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Beaufils F, Mas E, Mittaine M, Addra M, Fayon M, Delhaes L, Clouzeau H, Galode F, Lamireau T, Bui S, Enaud R. Increased Fecal Calprotectin Is Associated with Worse Gastrointestinal Symptoms and Quality of Life Scores in Children with Cystic Fibrosis. J Clin Med 2020; 9:jcm9124080. [PMID: 33348735 PMCID: PMC7766355 DOI: 10.3390/jcm9124080] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023] Open
Abstract
In cystic fibrosis (CF), cystic fibrosis transmembrane regulator (CFTR) dysfunction leads to digestive disorders that promote intestinal inflammation and dysbiosis enhancing gastrointestinal symptoms. In pancreatic insufficiency CF patients, both intestinal inflammation and dysbiosis, are associated with an increase in the fecal calprotectin (FC) level. However, associations between the FC level, gastrointestinal symptoms, and quality of life (QoL) remain poorly studied. We aimed to assess such associations in pancreatic insufficiency CF children. The FC level was measured in pancreatic insufficiency CF children’s stool samples. Children and their parents completed two questionnaires: The Gastrointestinal Symptoms Scales 3.0-PedsQLTM and the Quality of Life Pediatric Inventory 4.0-PedsQLTM. Lower scores indicated worse symptomatology or QoL. Thirty-seven CF children were included. A FC level above 250 µg/g was associated with worse gastrointestinal symptoms and QoL scores. The FC level was inversely correlated with several gastrointestinal scores assessed by children (i.e., Total, “Heart Burn Reflux”, “Nausea and Vomiting”, and “Gas and Bloating”). Several QoL scores were correlated with gastrointestinal scores. The FC level was weakly associated with clinical parameters. Some gastrointestinal and QoL scores were related to disease severity associated parameters. In CF, the FC level, biomarker previously related to intestinal inflammation and dysbiosis, was associated with worse digestive symptoms and QoL scores.
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Affiliation(s)
- Fabien Beaufils
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- Correspondence: ; Tel.: +33-5-56-79-98-24
| | - Emmanuel Mas
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- INSERM, INRA, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, F-31300 Toulouse, France
| | - Marie Mittaine
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
| | - Martin Addra
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
| | - Michael Fayon
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Laurence Delhaes
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
- CHU Toulouse, CRCM Pédiatrique, F-31300 Toulouse, France; (E.M.); (M.M.)
- CHU Bordeaux, Service de Parasitologie-Mycologie, F-33000 Bordeaux, France
| | - Haude Clouzeau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - François Galode
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Thierry Lamireau
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Stéphanie Bui
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
| | - Raphaël Enaud
- CHU Bordeaux, CRCM Pédiatrique, CIC 1401, Place Amélie Raba Léon, F-33000 Bordeaux, France; (M.F.); (L.D.); (H.C.); (F.G.); (T.L.); (S.B.); (R.E.)
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, University Bordeaux, U1045, F-33000 Bordeaux, France;
- Fédération Hospitalo-Universitaire FHU, ACRONIM, F-33000 Bordeaux, France
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Lieb JG, Patel D, Karnik N, Toskes PP. Study of the gastrointestinal bioavailability of a pancreatic extract product (Zenpep) in chronic pancreatitis patients with exocrine pancreatic insufficiency. Pancreatology 2020; 20:1092-1102. [PMID: 32800653 DOI: 10.1016/j.pan.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/28/2020] [Accepted: 07/10/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The Food and Drug Administration in 2006 required that all pancreatic enzyme products demonstrate bioavailability of lipase, amylase, and protease in the proximal small intestine. METHODS In this phase I open-label, randomized, crossover trial, 17 adult chronic pancreatitis (CP) patients with severe exocrine pancreatic insufficiency (EPI) underwent two separate gastroduodenal perfusion procedures (Dreiling tube suctioning and [14C]-PEG instillation by an attached Dobhoff tube in the duodenal bulb). Patients received Ensure Plus® alone and Ensure Plus with Zenpep (75,000 USP lipase units) in random order. The bioavailability of Zenpep was estimated by comparing the recovery of lipase, amylase, chymotrypsin activity in two treatment conditions. 14C-PEG was used to correct duodenal aspirates volume. The primary efficacy endpoint was lipase delivery in the duodenum after Zenpep administration under fed conditions. Secondary efficacy endpoints included chymotrypsin and amylase delivery, serum CCK levels, and measuring duodenal and gastric pH. RESULTS Zenpep administration with a test meal was associated with significant increase in duodenal aspiration of lipase (p = 0.046), chymotrypsin (p = 0.008), and amylase (p = 0.001), compared to the test meal alone, indicating release of enzymes to the duodenum. Lipase delivery was higher in the pH subpopulation (the efficacy population with acid hypersecretors excluded) (p = 0.01). Recovery of [14C]-PEG was 61%. Zenpep was generally well tolerated. All adverse events were mild and transient. CONCLUSIONS In CP patients with severe EPI, lipase, chymotrypsin and amylase were released rapidly into the duodenum after ingestion of Zenpep plus meal compared to meals alone. Results also reflected the known pH threshold for enzyme release from enteric coated products.
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Affiliation(s)
- John G Lieb
- Section of Gastroenterology, University of Florida, 1549 Gale Lemerand Drive, Gainesville, FL, 32610-3008, USA.
| | - Dhruvan Patel
- Section of Gastroenterology, University of Pennsylvania, 3400 Civic Center Blvd, 7th Floor, Philadelphia, PA, 19104, USA.
| | - Nihaal Karnik
- Department of Internal Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Phillip P Toskes
- Section of Gastroenterology, University of Florida, 1549 Gale Lemerand Drive, Gainesville, FL, 32610-3008, USA.
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Singh A, Koenen B, Kirby DF. Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients. Inflamm Bowel Dis 2020; 26:1155-1165. [PMID: 31626698 DOI: 10.1093/ibd/izz246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Indexed: 12/14/2022]
Abstract
Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.
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Affiliation(s)
- Amandeep Singh
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Koenen
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
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Rigo J, Hascoët J, Picaud JC, Mosca F, Rubio A, Saliba E, Radkë M, Simeoni U, Guillois B, Hays NP, Hartweg M, Billeaud C, Spalinger J. Comparative study of preterm infants fed new and existing human milk fortifiers showed favourable markers of gastrointestinal status. Acta Paediatr 2020; 109:527-533. [PMID: 31435957 PMCID: PMC7028100 DOI: 10.1111/apa.14981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
Abstract
Aim This study examined the influence of different human milk fortifiers on biomarkers of gastrointestinal immaturity and inflammation in preterm infants. Methods We report secondary outcomes from a controlled, double‐blind, randomised, parallel group study conducted from 2011 to 2014 in neonatal intensive care units at 11 metropolitan hospitals in France, Belgium, Germany, Switzerland and Italy. Preterm infants born at up to 32 weeks or weighing up to 1500 g were randomised to a new powdered human milk fortifier (n = 77) or a control fortifier (n = 76) for a minimum of 21 days. We analysed faecal markers of gut inflammation, namely alpha‐1 antitrypsin and calprotectin, and maturity, namely elastase‐1. Results Faecal alpha‐1 antitrypsin was slightly lower in the new than control fortifier group after 21 days of full enteral feeding, with a geometric mean and standard deviation of 1.52 ± 1.32 vs 1.82 ± 1.44 mg/g stools (P = .01). There was no significant difference in faecal calprotectin (median [Q1‐Q3] of 296 [136‐565] μg/g stools in both groups combined at study day 21). Faecal elastase‐1 was lower in the new fortifier than control fortifier group (202.5 ± 1.6 vs 257.7 ± 1.5 μg/g stools, P = .016). Conclusion Mean values for each parameter were within the ranges in healthy term infants, indicating favourable markers of gastrointestinal status in both groups. In addition, for faecal calprotectin, the relatively high concentration observed in preterm infants fed fortified human milk suggests that the threshold level for detecting necrotising enterocolitis should be revised.
