this test exist. The presence of an acidic intestinal milieu and hitherto poorly defined intestinal factors may contribute to the failure of current enzyme preparations to correct nutrient assimilation in cystic fibrosis. The many factors that contribute to bone health must be evaluated when developing treatment strategies.

Intraductal Secretin Stimulation Test: What Is the Proper Collection Time?

Pancreatic function tests are helpful methods to establish or exclude a diagnosis of chronic pancreatitis (CP). Many studies confirm the clinical utility of the intraductal secretin test (IDST), and that the most discriminatory parameters used are secretory flow rate (SFR) and bicarbonate concentration (BC)∗. Forty-five minutes (min) IDST collection time was recommended by some investigators. A shorter collection time has been proposed to increase the practicality of the IDST, but the precise time has been not well defined. The aim of our study is to establish the IDST proper collection time. Method: The results of 68 IDSTs done in our center were evaluated. Pure pancreatic juice (PPJ) was collected after an IV injection of 16 μg of synthetic secretin (SecreFlo, ChiRhoClin, Inc, Burtonsville). The first 5-min collection was discarded and the PPJ was then collected at 5 minutes intervals up to 45 min. A triple lumen manometry catheter was used to collect the PPJ. The parameters evaluated were the peak SFR, time of peak SFR, max BC (measured by back titration), and time of max BC. Normal SFR was defined as ≥3 ml/min and normal BC was defined as ≥105 mEq/L∗. Results: Max BC was reached by the collection time of 6-10 min in 11 patients (pts) (16%), by 11-15 min in 43 pts (63%), by 16-20 min in 60 pts (88%), by 21-25 min in 65 pts (95%) and by 26-30 min in all pts (100%). Peak SFR was reached by the collection time 6-10 min in 24 pts (36%), by 11-15 min in 37 pts (55%), by 16-20 min in 52 pts (77%), by 21-25 min in 57 pts (84%) and by 26-30 min in all pts (100%). However, all pts reached their final diagnostic classification (normal versus CP) for both the SFR and BC by 20 min collection period [i.e. either the SFR was low (<3 ml/min) from the beginning and remained low throughout the collection time, or normal (≥3 ml/min) within the first 20 min collection time; the same was seen for BC]. Further collection time did not change their final diagnosis. Based on BC criteria, 15 pts had CP (22%). Based on SFR criteria, 31 pts had CP (45%), by either criteria 45% had CP. Summary: The final clinical diagnosis of CP was established or excluded by the first 20 min collection period (for both SFR and BC) in all pts. Conclusions: The first 20-minute collection period during IDST was sufficient time for diagnosing or excluding CP in all pts in this series. This data confirms prior studies showing adequacy of 15-20 min IDST collection time.∗∗Sivak M. Gastroenterologic Endoscopy. 2nd W.B. Saunders Company, 2000:1116-1118.

Comparison of Endoscopic Ultrasound Chronic Pancreatitis Criteria to the Endoscopic Secretin-Stimulated Pancreatic Function Test

