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Iyer S, Enman M, Sahay P, Dudeja V. Novel therapeutics to treat chronic pancreatitis: targeting pancreatic stellate cells and macrophages. Expert Rev Gastroenterol Hepatol 2024; 18:171-183. [PMID: 38761167 DOI: 10.1080/17474124.2024.2355969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Chronic pancreatitis (CP) is a persistent, recurrent, and progressive disorder that is characterized by chronic inflammation and irreversible fibrosis of the pancreas. It is associated with severe morbidity, resulting in intense abdominal pain, diabetes, exocrine and endocrine dysfunction, and an increased risk of pancreatic cancer. The etiological factors are diverse and the major risk factors include smoking, chronic alcoholism, as well as other environmental and genetic factors. The treatment and management of CP is challenging, and no definitive curative therapy is currently available. AREAS COVERED This review paper aims to provide an overview of the different cell types in the pancreas that is known to mediate disease progression and outline potential novel therapeutic approaches and drug targets that may be effective in treating and managing CP. The information presented in this review was obtained by conducting a NCBI PubMed database search, using relevant keywords. EXPERT OPINION In recent years, there has been an increased interest in the development of novel therapeutics for CP. A collaborative multi-disciplinary approach coupled with a consistent funding for research can expedite progress of translating the findings from bench to bedside.
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Affiliation(s)
- Srikanth Iyer
- Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Macie Enman
- Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Preeti Sahay
- Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Vikas Dudeja
- Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
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Cúrdia Gonçalves T, Capela TL, Cotter J. Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:1-13. [PMID: 38314032 PMCID: PMC10836866 DOI: 10.1159/000530835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/12/2023] [Indexed: 02/06/2024]
Abstract
While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.
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Affiliation(s)
- Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Whitcomb DC, Buchner AM, Forsmark CE. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency: Expert Review. Gastroenterology 2023; 165:1292-1301. [PMID: 37737818 DOI: 10.1053/j.gastro.2023.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/18/2023] [Accepted: 07/04/2023] [Indexed: 09/23/2023]
Abstract
DESCRIPTION Exocrine pancreatic insufficiency (EPI) is a disorder caused by the failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine, leading to the maldigestion of nutrients and macronutrients, resulting in their variable deficiencies. EPI is frequently underdiagnosed and, as a result, patients are often not treated appropriately. There is an urgent need to increase awareness of and treatment for this condition. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to provide Best Practice Advice on the epidemiology, evaluation, and management of EPI. METHODS This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: EPI should be suspected in patients with high-risk clinical conditions, such as chronic pancreatitis, relapsing acute pancreatitis, pancreatic ductal adenocarcinoma, cystic fibrosis, and previous pancreatic surgery. BEST PRACTICE ADVICE 2: EPI should be considered in patients with moderate-risk clinical conditions, such as duodenal diseases, including celiac and Crohn's disease; previous intestinal surgery; longstanding diabetes mellitus; and hypersecretory states (eg, Zollinger-Ellison syndrome). BEST PRACTICE ADVICE 3: Clinical features of EPI include steatorrhea with or without diarrhea, weight loss, bloating, excessive flatulence, fat-soluble vitamin deficiencies, and protein-calorie malnutrition. BEST PRACTICE ADVICE 4: Fecal elastase test is the most appropriate initial test and must be performed on a semi-solid or solid stool specimen. A fecal elastase level <100 μg/g of stool provides good evidence of EPI, and levels of 100-200 μg/g are indeterminate for EPI. BEST PRACTICE ADVICE 5: Fecal elastase testing can be performed while on pancreatic enzyme replacement therapy. BEST PRACTICE ADVICE 6: Fecal fat testing is rarely needed and must be performed when on a high-fat diet. Quantitative testing is generally not practical for routine clinical use. BEST PRACTICE ADVICE 7: Response to a therapeutic trial of pancreatic enzymes is unreliable for EPI diagnosis. BEST PRACTICE ADVICE 8: Cross-sectional imaging methods (computed tomography scan, magnetic resonance imaging, and endoscopic ultrasound) cannot identify EPI, although they play an important role in the diagnosis of benign and malignant pancreatic disease. BEST PRACTICE ADVICE 9: Breath tests and direct pancreatic function tests hold promise, but are not widely available in the United States. BEST PRACTICE ADVICE 10: Once EPI is diagnosed, treatment with pancreatic enzyme replacement therapy (PERT) is required. If EPI is left untreated, it will result in complications related to fat malabsorption and malnutrition, having a negative impact on quality of life. BEST PRACTICE ADVICE 11: PERT formulations are all derived from porcine sources and are equally effective at equivalent doses. There is a need for H2 or proton pump inhibitor therapy with non-enteric-coated preparations. BEST PRACTICE ADVICE 12: PERT should be taken during the meal, with the initial treatment of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks. The subsequent dosage can be adjusted based on the meal size and fat content. BEST PRACTICE ADVICE 13: Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate. Dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets. BEST PRACTICE ADVICE 14: Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels. BEST PRACTICE ADVICE 15: EPI should be monitored and baseline measurements of nutritional status should be obtained (body mass index, quality-of-life measure, and fat-soluble vitamin levels). A baseline dual-energy x-ray absorptiometry scan should be obtained and repeated every 1-2 years.
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Affiliation(s)
- David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anna M Buchner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
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Jalal M, Leeds JS, Ching HL, Oprescu A, Tunbridge A, Greig J, Tesfaye S, Hopper AD. Are we missing pancreatic exocrine insufficiency in 'at-risk' groups? Prospective assessment of the current practice and yield of faecal elastase testing in patients with diabetes mellitus, HIV and/or high alcohol intake. Clin Med (Lond) 2023; 23:588-593. [PMID: 38065607 PMCID: PMC11046658 DOI: 10.7861/clinmed.2023-0185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
There is cumulative evidence that pancreatic exocrine insufficiency (PEI) is under-recognised and can occur in patients with 'at-risk' conditions. Thus, we aimed to assess the current practice and yield of requesting faecal elastase (FEL-1), an indicator of PEI, in patients with 'at-risk' conditions. We prospectively recruited patients attending secondary care clinics with diabetes mellitus (DM), people living with HIV (PLHIV) and inpatients admitted to hospital with high alcohol intake (HAI). All patients underwent testing with FEL-1. Those patients with PEI (FEL-1 <200 μg/g) were contacted and offered a follow-up review in gastroenterology clinic. In total, 188 patients were recruited (HAI, n=78; DM, n=64; and PLHIV, n=46). Previous FEL-1 testing had not been performed in any of the patients. The return rate of samples was 67.9% for patients with HAI, 76.6% for those with DM and 56.5% for those with PLHIV. The presence of PEI was shown in 20.4% of patients with DM, 15.4% of patients with PLHIV and 22.6% in those with HAI. Diarrhoea and bloating were the most reported symptoms in followed-up patients with low FEL-1 (31.8% and 22.7% of patients, respectively). Follow-up computed tomography (CT) scans in those patients with PEI identified chronic pancreatitis changes in 13.6% and pancreatic atrophy in 31.8% of patients. These results suggest that there is a lack of testing for PEI in 'at-risk' groups. Our findings also suggest that using FEL-1 to test for PEI in patients with DM, PLHIV and HAI has a significant impact, although further studies are required to validate these findings.