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Affiliation(s)
- Jacques Rigo
- Department of Neonatology CHR Citadelle University of Liège Liège Belgium
| | | | | | - Fabio Mosca
- Neonatal Intensive Care Unit Department of Clinical Science and Community Health Fondazione IRCCS “Ca' Granda” Ospedale Maggiore Policlinico University of Milan Milano Italy
| | | | - Elie Saliba
- Hôpital Clocheville CHU de Tours Tours France
| | | | - Umberto Simeoni
- Centre Hospitalier Universitaire Vaudois University of Lausanne Lausanne Switzerland
| | | | - Nicholas P. Hays
- Nestlé Product Technology Center – Nutrition La Tour‐de‐Peilz Switzerland
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Sleeve gastrectomy relieves exocrine pancreatic insufficiency in morbidly obese patients: a prospective case-control study. GASTROENTEROLOGY REVIEW 2020; 14:268-273. [PMID: 31988673 PMCID: PMC6983761 DOI: 10.5114/pg.2019.84223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/11/2019] [Indexed: 12/15/2022]
Abstract
Introduction Bariatric surgery is the most effective treatment modality in morbidly obese patients. Compared to Roux-en Y gastric bypass (RYGB), sleeve gastrectomy (SG) has better metabolic and nutritional outcomes after surgery. Exocrine pancreatic insufficiency (EPI) can be seen after RYGB but there is not any knowledge about EPI-SG association. Aim To assess exocrine pancreatic functions before and after the SG procedure. Material and methods This is a single-center, prospective and case-control study. Forty morbidly obese patients were included in the study. Their pre-operative and post-operative, third month fecal samples were collected. Exocrine pancreatic insufficiency was determined by using fecal elastase-1 and diagnosed when fecal elastase-1 levels were < 200 μg/g. Results The mean fecal elastase-1 level was 256.25 ±137.16 μg/g and the mean post-surgical fecal elastase-1 level was 437.7 ±212.43 μg/g (p = 0.001). In the pre-operative period, half of patients had FE levels under 200 μg/g. In the third month after surgery, only 4 patients had fecal elastase-1 levels under 200 μg/g. Comparison of fecal elastase-1 between pre-surgery and post-surgery revealed a significant difference (p = 0.001). Conclusions This is the first study to investigate EPI-SG association. Surgery-associated morbidity and mortality are the leading limitations of bariatric surgery procedures. Exocrine pancreatic insufficiency is one of them; prior studies demonstrate its increased frequency after RYGB. Our study revealed that SG relieves exocrine pancreatic insufficiency.
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Chaudhary A, Domínguez-ñoz JE, Layer P, Lerch MM. Pancreatic Exocrine Insufficiency as a Complication of Gastrointestinal Surgery and the Impact of Pancreatic Enzyme Replacement Therapy. Dig Dis 2020; 38:53-68. [PMID: 31422398 PMCID: PMC6979421 DOI: 10.1159/000501675] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 06/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) is characterized by inadequate production, insufficient secretion, and/or inactivation of pancreatic enzymes, resulting in maldigestion. The aim of this review was to analyze the prevalence and pathophysiology of PEI resulting from gastrointestinal (GI) surgery and to examine the use of pancreatic enzyme replacement therapy (PERT) for effectively managing PEI. SUMMARY A targeted PubMed search was conducted for studies examining the prevalence and pathophysiology of PEI in patients following GI surgery and for studies assessing the effects of PERT in these patients. PEI is a common complication following GI surgery that can lead to nutritional deficiencies, which may contribute to morbidity and mortality in patients. Timely treatment of PEI with PERT can prevent malnutrition, increase quality of life, and possibly reduce the associated mortality. Treatment of PEI should aim not only to alleviate symptoms but also to achieve significant improvements in nutritional parameters. Dose optimization of PERT is required for effective management of PEI, in addition to regular assessment of nutritional status, appropriate patient education, and reassessment if symptoms return. Key Messages: Difficulties in detecting PEI following GI surgery can result in undiagnosed and untreated maldigestion, leading to metabolic complications and increased morbidity. Both are preventable by early administration and monitoring for optimal doses of PERT.
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Affiliation(s)
- Adarsh Chaudhary
- aDepartment of Gastrointestinal Surgery, Gastrointestinal Oncology and Bariatric Surgery, Medanta, The Medicity, Gurgaon, India,*Adarsh Chaudhary, Department of Gastrointestinal Surgery, Gastrointestinal Oncology and Bariatric Surgery, Medanta, The Medicity, Sector 38, Gurgaon 122018 (India), E-Mail
| | - J. Enrique Domínguez-ñoz
- bDepartment of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Peter Layer
- cDepartment of Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - Markus M. Lerch
- dDepartment of Medicine, University Medicine Greifswald, Greifswald, Germany
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Brunet E, Caixàs A, Puig V. Review of the management of diarrhea syndrome after a bariatric surgery. ACTA ACUST UNITED AC 2019; 67:401-407. [PMID: 31843494 DOI: 10.1016/j.endinu.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 02/07/2023]
Abstract
Obesity is a prevalent health problem in our population. Bariatric surgery is the indicated treatment for severe cases. It is very effective (together with an adequate lifestyle modification) but it is also associated with frequent adverse events. One of the most frequent and disturbing adverse event is diarrhea. Diarrhea after bariatric surgery may be secondary to multiple causes and the physiopathogenic mechanisms may depend on the type of surgery performed. The most frequent diarrhea mechanisms are dumping syndrome, vagotomy, short bowel syndrome, carbohydrate malabsorption, protein malabsorption, alterations of the microbiota, Clostridium difficile infection, bacterial overgrowth, bile salt malabsorption, pancreatic insufficiency, endocrinological disorders, addictive disorders, and other digestive disorders not necessarily related to surgery.
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Affiliation(s)
- Eduard Brunet
- Unidad de Gastroenterología, Servicio de Aparato Digestivo, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
| | - Assumpta Caixàs
- Servicio de Endocrinología y Nutrición, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España.
| | - Valentí Puig
- Unidad de Gastroenterología, Servicio de Aparato Digestivo, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España
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Rodrigues-Pinto E, Caldeira A, Soares JB, Antunes T, Carvalho JR, Costa-Maia J, Oliveira P, Azevedo R, Liberal R, Bouça Machado T, Magno-Pereira V, Moutinho-Ribeiro P. Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Medical, Endoscopic, and Surgical Treatment (Part II). GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:404-413. [PMID: 31832495 DOI: 10.1159/000497389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/31/2019] [Indexed: 01/21/2023]
Abstract
Chronic pancreatitis (CP) is a complex disease that should be treated by experienced teams of gastroenterologists, radiologists, surgeons, and nutritionists in a multidisciplinary environment. Medical treatment includes lifestyle modification, nutrition, exocrine and endocrine pancreatic insufficiency correction, and pain management. Up to 60% of patients will ultimately require some type of endoscopic or surgical intervention for treatment. However, regardless of the modality, they are often ineffective unless smoking and alcohol cessation is achieved. Surgery retains a major role in the treatment of CP patients with intractable chronic pain or suspected pancreatic mass. For other complications like biliary or gastroduodenal obstruction, pseudocyst drainage can be performed endoscopically. The recommendations for CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part II.
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Affiliation(s)
| | - Ana Caldeira
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | | | - Teresa Antunes
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Joana Rita Carvalho
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Costa-Maia
- Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Pedro Oliveira
- Radiology Department, Hospital de Braga, Braga, Portugal
| | - Richard Azevedo
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal
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Martin AM, Sun EW, Keating DJ. Mechanisms controlling hormone secretion in human gut and its relevance to metabolism. J Endocrinol 2019; 244:R1-R15. [PMID: 31751295 PMCID: PMC6892457 DOI: 10.1530/joe-19-0399] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022]
Abstract
The homoeostatic regulation of metabolism is highly complex and involves multiple inputs from both the nervous and endocrine systems. The gut is the largest endocrine organ in our body and synthesises and secretes over 20 different hormones from enteroendocrine cells that are dispersed throughout the gut epithelium. These hormones include GLP-1, PYY, GIP, serotonin, and CCK, each of whom play pivotal roles in maintaining energy balance and glucose homeostasis. Some are now the basis of several clinically used glucose-lowering and weight loss therapies. The environment in which these enteroendocrine cells exist is also complex, as they are exposed to numerous physiological inputs including ingested nutrients, circulating factors and metabolites produced from neighbouring gut microbiome. In this review, we examine the diverse means by which gut-derived hormones carry out their metabolic functions through their interactions with different metabolically important organs including the liver, pancreas, adipose tissue and brain. Furthermore, we discuss how nutrients and microbial metabolites affect gut hormone secretion and the mechanisms underlying these interactions.
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Affiliation(s)
- Alyce M Martin
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Emily W Sun
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Damien J Keating
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Nutrition and Metabolism, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Correspondence should be addressed to D J Keating:
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Johnston PC, Thompson J, Mckee A, Hamill C, Wallace I. Diabetes and Chronic Pancreatitis: Considerations in the Holistic Management of an Often Neglected Disease. J Diabetes Res 2019; 2019:2487804. [PMID: 31687406 PMCID: PMC6800932 DOI: 10.1155/2019/2487804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/13/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
Diabetes secondary to chronic pancreatitis (CP) or type 3cDM refers to a brittle form of diabetes and is often characterised by hypoglycaemic episodes, erratic glycaemic control, and impaired quality of life. It differs from other forms of diabetes and is typically characterised by concurrent pancreatic endocrine and exocrine insufficiency which can present as malabsorption and nutritional deficiencies. In this review, we discuss the pathogenesis, epidemiology, and the practicalities of diagnosis, screening, and management of this condition.
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Affiliation(s)
| | - Judith Thompson
- Dietetics Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Allison Mckee
- Dietetics Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Connor Hamill
- Diabetes Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Ian Wallace
- Diabetes Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
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Rodrigues-Pinto E, Caldeira A, Soares JB, Antunes T, Carvalho JR, Costa-Maia J, Oliveira P, Azevedo R, Liberal R, Bouça Machado T, Magno-Pereira V, Moutinho-Ribeiro P. Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I). GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:346-355. [PMID: 31559325 DOI: 10.1159/000497388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/31/2019] [Indexed: 11/19/2022]
Abstract
Chronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.
