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Saad M, Vitale DS, Lin TK, Thapaliya S, Zhou Y, Zhang B, Trout AT, Abu-El-Haija M. Image or scope: Magnetic resonance imaging and endoscopic testing for exocrine and endocrine pancreatic insufficiency in children. Pancreatology 2023:S1424-3903(23)00099-6. [PMID: 37087303 DOI: 10.1016/j.pan.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/22/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES We sought to evaluate associations between Magnetic Resonance Imaging (MRI) findings, exocrine pancreatic insufficiency (EPI) and endocrine insufficiency (prediabetes or diabetes) in children. METHODS This was a retrospective study that included patients<21 years of age who underwent MRI and endoscopic pancreatic function testing (ePFT; reference standard for pancreatic exocrine function) within 3 months. MRI variables included pancreas parenchymal volume, secreted fluid volume in response to secretin, and T1 relaxation time. Data were analyzed for the full sample as well as the subset without acute pancreatitis (AP) at the time of imaging. RESULTS Of 72 patients, 56% (40/72) were female with median age 11.4 years. A 5 mL decrease in pancreas parenchymal volume was associated with increased odds of exocrine pancreatic dysfunction by both ePFT (OR = 1.16, p = 0.02 full sample; OR = 1.29, p = 0.01 no-AP subset), and fecal elastase (OR = 1.16, p = 0.04 full sample; OR = 1.23, p = 0.02 no-AP subset). Pancreas parenchymal volume had an AUC 0.71 (95% CI: 0.59, 0.83) for predicting exocrine pancreatic dysfunction by ePFT and when combined with sex and presence of AP had an AUC of 0.82 (95% CI: 0.72, 0.92). Regarding endocrine function, decreased pancreas parenchymal volume was associated with increased odds of diabetes (OR = 1.16, p = 0.03), and T1 relaxation time predicted glycemic outcomes with an AUC 0.78 (95% CI: 0.55-1), 91% specificity and 73% sensitivity. CONCLUSIONS Pancreas parenchymal volume is an MRI marker of exocrine and endocrine pancreatic dysfunction in children. A model including sex, AP, and pancreas volume best predicted exocrine status. T1 relaxation time is also an MRI marker of endocrine insufficiency.
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Affiliation(s)
- Michelle Saad
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - David S Vitale
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tom K Lin
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Samjhana Thapaliya
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yuan Zhou
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Bin Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Powell-Brett S, Hall L, Edwards M, Roberts K. A systematic review and meta-analysis of the accuracy and methodology of the 13C mixed triglyceride breath test for the evaluation of pancreatic function. Pancreatology 2023; 23:283-293. [PMID: 36805050 DOI: 10.1016/j.pan.2023.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION The diagnosis of pancreatic exocrine insufficiency (PEI) is challenging. The 13C mixed triglyceride breath test (13C MTGT) has emerged as a promising diagnostic method. However, there is need to assimilate high quality evidence to understand its accuracy and address variation in the conduct of the test. This systematic review aims to appraise the existing literature on the methodology and accuracy of the 13C MTGT. METHODS A systematic literature search of PUBMED, MEDLINE, and EMBASE databases identified articles describing the use of the 13C MTGT in the analysis of pancreatic function in adults. Data extraction addressed each methodological step in detail. These were combined in a narrative synthesis. For quantitative analysis, those studies within this search that assessed the accuracy of the 13C MTGT were selected. RESULTS 37 studies were included for qualitative review, 6 assessed sensitivity and specificity of the 13C MTGT against another measure of PEI and were included in quantitative synthesis. Areas with a majority consensus were pre-test overnight fasting, a test meal with a lipid load of at least 10 g, within-test control of exercise and dietary intake, breath sampling every 30 min and the preference of isotope ratio mass spectrometry (IRMS) for analysis. Good evidence suggests there is no benefit to extend the total timeframe of breath sampling beyond 6 h. Areas of uncertainty are a) Duration of PERT cessation b) the addition of metoclopramide, c) the ideal test meal and d) if the time frame can be shortened. Quantitative analysis among 6 studies demonstrated a pooled sensitivity and specificity of the 13C MTGT for diagnosing PEI of 0.84 (95% CI: 0.73-0.91) and 0.87 (95% CI: 0.79-0.93) respectively. CONCLUSION There is yet to emerge a clear standard of breath test methodology that is validated for all causes of PEI and suitable for routine use. The accuracy of the 13C MTGT for diagnosing PEI is encouraging when compared to other measures. We present a suggested set protocol based on the current literature and identify areas that need further, high quality evidence. With refinement, the 13C MTGT could become a valuable, non-invasive PEI diagnostic tool that could be used outside of specialist centres.