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Affiliation(s)
- Mustafa Jalal
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, and consultant gastreoenterologist, Royal Bournemouth Hospital, Bournemouth, UK
| | - John S Leeds
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Hey-Long Ching
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrei Oprescu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ann Tunbridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Greig
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew D Hopper
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, and University of Sheffield, Sheffield, UK
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Maydeo A, Kamat N, Dalal A, Patil G. Advances in the Management of Pain in Chronic Pancreatitis. Curr Gastroenterol Rep 2023; 25:260-266. [PMID: 37713043 DOI: 10.1007/s11894-023-00898-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP. RECENT FINDINGS Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.
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Affiliation(s)
- Amit Maydeo
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004.
| | - Nagesh Kamat
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
| | - Ankit Dalal
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
| | - Gaurav Patil
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
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Shestakova MV, Maev IV, Ametov AS, Antsiferov MB, Bordin DS, Galstyan GR, Dzgoeva FK, Kucheryavyy YA, Mkrtumyan AM, Nikonova TV, Pashkova EY. Pancreatic exocrine insufficiency in diabetes mellitus. DIABETES MELLITUS 2023; 26. [DOI: 10.14341/dm13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).
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Affiliation(s)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - A. S. Ametov
- Russian Medical Academy of Continuous Professional Education
| | - M. B. Antsiferov
- Endocrinological Dispensary of the Moscow City Health Department
| | - D. S. Bordin
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre; Tver State Medical University
| | | | | | | | - A. M. Mkrtumyan
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre
| | | | - E. Y. Pashkova
- Russian Medical Academy of Continuous Professional Education; Botkin Hospital
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Shestakova MV, Maev IV, Ametov AS, Antsiferov MB, Bordin DS, Galstyan GR, Dzgoeva FK, Kucheryavyy YA, Mkrtumyan AM, Nikonova TV, Pashkova EY. Pancreatic exocrine insufficiency in diabetes mellitus. DIABETES MELLITUS 2023; 26. [DOI: https:/doi.org/10.14341/dm13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).
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Affiliation(s)
| | - I. V. Maev
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - A. S. Ametov
- Russian Medical Academy of Continuous Professional Education
| | - M. B. Antsiferov
- Endocrinological Dispensary of the Moscow City Health Department
| | - D. S. Bordin
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre; Tver State Medical University
| | | | | | | | - A. M. Mkrtumyan
- A.I. Yevdokimov Moscow State University of Medicine and Dentistry; A.S. Loginov Moscow Clinical Scientific Centre
| | | | - E. Y. Pashkova
- Russian Medical Academy of Continuous Professional Education; Botkin Hospital
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de Rijk FEM, van Veldhuisen CL, Besselink MG, van Hooft JE, van Santvoort HC, van Geenen EJM, van Werkhoven CH, de Jonge PJF, Bruno MJ, Verdonk RC. Implementation of an evidence-based management algorithm for patients with chronic pancreatitis (COMBO trial): study protocol for a stepped-wedge cluster-randomized controlled trial. Trials 2023; 24:18. [PMID: 36611202 PMCID: PMC9824955 DOI: 10.1186/s13063-022-07044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is an inflammatory disease that may be complicated by abdominal pain, pancreatic dysfunction, nutritional deficiencies, and diminished bone density. Importantly, it is also associated with a substantially impaired quality of life and reduced life expectancy. This may partly be explained by suboptimal treatment, in particular the long-term management of this chronic condition, despite several national and international guidelines. Standardization of care through a structured implementation of guideline recommendations may improve the level of care and lower the complication rate of these patients. Therefore, the aim of the present study is to evaluate to what extent patient education and standardization of care, through the implementation of an evidence-based integrated management algorithm, improve quality of life and reduce pain severity in patients with CP. METHODS The COMBO trial is a nationwide stepped-wedge cluster-randomized controlled trial. In a stepwise manner, 26 centers, clustered in 6 health regions, cross-over from current practice to care according to an evidence-based integrated management algorithm. During the current practice phase, study participants are recruited and followed longitudinally through questionnaires. Individual patients contribute data to both study periods. Co-primary study endpoints consist of quality of life (assessed by the PANQOLI score) and level of pain (assessed by the Izbicki questionnaire). Secondary outcomes include process measure outcomes, clinical outcomes (e.g., pancreatic function, nutritional status, bone health, interventions, medication use), utilization of healthcare resources, (in) direct costs, and the level of social participation. Standard follow-up is 35 months from the start of the trial. DISCUSSION This is the first stepped-wedge cluster-randomized controlled trial to investigate whether an evidence-based integrated therapeutic approach improves quality of life and pain severity in patients with CP as compared with current practice. TRIAL REGISTRATION ISRCTN, ISRCTN13042622. Registered on 5 September 2020.
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Affiliation(s)
- Florence E. M. de Rijk
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands ,grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Charlotte L. van Veldhuisen
- grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Marc G. Besselink
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hjalmar C. van Santvoort
- grid.415960.f0000 0004 0622 1269Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.7692.a0000000090126352Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erwin J. M. van Geenen
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis H. van Werkhoven
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Pieter Jan F. de Jonge
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Marco J. Bruno
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Robert C. Verdonk
- grid.415960.f0000 0004 0622 1269Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Whitcomb DC, Duggan SN, Martindale R, Lowe M, Stallings VA, Conwell D, Barkin JA, Papachristou GI, Husain SZ, Forsmark CE, Kaul V. AGA-PancreasFest Joint Symposium on Exocrine Pancreatic Insufficiency. GASTRO HEP ADVANCES 2022; 2:395-411. [PMID: 39132652 PMCID: PMC11307793 DOI: 10.1016/j.gastha.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/03/2022] [Indexed: 08/13/2024]
Abstract
Exocrine pancreatic insufficiency (EPI) is a clinically defined syndrome based on the physician's assessment of a patient's maldigestion. However, current clinical definitions are inadequate in determining (1) the threshold of reduced pancreatic digestive enzyme secretion that determines "pancreatic insufficiency" in an individual patient; (2) the role of pancreatic function tests; (3) effects of differing metabolic needs, nutrition intake, and intestinal function/adaptation (4) when pancreatic enzyme replacement therapy is needed; and (5) how to monitor and titrate multiple therapies. Experts and key opinion leaders were invited to PancreasFest 2021 to discuss and help clarify mechanistic issues critical to defining EPI and to address misconceptions and barriers limiting advancements in patient care. Clinically EPI is defined as inadequate delivery of pancreatic digestive enzymes to meals to meet nutritional needs and is reversed with appropriate treatment. A new mechanistic definition of EPI was proposed that includes the disorders essence and character: (1) EPI is a disorder caused by failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine in concert with ingested nutrients, followed by enzymatic digestion of a series of individual snacks and meals over time to meet nutritional and metabolic needs, given (a) the specific macronutritional and micronutritional needs; (b) nutrient intake; (c) exocrine pancreatic function; and (d) intestinal anatomy, function, diseases, and adaptative capacity. (2) EPI is characterized by variable deficiencies in micronutrients and macronutrients, especially essential fats and fat-soluble vitamins, by gastrointestinal symptoms of nutrient maldigestion and by improvement or correction of nutritional state with lifestyle changes, disease treatment, optimized diet, dietary supplements, and/or administration of adequate pancreatic enzyme replacement therapy. EPI is complex and individualized and multidisciplinary approaches are needed to optimize therapy. Better pancreas function tests and biomarkers are needed to diagnose EPI and guide treatment.