Endosonography (EUS) has emerged as a major diagnostic tool in pancreatic imaging. Direct tests of pancreatic function are considered the most sensitive and accurate method to establish a diagnosis of chronic pancreatitis (CP), particularly when imaging studies are inconclusive. The aim of this study was to compare current EUS CP criteria with our newly described, purely endoscopic, secretin-stimulated pancreatic function test (ePFT). Fifty-six patients (25 male, mean age = 44 years) who were referred for evaluation/treatment of chronic abdominal pain with or without CP underwent both EUS and ePFT. The EUS protocol included the following: (1) EUS images were obtained in a standardized fashion from both gastric and duodenal stations, and (2) EUS images were scored independently by one of three therapeutic endoscopists for 0--9 parenchymal/ductal criteria as follows: 0-3 = normal, 4-5 = equivocal, >/=6 = definite CP. Endoscopic pancreatic function test (ePFT) protocol included the following: (1) upper endoscopy, (2) intravenous synthetic porcine secretin (0.2 mcg/kg, ChiRhoClin, Inc.) after test dose, (3) duodenal fluid aspirated every 15 min for 1 h, and (4) autoanalyzed for [HCO3] cutpoint of 80 mEq/L. According to EUS, 33 were normal, 13 equivocal, and 10 definite for CP. The mean peak [HCO3 -] range (in mEq/L) for each group was normal CP (83.7, range = 58-118), equivocal CP (68, range = 30-88), and definite CP (56, range=19-84). Using a peak [HCO3 -] of </=80 mEq/L as diagnostic for CP, the referent values (sensitivity%/specificity%) for EUS in the diagnosis of CP were normal (60/72), equivocal (36/94), and definite (26/100), respectively. An EUS score or greater than 5 had the best specificity (100%) and negative predictive value (100%). We conclude that endoscopic pancreatic function testing with secretin confirms that as EUS score increases, the peak pancreatic fluid bicarbonate decreases. We also conclude that EUS has excellent statistical inferences for diagnosing CP when at least 6 or more criteria are present. EUS as a screening test in patients with chronic abdominal pain and equivocal imaging studies may be of limited value.

Comparison of the Secretin Stimulated Endoscopic Pancreatic Function Test to Retrograde Pancreatogram

Duodenal intubation techniques with hormonal stimulation are the most accurate at diagnosing early chronic pancreatitis. Pancreatography (ERCP), the radiologic gold standard, can accurately diagnose chronic pancreatitis, but is expensive, may expose the patient to radiation, and/or induce acute pancreatitis. We have developed an endoscopic pancreatic function test (ePFT) that can assess pancreatic secretory function during upper endoscopy. We sought to determine the accuracy of the endoscopic secretin pancreatic function test using retrograde pancreatogram as the gold standard. Patients referred to The Pancreas Clinic for the evaluation and management of chronic abdominal pain and suspected chronic pancreatitis who had both endoscopic function testing and pancreatic duct imaging (ERCP) were studied. Pancreatograms were scored for duct morphologic characteristics (Cambridge classification) and compared to peak bicarbonate concentration in secretin stimulated duodenal juice. The ePFT consisted of a test dose of intravenous synthetic porcine secretin (0.2 microg), full-dose intravenous secretin (0.2 microg/kg) over 1 min, (3) upper endoscopy with moderate sedation, (4) gastric fluid aspirated and discarded, (5) duodenal fluid aspirations at 0, 15, 45, and 60 min after secretin injection, and (6) fluid analysis with lab autoanalyzer for bicarbonate concentration (historical normal cutpoint >80 mEq/L). Thirty-six patients had both the endoscopic function test and ERCP. Seventeen had chronic abdominal pain with normal pancreatograms, and nineteen had chronic abdominal pain with abnormal pancreatograms, consistent with chronic pancreatitis. The sensitivity and specificity of the endoscopic function test were 94% and 79%, respectively. The positive and negative predictive values were 80% and 94%, respectively. Overall agreement with ERCP was 86%. The ePFT with synthetic porcine secretin has excellent correlation with abnormal pancreatogram (chronic pancreatitis). Furthermore, a normal bicarbonate (negative function test, HCO(3) >80 mEq/L) essentially rules out chronic pancreatitis as a diagnostic cause of abdominal pain. Endoscopic pancreatic function testing may decrease the need for ERCP in patients with chronic abdominal pain.

The Efficiency of Endoscopic Pancreatic Function Testing Is Optimized Using Duodenal Aspirates at 30 and 45 Minutes After Intravenous Secretin

The endoscopic secretin test (ePFT) takes an hour to perform, limiting its practicality for routine use. We sought to determine which timed endoscopic collections best predict the peak bicarbonate concentration from full hour-long test. A cross-sectional study was performed of all ePFTs performed at our institution from 2000 to 2004. We compared 7 theoretical shortened tests [4-single collections (15, 30, 45, or 60 minutes after secretin) and 3-dual collections (15/30, 30/45, 45/60 minutes after secretin)] to the full test and to each other using multivariate linear and Deming regression models. The bicarbonate results of 240 ePFTs were analyzed. The dual 30/45-minute collection was the optimal method based on the closest agreement with the full test (94%). Deming regression reveals the 30/45 estimate to be the best combination from an analytic perspective, owing to its lack of significant proportional bias and minimal constant bias (5.1 mEq/L) as compared to the reference test. Use of the 30/45 method with the adjusted cutpoint 75 mEq/L produces very good specificity (93%) for ruling in exocrine insufficiency. A dual timed aspiration at 30 and 45 minutes can be used to screen for pancreatic exocrine insufficiency in patients with abdominal pain, simplifying the use of the ePFT in clinical practice.