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Affiliation(s)
| | - Ana Caldeira
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | | | - Teresa Antunes
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Joana Rita Carvalho
- Gastroenterology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José Costa-Maia
- Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Pedro Oliveira
- Radiology Department, Hospital de Braga, Braga, Portugal
| | - Richard Azevedo
- Gastroenterology Department, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal
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Sankararaman S, Schindler T, Sferra TJ. Management of Exocrine Pancreatic Insufficiency in Children. Nutr Clin Pract 2019; 34 Suppl 1:S27-S42. [DOI: 10.1002/ncp.10388] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Cleveland Ohio USA
| | - Thomas J. Sferra
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
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Rational Use of Pancreatic Enzymes for Pancreatic Insufficiency and Pancreatic Pain. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1148:323-343. [PMID: 31482505 DOI: 10.1007/978-981-13-7709-9_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe the rational use of enteric coated and unprotected replacement pancreatic enzymes for treatment of malabsorption due to pancreatic insufficiency and for pancreatic pain. Enteric coated formulations mix poorly with food allowing separation of enzymes and nutrients when emptying from the stomach. The site of dissolution of the enteric coating in the intestine is also unpredictable and enzymes may not be released until the distal intestine. Together, these barriers result in the lack of dose-response such that the strategy of increasing the dosage following a suboptimal effect is often ineffective. The ability to maintain the intragastric pH ≥4 with the combination of proton pump inhibitors and antacids suggests that it should be possible to reliably obtain a good response with uncoated enzymes. We also discuss the recognition, treatment and prevention of nutritional deficiencies associated with pancreatic insufficiency and recommend a test and treat strategy to identify and resolve nutritional deficits. Finally, we focus on mechanisms causing pain that may be amenable to therapy with pancreatic enzymes. Pain due to malabsorbed digestive contents can be prevented by successful therapy of malabsorption. Feedback inhibition of endogenous pancreatic secretion can prevent pain associated with pancreatic secretion but requires use of non-enteric coated formulations.
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65
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Choe JW, Hyun JJ. [Relief of Cancer Pain in Patients with Pancreatic Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:81-86. [PMID: 31438659 DOI: 10.4166/kjg.2019.74.2.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer is a dismal disease with a poor prognosis and is one of the most painful malignancies. Therefore, adequate pain control is essential to improving the patient's quality of life. Pain in pancreatic cancer has complex pathophysiologic mechanisms and different characteristics. The choice of pain management modalities should be individualized depending on the pain characteristics using a multidisciplinary approach. The treatment options available include medical treatment, chemotherapy, celiac plexus/ganglion neurolysis, radiotherapy, and endoscopic technique. This review discusses the medical and interventional options, leading to optimal pain management in patients with pancreatic cancer.
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Affiliation(s)
- Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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66
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Adolph TE, Mayr L, Grabherr F, Schwärzler J, Tilg H. Pancreas–Microbiota Cross Talk in Health and Disease. Annu Rev Nutr 2019; 39:249-266. [DOI: 10.1146/annurev-nutr-082018-124306] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The pancreas controls metabolism through endocrine and exocrine functions. Pancreatic diseases comprise a spectrum of mild to life-threatening conditions, including acute and chronic pancreatitis, diabetes, and pancreatic cancer, which affect endocrine and exocrine pancreatic function and impose a substantial disease burden on individuals. Increasing experimental evidence demonstrates that the intestinal microbiota has an important impact on pancreatic function and diseases. This influence may be conferred by bacterial metabolites, such as short-chain fatty acids, or the modulation of immune responses. In turn, pancreatic factors, such as the excretion of antimicrobials, might have a substantial impact on the composition and functional properties of the gut microbiota. Here, we summarize experimental and clinical approaches used to untie the intricate pancreas–microbiota cross talk. Future advances will allow clinicians to manipulate the intestinal microbiota and guide patient management in pancreatic diseases.
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Affiliation(s)
- Timon E. Adolph
- Department of Internal Medicine I (Gastroenterology, Hepatology, Endocrinology and Metabolism), Medical University Innsbruck, Innsbruck 6020, Austria
| | - Lisa Mayr
- Department of Internal Medicine I (Gastroenterology, Hepatology, Endocrinology and Metabolism), Medical University Innsbruck, Innsbruck 6020, Austria
| | - Felix Grabherr
- Department of Internal Medicine I (Gastroenterology, Hepatology, Endocrinology and Metabolism), Medical University Innsbruck, Innsbruck 6020, Austria
| | - Julian Schwärzler
- Department of Internal Medicine I (Gastroenterology, Hepatology, Endocrinology and Metabolism), Medical University Innsbruck, Innsbruck 6020, Austria
| | - Herbert Tilg
- Department of Internal Medicine I (Gastroenterology, Hepatology, Endocrinology and Metabolism), Medical University Innsbruck, Innsbruck 6020, Austria
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67
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Widodo AD, Timan IS, Bardosono S, Siagian M, Winarta W, Prasetyo D, Firmansyah A. Poor diagnostic values of stool analysis and steatocrit test in detecting exocrine pancreatic insufficiency. MEDICAL JOURNAL OF INDONESIA 2019. [DOI: 10.13181/mji.v28i2.1690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Exocrine pancreatic insufficiency (EPI) is one of the most challenging cases to be diagnosed accurately in Indonesia because of the unavailability of the fecal elastase-1 (FE-1) test, which is the primary indirect diagnostic tool till date. Stool analysis and steatocrit test are feasible alternatives as they can detect nutrient malabsorption, a consistent feature in EPI. Despite the common practice of using both tests, no study has ever been conducted in Indonesia to evaluate their accuracy.
METHODS This cross-sectional diagnostic study was conducted in 182 children aged 6–60 months. Study subjects were divided into children with persistent diarrhea (PD), those with malnutrition, and healthy children. Children with PD and malnutrition were selected on the basis of clinical criteria and the WHO z-score. FE-1 test was used as the gold standard to detect EPI. Primary endpoints of this study were sensitivity and specificity of the stool analysis and the steatocrit test. The accuracy of both tests, represented by area under the curve (AUC) values, was also evaluated individually and in combination.
RESULTS Each component of stool analysis and steatocrit test in each subgroup of patients generally had higher specificity than sensitivity. The specificity of both tests among healthy and malnourished children was good (≥70%), but among children with PD, the specificity of some components was <70%. The individual and combined AUC values of both tests in each subgroup of subjects were poor (<0.7).
CONCLUSIONS Stool analysis and steatocrit test cannot be used as alternative methods for FE-1 to detect EPI.
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Brennan GT, Saif MW. Pancreatic Enzyme Replacement Therapy: A Concise Review. JOP : JOURNAL OF THE PANCREAS 2019; 20:121-125. [PMID: 31736680 PMCID: PMC6858980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pancreatic enzyme replacement therapy is safe and effective at treating pancreatic exocrine insufficiency. There are multiple causes of pancreatic exocrine insufficiency including chronic pancreatitis, cystic fibrosis and pancreatic cancer. Testing fecal elastase-1 level is useful for the diagnosis of pancreatic exocrine insufficiency. Starting doses of pancreatic enzyme replacement therapy should be at least 30-40,000 IU with each meal and 15-20,000 IU with snacks. pancreatic enzyme replacement therapy should be taken in divided doses throughout meals. Patients who do not respond to initial dosages should be evaluated for alternative etiologies and pancreatic enzyme replacement therapy optimized. Despite ease of use and benefit of pancreatic enzyme replacement therapy, challenges still remain clinically and this review hopes to provide a concise guide for clinicians.
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Affiliation(s)
- Gregory T Brennan
- Division of Gastroenterology, University of California Irvine, Orange, California
| | - Muhammad Wasif Saif
- Deputy Physician-in-Chief and Director, Medical Oncology at Northwell health Cancer Institute Professor, Medical Oncology, Zucker School of Medicine, Hempstead, New York
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69
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Jalal M, Campbell JA, Hopper AD. Practical guide to the management of chronic pancreatitis. Frontline Gastroenterol 2019; 10:253-260. [PMID: 31288255 PMCID: PMC6583580 DOI: 10.1136/flgastro-2018-101071] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/19/2018] [Indexed: 02/04/2023] Open
Abstract
Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.
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Affiliation(s)
- Mustafa Jalal
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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The Etiology of Pancreatic Manifestations in Patients with Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8070916. [PMID: 31247968 PMCID: PMC6679036 DOI: 10.3390/jcm8070916] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an idiopathic chronic and recurrent condition that comprises Crohn's disease and ulcerative colitis. A pancreatic lesion is one of the extraintestinal lesions in patients with IBD. Acute pancreatitis is the representative manifestation, and various causes of pancreatitis have been reported, including those involving adverse effects of drug therapies such as 5-aminosalicylic acid and thiopurines, gall stones, gastrointestinal lesions on the duodenum, iatrogenic harm accompanying endoscopic procedures such as balloon endoscopy, and autoimmunity. Of these potential causes, autoimmune pancreatitis (AIP) is a relatively newly recognized disease and is being increasingly diagnosed in IBD. AIP cases can be divided into type 1 cases involving lymphocytes and IgG4-positive plasma cells, and type 2 cases primarily involving neutrophils; the majority of AIP cases complicating IBD are type 2. The association between IBD and chronic pancreatitis, exocrine pancreatic insufficiency, pancreatic cancer, etc. has also been suggested; however, studies with high-quality level evidence are limited, and much remains unknown. In this review, we provide an overview of the etiology of pancreatic manifestation in patients with IBD.