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Affiliation(s)
- David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Cell Biology and Molecular Physiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sinead N. Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Tallaght University Hospital, Dublin, Republic of Ireland
| | - Robert Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Mark Lowe
- Department of Pediatric Science, Washington University School of Medicine, St. Louis, Missouri
| | - Virginia A. Stallings
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Darwin Conwell
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jodie A. Barkin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Georgios I. Papachristou
- Division of Gastroenterology, Department of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sohail Z. Husain
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford School of Medicine and Stanford Medicine Children's Health, Stanford, California
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Florida, Gainesville, Florida
| | - Vivek Kaul
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
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Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients 2022; 14:4570. [PMID: 36364832 PMCID: PMC9656643 DOI: 10.3390/nu14214570] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 08/13/2023] Open
Abstract
This review summarizes the main pancreatic diseases from a nutritional approach. Nutrition is a cornerstone of pancreatic disease and is sometimes undervalued. An early identification of malnutrition is the first step in maintaining an adequate nutritional status in acute pancreatitis, chronic pancreatitis and pancreatic cancer. Following a proper diet is a pillar in the treatment of pancreatic diseases and, often, nutritional counseling becomes essential. In addition, some patients will require oral nutritional supplements and fat-soluble vitamins to combat certain deficiencies. Other patients will require enteral nutrition by nasoenteric tube or total parenteral nutrition in order to maintain the requirements, depending on the pathology and its consequences. Pancreatic exocrine insufficiency, defined as a significant decrease in pancreatic enzymes or bicarbonate until the digestive function is impaired, is common in pancreatic diseases and is the main cause of malnutrition. Pancreatic enzymes therapy allows for the management of these patients. Nutrition can improve the nutritional status and quality of life of these patients and may even improve life expectancy in patients with pancreatic cancer. For this reason, nutrition must maintain the importance it deserves.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, Martínez de Velasco Avenue 36, 22004 Huesca, Spain
| | - Guillermo García-Rayado
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
| | - Enrique Alfaro-Almajano
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
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Singh P, Chakraborty B, Sarkhel S, Ray S, Patra PS, Das K. Indian Outpatients with Idiopathic Chronic Pancreatitis Have Catastrophic Healthcare Expenditure, Malnutrition, Anxiety/Depression and Work-Impairment. Dig Dis Sci 2022; 67:3612-3622. [PMID: 34581905 DOI: 10.1007/s10620-021-07255-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/16/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is paucity of data regarding economic burden, employment affection, psychological and nutritional status of CP patients, of non-alcoholic etiology, especially during their periods of stable disease, i.e., without any complications and/or recent endoscopic/surgical interventions. METHODS In a prospective cohort study, conducted in outpatient clinic of a tertiary-care hospital, 66 consecutive adults with Idiopathic CP (± diabetes) and 152 matched (by age, socioeconomic status and monthly income) healthy controls were assessed for: (1) healthcare expenses in previous month by recall (catastrophic if > 40% of income); (2) nutritional status by anthropometry and food frequency questionnaire; (3) psychological status by Hospital Anxiety and Depression Scale (HADS); and (4) work-impairment by work productivity and activity impairment questionnaire: general health (WPAI-GH). CP patients were again reassessed for the above parameters after 6 and 12 month, respectively. RESULTS Seventy-six percent CP patients (vis-à-vis 0% controls) had catastrophic healthcare expenditure. Forty-nine percent of CP patients(vis-à-vis 0% controls) met their healthcare expenses by either selling assets or obtaining loans at high-interest or from charitable donations. CP patients had lower BMI, were more likely to be malnourished and had a lower calorie intake vis-à-vis controls (median (IQR) recommended daily allowance (RDA): 71(19)% vs 97(23)%; [p < 0.0001]). Their median HADS Anxiety and depression scores were significantly higher than controls. Thirty-one (47%) CP patients were employed vis-a-vis 102 (67%) controls (p = 0.006); they had significantly higher work impairment. After one year, there was improvement in some of these above parameters in CP patients. CONCLUSION Idiopathic CP outpatients had catastrophic healthcare expenditure, malnutrition, abnormal psychological scores and work-impairment vis-à-vis healthy controls. Some of these parameters improved on follow-up.
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Affiliation(s)
- Pankaj Singh
- Division of Gastroenterology, School of Digestive and Liver Disease, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India
| | - Bidhan Chakraborty
- Division of Gastroenterology, School of Digestive and Liver Disease, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India
| | - Sujit Sarkhel
- Department of Psychiatry, Bangur Institute of Neurosciences, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India
| | - Sukanta Ray
- Division of Gastrointestinal Surgery, School of Digestive and Liver Disease, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India
| | - Partha Sarathi Patra
- Division of Gastroenterology, School of Digestive and Liver Disease, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Disease, IPGME&R, 244 AJC Bose Road, Kolkata, 700020, India.
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Jalal M, Campbell JA, Tesfaye S, Al-Mukhtar A, Hopper AD. Yield of testing for micronutrient deficiencies associated with pancreatic exocrine insufficiency in a clinical setting: An observational study. World J Clin Cases 2021; 9:11320-11329. [PMID: 35071562 PMCID: PMC8717493 DOI: 10.12998/wjcc.v9.i36.11320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/17/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) can be difficult to diagnose and causes maldigestion symptoms and malabsorption. There has been a number of studies that have identified PEI associated micronutrient deficiencies (PEI-MD), however there is variation in both the frequency and type of PEI-MD reported, with the majority of studies including patients with PEI due to chronic pancreatitis (CP) or CP without PEI. There is a paucity of information regarding the prevalence of PEI-MD in patients with PEI without CP and the yield of testing for PEI-MD in a clinical setting in patients with suspected benign pancreatic diseases.
AIM To prospectively assess the yield and type of PEI–MD in patients with and without PEI secondary to benign pancreatic disease.
METHODS Patients investigated for maldigestion symptoms with Faecal Elastase-1 (FEL-1) and suspected or proven benign pancreatic disease were prospectively identified. At the time of FEL-1 testing, serum samples were taken for micronutrients identified by previous studies as PEI-MD: prealbumin, retinol binding protein, copper, zinc, selenium, magnesium and later in the study lipid adjusted vitamin E. FEL-1 was recorded, with a result < 200 µg/g considered diagnostic of PEI. Patients underwent computed tomography (CT) imaging when there was a clinical suspicion of CP, a new diagnosis of PEI recurrent, pancreatic type pain (epigastric abdominal pain radiating to back with or without previous acute pancreatitis attacks) or weight loss.