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Affiliation(s)
- Sarah Powell-Brett
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Lewis Hall
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Michael Edwards
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Roberts
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Johnston PC, Thompson J, Roberts B, McKee A, Taylor M, Ellison V. Faecal elastase testing and factors linked with development of pancreatic exocrine insufficiency in diabetes: the Belfast Trust experience. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Philip C Johnston
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast Northern Ireland, UK
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Judith Thompson
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Brona Roberts
- Department of Chemical Pathology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Allison McKee
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
| | - Mark Taylor
- Department of Hepatobiliary Surgery, Mater Hospital, Belfast Northern Ireland, UK
| | - Victoria Ellison
- Department of Diabetes and Endocrinology, Belfast City Hospital, Belfast Northern Ireland, UK
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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Abstract
Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.
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Evrimler S, Swensson JK, Soufi M, Tirkes T, Schmidt CM, Akisik F. Wirsungocele: evaluation by MRCP and clinical significance. Abdom Radiol (NY) 2021; 46:616-622. [PMID: 32737547 DOI: 10.1007/s00261-020-02675-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/14/2020] [Accepted: 07/18/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Wirsungocele is a rare cystic dilatation of the main pancreatic duct seen at the terminal portion of the duct of Wirsung. The purpose of our study is to evaluate the diagnostic value of MRCP in detection of Wirsungocele and the association between the MRCP-determined size of Wirsungocele and the MRCP-clinical findings of pancreatitis. METHODS Thirty-four patients with reported 'Wirsungocele' were analyzed in the study. Two radiologists reviewed MRCP/S-MRCP images for the presence and diameter of Wirsungocele (WD), main pancreatic duct dilatation (MPDD), side branch ectasia (SBE), acinarization, and duodenal filling grade. Electronic medical record review included symptoms (abdominal pain), signs (recurrent acute/chronic pancreatitis), and select laboratory testing (serum amylase and lipase). Inter-reader agreement values were calculated by ICC. Pearson correlation analysis was performed to evaluate the association of WD with radiological and clinical findings. The comparison of WD on MRCP versus S-MRCP was calculated by Wilcoxon test. Mann-Whitney U test was used for two independent variable comparisons. RESULTS The sensitivity of MRCP for the detection of Wirsungocele calculated using the S-MRCP and ERCP as the reference method was 76.9% and 100%, respectively. There was a significant difference in the diameter of Wirsungocele measured by MRCP vs S-MRCP (p < 0.001). There was good inter-reader agreement for the detection of Wirsungocele on MRCP and measurement of WD on MRCP and S-MRCP (ICC: 0.79, 0.89, and 0.80, respectively, p < 0.001). There was a significant difference in WD between the patients with and without MPDD (p < 0.05). There was a significant positive correlation between WD and MPDD (r = 0.66, p < 0.05). WD was significantly associated with recurrent acute pancreatitis (p < 0.05). CONCLUSION MRCP is a highly sensitive and non-invasive imaging tool for detection of Wirsungocele. Greater Wirsungocele diameter is associated with MPDD and recurrent acute pancreatitis.
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Affiliation(s)
- Sehnaz Evrimler
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
- Department of Radiology, Suleyman Demirel University School of Medicine, East Campus, Cunur, 32260, Isparta, Turkey
| | - Jordan K Swensson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - Mazhar Soufi
- Department of Surgery, Indiana University School of Medicine, 550 N University Blvd Suite 1295, Indianapolis, IN, 46202, USA
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 550 N University Blvd Suite 1295, Indianapolis, IN, 46202, USA
| | - Fatih Akisik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd Room 0663, Indianapolis, IN, 46202, USA.