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71
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Layer P, Kashirskaya N, Gubergrits N. Contribution of pancreatic enzyme replacement therapy to survival and quality of life in patients with pancreatic exocrine insufficiency. World J Gastroenterol 2019; 25:2430-2441. [PMID: 31171887 PMCID: PMC6543241 DOI: 10.3748/wjg.v25.i20.2430] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/02/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
The objective of this study was to analyze the current evidence for the use of pancreatic enzyme replacement therapy (PERT) in affecting survival and quality of life in patients with pancreatic exocrine insufficiency (PEI). Systematic searches of the literature were performed using the PubMed database. Articles were selected for inclusion if they reported findings from trials assessing the effects of PERT on quality of life, survival, malabsorption, growth parameters (such as height, body weight and body mass index), or gastrointestinal symptoms (such as abdominal pain, stool consistency and flatulence). PERT improved PEI-related malabsorption and weight maintenance in patients with cystic fibrosis, chronic pancreatitis, pancreatic cancer, and post-surgical states. In patients with chronic pancreatitis, PERT improved PEI-related symptoms and quality of life measures. Several small retrospective studies have also suggested that PERT may have a positive impact on survival, but long-term studies assessing this effect were not identified. PERT is effective for treating malnutrition and supporting weight maintenance, and it is associated with improved quality of life and possibly with enhanced survival in patients with PEI. However, there is evidence that not all patients with PEI receive adequate PERT. Future work should aim to assess the long-term effects of PERT on the survival of patients with PEI.
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Affiliation(s)
- Peter Layer
- Department of Internal Medicine, Israelitic Hospital, Hamburg 22297, Germany
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis group), Federal State Budgetary Institution “Research Centre for Medical Genetics”, Moscow 115522, Russia
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman 83001, Ukraine
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72
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Tjora E, Erchinger F, Engjom T, Aksnes L, Dimcevski G, Gudbrandsen OA. Analysis of lipase activity in duodenal juice. Comparison of an automated spectrophotometric assay to a fluorometric microplate assay, and factors affecting sample stability. Scand J Gastroenterol 2019; 53:1206-1211. [PMID: 30353747 DOI: 10.1080/00365521.2018.1518481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct pancreas function testing (DPFT) has been regarded as gold standard for assessment of exocrine pancreas function. One of the outcomes from DPFT is pancreatic lipase activity in duodenal juice, but no standard assay for measuring pancreas lipase activity in duodenal juice exists. AIMS To optimize and evaluate an autoanalyzer assay for measuring lipase activity in duodenal juice. METHODS We used samples of duodenal juice from our biobank, collected through a short endoscopic secretin test in patients with suspected exocrine pancreas insufficiency. Samples were analyzed on a Cobas autoanalyzer (Roche Diagnostics), using a colorimetric, kinetic enzyme activity assay. We compared stability of samples diluted in saline to samples diluted in 3-(N-morpholino) propane sulfonic acid (MOPS) buffer added bovine serum albumin (BSA). Results from the Cobas assay were compared to Confluolip method, a fluorometric, kinetic enzyme assay, modified to fit into a microplate setting. RESULTS We tested the stability of 54 samples from 21 patients. Diluting samples with MOPS buffer added BSA gave stable results, and was superior to diluting samples in saline. We compared the two assays in 50 samples from 20 patients and found a good correlation between the two assays (r = 0.91, p < .001). There was a significant proportional bias between the two assays, but no significant systematic bias. CONCLUSION Pancreatic lipase activity in duodenal juice samples diluted in MOPS buffer added BSA is stable for one hour at room temperature. Quantification of lipase activity in duodenal juice using a standard automated activity assay has comparable accuracy to a manual fluorometric method.
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Affiliation(s)
- Erling Tjora
- a Department of Paediatrics , Haukeland University Hospital , Bergen , Norway.,b Center for Diabetes Research , University of Bergen , Bergen , Norway
| | - Friedemann Erchinger
- c Department of Clinical Medicine , University of Bergen , Bergen , Norway.,d Medical Department , Voss Hospital , Voss , Norway
| | - Trond Engjom
- c Department of Clinical Medicine , University of Bergen , Bergen , Norway.,e Medical Department , Haukeland University Hospital , Bergen , Norway
| | - Lage Aksnes
- f Department of Clinical Science , University of Bergen , Bergen , Norway
| | - Georg Dimcevski
- c Department of Clinical Medicine , University of Bergen , Bergen , Norway.,e Medical Department , Haukeland University Hospital , Bergen , Norway
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Tahtacı M, Algın O, Karakan T, Yürekli ÖT, Alışık M, Köseoğlu H, Metin MR, Bolat AD, Erel Ö, Ersoy O. Can pancreatic steatosis affect exocrine functions of pancreas? TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 29:588-594. [PMID: 30260782 DOI: 10.5152/tjg.2018.17696] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Pancreatic steatosis (PS) is a generally used term to define accumulation of fat in the pancreas. In theory PS may be able to affect the exocrine function of pancreas. In this study we aimed to determine the effect of PS on exocrine pancreas function. MATERIALS AND METHODS Forty-three patients with PS determined by 3 tesla magnetic resonance imaging (MRI) and 48 patients without PS were included in this study. Patients with PS were classified as group 1 and control patients were classified as group 2. Fecal elastase-1 levels were determined. Fecal elastase-1 levels <200 μg/g were defined as exocrine pancreatic insufficiency (EPI). Patients with PS were further grouped according to severity and anatomic distribution of steatosis based on findings of 3 tesla MRI. RESULTS Fecal elastase-1 levels was significantly lower in group 1 compared to group 2 (319.76±45.7 vs 549.31±69.4, respectively, p=0.003). Proportion of patients with EPI was significantly higher in group 1 than group 2 (35.5% vs 12% p=0.042). There were no significant differences in terms of severity or the anatomic distribution of PS in patients with PS with EPI based on MRI (p=0.052, p=0.198, p=0.405) Conclusion: Current study demonstrates that PS can cause EPI.
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Affiliation(s)
- Mustafa Tahtacı
- Department of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Oktay Algın
- Department of Radiology, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Tarkan Karakan
- Department of Gastroenterology, Gazi University School of Medicine, Ankara, Turkey
| | - Öykü Tayfur Yürekli
- Department of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Murat Alışık
- Department of Biochemistry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Hüseyin Köseoğlu
- Department of Gastroenterology, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Melike Ruşen Metin
- Department of Radiology, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Aylin Demirezer Bolat
- Department of Gastroenterology, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Özcan Erel
- Department of Biochemistry, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Osman Ersoy
- Department of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
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Landers A, Brown H, Strother M. The effectiveness of pancreatic enzyme replacement therapy for malabsorption in advanced pancreatic cancer, a pilot study. Palliat Care 2019; 12:1178224218825270. [PMID: 30799929 PMCID: PMC6378466 DOI: 10.1177/1178224218825270] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022] Open
Abstract
Advanced adenocarcinoma of the pancreas has a globally poor prognosis. One of the characteristic features of pancreatic cancer (PC) is pancreatic exocrine insufficiency (PEI). This leads to a malabsorption syndrome and subsequent digestive symptoms. Given the high prevalence of PEI and malabsorption in PC, empiric use of pancreatic enzyme replacement therapy (PERT) is recommended. The aim of this pilot study was to determine the potential efficacy of PERT in improving symptoms and quality of life in those with metastatic PC. The study recruited patients with advanced PC referred to a specialist palliative care service. Following an initial assessment, patients were commenced on pancrealipase 25,000IU (Creon) and reassessed after 1 week and 3 weeks post-initiation of supplementation. These assessments included demographics, malabsorption symptom checklist, and completion of two validated quality-of-life questionnaires, the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-PAN26. PERT was associated with statistically significant improvement of symptoms in both the general (QLQ-C30) and pancreatic cancer specific tool (PAN26). Within 1 week of PERT initiation, there was a reduction in diarrhoea scores (26 vs. 8, p<0.005), pancreatic and hepatic pain (47 vs. 33 and 24 vs. 11, respectively, p<0.05). After 3 weeks, there were significant improvements in pancreatic pain and bloating/gas symptoms (47 vs. 26 and 46 vs. 26, respectively, p< 0.005). PERT appears to have the potential to improve symptoms of malabsorption in patients with metastatic PC.