PANCREATIC DUCTAL SONOGRAPHIC ABNORMALITIES ARE ASSOCIATED WITH IMPAIRED DUCT-CELL EXOCRINE FUNCTION

Background: Few studies have compared endoscopic ultrasound (EUS) with pancreatic function testing (PFT). Therefore, the significance of specific EUS criteria as predictors of exocrine insufficiency is poorly understood. Secretin PFT quantifies bicarbonate secretion as a reflection of duct-cell function (DCF). Aim: Assess DCF in pts with each of 9 EUS criteria. Methods: 198 consecutive pts who underwent both EUS and secretin endoscopic PFT included. Abnormal DCF was defined as a peak bicarbonate concentration <80 mEq/L. Chi Square tests were used to assess proportions. Results: 95/198 had abnormal DCF. Abnormal DCF was most common in patients with cysts (85%), side-branch ectasia (83%), main duct irregularity (79%), and main duct dilation (72%) (Table). Abnormal DCF was least common in patients with hyperechoic duct walls (46%), foci (51%), and strands (51%). Abnormal DCF was observed in only 69% of patients with calcifications.TableConclusions: 1. Duct abnormalities (side-branch ectasia, main-duct irregularity, and dilation) and cysts are significantly associated with impaired DCF. 2. Parenchymal findings (hyperechoic foci, strands, calcifications) are not significantly associated with impaired DCF. Implication: Comparison of EUS with the cholecystokinin PFT to measure acinar-cell function (enzyme-secretory capacity) may establish the functional importance of parenchymal abnormalities.

DETERMINATION OF THE DIAGNOSTIC ACCURACY OF SERUM TRYPSINOGEN AS A SCREENING TEST FOR THE EVALUATION OF PANCREAS EXOCRINE INSUFFICIENCY

Background: The diagnosis of early pancreas exocrine insufficiency remains difficult to determine. The validity and clinical efficacy of current serologic and radiologic studies have not been determined from a gold standard. For example, serum trypsinogen is a commonly used serologic marker to screen for pancreatic disease by non-gastroenterologist. The endoscopic pancreatic function test affords clinical investigators a less cumbersome, "non-histologic" gold standard for comparison studies to determine diagnostic accuracy of screening tests. Aim: To determine the accuracy of serum trypsinogen by comparison to the "gold standard" synthetic secretin stimulation test Methods: The Pancreas Clinic database was queried for patients with serum trypsinogen and 1 hour pancreatic function test studies. Serum trypsinogen was measured as trypsin-like immunoreactivity (abnormal: ≤ 40 ng/mL, normal: > 40 ng/ml) Peak duodenal fluid bicarbonate was measured with an autoanlyzer after synthetic secretin stimulation. (abnormal: ≤ 80 meq/L, normal: > 80meq/L). Data analysis: Microsoft Excel statistical software package. Results: A total of 48 patients were identified: 20 males, mean age 46 years. A 2 × 2 table was constructed to determine the validity and clinical efficacy of serum trypsinogen when compared to peak bicarbonate concentration. There were a significant number of false negatives (n = 15) and false positives (n = 6) which greatly effected the validity of the test. Sensitivity and specificity were 53% and 63%, respectively. Furthermore, the clinical efficacy was also poor, with positive and negative predictive values of 74% and 40, respectively.Table 1: 2×2 Table - Trypsinogen versus BicarbonateConclusions: 1) Accuracy of serum trypsinogen for pancreas exocrine insufficiency is poor. 2) Serum trypsinogen should not be used to screen for exocrine pancreas function. Clinical Implication: The endoscopic pancreatic function test can be used by clinical investigators to determine the validity and clinical efficacy of commonly used diagnostic procedures in the evaluation of pancreas exocrine insufficiency.

