Pancreatic Function Test Research Articles

MRI and S‐MRCP findings in patients with suspected chronic pancreatitis: Correlation with endoscopic pancreatic function testing (ePFT)

To review magnetic resonance imaging (MRI) and secretin stimulated magnetic resonance cholangiopancreatography (S-MRCP) findings of patients with suspected chronic pancreatitis and compare them with endoscopic pancreatic function testing (ePFT). MRI and S-MRCP findings of 36 patients with clinically suspected chronic pancreatitis were reviewed. Baseline ductal changes, duodenal filling grades, and pancreatic duct caliber change (PDC) on S-MRCP, mean values of pancreatic anteroposterior (AP) diameter, signal intensity ratio (SIR) between pancreas and the spleen on T1-weighted fat saturated images, and arterial to venous (A/V) enhancement ratios were compared between groups of normal and abnormal pancreatic exocrine function determined by ePFT. All patients (n = 24) with normal ePFT (HCO(3) >80 mEq/L) had grade 3 normal duodenal filling. Patients with abnormal ePFT (HCO(3) <80 mEq/L) (n = 12) had grade 1 (n = 1) and grade 2 (n = 11) diminished duodenal filling (P < 0.0001). PDC was 1.51 in the normal ePFT group versus 1.27 in the abnormal ePFT group (P = 0.01). No significant differences were found in terms of mean pancreatic AP diameter (21.8 vs. 19.8 cm), SIR (1.59 vs. 1.44), and A/V (1.08 vs. 1.01) between groups of normal/abnormal pancreatic exocrine function. Despite discrepancies between pancreatic exocrine function and the findings on standard MRI/MRCP, the S-MRCP findings are comparable to ePFT in the evaluation of chronic pancreatitis.

Sweat chloride concentration and pancreatic function tests in patients with diffuse panbronchiolitis

Sweat chloride concentration and pancreatic function tests in patients with diffuse panbronchiolitis

Combined Endoscopic Ultrasound and Secretin Endoscopic Pancreatic Function Test in Patients Evaluated for Chronic Pancreatitis

Endoscopic ultrasound and endoscopic secretin pancreatic function test may be combined in a single endoscopic session (EUS/ePFT) to diagnose chronic pancreatitis (CP). Our primary aim was to assess the correlation and concordance of combined EUS and secretin ePFT bicarbonate results in suspected minimal change CP. Radial EUS included scoring for nine criteria (normal<4 criteria) with endoscopic collection of duodenal samples at 15, 30, and 45 min after secretin stimulation (normal peak bicarbonate>or=80 mmol/l). Three hundred and two patients completed the EUS/ePFT (252 for suspected minimal change CP, 38 for established CP, 12 for painless steatorrhea). In patients evaluated for suspected minimal change CP, a moderate negative correlation was observed between endoscopic ultrasound score and peak bicarbonate (r=-0.38, P<0.001). The EUS and ePFT results were 76% concordant and 24% discordant. The ePFT was 85% sensitive and EUS was 100% sensitive for detecting patients with established calcific CP. The EUS/ePFT diagnosed CP in two of 12 of patients evaluated for painless steatorrhea or diarrhea with weight loss. The combined EUS/ePFT is feasible and safe. There is only moderate correlation and concordance of endoscopic ultrasound and endoscopic pancreatic function test results in patients with suspected minimal change CP. The EUS and ePFT results produce complimentary functional and structural information for the evaluation of CP.

Type 2 diabetes mellitus with pancreatic β cell dysfunction in 3 horses confirmed with minimal model analysis

Type 2 diabetes mellitus (T2DM) is diagnosed rarely in equine practice although it may be under-recognised. A greater awareness of the condition and therapeutic considerations would be to the benefit of such cases presenting in practice. More investigation into the pharmacological management of these cases is needed. Three cases of diabetes mellitus were investigated using a specific test for insulin sensitivity and pancreatic beta cell function in order to define accurately and characterise the existence of T2DM in all 3 subjects. The insulin-modified frequently sampled i.v. glucose tolerance test was performed in each case and the data so obtained were subject to minimal model analysis of insulin-glucose dynamics. Cases were then monitored following treatment using a combination of dietary modification, metformin, glibenclamide and pergolide. Marked insulin resistance was identified in each case and, furthermore, severe pancreatic beta cell dysfunction was present therefore classifying each case as end stage T2DM. Treatment was nevertheless associated with restoration of normoglycaemia in all cases. T2DM in horses may be more common than generally considered.In some cases individuals may respond to therapy aimed at restoring insulin sensitivity and pancreatic function. Drugs used in other species for the treatment of T2DM have not yet been adequately tested in horses. T2DM should be considered as an important differential diagnosis in mature to elderly horses and ponies suffering from weight loss, polydipsia and polyuria. Clinicians should be encouraged to offer treatment and management advice when such cases are encountered.