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Affiliation(s)
- Amanda Landers
- Department of Medicine, University of Otago, Christchurch New Zealand
| | - Helen Brown
- Nurse Maude Hospice Palliative Care Service, Nurse Maude Association, Christchurch, New Zealand
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Yamamoto A, Ito K, Yasokawa K, Kanki A, Tanimoto D, Hayashida M, Tamada T. Symptoms that are associated with decreased pancreatic enzyme flow: MRCP assessment. J Magn Reson Imaging 2019; 50:417-423. [PMID: 30637845 DOI: 10.1002/jmri.26619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pancreatic exocrine insufficiency is one of the causes of malabsorption syndrome. In many cases of malabsorption syndrome, pancreatic exocrine insufficiency can be treated with pancreatic enzyme replacement therapy. Therefore, it is important to detect pancreatic endocrine insufficiency as early and accurately as possible. Recent studies have shown that cine-dynamic MR cholangiopancreatography (MRCP) may be useful to evaluate pancreatic exocrine function PURPOSE: To identify abdominal symptoms that suggest decreased flow of pancreatic enzyme secretion for which cine-dynamic MRCP should be performed to diagnose pancreatic exocrine insufficiency. STUDY TYPE Prospective. POPULATION In all, 111 patients with various types of abdominal symptoms. FIELD STRENGTH/SEQUENCE 5 T or 3 T, MRCP with spatially selective inversion recovery pulse (cine-dynamic MRCP). ASSESSMENT Cine-dynamic MRCP was performed and an 18-question clinical questionnaire on abdominal symptoms was administered. The secretion grade derived from cine-dynamic MRCP was compared between those answering "yes" and "no" for all 18 items STATISTICAL TESTS: Univariate analysis and further analyzed using multiple regression analysis. The associations between the secretion grade and the items in the clinical questionnaire were analyzed by univariate analysis and further analyzed using multiple regression analysis. RESULTS The following three items showed significantly negative correlations with secretion grade: Q9, Does your rectal gas smell foul? (β = -0.44, P = 0.001); Q13, Is stool quantity large? (β = -0.41, P = 0.001); and Q18, Are your stools soft? (β = -0.53, P < 0.001). No significant correlations with exocrine pancreatic function measured by cine-dynamic MRCP were seen for the remaining 15 abdominal symptom items. DATA CONCLUSION Abdominal symptoms that suggest decreased flow of pancreatic enzyme secretion were foul rectal gas, large stool, and soft stool. Pancreatic exocrine insufficiency due to decreased pancreatic enzyme flow may be suspected in patients with these abdominal symptoms. LEVEL OF EVIDENCE 1 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019;50:417-423.
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Affiliation(s)
- Akira Yamamoto
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
| | - Katsuyoshi Ito
- Department of Radiology, Yamaguchi University, Ube, Japan
| | - Kazuya Yasokawa
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
| | - Akihiko Kanki
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
| | - Daigo Tanimoto
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
| | - Minoru Hayashida
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
| | - Tsutomu Tamada
- Department of Radiology, Kawasaki Medical School, Kurashiki, Japan
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de la Iglesia D, Vallejo-Senra N, López-López A, Iglesias-Garcia J, Lariño-Noia J, Nieto-García L, Domínguez-Muñoz JE. Pancreatic exocrine insufficiency and cardiovascular risk in patients with chronic pancreatitis: A prospective, longitudinal cohort study. J Gastroenterol Hepatol 2019; 34:277-283. [PMID: 30156337 DOI: 10.1111/jgh.14460] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Previous studies have suggested that chronic pancreatitis (CP) is associated with increased risk of cardiovascular (CV) disease independently of other major risk factors. We evaluated the risk of CV events in a well-phenotyped cohort of patients with CP and its association with pancreatic exocrine insufficiency (PEI) among other CV risk factors. METHODS This was a prospective, longitudinal cohort study of patients with CP, followed up at the Pancreas Unit of the University Hospital of Santiago de Compostela, Spain. RESULTS Four hundred thirty patients were included (mean 47.8 ± 14.4 years of age, 79.1% male). Mean follow-up was 8.6 ± 4.6 years. CP etiology was toxic (alcohol and/or smoking) in 290 patients (67.4%). PEI and pancreatogenic diabetes mellitus (DM) were present in 29.3% and 29.5% of the patients, respectively. A total of 45 CV events was recorded (10.5%); 21 patients had a major CV event (stroke or myocardial infarction) and 27 developed clinically relevant peripheral arterial disease. A higher incidence of CV events was recorded in patients with PEI than in those without (incidence rate ratio 3.67, 95% confidence interval [CI] 1.92-7.24; P < 0.001). In the multivariate analysis, PEI without DM (OR 4.96; 95% CI 1.68 to 14.65), coexistence of PEI and DM (OR 6.54; 95% CI 2.71 to 15.77), arterial hypertension (OR 3.40; 95% CI 1.50 to 7.72), and smoking (OR 2.91, 95% CI 1.07 to 7.97) were independently associated with increased CV risk. CONCLUSIONS Together with known major CV risk factors like smoking and hypertension, PEI is significantly associated with the risk of CV events in patients with CP.
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Affiliation(s)
- Daniel de la Iglesia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nicolau Vallejo-Senra
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Andrea López-López
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jose Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Laura Nieto-García
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Juan Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago (IDIS), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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A Chinese consensus statement on the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatic surgery (2018). JOURNAL OF PANCREATOLOGY 2018. [DOI: 10.1097/jp9.0000000000000004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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78
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Shandro BM, Nagarajah R, Poullis A. Challenges in the management of pancreatic exocrine insufficiency. World J Gastrointest Pharmacol Ther 2018; 9:39-46. [PMID: 30397535 PMCID: PMC6212541 DOI: 10.4292/wjgpt.v9.i5.39] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1 (FE-1) stool test is widely available and has been shown to be as effective as the 13C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.
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Affiliation(s)
- Benjamin Myles Shandro
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Rani Nagarajah
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Andrew Poullis
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
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Exocrine Pancreatic Insufficiency and Malnutrition in Chronic Pancreatitis: Identification, Treatment, and Consequences. Pancreas 2018; 47:1015-1018. [PMID: 30074926 PMCID: PMC6462188 DOI: 10.1097/mpa.0000000000001137] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the impact of exocrine pancreatic insufficiency (EPI) on chronic pancreatitis (CP) patients and to identify challenges with its diagnosis and treatment. METHODS Ninety-one patients with CP diagnosed with endoscopic ultrasound were identified and assessed for symptoms of EPI, fat-soluble vitamin levels, dual-energy x-ray absorptiometry scan T-scores, and treatment with pancreatic enzyme replacement therapy. All patients were also screened with the Malnutrition Universal Screening Test. RESULTS Exocrine pancreatic insufficiency was diagnosed in 84.6% (77/91) of patients based on symptoms of bloating, steatorrhea, or weight loss. Of these patients, 35.2% (19/54) had vitamin A deficiency, 62.5% (55/88) had vitamin D deficiency, and 17.7% (9/51) had vitamin E deficiency. Either osteopenia or osteoporosis was found in 68.9% (31/45). A medium or higher risk for malnutrition based on Malnutrition Universal Screening Test score of 1 or higher was found in 31.5% (28/89). Malnutrition Universal Screening Test score of 1 or higher was associated with an increased risk for osteopenia and osteoporosis on Fisher's exact test (P = 0.0037). CONCLUSIONS There is a high prevalence of fat-soluble vitamin deficiencies, osteopathy, and malnutrition in CP patients, which is underestimated due to a lack of effective diagnosis and suboptimal therapies for EPI.
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Increased Risk of Mortality Associated With Pancreatic Exocrine Insufficiency in Patients With Chronic Pancreatitis. J Clin Gastroenterol 2018; 52:e63-e72. [PMID: 28858943 DOI: 10.1097/mcg.0000000000000917] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) is a common serious complication in chronic pancreatitis (CP); however, little is known about its effect on mortality in these patients. In this study, we assessed the mortality risk of PEI in patients with CP. STUDY A prospective, longitudinal cohort study conducted in patients with CP under long-term follow-up. CP and PEI were diagnosed using pancreatic imaging and the C-labeled mixed triglyceride breath test, respectively. Multivariate analysis was performed to evaluate the impact of PEI and other clinical features on mortality risk. RESULTS Patients (N=430) were analyzed (79.1% male; mean age, 47.8 y) during a mean follow-up of 8.6±4.6 years. PEI prevalence was 29.3% and mortality was 10.9%. Most frequent causes of death were cancer (40.4%), infection (21.3%), and acute cardiovascular event (14.9%). Multivariate analyses showed associations between increased mortality and presence of PEI [hazard ratio (HR), 2.59; 95% confidence interval (CI), 1.42-4.71; P<0.003], liver cirrhosis (HR, 3.87; 95% CI, 1.95-7.69; P<0.001), age at diagnosis (HR, 1.05; 95% CI, 1.03-1.09; P<0.001), toxic etiology of CP (HR, 3.11; 95% CI, 1.11-8.70; P<0.05) and respiratory comorbidity (HR, 2.19; 95% CI, 1.12-4.31; P<0.03). Nutritional markers were significantly lower in patients with PEI versus those without PEI (P<0.001) and in those who died versus survivors (P<0.001). CONCLUSIONS PEI was a significant independent risk factor for mortality in patients with CP. These results support further research into the optimal treatment of PEI to reduce mortality in this population.