RESULTS After exclusions, 112 patients were recruited that underwent testing for FEL-1 and PEI-MD. PEI was identified in 41/112 (36.6%) patients and a pancreatic CT was performed in 82 patients. Overall a PEI-MD was identified in 21/112 (18.8%) patients. The yield of PEI-MD was 17/41 (41.5%) if PEI was present which was significantly higher than those without 4/71 (5.6%) (P = 0.0001). The yield of PEI–MD was significantly higher when PEI and CP were seen together 13/22 (59.1%) compared to CP without PEI and PEI without CP (P < 0.03). Individual micronutrient assessment showed a more frequent occurrence of prealbumin 8/41 (19.5%), selenium 6/41 (14.6%) and magnesium 5/41 (12.2%) deficiency when PEI was present (< 0.02). The accuracy of using the significant micronutrients identified in our cohort as a predictor of PEI showed a positive predictive value of 80%-85.7% [95% confidence interval (CI): 38%-100%] and a low sensitivity of 9.8%-19.5% [95% CI: 3.3%-34.9%].
CONCLUSION Testing for PEI-MD in patients with suspected pancreatic disease has a high yield, specifically when PEI and CP are found together. PEI-MD testing should include selenium, magnesium and prealbumin.
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Affiliation(s)
- Mustafa Jalal
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
- Department of Infection, Immunology and Cardiovascular disease, University of Sheffield, Sheffield S10 2TN, United Kingdom
| | - Jennifer Anne Campbell
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
| | - Solomon Tesfaye
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
| | - Ahmed Al-Mukhtar
- Department of Surgery, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
| | - Andrew Derek Hopper
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
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14
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Grigor’eva IN, Efimova OV. Risk factors for pancreatitis and pancreatic cancer. TERAPEVT ARKH 2021; 93:875-882. [DOI: 10.26442/00403660.2021.08.200970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022]
Abstract
Aim. To identify and compare the frequency of alcohol consumption, tobacco smoking, levels of main macronutrients, vitamins and mineral elements consumption in patients with acute (AP) and chronic pancreatitis (CP) and pancreatic cancer (PC).
Materials and methods. At the observational clinical cross-sectional uncontrolled case-study 65 patients with AP or CP (group 1) and 45 patients with PC (group 2) were examined. A survey of patients was carried out: questionnaire on tobacco smoking, a frequency questionnaire on alcohol consumption, a questionnaire for assessing the frequency of food consumption.
Results. The frequency of smoking (33.8, 20.0%; p0.05), alcohol consumption 1 times/week during the last year (21.5, 15.6%; p0.05) did not differ significantly between the two groups. The highest consumption rates of total, vegetable, animal protein, total carbohydrates, refined sugar, animal fat, cholesterol, MUFA, dietary fiber, vitamins (-carotene, vitamin B1, B2, C, PP), mineral elements (iron, potassium, calcium, magnesium, sodium, phosphorus) and the daily energy content of the diet were determined in PC than in the AP and CP group. Among patients of group 1, deficient intake of fat-soluble vitamin A (93.3, 54.8%; p=0.009) and vitamin E (80.0, 48.4%; p=0.041) was more common in the subgroup of patients with excretory pancreatic insufficiency than without it, and the chance of having hypercholesterolemia was associated with a deficient intake of vitamin E [Ex(B)=3.3, 95% CI 1.59.3; p=0.027].
Conclusion. There were no differences in the frequency of smoking and alcohol consumption between patients with AP and CP and PC. The highest indices of the main macronutrients, daily energy content of the diet, micronutrients (except for vitamins A, E) were found in PC than in the group of patients with AP and CP. Among patients with AP and CP with excretory pancreatic insufficiency, a lower intake of fat-soluble vitamins was noted and associations of hypercholesterolemia with deficient intake of vitamin E were obtained.
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15
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Exocrine pancreatic function and dynamic of digestion after restrictive and malabsorptive bariatric surgery: a prospective, cross-sectional, and comparative study. Surg Obes Relat Dis 2021; 17:1766-1772. [PMID: 34332909 DOI: 10.1016/j.soard.2021.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/23/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Gastrointestinal anatomical changes after restrictive and malabsorptive bariatric surgery lead to important disturbances in the process of digestion and absorption of nutrients and could lead to exocrine pancreatic insufficiency (EPI). OBJECTIVE The aim of the present study was to evaluate and to compare pancreatic function and the dynamic of digestion and absorption of nutrients after restrictive and malabsorptive bariatric surgical procedures. SETTING University Hospital of Santiago de Compostela, Santiago de Compostela, Spain. METHODS A prospective, observational, cross-sectional, comparative study of patients after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD/DS) was carried out. Patients with obesity who did not undergo surgery were included as control group. Pancreatic function and the dynamic of digestion and absorption of nutrients were evaluated by the 13C-mixed triglyceride (13C-MTG) breath test. Six-hour 13C-cumulative recovery rate (13C-CRR), 13C exhalation peak, and 1-hour maximal 13C-CRR were calculated. RESULTS One-hundred five patients were included (mean age, 49.8 yr; 84 women). Six-hour 13C-CRR was significantly reduced after BPD/DS (P < .001) but not after SG and RYGB. EPI was present in 75% of patients after BPD/DS, 8.3% of patients after RYGB, and 4.3% of patients after SG. Compared with the control group who did not undergo surgery, digestion and absorption of nutrients tended to occur earlier after SG, whereas it was delayed after RYGB and mainly after BPD/DS (P < .001). CONCLUSION Bariatric surgery significantly alters the dynamic of the digestive process. EPI is very common after BPD/DS, frequent after RYGB, and less frequent after SG. This information is clinically relevant since EPI is a treatable condition associated with symptoms, nutritional deficiencies, and complications.
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Cañamares-Orbis P, Bernal-Monterde V, Sierra-Gabarda O, Casas-Deza D, Garcia-Rayado G, Cortes L, Lué A. Impact of Liver and Pancreas Diseases on Nutritional Status. Nutrients 2021; 13:1650. [PMID: 34068295 PMCID: PMC8153270 DOI: 10.3390/nu13051650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/02/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022] Open
Abstract
Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an adequate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow-up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and the efficacy of nutritional interventions in these settings.
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Affiliation(s)
- Pablo Cañamares-Orbis
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
| | - Vanesa Bernal-Monterde
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Olivia Sierra-Gabarda
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Diego Casas-Deza
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Guillermo Garcia-Rayado
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Luis Cortes
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Alberto Lué
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
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Montoro-Huguet MA, Belloc B, Domínguez-Cajal M. Small and Large Intestine (I): Malabsorption of Nutrients. Nutrients 2021; 13:1254. [PMID: 33920345 PMCID: PMC8070135 DOI: 10.3390/nu13041254] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Numerous disorders can alter the physiological mechanisms that guarantee proper digestion and absorption of nutrients (macro- and micronutrients), leading to a wide variety of symptoms and nutritional consequences. Malabsorption can be caused by many diseases of the small intestine, as well as by diseases of the pancreas, liver, biliary tract, and stomach. This article provides an overview of pathophysiologic mechanisms that lead to symptoms or complications of maldigestion (defined as the defective intraluminal hydrolysis of nutrients) or malabsorption (defined as defective mucosal absorption), as well as its clinical consequences, including both gastrointestinal symptoms and extraintestinal manifestations and/or laboratory abnormalities. The normal uptake of nutrients, vitamins, and minerals by the gastrointestinal tract (GI) requires several steps, each of which can be compromised in disease. This article will first describe the mechanisms that lead to poor assimilation of nutrients, and secondly discuss the symptoms and nutritional consequences of each specific disorder. The clinician must be aware that many malabsorptive disorders are manifested by subtle disorders, even without gastrointestinal symptoms (for example, anemia, osteoporosis, or infertility in celiac disease), so the index of suspicion must be high to recognize the underlying diseases in time.