Gender-Specific Reference Standards and Classification of Pancreatic Function for the Endoscopic Pancreatic Function Test (ePFT)

Gender-Specific Reference Standards and Classification of Pancreatic Function for the Endoscopic Pancreatic Function Test (ePFT)

The Endoscopic Pancreatic Function Test

Am J Gastroenterol 2009;104:2381-2383; doi:10.1038/ajg.2008.181 1Center for Pancreatic Disease, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Darwin L. Conwell, MD, MS, 75 Francis Street, Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. E-mail: [email protected]

Endoscopic Ultrasound (EUS) and Secretin Endoscopic Pancreatic Function Test (ePFT): Histopathological Correlation in Chronic Pancreatitis (CP) 2009 Presidential Poster

Endoscopic Ultrasound (EUS) and Secretin Endoscopic Pancreatic Function Test (ePFT): Histopathological Correlation in Chronic Pancreatitis (CP) 2009 Presidential Poster

Prospective comparison of radial and linear endoscopic ultrasound for diagnosis of chronic pancreatitis

Linear endoscopic ultrasonography (EUS) is currently favored by many endosonographers for the evaluation of pancreatic pathology. However, radial EUS was used in early studies validating EUS for chronic pancreatitis. Radial and linear EUS have never been compared for the diagnosis of chronic pancreatitis. The aim of this study was to compare radial and linear EUS for the diagnosis of chronic pancreatitis using the secretin-stimulated endoscopic pancreatic function test (ePFT) as the reference standard. One hundred consecutive patients evaluated for pain of possible pancreatic origin underwent combined radial EUS, linear EUS, and secretin ePFT during a single endoscopic session. EUS images were acquired on videotape and blindly scored by three reviewers. The main outcome measure was diagnostic accuracy. The accuracy of radial EUS and linear EUS (cutpoint > or = 4 criteria) was 84 % and 74 %, respectively. The statistical test for noninferiority was significant ( P < 0.001) suggesting that the accuracy of radial EUS is as good as or superior to linear EUS. The ratio of accuracy (pi (radial)/pi (linear)) was 1.14 (95 % confidence interval [CI] 0.99 to 1.28). No statistically significant differences were found between radial and linear EUS in terms of sensitivity, specificity, or overall discriminative ability (area under receiver operating characteristic curve 0.84 vs. 0.76, P = 0.10). Interobserver variability was similar for radial (Fleiss' kappa = 0.61, 95 %CI 0.43 to 0.79) and linear EUS (kappa = 0.50, 95 %CI 0.28 to 0.72). The accuracy of radial EUS is as good as linear EUS for the diagnosis of chronic pancreatitis.

Chronic pancreatitis

We review important new clinical observations in chronic pancreatitis made in the last year. Cholecystokinin-stimulated endoscopic pancreatic function testing has low specificity for diagnosis of early chronic pancreatitis, likely because of correctable technical limitations or failure to exclude confounding diseases. Fecal elastase 1 is a poor test for diagnosing pancreatic malabsorption. A 2-week trial of corticosteroids may differentiate autoimmune pancreatitis (AIP) from pancreatic cancer in select patients. A genetic screen may help to predict relapse of AIP. Repeated, 6-month visits to counsel against alcohol use may reduce recurrent attacks of alcoholic pancreatitis. A five-component antioxidant cocktail may reduce the frequency of pain in chronic pancreatitis by 1.5 days per month. Researchers this last year have further characterized clinical aspects of chronic pancreatitis that may lead to improved detection of early chronic pancreatitis and AIP, risk stratification and application of risk-lowering strategies to prevent relapses in AIP or the development of recurrent (and possibly chronic) alcoholic pancreatitis and new evidence that antioxidants may have a modest effect on reducing the dominant symptom in chronic pancreatitis, abdominal pain.