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Pekar J, Ret D, Untersmayr E. Stability of allergens. Mol Immunol 2018; 100:14-20. [PMID: 29606336 PMCID: PMC6020993 DOI: 10.1016/j.molimm.2018.03.017] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 02/07/2023]
Abstract
For proteins to cause IgE-mediated allergic reactions, several common characteristics have to be defined, including small molecular size, solubility and stability to changing pH levels and enzymatic degradation. Nevertheless, these features are not unique for potent allergens, but are also observed in non-allergenic proteins. Due to the increasing awareness by regulatory authorities regarding the allergy pandemic, definition of characteristics unique to potent allergens would facilitate allergenicity assessment in the future. Despite major research efforts even to date the features unique for major allergens have not been elucidated so far. The route of allergen entry into the organism determines to a great extent these required characteristics. Especially orally ingested allergens are exposed to the harsh milieu of the gastrointestinal tract but might additionally be influenced by food processing. Depending on molecular properties such as disulphide bonds contributing to protein fold and formation of conformational IgE epitopes, posttranslational protein modification or protein food matrix interactions, enzymatic and thermal stability might differ between allergens. Moreover, also ligand binding influences structural stability. In the current review article, we aim at highlighting specific characteristics and molecular pattern contributing to a stabilized protein structure and overall allergenicity.
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Affiliation(s)
- Judith Pekar
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, 1090 Vienna, Austria
| | - Davide Ret
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, 1090 Vienna, Austria; Division of Macromolecular Chemistry, Institute of Applied Synthetic Chemistry, Vienna University of Technology, 1060 Vienna, Austria
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, 1090 Vienna, Austria.
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Vanga RR, Tansel A, Sidiq S, El-Serag HB, Othman M. Diagnostic Performance of Measurement of Fecal Elastase-1 in Detection of Exocrine Pancreatic Insufficiency: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:1220-1228.e4. [PMID: 29374614 PMCID: PMC6402774 DOI: 10.1016/j.cgh.2018.01.027] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 01/13/2018] [Accepted: 01/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Tests to quantify fecal levels of chymotrypsin like elastase family member 3 (CELA3 or elastase-1) in feces are widely used to identify patients with exocrine pancreatic insufficiency (EPI). However, the diagnostic accuracy of this test, an ELISA, is not clear. We performed a systematic review and meta-analysis to determine the accuracy of measurement of fecal elastase-1 in detection of EPI. METHODS We searched PubMed, Embase, and reference lists for articles through November 2016 describing studies that compared fecal level of elastase-1 with results from a reference standard, direct method (secretin stimulation test), or indirect method (measurement of fecal fat) for detection of EPI. Sensitivity and specificity values were pooled statistically using bivariate diagnostic meta-analysis. RESULTS We included total of 428 cases of EPI and 673 individuals without EPI (controls), from 14 studies, in the meta-analysis. The assay for elastase-1, compared to secretin stimulation test, identified patients with pancreatic insufficiency with a pooled sensitivity value of 0.77 (95% CI, 0.58-0.89) and specificity value of 0.88 (95% CI, 0.78-0.93). In an analysis of 345 cases of EPI and 312 controls, from 6 studies, the fecal elastase-1 assay identified patients with EPI with a pooled sensitivity value of 0.96 (95% CI, 0.79-0.99) and specificity value of 0.88 (95% CI, 0.59-0.97), compared to quantitative fecal fat estimation. In patients with low pre-test probability of EPI (5%), the fecal elastase-1 assay would have a false-negative rate of 1.1% and a false-positive rate of 11%, indicating a high yield in ruling out EPI but not in detection of EPI. In contrast, in patients with high pre-test probability of EPI (40%), approximately 10% of patients with EPI would be missed (false negatives). CONCLUSIONS In a systematic review and meta-analysis of studies that compared fecal level of elastase-1 for detection of EPI, we found that normal level of elastase-1 (above 200 mcg/g) can rule out EPI in patients with a low probability of this disorder (such as those with irritable bowel syndrome with diarrhea). However, in these patients, an abnormal level of elastase-1 (below 200 mcg/g) has a high false-positive rate.
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Affiliation(s)
- Rohini R. Vanga
- Section of Gastroenterology and Hepatology, Department of
Medicine, Baylor College of Medicine, Houston, TX
| | - Aylin Tansel
- Section of Gastroenterology and Hepatology, Department of
Medicine, Baylor College of Medicine, Houston, TX
| | | | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of
Medicine, Baylor College of Medicine, Houston, TX,Center for Innovations in Quality, Effectiveness, and
Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX,Section of Gastroenterology and Hepatology, Michael E.
DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Mohamed Othman
- Section of Gastroenterology and Hepatology, Department of
Medicine, Baylor College of Medicine, Houston, TX
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Qualitative Assessment of the Symptoms and Impact of Pancreatic Exocrine Insufficiency (PEI) to Inform the Development of a Patient-Reported Outcome (PRO) Instrument. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 10:615-628. [PMID: 28332032 PMCID: PMC5605612 DOI: 10.1007/s40271-017-0233-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) affects patients with chronic pancreatitis (CP) and cystic fibrosis (CF) who produce insufficient digestive pancreatic enzymes. Common symptoms include steatorrhoea, diarrhea, and abdominal pain. OBJECTIVE The objective of the study was to develop and test the content validity of a patient-reported outcome (PRO) instrument assessing PEI symptoms and their impact on health-related quality of life. METHODS Instrument development was supported by a literature review, expert physician interviews (n = 10: Germany 4, UK 3, France 3), and exploratory, qualitative, concept-elicitation interviews with patients with CF and CP with PEI (n = 61: UK 29, Germany 18, France 14) and expert physicians (n = 10). Cognitive debriefing of the draft instrument was then performed with patients with PEI (n = 37: UK 24, Germany 8, France 5), and feasibility was assessed with physicians (n = 3). For all interviews, verbatim transcripts were qualitatively analysed using thematic analysis methods and Atlas.ti computerized qualitative software. All themes were data driven rather than a priori. RESULTS Patient interviews elicited symptoms and impacts not reported in the literature. Six symptom concepts emerged: pain, bloating, bowel symptoms, nausea/vomiting, eating problems, and tiredness/fatigue. Six impact domains were also identified. A 45-item instrument was developed in English, French, and German for testing in cognitive debriefing patient interviews. Following cognitive debriefing, 18 items were deleted. CONCLUSION Rigorous qualitative patient research and expert clinical input supported development of a PEI-specific PRO with the potential to aid management and monitoring of unmet needs among patients with PEI. The next step is to perform psychometric evaluation of the resulting instrument.
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Wu W, Lin L, Lin Z, Yang W, Cai Z, Hong J, Qiu J, Lin C, Lin N, Wang Y. Duodenum Exclusion Alone Is Sufficient to Improve Glucose Metabolism in STZ-Induced Diabetes Rats. Obes Surg 2018; 28:3087-3094. [DOI: 10.1007/s11695-018-3291-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Purpose Chronic pancreatitis (CP) can cause fat or bile acid malabsorption due to exocrine insufficiency. Fat or bile acid malabsorption has been reported to increase the risk of urolithiasis through increased intestinal oxalate absorption. However, no studies have reported an association between CP and urolithiasis. Methods We identified 15,848 patients (age: ≥20 years) diagnosed as having CP between 2000 and 2010 from the National Health Insurance Research Database as the study cohort. Beneficiaries without a history of CP were randomly selected and propensity-matched with the study cohort in a 1:4 ratio according to age; sex; comorbidities of hyperlipidemia, diabetes, obesity, hypertension, chronic obstructive pulmonary disease, alcohol-related illness, stroke, and coronary artery disease; and the index date. The prevalence of inflammatory bowel disease (0.44%), hyperparathyroidism (0.10%), or end stage renal disease (1.55%) in CP patients was low, but these comorbidities were also considered in the analysis. All patients were followed until the end of 2011 or withdrawal from the National Health Insurance program to determine the incidence of urolithiasis. Results The cumulative incidence of urolithiasis was higher in the CP cohort than that in the non-CP cohort (log-rank test, P < 0.001) with a 1.89-fold risk of urolithiasis (95% confidence interval [CI] = 1.74–2.06). The prevalence of CP was higher in men (81.9%) and in patients younger than 49 years (63.5%; mean age: 48.5 ± 15.3 years). CP was associated with the development of urolithiasis in each age group (≤49 years: aHR = 2.00, 95% CI = 1.81–2.22; 50–64 years: aHR = 1.71, 95% CI = 1.40–2.09; ≥65 years: aHR = 1.54, 95% CI = 1.20–1.98) and each sex (women: aHR = 2.10, 95% CI = 1.67–2.66; men; aHR = 1.86, 95% CI = 1.70–2.04). Among the patients without comorbidities, the rate of urolithiasis increased from 2.93/1,000 person-years in non-CP patients to 8.28/1,000 person-years in CP patients. Among the patients with comorbidities, the rate of urolithiasis increased from 6.12/1,000 person-years in non-CP patients to 10.9/1,000 person-years in CP patients. The contribution of CP to the relative risk of urolithiasis was greater in patients without comorbidities (without comorbidities: aHR = 2.81, 95% CI = 2.30–3.44) than in those with comorbidities (aHR = 1.76, 95% CI = 1.61–1.94). Conclusion CP is associated with urolithiasis in this population-based cohort study. The contribution of CP to the relative risk of urolithiasis was even greater in patients with a lower risk of urolithiasis, such as those without other comorbidities. Our findings warrant a survey and education on urolithiasis for patients with CP.