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Affiliation(s)
- Miguel A. Montoro-Huguet
- Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Ciencias de la Salud y del Deporte, University of Zaragoza, 50009 Zaragoza, Spain
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Blanca Belloc
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Manuel Domínguez-Cajal
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maev IV, Kucheryavyy YA, Gubergrits NB, Bonnacker I, Shelest EA, Janssen-van Solingen GP, Domínguez-Muñoz JE. Differences in In Vitro Properties of Pancreatin Preparations for Pancreatic Exocrine Insufficiency as Marketed in Russia and CIS. Drugs R D 2020; 20:369-376. [PMID: 33211277 PMCID: PMC7691409 DOI: 10.1007/s40268-020-00326-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic enzyme-replacement therapy (PERT), provided as pancreatin to patients with pancreatic exocrine insufficiency (PEI), is considered an essential substitute for the pivotal physiological function the pancreas fulfills in digestion. PEI involves a reduction in the synthesis and secretion of pancreatic enzymes (lipase, protease, amylase), which leads to an inadequate enzymatic response to a meal and consequently to maldigestion and malabsorption of nutrients. The efficacy of PERT is strongly dependent on enzyme activity, dissolution, and pancreatin particle size. Objective The physiological properties of eight pancreatin preparations (nine batches; five different brands) available in Russia and CIS (Commonwealth of Independent States: Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Uzbekistan) were investigated. Methods The lipase activity, dissolution, and particle size distribution of samples from multiple batches of pancreatin of different strengths were measured. Results Regarding lipase activities, all pancreatin preparations except Micrazim® matched the labeled content. Considerable differences were observed in particle size and dissolution. Conclusion Pancreatin preparations available in Russia and CIS demonstrate product-to-product and batch-to-batch variability regarding the measured properties of lipase activity, dissolution, and particle size. This may impact the efficacy of PERT and therefore clinical outcomes.
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Affiliation(s)
- Igor V Maev
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - Yury A Kucheryavyy
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - Natalya B Gubergrits
- Donetsk National Medical University, Ministry of Health of Ukraine, Lyman, Ukraine
| | | | | | | | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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State of the Art in Exocrine Pancreatic Insufficiency. Medicina (B Aires) 2020; 56:medicina56100523. [PMID: 33036352 PMCID: PMC7599987 DOI: 10.3390/medicina56100523] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/26/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is defined as the maldigestion of foods due to inadequate pancreatic secretion, which can be caused by alterations in its stimulation, production, transport, or interaction with nutrients at duodenal level. The most frequent causes are chronic pancreatitis in adults and cystic fibrosis in children. The prevalence of EPI is high, varying according to its etiology, but it is considered to be underdiagnosed and undertreated. Its importance lies in the quality of life impairment that results from the malabsorption and malnutrition and in the increased morbidity and mortality, being associated with osteoporosis and cardiovascular events. The diagnosis is based on a set of symptoms, indicators of malnutrition, and an indirect non-invasive test in at-risk patients. The treatment of choice combines non-restrictive dietary measures with pancreatic enzyme replacement therapy to correct the associated symptoms and improve the nutritional status of patients. Non-responders require the adjustment of pancreatic enzyme therapy, the association of proton pump inhibitors, and/or the evaluation of alternative diagnoses such as bacterial overgrowth. This review offers an in-depth overview of EPI in order to support the proper management of this entity based on updated and integrated knowledge of its etiopathogenesis, prevalence, diagnosis, and treatment.
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Micronutrient deficits in patients with chronic pancreatitis: prevalence, risk factors and pitfalls. Eur J Gastroenterol Hepatol 2020; 32:1328-1334. [PMID: 32732813 DOI: 10.1097/meg.0000000000001866] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We investigated the prevalence of micronutrient deficiencies and associated patient and disease-related risk factors in patients with chronic pancreatitis (CP). METHODS We enrolled 115 consecutive CP outpatients. Micro-nutritional assessments included plasma levels of fat-soluble vitamins (A, D and E) and trace elements (magnesium and zinc). Bioelectrical impedance and muscle function tests were used to characterize the macro-nutritional status (sarcopenia and phase angle). Prevalence of micro-nutritional deficiencies was estimated and associated with a number of patient and disease characteristics including presence of exocrine pancreatic insufficiency (EPI) and diabetes mellitus. In an additional analysis, we explored the association between micronutrient levels and macro-nutritional status. RESULTS The mean age of patients was 57.9 ± 13.0 years, 71% were men and 50% had an alcoholic aetiology. Vitamin D deficiency (22%) was the most common micronutrient deficit followed by zinc deficiency (20%) and magnesium deficiency (17%). Vitamin A deficiency (10%) and vitamin E deficiency (7%) were only seen in patients with EPI (P ≤ 0.03), while the presence of trace element deficits was associated with plasma albumin levels (P ≤ 0.006). Plasma zinc levels were decreased in sarcopenic patients (P < 0.001) and positively correlated to phase angle (coefficient 0.28; P < 0.001). CONCLUSION Various micronutrient deficits were observed in CP outpatients, and associated risk factors were diverse and distinct for the individual nutrients. Taken together, our findings highlight the complexity of micronutrient assessment in patients with CP and emphasise the importance of simultaneous evaluation of plasma protein levels, inflammatory activity and macro-nutritional status.
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Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
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Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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What do Brazilian owners know about canine obesity and what risks does this knowledge generate? PLoS One 2020; 15:e0238771. [PMID: 32956414 PMCID: PMC7505417 DOI: 10.1371/journal.pone.0238771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
Canine obesity is associated with genetic, environmental, and behavioural factors, with the latter including both the behaviour of the dog and the owner. Knowledge about owner perception of canine obesity and its treatment can inform the development of new strategies to help prevent and manage this disease. Therefore, the aim of this study was to evaluate the opinions of dog owners regarding canine obesity and weight management. Dog owners residing in the city of Sao Paulo (Brazil) completed a questionnaire, either at home or in the waiting rooms of 3 veterinary hospitals. Owners determined their dog's body condition score (BCS), and this was compared with BCS determined by a veterinarian. Questionnaire findings from dogs that were in overweight (BCS 6-7/9) or obese (BCS (8-9/9) condition were compared with those in ideal weight (4-5/9) using chi-square tests and odds ratios. A total of 926 dogs were included, of which 480 (52%), 317 (34%) and 129 (14%) were in ideal, overweight and obese condition, respectively. Many owners under-estimated their dog's weight status, with the proportion increasing as the dog's weight status increased (ideal 60/480, 13%; overweight 174/317, 55%; obese 88/129, 68%; P<0.001). Although most owners (890/926, 96%) believed that canine obesity could pose health risks, the proportion that disagreed increased as weight status increased (ideal 12/480, 2%; overweight 14/317, 4%; 10/129, 8%; P = 0.006). Finally, although most owners (880/926, 95%) stated that they would let their dog undergo weight management, only a minority (182/926; 20%) believed that a trained professional was needed, and they had various misperceptions including potential cost and what the strategies that would be effective. Based on the findings of this study, it would be advisable for veterinarians to spend time addressing these misperceptions, in the hope of both improving awareness of obesity and the outcomes of weight management.