Tests of pancreatic exocrine function – Clinical significance in pancreatic and non-pancreatic disorders

The pancreas functions as the main factory for digestive enzymes and therefore enables food utilisation. Pancreatic exocrine insufficiency, partial or complete loss of digestive enzyme synthesis, occurs primarily in disorders directly affecting pancreatic tissue integrity. However, other disorders of the gastrointestinal tract, such as coeliac disease, inflammatory bowel disease, Zollinger-Ellison syndrome or gastric resection can either mimic or cause pancreatic exocrine insufficiency. The overt clinical symptoms of pancreatic exocrine insufficiency are steatorrhoea and maldigestion, which frequently become apparent in advanced stages. Several direct and indirect function tests are available for assessment of pancreatic function but until today diagnosis of excretory insufficiency is difficult as in mild impairment clinically available function tests show limitations of diagnostic accuracy. This review focuses on diagnosis of pancreatic exocrine insufficiency in pancreatic and non-pancreatic disorders.

M1281 Evaluation of a New Endoscopic Pancreatic Function Test (ePFT) Technique Using Combined Secretin and Cholecystokinin (CCK) Stimulation

M1281 Evaluation of a New Endoscopic Pancreatic Function Test (ePFT) Technique Using Combined Secretin and Cholecystokinin (CCK) Stimulation

Comparison of the Accuracy of Standard and Rosemont Endoscopic Ultrasound (EUS) Scoring for the Diagnosis of Chronic Pancreatitis (CP)

Introduction: The Rosemont classification has been developed to improve the EUS diagnosis of CP. The accuracy of Rosemont scoring compared with standard scoring is not known. Aim: To compare the ability of Rosemont and standard scoring to accurately classify patients with and without chronic pancreatitis (CP). Methods: EUS videos were independently read on 2 occasions by 14 experts: First, the videos were read using standard scoring (9 criteria). Second, after viewing a presentation of the Rosemont Classification, the same experts re-read the videos using Rosemont scoring. The standard and Rosemont interpretations were compared with a composite reference standard, based on risk factors (RF, acute pancreatitis, alcohol, SOD, pancreas divisum, high triglycerides, and genetic mutations), secretin pancreatic function test (PFT) results, and CT findings. The videos were assigned in 4 groups: 1. No CP (n=3): No pain, no RF, normal CT, 2. CP unlikely (n=11): Pain, no RF, nl CT, nl PFT, 3. Minimal change CP (n=4): Pain, RF present, normal CT, abnl PFT, 4. Definite CP (n=13): diagnostic CT (calcifications, duct dilation, atrophy). Results: 434 interpretations were included (14 experts x 31 videos). Two analyses were performed: The first analysis included pts with definite absence or presence of CP (groups 1 and 4): Standard scoring correctly classified group 1 pts as "normal" (<3 criteria) in 27/42 interpretations and "indeterminate" (3 or 4 criteria) in 13/42 (total 96%). Rosemont scoring correctly classified pts as "normal" in 28 and "indeterminate" in 12 (total 96%). Standard scoring correctly classified pts in group 4 as "abnormal" (≥5 criteria) in 138/182 interpretations (76%). Rosemont correctly classified these pts as "most consistent" in 113 and "suggestive" in 39 (total 83%). The second analysis included pts in all 4 groups: Standard scoring classified pts in group 1 and 2 as "normal" 108/196 times and "indeterminate" 75/196 times (total 93%). Rosemont scoring classified pts as "normal" 133 times and "indeterminate" 47 times (total 92%). Standard scoring classified pts in groups 3 and 4 as abnormal 156/238 times (66%). Rosemont classified these pts as "most consistent" 129 times and "suggestive" 47 times (total 74%). Conclusions: 1. Both scoring systems correctly classify patients without CP as "normal" or "indeterminate" in more than 90% of interpretations (high specificity for both). 2. Rosemont correctly classified patients with CP slightly more often than standard scoring. 3. The performance of both scoring systems decrease when patients with suspected minimal change CP are included.