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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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Hafezi-Nejad N, Singh VK, Faghih M, Kamel IR, Zaheer A. Jejunal response to secretin is independent of the pancreatic response in secretin-enhanced magnetic resonance cholangiopancreatography. Eur J Radiol 2019; 112:7-13. [PMID: 30777222 DOI: 10.1016/j.ejrad.2018.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/14/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate whether jejunal secretions are independent of the pancreatic response to secretin in secretin-enhanced Magnetic Resonance Cholangiopancreatography (s-MRCP) examination of subjects with and without chronic pancreatitis (CP). METHODS Patients were identified through a search of s-MRCP examinations performed between 2014-2016 (n = 513) as well as the multidisciplinary pancreatitis clinic registry (n = 586). Fifty cases with CP (based on M-ANNHEIM criteria) and 50 matched controls were selected. Signal intensity changes after secretin administration (˜1-5 min' post-secretin response) in three locations were assessed: second portion of the duodenum (D2), third/fourth portions of the duodenum (D3-4), and the jejunum. The post-secretin response was compared between (cases vs. controls) and within the study groups. RESULTS There was a significantly lower 1-5 min' post-secretin response among CP patients in D2 (all p-values <0.01). However, no significant difference in 1-5 min' post-secretin response was detected in the jejunum. Minute-by-minute analysis of the post-secretin response showed a significant increase up to the 5th minute only in D2 of the control group. The post-secretin response in the jejunum was significant after 1 min but was similar among patients with CP and controls. CP was a significant determinant of post-secretin response in D2 but not in the jejunum. CONCLUSIONS Early post-secretin response at jejunum is independent of the pancreatic response that can be detected at D2, and should not be misinterpreted as a rapid pancreatic response. Therefore, pancreatic function on s-MRCP should be assessed by the presence of fluid in D2 and not jejunum.
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Affiliation(s)
- Nima Hafezi-Nejad
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Mahya Faghih
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Ihab R Kamel
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
| | - Atif Zaheer
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, United States; Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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Prospective Assessment of Normal Pancreatic Secretory Function Measured by MRI in a Cohort of Healthy Children. Am J Gastroenterol 2018; 113:1385. [PMID: 29973704 DOI: 10.1038/s41395-018-0190-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/07/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Magnetic resonance imaging (MRI) with secretin stimulation promises to allow non-invasive testing for exocrine pancreatic insufficiency but normal data do not exist for children. The purpose of this study was to define, in healthy children, normal pancreatic secreted fluid volume and secretion rate, measured by MRI, in response to secretin. METHODS In this Institutional Review Board-approved, prospective, cross-sectional study, 50 healthy children ages 6 to <16 years underwent MRI with secretin stimulation. Images were obtained before and at 1, 5, 10 and 15 min after secretin administration to calculate total secreted fluid volume and secretion rate based on image segmentation. Regression was used to define the relationship between secretory function and participant size measures, and linear quantile regression was used to define normal secretory values based on size measures. RESULTS Median total secreted fluid volume post secretin was 79 mL (range: 32-162 mL; 5th and 95th percentiles: 43 and 123 mL) and median secretion rate was 5.1 mL/min (range: 2-9.4 mL/min; 5th and 95th percentiles: 2.3 and 7.7 mL/min). Secreted volume and secretion rate had the strongest correlation with body surface area (BSA) (r = 0.54 and 0.59, respectively) and multiple regression defined BSA as the only significant predictor of secretory function. Each 1 m2 increase in BSA was associated with a 38 mL increase in secreted fluid volume. CONCLUSIONS In children, pancreatic secretory response to secretin, measured by MRI, depends on participant size, particularly BSA. Secreted volume <43 mL or a secretion rate <2.3 mL/min (5th percentile values) can be considered abnormal for children.
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Kamath MG, Pai CG, Kamath A, Kurien A. Comparing acid steatocrit and faecal elastase estimations for use in M-ANNHEIM staging for pancreatitis. World J Gastroenterol 2017. [PMID: 28405150 DOI: 10.3748/wjg.v23.i12.2217.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
AIM To compare two tests for exocrine pancreatic function (EPF) for use in M-ANNHEIM staging for pancreatitis. METHODS One hundred and ninety four consecutive patients with acute pancreatitis (AP; n = 13), recurrent acute pancreatitis (RAP; n = 65) and chronic pancreatitis (CP; n = 116) were enrolled. EPF was assessed by faecal elastase-1 (FE-1) estimation and stool fat excretion by the acid steatocrit method. Patients were classified as per M-ANNHEIM stages separately based on the results of the two tests for comparison. Independent Student's t-test, χ2 test, Kruskal-Wallis test, Mann-Whitney U test and McNemar's test were used as appropriate. RESULTS Sixty-one (52.5%) patients with CP had steatorrhoea when assessed by the acid steatocrit method; 79 (68.1%) with CP had exocrine insufficiency by the FE-1 test (χ2 test, P < 0.001). The results of acid steatocrit and FE-1 showed a significant negative correlation (Spearman's rho = -0.376, P < 0.001). A statistically significant difference was seen between the M-ANNHEIM stages as classified separately by acid steatocrit and the FE-1. Thirteen (6.7%), 87 (44.8%), 89 (45.8%) and 5 (2.5%) patients were placed in M-ANNHEIM stages 0, I, II, and III respectively, with the use of acid steatocrit as against 13 (6.7%), 85 (43.8%), 75 (38.6%), and 21 (10.8%) respectively by FE-1 in stages 0, I, II, and III thereby altering the stage in 28 (14.4%) patients (P < 0.001, McNemar's test). CONCLUSION FE-1 estimation performed better than the acid steatocrit test for use in the staging of pancreatitis by the M-ANNHEIM classification since it diagnosed a higher proportion of patients with exocrine insufficiency.