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Abstract
PURPOSE OF REVIEW Pancreatic function tests are mainly used for the diagnosis of exocrine pancreatic insufficiency (EPI) in patients with pancreatic diseases or after pancreatic or gastric surgery. Breath tests evaluate not just pancreatic secretion but the digestion capacity of the pancreas. These tests are good candidates for the diagnosis of EPI as they are noninvasive, accurate and easy to apply to clinical practice. RECENT FINDINGS The C-labelled mixed triglyceride (MTG) breath test has been optimized and validated against adequate reference methods for the diagnosis of EPI in patients with chronic pancreatitis and for the evaluation of the efficacy of pancreatic enzyme replacement therapy (PERT). In addition, reported C-MTG breath test results in patients with other pancreatic diseases and after pancreatic and gastric surgery support the accuracy and clinical applicability of this test. The evidence of pancreatic function breath tests with other C-labelled substrates is limited. SUMMARY Increasing evidence supports the accuracy and clinical usefulness of the C-MTG breath test for the diagnosis of EPI and the evaluation of the efficacy of PERT in different clinical conditions. Commercial availability of this test is required for a wide clinical use. The use of optimized and validated breath test protocols is mandatory.
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Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet 2020; 396:499-512. [PMID: 32798493 DOI: 10.1016/s0140-6736(20)31318-0] [Citation(s) in RCA: 227] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022]
Abstract
Chronic pancreatitis is a multifactorial, fibroinflammatory syndrome in which repetitive episodes of pancreatic inflammation lead to extensive fibrotic tissue replacement, resulting in chronic pain, exocrine and endocrine pancreatic insufficiency, reduced quality of life, and a shorter life expectancy. The incidence and prevalence of chronic pancreatitis is rising and no curative treatment is available. Using novel diagnostic algorithms, definitive chronic pancreatitis can be diagnosed by imaging criteria alone, whereas probable chronic pancreatitis requires clinical features and imaging criteria. Criteria for the diagnosis of early chronic pancreatitis are still under discussion and need prospective validation in clinical trials. Cross-sectional imaging should be used first; endoscopic ultrasound is needed only when CT or MRI are inconclusive or to plan therapeutic interventions. Management of chronic pancreatitis requires an interdisciplinary approach including primary care practitioners, gastroenterologists, surgeons, radiologists, pain specialists, and nutritional therapists. Patients with chronic pancreatitis should be seen at least once a year and re-evaluated for causal risk factors, symptom control, and complications such as malnutrition, pancreatic exocrine insufficiency, and diabetes; refer to a specialised centre if symptoms are poorly controlled or there is risk of deterioration. Scoring systems to monitor disease progression have been developed and validated internationally. Interventional treatments for pain or cholestasis should be done by specialists only, and early discussion of treatment approaches should include all medical disciplines involved in care. Throughout this Seminar, we address research needs such as staging of pancreatitis, aspects of malnutrition and pain, and cancer surveillance, to help improve the care of patients.
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Affiliation(s)
- Georg Beyer
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine, University of Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Medical Department II, University Hospital, LMU Munich, Munich, Germany.
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26
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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Carnie LE, Lamarca A, McNamara MG, Bibby N, O'Reilly DA, Valle JW. The assessment of pancreatic exocrine function in patients with inoperable pancreatic cancer: In need of a new gold-standard. Pancreatology 2020; 20:668-675. [PMID: 32284260 DOI: 10.1016/j.pan.2020.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/17/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency is commonplace in patients with pancreatic cancer, adversely impacting on quality of life and survival. Whilst the management of exocrine insufficiency is well established, diagnosis remains challenging in clinical practice. A plethora of diagnostic tests exist. Nevertheless, a lack of consensus remains about the optimal diagnostic method, specifically in patients with pancreatic cancer. Research, to date, has primarily been undertaken in patients with chronic pancreatitis and cystic fibrosis. This manuscript will review the current literature and will examine the evidence around the diagnostic tests available for pancreatic exocrine insufficiency and whether any exists specifically for pancreatic cancer cohorts. FINDINGS Evidence to recommend an individual test for the diagnosis of pancreatic exocrine insufficiency in clinical practice is lacking. Direct testing (by direct sampling of pancreatic secretions) has the highest specificity and sensitivity but is no longer routinely deployed or feasible in practice. Indirect testing, such as faecal elastase, is less accurate with high false-positive rates, but is routinely available in clinical practice. The 13C-mixed triglyceride breath test and the gold-standard 72-h faecal fat test have high specificity for indirect tests, but are not routinely available and cumbersome to undertake. A combination approach including nutritional markers and faecal elastase has more recently been proposed. CONCLUSION Further research is required to identify the most optimal and accurate diagnostic tool to diagnose pancreatic exocrine insufficiency in patients with pancreatic cancer in clinical practice.
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Affiliation(s)
- Lindsay E Carnie
- Nutrition & Dietetics, The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK
| | - Mairéad G McNamara
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK
| | - Neil Bibby
- Dietetics, Manchester Royal Infirmary, Manchester, UK
| | | | - Juan W Valle
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, UK.
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Abstract
PURPOSE OF REVIEW Type 1 and type 2 diabetes are often accompanied by mostly mild forms of exocrine pancreatic insufficiency. Despite high prevalence, little is known about the clinical consequences of exocrine pancreatic insufficiency and its optimal (nutritional) treatment. Even less is known if and to what extent exocrine pancreas insufficiency also affects glycemic control in diabetes. This article aims for summarizing current clinical knowledge on screening, diagnosis, and treatment and gives an overview on the pathophysiology of exocrine pancreatic insufficiency in diabetes. RECENT FINDINGS Recent studies reveal novel insights into the close interaction of acinar, ductal, and endocrine cells and the gut-pancreas axis. Exocrine pancreatic insufficiency is a clinically relevant, frequent but poorly understood disorder in both type 1 and type 2 diabetes.