13C-MIXED TRIGLYCERIDE BREATH TEST (13C-MTG) DEMONSTRATES SUPERIORITY OF ENTERIC COATED MONOLITHIC ENZYME PREPARATION OVER PLACEBO

Background: Currently, no non-invasive pancreatic function tests are broadly available apart from fecal elastase-1 (El-1) which has limited sensitivity and specificity. We applied the 13C-MTG for measurement of the effects of a monolithic enteric coated enzyme preparation (i.e. single unit, no microgranules) on lipid digestion and absorption. Due to dissociation between gastric emptying of meal nutrients and enzyme supplements, these older preparations are assumed to be virtually ineffective and potential effects can only be shown by sensitive methods. Methods: 20 patients with documented chronic pancreatitis (19 males, 1 female, age: 52±2 yrs, BMI: 23.1±0.7 kg/m2, El-1: 42.1±8.2 μg/g, mean-SEM) were included in 3 study centres. On two study days which were 3-14 days apart and each preceeded by at least 3 days without intake of enzyme supplements, patients received a monolithic enteric-coated pancreatin preparation (40,000 U of lipase) or placebo together with a standardised test meal containing 250 mg of 13C-mixed triglycerides according to a randomised, double blind, cross-over study design. Differences between cumulative 13C-exhalation were evaluated as markers of lipid digestion during treatment with verum and placebo. Results: (mean±SEM, statistics: ANOVA): One patient had to be excluded because of major protocol violations; 6 patients were excluded from the per protocol analysis because of normal intestinal lipolysis during placebo treatment despite decreased El-1. In the remaining 13 patients, mean cumulative 13C-exhalation over 6 and 8 hours was markedly higher following treatment with verum compared to placebo (6 h: 11±2 vs. 5±1% of dose, p = 0.035; 8 h: 18±3 vs. 9±1% of dose, p = 0.015). Conclusions: In contrast to current belief, single administration of a monolithic enteric-coated pancreatin preparation containing 40,000 U of lipase significantly improves lipid digestion and absorption compared to placebo in patients with severe pancreatic exocrine insufficiency. Sensitivity of the 13C-MTG allows detection of these effects and, thus, this non-invasive test may expand our diagnostic armamentarium in pancreatic exocrine insufficiency.

Serial Contrast-Enhanced MRI of the Pancreas: Correlation With Secretin-Stimulated Endoscopic Pancreatic Function Test

The purpose of this study was to determine the relationship between the pancreatic enhancement on serial contrast-enhanced MRI (CEMRI) and pancreatic exocrine function using the secretin-stimulated endoscopic pancreatic function test (ePFT). A total of 30 patients with clinical symptoms consistent with chronic pancreatitis underwent CEMRI of the abdomen and ePFT within a 1- to 4-week interval. CEMRI was performed in arterial, early venous, and late venous phases. Secretin ePFT was performed with the measurement of HCO(3) concentration from the duodenal aspirates after secretin stimulation. Contrast enhancement ratio of the arterial phase to early venous phase was measured on CEMRI (SIRa/SIRv). A three-point evaluation system was used for grading the HCO(3) concentration and the enhancement ratio on MRI. For the significance of correlation, kappa statistics was used. Sensitivity and specificity of CEMRI was determined for the diagnosis of early chronic pancreatitis accepting ePFT as a reference. Twenty patients had identical scores on both secretin ePFT and CEMRI. Ten patients revealed discrepancy in scores. Kappa statistics revealed moderate agreement between MRI and ePFT (kappa = 0.44). Sensitivity and specificity values for the diagnosis of pancreatitis were 82% and 57%, respectively. Positive predictive value was 56%, and negative predictive value was 86%. The results of our data indicate that serial CEMRI is an appropriate imaging technique to rule out early chronic pancreatitis. However, secretin-stimulated imaging or ePFT may still be needed for the definite diagnosis of pancreatic exocrine dysfunction.