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Affiliation(s)
- Chien-Hua Chen
- Digestive Disease Center, Show-Chwan Memorial Hospital, Changhua, Taiwan
- Digestive Disease Center, Changbing Show-Chwan Memorial Hospital, Lukang Township, Changhua County, Taiwan
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan
- Chung Chou University of Science and Technology, Yuanlin Township, Changhua County, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Long-Bin Jeng
- Graduate Institute of Clinical Medical Science, School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Surgery, Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
- * E-mail:
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Nofal YH, Abu Dail Y, Assaf Y, Abo Samra H, Abbas F, Hamzeh A, Alhaj Hasan N. Pancreatic enzyme replacement therapy for steatorrhoea in pancreatic cancer. Cochrane Database Syst Rev 2018; 2018:CD012952. [PMCID: PMC6491113 DOI: 10.1002/14651858.cd012952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To evaluate the efficacy of PERT for the treatment of steatorrhoea in people with pancreatic cancer by accessing whether it: reduces the severity and duration of common symptoms, including fatty (greasy or oily appearance and residue), foul‐smelling, pale‐coloured, and heavy stools (bulky and difficult‐to‐flush), which are usually associated with weight loss and nutritional deficiencies as a result of fat malabsorption and the concomitant malabsorption of amino acids and vitamins, and abdominal pain or cramps (Cheifetz 2011 ; Kasper 2015 ); is an acceptable treatment, as assessed by the number of side effects/adverse events, study dropout rates, and participant satisfaction levels; has an impact on chemotherapy adherence; has an impact on postoperative outcomes.
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Affiliation(s)
- Yazan H Nofal
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Yaser Abu Dail
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Yazan Assaf
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Hayan Abo Samra
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Fatima Abbas
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Ammar Hamzeh
- Damascus UniversityFaculty of MedicineAl MazzehDamascusSyrian Arab Republic00963
| | - Nahla Alhaj Hasan
- IRC: International Rescue CommitteeHealth servicesMalikiehSyrian Arab Republic
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Durie P, Baillargeon JD, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin 2018; 34:25-33. [PMID: 28985688 DOI: 10.1080/03007995.2017.1389704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release. PURPOSE To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI. METHODS For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? FINDINGS The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist. CONCLUSIONS In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.
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Affiliation(s)
- P Durie
- a Hospital for Sick Children and University of Toronto , Toronto , ON , Canada
| | - J-D Baillargeon
- b Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke , Sherbrooke , QC , Canada
| | - S Bouchard
- c Centre Hospitalier de l'Université de Montréal , Montréal , QC , Canada
| | - F Donnellan
- d Vancouver General Hospital , Vancouver , BC , Canada
| | | | - C Teshima
- f St. Michael's Hospital and University of Toronto , Toronto , ON , Canada
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Pluschke AM, Jochems PGM, Williams BA, Gidley MJ. Protection of α-amylase from proteolysis by adsorption to feed components in vitro and in the porcine small intestine. ANIMAL PRODUCTION SCIENCE 2018. [DOI: 10.1071/an15765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The interactions between digestive enzymes and non-substrate feed components, and the impacts these have on enzyme activity, have rarely been studied. The aim of the present study was to determine the ability of granular wheat starch and whole porcine diets to protect porcine pancreatic α-amylase from proteolysis by trypsin both in vitro and in vivo. Granular wheat starch protected α-amylase from degradation in vitro by adsorbing trypsin and reducing its proteolytic activity. This protection was also found for a complete pig diet and corresponded to undetectable soluble-trypsin activity in the presence of the diet. Pancreatic α-amylase from small intestinal digesta of pigs was active from the duodenum to the ileum (~200–330 U/mL) irrespective of the addition of a protease inhibitor immediately after sampling, most likely due to binding with other food components protecting it from proteolysis. We conclude that non-specific binding between pancreatic digestive enzymes and food components may be competitive with enzyme–substrate complex formation, and therefore important in determining differences in the rate of digestion of macronutrients along the small intestine.
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89
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Pancreatic Exocrine Insufficiency after Bariatric Surgery. Nutrients 2017; 9:nu9111241. [PMID: 29137169 PMCID: PMC5707713 DOI: 10.3390/nu9111241] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/08/2017] [Accepted: 11/10/2017] [Indexed: 12/14/2022] Open
Abstract
Morbid obesity is a lifelong disease, and all patients require complementary follow-up including nutritional surveillance by a multidisciplinary team after bariatric procedures. Pancreatic exocrine insufficiency (PEI) refers to an insufficient secretion of pancreatic enzymes and/or sodium bicarbonate. PEI is a known multifactorial complication after upper gastrointestinal surgery, and might constitute an important clinical problem due to the large number of bariatric surgical procedures in the world. Symptoms of PEI often overlap with sequelae of gastric bypass, making the diagnosis difficult. Steatorrhea, weight loss, maldigestion and malabsorption are pathognomonic for both clinical conditions. Altered anatomy after bypass surgery can make the diagnostic process even more difficult. Fecal elastase-1 (FE1) is a useful diagnostic test. PEI should be considered in all patients after bariatric surgery with prolonged gastrointestinal complaints that are suggestive of maldigestion and/or malabsorption. Appropriate pancreatic enzyme replacement therapy should be part of the treatment algorithm in patients with confirmed PEI or symptoms suggestive of this complication.
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Gan C, Chen YH, Liu L, Gao JH, Tong H, Tang CW, Liu R. Efficacy and safety of pancreatic enzyme replacement therapy on exocrine pancreatic insufficiency: a meta-analysis. Oncotarget 2017; 8:94920-94931. [PMID: 29212278 PMCID: PMC5706924 DOI: 10.18632/oncotarget.21659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/21/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pancreatic enzyme replacement therapy (PERT) is widely applied to patients with exocrine pancreatic insufficiency (EPI), but its effect and safety has not been quantified. Therefore we performed a meta-analysis to determine the efficacy and tolerance of PERT on patients with EPI. MATERIALS AND METHODS PubMed, Medline, Cochrane library database, Evidence-based medicine/clinical trials published before December 2016 were searched by two independent reviewers to identify prospective randomized controlled trials (RCTs). RESULTS Seven RCTs, randomizing a total of 282 patients, were filtrated and assessed qualitatively (Jadad score). PERT increased CFA (WMD: 26.56, 20.35 to 32.76, I2= 79.6%, P < 0.001) compared with baseline, and CFA (WMD: 17.97, 12.61 to 23.34, I2 = 76.7%, P < 0.001) vs. placebo. Meanwhile, CNA, SFE, SNE and SW were significantly improved in PERT compared with baseline and placebo, with no statistical differences in adverse events. Subgroup analysis indicated that standard forms of PERT displayed more effectiveness with significantly decreased heterogeneity, and large sample size also reduced the heterogeneity to some degree. CONCLUSIONS PERT is demonstrated to be effective and tolerable in patients with EPI, especially using standard administration of PERT. Larger and higher quality studies on EPI are demanded to long-term effect of standard PERT treatment.
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Affiliation(s)
- Can Gan
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Hua Chen
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Liu
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Hang Gao
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Huan Tong
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng-Wei Tang
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Liu
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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91
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Singh VK, Schwarzenberg SJ. Pancreatic insufficiency in Cystic Fibrosis. J Cyst Fibros 2017; 16 Suppl 2:S70-S78. [DOI: 10.1016/j.jcf.2017.06.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022]
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92
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Poquet L, Wooster TJ. Infant digestion physiology and the relevance of in vitro biochemical models to test infant formula lipid digestion. Mol Nutr Food Res 2017; 60:1876-95. [PMID: 27279140 DOI: 10.1002/mnfr.201500883] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/05/2016] [Accepted: 05/31/2016] [Indexed: 01/30/2023]
Abstract
Lipids play an important role in the diet of preterm and term infants providing a key energy source and essential lipid components for development. While a lot is known about adult lipid digestion, our understanding of infant digestion physiology is still incomplete, the greatest gap being on the biochemistry of the small intestine, particularly the activity and relative importance of the various lipases active in the intestine. The literature has been reviewed to identify the characteristics of lipid digestion of preterm and term infants, but also to better understand the physiology of the infant gastrointestinal tract compared to adults that impacts the absorption of lipids. The main differences are a higher gastric pH, submicellar bile salt concentration, a far more important role of gastric lipases as well as differences at the level of the intestinal barrier. Importantly, the consequences of improper in vitro replication of gastric digestions conditions (pH and lipase specificity) are demonstrated using examples from the most recent of studies. It is true that some animal models could be adapted to study infant lipid digestion physiology, however the ethical relevance of such models is questionable, hence the development of accurate in vitro models is a must. In vitro models that combine up to date knowledge of digestion biochemistry with intestinal cells in culture are the best choice to replicate digestion and absorption in infant population, this would allow the adaptation of infant formula for a better digestion and absorption of dietary lipids by preterm and term infants.
