Recommendations from the European guidelines for the diagnosis and therapy of pancreatic exocrine insufficiency

BACKGROUND

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below a level that allows normal digestion of nutrients. Pancreatic disease and pancreatic surgery are the main causes of PEI, but other conditions can affect the digestive function of the pancreas.

METHODS

In collaboration with European Digestive Surgery (EDS), European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society for Clinical Nutrition and Metabolism (ESPEN), European Society of Digestive Oncology (ESDO), and European Society of Primary Care Gastroenterology (ESPCG) the working group developed European guidelines for the diagnosis and therapy of PEI. United European Gastroenterology (UEG) provided both endorsement and financial support for the development of the guidelines.

RESULTS

Recommendations covered topics related to the clinical management of PEI: concept, pathogenesis, clinical relevance, general diagnostic approach, general therapeutic approach, PEI secondary to chronic pancreatitis, PEI after acute pancreatitis, PEI associated with pancreatic cancer, PEI secondary to cystic fibrosis, PEI after pancreatic surgery, PEI after esophageal, gastric, and bariatric surgery, PEI in patients with type 1 and type 2 diabetes, and PEI in other conditions.

CONCLUSIONS

The European guidelines for the diagnosis and therapy of PEI provide evidence-based recommendations concerning key aspects of the etiology, diagnosis, therapy, and follow-up, based on current available evidence. These recommendations should serve as a reference standard for existing management of PEI and as a guide for future clinical research. This article summarizes the recommendations and statements.

Gastrointestinal bleeding in long-distance runners: a systematic review

OBJECTIVE

Long-distance running has become increasingly popular in recent decades all over the world. Besides musculoskeletal injuries, gastrointestinal (GI) complaints are also very common in athletes.

METHODS

A systematic search limited to articles in the English language was performed to identify studies on GI bleeding in long-distance runners. The primary outcomes were the incidence and outcome of overt and occult GI bleeding in long-distance runners.

RESULTS

A total of 51 articles were included in the final analysis. We found 22 articles reporting 36 cases of overt GI bleeding in long-distance runners. GI bleeding has been reported as a cause of death in one patient. Conservative treatment was used in most of the cases, and surgery was performed on four patients. We found 22 articles (759 runners included) related to occult GI bleeding and seven articles (6671 runners included) related to occult GI bleeding, based on questionnaire-based surveys.

CONCLUSION

Gastrointestinal bleeding may occur in long-distance runners, highlighting the need for further investigation into this issue. It is essential to conduct well-designed prospective studies on this topic, preferably using noninvasive diagnostic methods, such as capsule panendoscopy, to improve our understanding and management of this condition.

A Case with Multiple Pathologies in the Pancreatic Head

Objectives: Autoimmune pancreatitis (AIP) type 1, paraduodenal (groove) pancreatitis, and follicular pancreatitis are rare clinical entities whose diagnosis may be challenging, given the potential imaging overlap with pancreatic cancer. Methods: We performed a retrospective analysis of the medical chart of a patient with multiple pancreas pathologies. Results: We present a case with multiple pancreas pathologies, including a poorly differentiated ductal adenocarcinoma of pancreatobiliary type, an intraductal papillary mucinous lesion (pre-existing lesion of IPMN type), and an inflammatory process with complex features, in which paraduodenal (groove) pancreatitis, follicular pancreatitis, and IgG4-related pancreatitis (AIP type 1) were also present. Conclusions: The diagnosis of AIP and paraduodenal pancreatitis is not always straightforward, and in some cases, it is not easy to differentiate them from pancreatic cancer. Surgery should be considered in patients when a suspicion of malignant/premalignant lesions cannot be excluded after a complete diagnostic work-up.

Metabolic Dysfunction-Associated Steatotic Liver Disease and Pancreatic Disease-A Population-Based Nationwide Cohort and Sibling-Controlled Study

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) has been linked to pancreatic diseases, but evidence from population-based studies with liver histology is lacking.

AIMS AND METHODS

In this population-based cohort including all Swedish adults (n = 8563) with biopsy-proven MASLD, we aimed to investigate incidences of pancreatic diseases compared with matched reference individuals from the general population (n = 38,858) and full siblings (n = 6696). Using Cox proportional hazard models, we calculated multivariable adjusted hazard ratios (aHRs) and confidence intervals (CIs).

RESULTS

We documented 359 incidents of pancreatic diseases in MASLD patients and 880 events in matched reference individuals, resulting in an incidence rate difference of 1.54 (95% CI, 1.25-1.84). The relative risk of pancreatic disease was highest in the first two years after MASLD diagnosis (aHR, 2.19 [95% CI, 1.92-2.50), but remained statistically significant increased even up to ten years [aHR, 1.60 (95% CI, 1.38-1.85)]. The most common pancreatic disease in individuals with MASLD was acute non-biliary pancreatitis (1.44 vs. 0.44 events/1000 PY), followed by chronic pancreatitis (0.54 vs. 0.12/1000 PY) and pancreatic cancer (0.88 vs. 0.47/1000 PY). We documented 130 versus 344 pancreas-related deaths among individuals with MASLD and their matched comparators, yielding an absolute risk difference of 0.51/1000 PY and an aHR of 2.41 (95%CI = 1.95-2.97). The findings were consistent in sibling-controlled analyses with an aHR of 2.21 (95%CI = 1.69-2.90).

CONCLUSIONS

MASLD was associated with significantly higher rates of acute and chronic pancreatitis of predominantly non-biliary origin, as well as an increased risk of pancreatic cancer and pancreas-related mortality.