The endoscopic pancreatic exocrine function test (ePFT): Can it be the new “gold standard”?

Stevens T, Conwell DL, Zuccaro G Jr, Van Lente F, Purich E, Khandwala F, Fein S. (Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio). A randomized crossover study of secretin-stimulated endoscopic and Dreiling tube pancreatic function test methods in healthy subjects. Am J Gastroenterol 2006;101:351–355.

Does Secretin-stimulated MRCP Predict Exocrine Pancreatic Insufficiency?

Data on magnetic resonance cholangiopancreatography with secretin stimulation (S-MRCP) for the assessment of exocrine pancreatic insufficiency (EPI) are limited. We compared pancreatic function tests with the findings of S-MRCP in patients with chronic pancreatitis (CP) and disease controls. S-MRCP was performed in 23 patients (18 CP, 5 disease controls). MRCP images were analyzed for secretin-induced duodenal liquid filling (0=no filling; 1=duodenal bulb; 2=up to lower flexure; 3=beyond lower flexure). EPI was evaluated by fecal elastase, fecal fat concentration, and a 13C mixed chain triglyceride breath test. Clinically relevant EPI was stated if 2 of 3 tests were pathologic. EPI was diagnosed in 10 of 18 patients with CP. Patients without EPI showed either grade 2 (n=4) or grade 3 (n=9) duodenal filling, whereas only 1/10 patients with EPI showed grade 3 duodenal filling. Sensitivity and specificity of S-MRCP for the diagnosis of EPI were 69% and 90%, respectively. Assessment of duodenal filling should be performed in patients who undergo S-MRCP for the evaluation of pancreatic morphology. However, minor degrees of duodenal filling are equivocal and require further diagnostic evaluation.

Reviews: Altered Laboratory Findings Associated with End‐Stage Renal Disease

ABSTRACTSeveral laboratory parameters can be altered in advanced renal failure. Results may be difficult to interpret and may become misleading and unreliable in such a context. On the other hand, some of the alterations may reflect real abnormalities. Thus sufficient knowledge and careful judgment are required by the clinician. We reviewed different publications related to biochemical anomalies in renal failure and report some of the main findings. The sections are divided as follows: cardiovascular risk factors and markers, inflammation markers, pancreatic and liver function tests, hormones, bone turnover indices and parathyroid hormone assays, tumor markers, carbohydrate metabolism indicators, and others. The information provided should be useful to clinicians involved in the care of renal failure patients.

A Shortened Endoscopic Pancreatic Function Test (ePFT) with the Newly Developed Synthetic Human Secretin for the Evaluation of Chronic Abdominal Pain (CAP)

Purpose: Screening pts with CAP for CP with invasive imaging can lead to iatrogenic complications. We have developed an ePFT that is safe and widely applicable. The major limitation of this procedure has been the duration of endoscopy (one hour). A shorter procedure would be desirable. Furthermore, a new FDA approved, synthetic human secretin has been developed with excellent pharmacokinetics. Null hypothesis: Peak bicarbonates are equal in CAP normal imaging (CAP_NML) versus CAP abnormal imaging (CAP_ABNML). Alternative hypothesis: Peak bicarbonates are different. Aims: To determine if a shortened ePFT with synthetic human secretin can distinguish between CAP_NML and CAP_ABNML. Methods: The Pancreas Disease Database was reviewed for a 12 month period for pts seen for CAP. Pts were referred with CAP and suspected CP. All pts underwent function testing and abdominal imaging (CT ± MRI). Pts were classified into two groups: chronic abdominal pain with normal imaging (CAP_NML) and CAP with abnormal/equivocal imaging (CAP_ABNML). Shortened 30 min ePFT Protocol: 1) IV human secretin pre-procedure area 2) EGD with 1–3 min duodenal fluid aspiration @ 3 separate collection times: 30, 45 and 60 min after secretin stimulation. Fluid autoanalyzed for bicarbonate concentration. (normal: bicarbonate > 80 meq/L). Results: 44 pts were identified for this comparison analysis: 35-CAP_NML and 9- CAP_ABNML. 94.2% (33/35) pts with CAP_NML had peak bicarbonate levels > 80 meq/L. 63% (7/9) pts with CAP_ABNML had bicarbonate levels less than 80 meq/L.The median bicarbonate for CAP_NML versus CAP_ABNML was 93 and 56 meq/L, respectively (p < 0.0004, Table). There were no complications or episodes of procedure induced pancreatitis.Table: Comparison of Peak Bicarbonate in CAP_NML and CAP_ABNML.Conclusions: A shortened ePFT with synthetic human secretin can be used to screen pts with CAP for chronic pancreatitis.