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Affiliation(s)
- Laure Poquet
- Nestlé Research Center, Vers-Chez-Les-Blanc, Lausanne 26, Switzerland
| | - Tim J Wooster
- Nestlé Research Center, Vers-Chez-Les-Blanc, Lausanne 26, Switzerland
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93
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Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 2017; 23:7059-7076. [PMID: 29093615 PMCID: PMC5656454 DOI: 10.3748/wjg.v23.i39.7059] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 05/27/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases (diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin (CCK); celiac or inflammatory bowel disease (IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery (asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy (PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI (66%-92%). EPI occurs in patients with type 1 (26%-57%) or type 2 diabetes (20%-36%) and is typically mild to moderate; by definition, all patients with type 3c (pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease (4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD (14%-74%) and up to 100% of gastrointestinal surgery patients (47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Mark E Haupt
- Medical Affairs, AbbVie Inc., North Chicago, IL 60064, United States
| | - David E Geller
- Cystic Fibrosis Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
| | - Jerry A Hall
- CREON® Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
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DALLAS DAVIDC, SANCTUARY MEGANR, QU YUNYAO, KHAJAVI SHABNAMHAGHIGHAT, VAN ZANDT ALEXANDRIAE, DYANDRA MELISSA, FRESE STEVENA, BARILE DANIELA, GERMAN JBRUCE. Personalizing protein nourishment. Crit Rev Food Sci Nutr 2017; 57:3313-3331. [PMID: 26713355 PMCID: PMC4927412 DOI: 10.1080/10408398.2015.1117412] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Proteins are not equally digestible-their proteolytic susceptibility varies by their source and processing method. Incomplete digestion increases colonic microbial protein fermentation (putrefaction), which produces toxic metabolites that can induce inflammation in vitro and have been associated with inflammation in vivo. Individual humans differ in protein digestive capacity based on phenotypes, particularly disease states. To avoid putrefaction-induced intestinal inflammation, protein sources, and processing methods must be tailored to the consumer's digestive capacity. This review explores how food processing techniques alter protein digestibility and examines how physiological conditions alter digestive capacity. Possible solutions to improving digestive function or matching low digestive capacity with more digestible protein sources are explored. Beyond the ileal digestibility measurements of protein digestibility, less invasive, quicker and cheaper techniques for monitoring the extent of protein digestion and fermentation are needed to personalize protein nourishment. Biomarkers of protein digestive capacity and efficiency can be identified with the toolsets of peptidomics, metabolomics, microbial sequencing and multiplexed protein analysis of fecal and urine samples. By monitoring individual protein digestive function, the protein component of diets can be tailored via protein source and processing selection to match individual needs to minimize colonic putrefaction and, thus, optimize gut health.
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Affiliation(s)
- DAVID C. DALLAS
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - MEGAN R. SANCTUARY
- Foods for Health Institute, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Department of Nutrition, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - YUNYAO QU
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - SHABNAM HAGHIGHAT KHAJAVI
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Department of Food Science and Technology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - ALEXANDRIA E. VAN ZANDT
- Department of Nutrition, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - MELISSA DYANDRA
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - STEVEN A. FRESE
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - DANIELA BARILE
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
| | - J. BRUCE GERMAN
- Department of Food Science and Technology, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
- Foods for Health Institute, University of California, Davis, One Shields Avenue, Davis, CA 95616, United States
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Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, Manta R, Dioscoridi L. Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification. Dig Dis Sci 2017; 62:2648-2657. [PMID: 28780610 DOI: 10.1007/s10620-017-4697-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention. AIM To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature. METHODS We performed an extensive review of the literature on pancreatic fistulae and leaks. RESULTS In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment. CONCLUSIONS A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.
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Affiliation(s)
- Massimiliano Mutignani
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Stefanos Dokas
- Endoscopy Department, St Lukes Private Hospital, 55236, Panorama, Thessaloníki, Greece.
| | - Alberto Tringali
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Francesco Pugliese
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Marcello Cintolo
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Raffaele Manta
- Digestive Endoscopy Unit, Nuovo Ospedale Civile S. Agostino Estense di Baggiovara, Via Pietro Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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96
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Nikfarjam M, Wilson JS, Smith RC. Diagnosis and management of pancreatic exocrine insufficiency. Med J Aust 2017; 207:161-165. [PMID: 28814218 DOI: 10.5694/mja16.00851] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION 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.
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Affiliation(s)
| | - Jeremy S Wilson
- South Western Sydney Clinical School, Liverpool Hospital, UNSW, Sydney, NSW
| | - Ross C Smith
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW
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de la Iglesia-García D, Huang W, Szatmary P, Baston-Rey I, Gonzalez-Lopez J, Prada-Ramallal G, Mukherjee R, Nunes QM, Domínguez-Muñoz JE, Sutton R. Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut 2017; 66:1354-1355. [PMID: 27941156 PMCID: PMC5530474 DOI: 10.1136/gutjnl-2016-312529] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 11/06/2016] [Accepted: 11/18/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The benefits of pancreatic enzyme replacement therapy (PERT) in chronic pancreatitis (CP) are inadequately defined. We have undertaken a systematic review and meta-analysis of randomised controlled trials of PERT to determine the efficacy of PERT in exocrine pancreatic insufficiency (EPI) from CP. DESIGN Major databases were searched from 1966 to 2015 inclusive. The primary outcome was coefficient of fat absorption (CFA). Effects of PERT versus baseline and versus placebo, and of different doses, formulations and schedules were determined. RESULTS A total of 17 studies (511 patients with CP) were included and assessed qualitatively (Jadad score). Quantitative data were synthesised from 14 studies. PERT improved CFA compared with baseline (83.7±6.0 vs 63.1±15.0, p<0.00001; I2=89%) and placebo (83.2±5.5 vs 67.4±7.0, p=0.0001; I2=86%). PERT improved coefficient of nitrogen absorption, reduced faecal fat excretion, faecal nitrogen excretion, faecal weight and abdominal pain, without significant adverse events. Follow-up studies demonstrated that PERT increased serum nutritional parameters, improved GI symptoms and quality of life without significant adverse events. High-dose or enteric-coated enzymes showed a trend to greater effectiveness than low-dose or non-coated comparisons, respectively. Subgroup, sensitive and meta-regression analyses revealed that sample size, CP diagnostic criteria, study design and enzyme dose contributed to heterogeneity; data on health inequalities were lacking. CONCLUSIONS PERT is indicated to correct EPI and malnutrition in CP and may be improved by higher doses, enteric coating, administration during food and acid suppression. Further studies are required to determine optimal regimens, the impact of health inequalities and long-term effects on nutrition.
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Affiliation(s)
- Daniel de la Iglesia-García
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK,Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Compostela, Spain
| | - Wei Huang
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK,Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Peter Szatmary
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK
| | - Iria Baston-Rey
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Compostela, Spain
| | - Jaime Gonzalez-Lopez
- Department of Pharmacy, University Hospital of Santiago de Compostela, Compostela, Spain
| | - Guillermo Prada-Ramallal
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Compostela, Spain
| | - Rajarshi Mukherjee
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK
| | - Quentin M Nunes
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK
| | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Compostela, Spain
| | - Robert Sutton
- NIHR Liverpool Pancreas Biomedical Research Unit, Royal Liverpool University Hospital, University of Liverpool, Liverpool, UK
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Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. World J Gastroenterol 2017; 23:4689-4700. [PMID: 28765690 PMCID: PMC5514634 DOI: 10.3748/wjg.v23.i26.4689] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023] Open
Abstract
Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.
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Janssens PMW. Recognizing and differentiating uncommon body fluids: Considerations and tools for a proper practical approach. Clin Chim Acta 2017; 471:6-11. [PMID: 28495388 DOI: 10.1016/j.cca.2017.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/05/2017] [Accepted: 05/06/2017] [Indexed: 11/17/2022]
Abstract
Clinical laboratories are regularly requested to inspect uncommon body fluids obtained from patients because clinicians are uncertain as to the origin of the collected material. They may need this information for the actual diagnosis, to confirm a supposition, or for guiding treatment and invasive operations like draining and puncturing. Often there is also a need to know more precisely what is going on in the cavity that gave rise to the fluid, for instance a local infection or metastasis, or whether the cavity is connected to organs or fluid compartments nearby etcetera. The results of the laboratory investigations often have () direct consequences. As the investigation of uncommon body fluids is distinct from routine laboratory analyses it requires special attention. This paper presents an overview of the characteristics of uncommon human body fluids, constituents useful as markers for recognizing and differentiating fluids and considerations that have to be taken into account when interpreting the results of analyses. In addition a number of practical recommendations for approaching the task of identifying uncommon body fluids are given.
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Affiliation(s)
- Pim M W Janssens
- Laboratory of Clinical Chemistry and Haematology, Rijnstate Hospital, P.O. Box 9555, 6800 TA Arnhem, The Netherlands.
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100
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A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review. Am J Gastroenterol 2017; 112:537-554. [PMID: 28139655 PMCID: PMC5659272 DOI: 10.1038/ajg.2016.610] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/01/2016] [Indexed: 12/11/2022]
Abstract
In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.
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