The Combined Endoscopic Ultrasound and Secretin Endoscopic Pancreatic Function Test (EUS/PFT) Influences Diagnosis and Management of Chronic Pancreatitis

The Combined Endoscopic Ultrasound and Secretin Endoscopic Pancreatic Function Test (EUS/PFT) Influences Diagnosis and Management of Chronic Pancreatitis

Exocrine Pancreatic Function Testing in Patients With Cystic Fibrosis and Pancreatic Sufficiency: A Correlation Study

Most patients with cystic fibrosis (CF) have pancreatic insufficiency; however, 15% of the patients are pancreatic sufficient (PS). Several laboratory tests have been developed to distinguish between pancreatic insufficiency and PS. The gold standard to determine pancreatic function apart from direct pancreatic stimulation test is the 72-hour fecal fat excretion, expressed as coefficient of fat absorption (CFA). The aim was to test the correlation between 2 other tests, fecal elastase-1 and serum immunoreactive trypsinogen (IRT), as compared with fecal fat excretion. 21 patients with CF-PS performed the 3 tests of fecal fat excretion, fecal elastase-1, and IRT. Correlation between the tests was evaluated by the kappa statistics test, sensitivity and specificity, and positive and negative predictive values. CFA was abnormal in 5 patients, elastase was <200microg/g in 4 patients, and IRT was <20 ng/mL in 2 patients. The correlation between CFA and IRT was negative(kappa=-0.154), and between CFA and fecal elastase-1 was poor (kappa=0.213). The sensitivity, specificity, and positive and negative predictive values of IRT versus CFA were 0%, 88%, 0%, and 78%, and for fecal elastase-1 were 40%, 81%, 40%, and 81%, respectively. In CF-PS, poor correlation was found between IRT, fecal elastase-1, and CFA, therefore neither fecal elastase-1 in the stool nor IRT in the serum reaches the sensitivity or the specificity of the fecal fat excretion. Thus, fecal fat excretion is required in patients with CF for evaluation of pancreatic function.

P081 - Pancreatic insufficiency in inflammatory bowel disease. Assessment by fecal elastase-1

Clinically significant disease of the pancreas in association with inflammatory bowel disease (IBD) is unusual but reported. IBD patients have a risk of developing pancreatitis as well as pancreatic insufficiency (PI). Pancreatic elastase-1 is a human and pancreas specific enzyme that is not degraded during intestinal transport and correlates with exocrine pancreatic function test. The aim of this study was to evaluate the relationship between inflammatory bowel disease and pancreatic insufficiency as an extraintestinal manifestation of IBD.

Pancreatic Function Testing – Valuable but Underused

Dr Chris Forsmark is Chief of the Division of Gastroenterology, Hepatology and Nutrition at the University of Florida (Gainesville, Florida, USA)

Endoscopic methods for the diagnosis of chronic pancreatitis

Diagnosing chronic pancreatitis (CP) is challenging, particularly in patients with chronic abdominal pain but no obvious pancreatic insufficiency or calcifications. A variety of methods are available to diagnose and stage CP, but no gold standard currently exists, and diagnostic criteria are reliable only in severe CP. This review will focus on endoscopic methods for diagnosing early CP including endoscopic retrograde pancreatography (ERP), endoscopic ultrasound (EUS), and endoscopic pancreatic function testing (ePFT). These methods are often used in combination to diagnose or exclude CP. Although there are a variety of methods available, diagnosing mild and moderate CP remains a challenge, and further refinements of diagnostic criteria are needed to advance the field of endoscopic diagnosis of CP.

Findings on Endoscopic Retrograde Cholangiopancreatography and Pancreatic Function Test in Suspected Chronic Pancreatitis and Negative Cross-Sectional Imaging

The diagnosis of chronic pancreatitis (CP) often relies on cross-sectional imaging, which may be insensitive for early disease. The aim of this study was to assess the utility of cholecystokinin pancreatic function test and endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of CP in patients with negative or inconclusive cross-sectional imaging. Consecutive patients with suspicion of CP and negative or inconclusive cross-sectional imaging (computerized tomography and magnetic resonance cholangiopancreatography) were evaluated with cholecystokinin-stimulated endoscopic pancreatic function test (ePFT) and ERCP. The setting was a referral center for difficult diagnostic scenarios. Pancreatograms were scored according to Cambridge classification (I-IV). The ePFT was used to determine the peak lipase concentration in pancreatic juice during timed duodenal aspiration. The gold standard for the diagnosis of CP was long-term clinical follow-up evaluation. Thirty-five patients met the study criteria. The median duration of follow-up evaluation was 7 years (25th, 75th percentiles: 3, 7). Twenty-four of the 35 patients were diagnosed with CP based on long-term follow-up evaluation with a clinical composite reference standard. The sensitivity, specificity, and positive and negative predictive values were 96%, 37%, 77%, and 80% for ePFT and 71%, 91%, 94%, and 59% for ERCP, respectively. A low peak lipase concentration on the initial ePFT was associated with development of steatorrhea during the follow-up period (P = .02). ePFT is a sensitive test for the diagnosis of patients with suspicion of CP and negative or inconclusive cross-sectional imaging. ERCP has modest sensitivity and high specificity for this purpose. A normal ePFT rules out CP with a high degree of certainty. An abnormal test result requires follow-up evaluation and diagnostic confirmation.