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Affiliation(s)
- Bernhard Radlinger
- Department of Internal Medicine 1, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gabriele Ramoser
- Department of Pediatrics II, Medical University Innsbruck, Innsbruck, Austria
| | - Susanne Kaser
- Department of Internal Medicine 1, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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29
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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: 108] [Impact Index Per Article: 27.0] [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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30
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Stigliano S, Archibugi L, Signoretti M, Zerboni G, Capurso G. The baseline nutritional status assessed by MUST score has a low accuracy in predicting the risk of hospitalization during follow-up in patients with chronic pancreatitis: A cohort study. Pancreatology 2020; 20:182-186. [PMID: 31926768 DOI: 10.1016/j.pan.2019.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hospitalization and death in patients with chronic pancreatitis (CP) are often due to extra-pancreatic events. Recent guidelines recommend the use of the MUST score to assess CP patients' nutritional status, but its association with clinical outcomes has been poorly investigated. The aims of this study are to evaluate the incidence of extra-pancreatic events in patients with CP during follow-up and their association with the nutritional status. METHODS Retrospective analysis of single-centre cohort of CP patients prospectively enrolled and followed-up. Exocrine pancreatic insufficiency (EPI) was assessed by fecal elastase, MUST score calculated at diagnosis. The occurrence of hospitalizations or death were recorded. Differences between subgroups were analysed by Fisher's and T-test and hospitalization-free survival with Kaplan-Meier curves and Cox regression analysis. RESULTS Of 111 enrolled patients (64% male; mean age 57); 52% had alcoholic aetiology, 53% EPI, 10% severe CP and 26% a MUST score≥2 at diagnosis. During a median follow-up of 37 months, 3.6% of patients died and 34.2% needed hospitalization, in 50% of cases for extrapancreatic events (2% cardiovascular events, 8% infections and 3% cancer). There was no significant association between EPI, BMI<20 kg/m2, MUST score≥2, alcoholic aetiology and extra pancreatic events or need of hospitalization. A baseline MUST score≥2 had an accuracy of only 64.8% in predicting subsequent hospitalization. CONCLUSIONS A sizeable portion of CP patients are at high risk of malnutrition and are hospitalized during the follow-up, often for extra-pancreatic events. The nutritional status evaluated with the MUST score lacks accuracy in predicting the risk of these events.
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Affiliation(s)
- Serena Stigliano
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Italy; Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, Italy
| | - Livia Archibugi
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Italy; Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Marianna Signoretti
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Italy; Department of Gastroenterology, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Giulia Zerboni
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Italy; Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy.
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CT- and MRI-Based Assessment of Body Composition and Pancreatic Fibrosis Reveals High Incidence of Clinically Significant Metabolic Changes That Affect the Quality of Life and Treatment Outcomes of Patients with Chronic Pancreatitis and Pancreatic Cancer. ACTA ACUST UNITED AC 2019; 55:medicina55100649. [PMID: 31569661 PMCID: PMC6843405 DOI: 10.3390/medicina55100649] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 12/16/2022]
Abstract
Background and Objectives: Both chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) may lead to cachexia, sarcopenia, and osteoporosis due to different mechanisms. Neither patient gender, age, nor body weight are good predictors of these metabolic changes having a significant negative impact on the quality of life (QOL) and treatment outcomes. The aim of this study was to evaluate radiological changes in body composition and to compare them with manifestations of exocrine and endocrine pancreatic insufficiency, body mass, and QOL among patients with CP and PDAC. Materials and Methods: Prospectively collected data of 100 patients with diagnosed CP or PDAC were used for analysis. All patients underwent dual-energy X-ray absorptiometry (DXA), computed tomography (CT), and magnetic resonance imaging (MRI). The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) was used to assess QOL. Diabetes and changes in fecal elastase-1 were also assessed. Results: There was no significant difference in skeletal muscle mass (SMM) among patients with CP and PDAC (p = 0.85). Significantly more underweight patients had low SMM (p = 0.002). Patients with CP had more pronounced pancreatic fibrosis (PF) (p < 0.001). Data showed a significant relationship between a high degree of PF and occurrence of diabetes (p = 0.006) and low fecal elastase-1 levels (p = 0.013). A statistically significant lower QOL was determined in patients with PF ≥ 50% and in the CP group. Conclusions: Sarcopenia and osteoporosis/osteopenia are highly prevalent among patients with chronic pancreatitis and pancreatic cancer, and CT- and MRI-based assessment of body composition and pancreatic fibrosis could be a potentially useful tool for routine detection of these significant metabolic changes.
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Abstract
PURPOSE OF REVIEW Pancreatic exocrine insufficiency (PEI) is one of the well known causes of malabsorption syndrome. An insufficient secretion of pancreatic enzymes and bicarbonate secondary to different pancreatic diseases and upper gastrointestinal and pancreatic surgery leads to maldigestion and malabsorption of nutrients. Patients with PEI may present with symptoms of malabsorption and different nutritional deficiencies. Recent data support the high clinical relevance of PEI and its treatment. RECENT FINDINGS Deficiencies of fat-soluble vitamins, proteins, micronutrients and antioxidants in patients with PEI are associated not only with an increased risk of osteoporosis and sarcopenia but also of cardiovascular events and mortality. Pancreatic enzyme replacement therapy (PERT) allows improving fat and protein digestion, relieving maldigestion-related symptoms, normalizing the nutritional status, and improving quality of life of patients with PEI. Recent data support the efficacy of PERT on survival in patients with pancreatic cancer. Dose of oral pancreatic enzymes should be adequate to normalize the nutritional status of PEI patients. SUMMARY Increasing evidence supports the relevance of PEI management by dietary advice and appropriate PERT. Well designed and powered randomized, placebo-controlled clinical trials are needed to further evaluate the clinical impact of PEI and its treatment in clinical practice.
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33
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Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8081098. [PMID: 31349549 PMCID: PMC6723806 DOI: 10.3390/jcm8081098] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/06/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022] Open
Abstract
Liver, pancreatic, and inflammatory bowel diseases are often associated with nutritional difficulties and necessitate an adequate nutritional therapy in order to support the medical treatment. As most patients with non-alcoholic fatty liver disease are overweight or obese, guidelines recommend weight loss and physical activity to improve liver enzymes and avoid liver cirrhosis. In contrast, patients with alcoholic steatohepatitis or liver cirrhosis have a substantial risk for protein depletion, trace elements deficiency, and thus malnutrition. Patients with chronic pancreatitis and patients with inflammatory bowel disease have a similar risk for malnutrition. Therefore, it clearly is important to screen these patients for malnutrition with established tools and initiate adequate nutritional therapy. If energy and protein intake are insufficient with regular meals, oral nutritional supplements or artificial nutrition, i.e., tube feeding or parenteral nutrition, should be used to avoid or treat malnutrition. However, the oral route should be preferred over enteral or parenteral nutrition. Acute liver failure and acute pancreatitis are emergencies, which require close monitoring for the treatment of metabolic disturbances. In most patients, energy and protein requirements are increased. In acute pancreatitis, the former recommendation of fasting is obsolete. Each disease is discussed in this manuscript and special recommendations are given according to the pathophysiology and clinical routine.