Abnormal Pancreatic Structural Changes on MRI/MRCP Consistent with Chronic Pancreatitis Can Occur with Normal Endoscopic Secretin Stimulated Pancreatic Function Testing (ePFT)

Abnormal Pancreatic Structural Changes on MRI/MRCP Consistent with Chronic Pancreatitis Can Occur with Normal Endoscopic Secretin Stimulated Pancreatic Function Testing (ePFT)

Celiac disease and chronic calcific pancreatitis with pancreas divisum

Varying degrees of exocrine pancreatic dysfunction have been reported in patients with celiac disease.1-7 Usually, the pancreatic dysfunction is mild, detectable only by sensitive pancreatic function tests, and it normalizes with the recovery of the the intestinal mucosal lesion after institution of a gluten-free diet.4 The coexistence of celiac disease and advanced pancreatic insufficiency requiring pancreatic enzyme supplementation is rare.1-6 Moreover, calcific pancreatitis along with celiac disease is also rare.

Hyperechoic Abnormalities of Pancreatic Parenchyma On EUS in Patient with Normal Pancreatic Duct On ERP: Are They True Or Fake?

Background and Aim: Traditionally, the gold standard for the diagnosis of chronic pancreatitis (CP) has been either endoscopic retrograde pancreatography (ERP) and/or pancreatic function test. Recently, endoscopic ultrasonography (EUS) is considered a useful modality for the diagnosis of CP because of its ability to place the transducer in close proximity to the pancreas. Among patients with CP, EUS may reveal abnormal parenchyma in the form of hyperechoic changes, such as echogenic strands and hyperechoic foci. However, since these findings sometimes identified in patient with normal pancreatic duct on ERP, it will be confused whether it may diagnose early CP or not. The aim of this study was to investigate the implication of hyperechoic abnormalities on EUS in normal ERP. Patients and Methods: One hundred ten patients who were undergone both EUS and ERP within 2 months were enrolled, excluding in patient with pancreatic cancer, IPMN and lower biliary ductal cancer. CP was defined using the Cambridge classification of ERP findings. On EUS images, fine-reticular pattern as normal pancreatic parenchyma, and hyperechoic foci/strand as hyperechoic abnormalities were evaluated. Results: Normal/abnormal pancreatic duct on ERP was identified in 86 (78.2%) /24 (21.8%) patients, respectively. Fine-reticular pattern on EUS was seen in 76 (76/86: 88.3%)/3 (12/24: 50%) patients who had normal/abnormal ERP (p < 0.01). On the other, in 43 patients who had no EUS abnormalities, all patients (100%) were identified fine reticular pattern. Moreover, in 22 patients who had no fine-reticular pattern on EUS, all patients (100%) were identified parenchymal abnormalities. These results strongly suggested fine-reticular pattern indicated normal pancreatic parenchyma. On the basis of above findings, EUS abnormalities on normal ERP were investigated. Hyperechoic abnormalities on EUS were seen in 46 (53.7%) patients with normal ERP. In these 46 patients, fine-reticular pattern on EUS was seen in 36 patients, and none of them have become definite CP in the follow-up period. Conclusion: Hyperechoic EUS abnormalities (foci/strands) were not necessarily mean that presence of early chronic pancreatitis. Fine-reticular pattern is useful for differentiation whether hyperechoic abnormalities are true or fake.