ONSET OF EXOCRINE AND ENDOCRINE INSUFFICIENCY IN THE FOLLOW UP OF PATIENTS SUFFERING FROM AUTOIMMUNE PANCREATITIS (AIP)

Background: Autoimmune pancreatitis (AIP) is particular form of pancreatitis where an immune-mediated mechanism has been postulated. Few data are available from the literature for the long-term outcome of the disease. Aim: To investigate the onset of exocrine and endocrine insufficiency in patients suffering from AIP compared to patients suffering from other forms of chronic pancreatitis (CP). Patients and Methods: Patients suffering from AIP, from CP associated with daily alcohol intake higher than 80 g/day for at least 5 yrs (ACP), and from idiopathic CP (ICP) were enrolled. Inclusion criteria were: admission from 1996 to 2006; clinical onset of the disease within 1 year from the admission; no previous diagnosis of chronic pancreatitis. Definitive diagnosis of CP based on the basis of clinical history, radiological investigations, pancreatic function tests, histology, surgical evidence. All patients were therefore followed at least every two years. Exocrine pancreatic insufficiency was diagnosed on the basis of faecal fat output >7 g/day or faecal elastase-1 lower than 100 μg/g of stool. Endocrine pancreatic insufficiency (diabetes) was diagnosed on the basis of fasting serum glucose levels higher than 127 mg/L or abnormal oral glucose tolerance test (OGTT). Results: 70 AIP patients (46 M and 29 F, mean age 43.1 ± 15.4 yrs), 57 ACP (54 M and 3 F, mean age 43.9 ± 9.7 yrs) and 40 ICP (18 M and 22 F, mean age 43.6 ± 13 yrs) were studied. The survival curve for the onset of pancreatic exocrine and endocrine insufficiency was similar in AIP compared to ACP and ICP. Exocrine pancreatic insufficiency, but not endocrine, was significantly correlated with pancreatic surgery in AIP but not in non AIP-CP groups (p < 0.0001). Conclusions: The onset of exocrine and endocrine insufficiency in AIP is similar to that observed in ACP and ICP. This indicates that the inflammatory process in AIP is chronic, with a progressive destruction of pancreatic parenchyma, even in the absence of clinical signs and symptoms.

Pancreatic Function Testing Is Best Determined by the Extended Endoscopic Collection Technique

To evaluate whether the extended secretin-stimulated direct endoscopic pancreatic function test (ePFT) technique is superior to the rapid 15 minute secretin-stimulated ePFT in determining pancreatic exocrine function. We conducted a retrospective study of 53 patients with chronic abdominal pain and normal pancreatic imaging. These patients had ePFT testing with the following modified endoscopic collection system. Porcine synthetic or human secretin was intravenously administered 15 minutes before endoscopic duodenal aspiration. The first 10-minute collection was performed in the third portion of the duodenum. A Liguory drainage tube was placed in the third portion of the duodenum. Two additional 10-minute-period collections were obtained via the drainage tube at 30 and 45 minutes after intravenous administration of secretin. All fluid collections were analyzed for bicarbonate (HCO3) concentration. Peak HCO3 concentrations at 15 minutes occurred in 62%, at 30 to 40 minutes in 23%, and at 45 to 55 minutes in 15%. Normal concentrations of HCO3 (> or =80 mEq/L) were seen in 70%, abnormal concentration in 7%, and equivocal concentrations (60-79 mEq/L) in 23% even after 55 minutes of duodenal collections. Collections beyond 15 minutes are necessary to improve accuracy of the ePFT in determining pancreatic exocrine function.