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Kotagal M, Slusher J, Ahmad S, Aronson LA, Brunner J, Chima R, Elder DA, Goldschneider KR, Hornung L, Lin TK, Ogg SM, Palermo JJ, Rich K, Rose J, Sekoulopoulos S, Szabova A, Abu-El-Haija M, Nathan JD. In-hospital and 90-day outcomes after total pancreatectomy with islet autotransplantation for pediatric chronic and acute recurrent pancreatitis. Am J Transplant 2019; 19:1187-1194. [PMID: 30372594 PMCID: PMC8579320 DOI: 10.1111/ajt.15150] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/18/2018] [Accepted: 10/11/2018] [Indexed: 01/25/2023]
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is used to treat debilitating chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) that has failed medical and endoscopic therapy. We performed a retrospective review of TPIAT patients at a free-standing children's hospital to evaluate perioperative outcomes. Twenty patients (median age 13, 65% female) underwent TPIAT (2015 through 2017). Of the 20 patients, 95% had CP and 1 patient (5%) had ARP alone. Seventy-five percent of the patients had a pancreatitis-associated genetic mutation; 40% had pancreas divisum. The median surgical time was 757 (IQR 657 to 835) minutes. Median islet equivalents per kg of body weight (IEQ/kg) were 6404 (IQR 5018 to 7554). At 90 days postoperatively vs preoperatively, significantly fewer patients were receiving parenteral nutrition (0% vs 25%, P = .006) and opioids (45% vs 75%, P = .01). Short Form 36-Item Health Survey (SF-36) physical health module scores and total scores improved (34.0 preoperatively vs 54.6 at 90 days, P = .008, and 47.1 vs 65.3, P = .007, respectively); SF-10 physical health scores also improved (13.4 vs 33.1, P = .02). Insulin requirement decreased from 0.5 unit/kg/day to 0.4 unit/kg/day between discharge and 90 days (P = .02). TPIAT is an effective option when debilitating disease persists despite maximal medical and endoscopic therapy. Opioid, parenteral nutrition, and exogenous insulin use can successfully be weaned within 90 days after TPIAT, with gains in health-related quality of life.
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Affiliation(s)
- Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joyce Slusher
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Syed Ahmad
- Division of Surgical Oncology, Pancreas Disease Center, University of Cincinnati Medical Center, Cincinnati, Ohio
- Pancreas Disease Center, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Lori A. Aronson
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John Brunner
- Division of Surgical Oncology, Pancreas Disease Center, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Ranjit Chima
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Deborah A. Elder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kenneth R. Goldschneider
- Pain Management Center, Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tom K. Lin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M. Ogg
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joseph J. Palermo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Rich
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - John Rose
- Pain Management Center, Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Stephen Sekoulopoulos
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Alexandra Szabova
- Pain Management Center, Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jaimie D. Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Kwon CI, Cho JH, Choi SH, Ko KH, Tirkes T, Gromski MA, Lehman GA. Recent advances in the diagnosis and management of chronic pancreatitis. Korean J Intern Med 2019; 34:242-260. [PMID: 30840807 PMCID: PMC6406102 DOI: 10.3904/kjim.2019.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/13/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis is a chronic condition characterized by pancreatic inflammation that causes fibrosis and the destruction of exocrine and endocrine tissues. Chronic pancreatitis is a progressive disease, and no physiological treatment is available to reverse its course. However, with advances in medical technology, the existing diagnostic and treatment methods for chronic pancreatitis are evolving. Managing patients with chronic pancreatitis is challenging and necessitates a multidisciplinary approach. In this review, we discuss the recent advances in the diagnosis and management of chronic pancreatitis and introduce future alternative modalities.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Hoon Choi
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Temel Tirkes
- Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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36
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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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Erchinger F, Øvre AKN, Aarseth MM, Engjom T, Brønstad I, Dimcevski G, Gudbrandsen OA, Tjora E. Fecal fat and energy loss in pancreas exocrine insufficiency: the role of pancreas enzyme replacement therapy. Scand J Gastroenterol 2018; 53:1132-1138. [PMID: 30193081 DOI: 10.1080/00365521.2018.1499801] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic pancreatitis (CP) can lead to severe pancreatic exocrine insufficiency (PEI). Pancreatic enzyme replacement therapy (PERT) is well established, but knowledge of the physiological response to increasing doses on fecal fat- and energy loss is scarce. METHODS We included 10 patients with CP and established PEI and 12 healthy controls for a prospective interventional study. Subjects received no PERT in the first week followed by four weeks PERT incrementally increasing doses every week. For each week, three-day stool collection followed three days registration of nutritional intake. We measured the fecal output of fat and energy by van de Kamer titration and decomposition vessel calorimetry, respectively. We calculated fecal fat- and energy loss per day, the coefficient of fat absorption (CFA) and coefficient of energy absorption (CEA). RESULTS Without PERT treatment, CP patients with PEI had significantly higher daily fecal fat and energy loss (p = .022; p = .035) compared to HC. In CP patients, there was a significant reduction of fecal fat and energy loss (p = .045; p = .037) when PERT doses reached maximum intake of 75,000 units per meal. In CP patients, there was a strong positive correlation between fecal loss of energy and fat (r = 0.99), and between fecal loss of energy and daily stool weight (r = 0.97). CFA and CEA correlated negatively with daily fecal fat loss (r = -0.72) and fecal energy loss (r = -0.65). CONCLUSIONS PERT reduces fecal energy and fat loss in patients with CP and PEI. Fecal energy loss in CP patients is strongly dependent on fecal fat loss, and on fecal weight.
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Affiliation(s)
- Friedemann Erchinger
- a Department of Medicine , Voss Hospital, Haukeland University Hospital , Voss , Norway.,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | | | | | - Trond Engjom
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Ingeborg Brønstad
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,d National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway
| | - Georg Dimcevski
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway
| | | | - Erling Tjora
- e Department of Pediatrics , Haukeland University Hospital , Bergen , Norway.,f KG Jebsen center for Diabetes Research, Department of Clinical Science , University of Bergen , Bergen , Norway
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Abstract
PURPOSE OF REVIEW Pancreatic exocrine insufficiency (PEI), defined as a secretion of pancreatic enzymes and bicarbonate insufficient to maintain a normal digestion, is a frequent but frequently underdiagnosed and undertreated condition. PEI may be secondary to different pancreatic diseases and extrapancreatic conditions. Recent data support the high clinical relevance of PEI and its treatment. RECENT FINDINGS Together with symptoms of maldigestion, PEI is associated with nutritional deficiencies leading to osteoporosis, low-trauma fractures, sarcopenia and increased mortality. No single widely available test allows to diagnose PEI accurately. Diagnosis of PEI requires the evaluation of symptoms, nutritional markers and a noninvasive pancreatic function test in the appropriate clinical context. Pancreatic enzyme replacement therapy (PERT) improves digestion, symptoms, nutritional status and quality of life of patients with PEI. In addition, PERT is associated with a longer survival in patients with unresectable pancreatic cancer and after surgery for pancreatic cancer or chronic pancreatitis. SUMMARY Awareness of PEI in different clinical conditions is required. Nutritional advice and appropriate PERT are mandatory to reduce the morbidity and mortality associated with PEI. Further studies on the clinical impact of PEI and its treatment are needed, especially in diseases other than chronic pancreatitis and cystic fibrosis.
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