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Affiliation(s)
- M Ganesh Kamath
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - C Ganesh Pai
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - Asha Kamath
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
| | - Annamma Kurien
- M Ganesh Kamath, Department of Physiology, Melaka Manipal Medical College, Manipal University, Manipal 576104, India
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Gan C, Chen YH, Liu L, Gao JH, Tong H, Tang CW, Liu R. Efficacy and safety of pancreatic enzyme replacement therapy on exocrine pancreatic insufficiency: a meta-analysis. Oncotarget 2017; 8:94920-94931. [PMID: 29212278 PMCID: PMC5706924 DOI: 10.18632/oncotarget.21659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/21/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pancreatic enzyme replacement therapy (PERT) is widely applied to patients with exocrine pancreatic insufficiency (EPI), but its effect and safety has not been quantified. Therefore we performed a meta-analysis to determine the efficacy and tolerance of PERT on patients with EPI. MATERIALS AND METHODS PubMed, Medline, Cochrane library database, Evidence-based medicine/clinical trials published before December 2016 were searched by two independent reviewers to identify prospective randomized controlled trials (RCTs). RESULTS Seven RCTs, randomizing a total of 282 patients, were filtrated and assessed qualitatively (Jadad score). PERT increased CFA (WMD: 26.56, 20.35 to 32.76, I2= 79.6%, P < 0.001) compared with baseline, and CFA (WMD: 17.97, 12.61 to 23.34, I2 = 76.7%, P < 0.001) vs. placebo. Meanwhile, CNA, SFE, SNE and SW were significantly improved in PERT compared with baseline and placebo, with no statistical differences in adverse events. Subgroup analysis indicated that standard forms of PERT displayed more effectiveness with significantly decreased heterogeneity, and large sample size also reduced the heterogeneity to some degree. CONCLUSIONS PERT is demonstrated to be effective and tolerable in patients with EPI, especially using standard administration of PERT. Larger and higher quality studies on EPI are demanded to long-term effect of standard PERT treatment.
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Affiliation(s)
- Can Gan
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Hua Chen
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Liu
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin-Hang Gao
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Huan Tong
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng-Wei Tang
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Rui Liu
- Division of Peptides Related with Human Diseases, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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12
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Abstract
Imaging of the endocrine pancreas is dominated by neuroendocrine tumors, a diverse category of neoplasms that may or may not cause symptoms from hormone hypersecretion. These tumors may also be evidence of several different genetic syndromes. Understanding the usefulness of different imaging modalities and entities that simulate neuroendocrine tumors is key for both radiologists and referring physicians.
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Affiliation(s)
- Mark Masciocchi
- Department of Radiology, UMass Memorial Medical Center, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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13
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Nikfarjam M, Wilson JS, Smith RC. Diagnosis and management of pancreatic exocrine insufficiency. Med J Aust 2017; 207:161-165. [PMID: 28814218 DOI: 10.5694/mja16.00851] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In 2015, the Australasian Pancreatic Club (APC) published the Australasian guidelines for the management of pancreatic exocrine insufficiency (http://pancreas.org.au/2016/01/pancreatic-exocrine-insufficiency-guidelines). Pancreatic exocrine insufficiency (PEI) occurs when normal digestion cannot be sustained due to insufficient pancreatic digestive enzyme activity. This may be related to a breakdown, at any point, in the pancreatic digestive chain: pancreatic stimulation; synthesis, release or transportation of pancreatic enzymes; or synchronisation of secretions to mix with ingested food. Main recommendations: The guidelines provide advice on diagnosis and management of PEI, noting the following: A high prevalence of PEI is seen in certain diseases and conditions, such as cystic fibrosis, acute and chronic pancreatitis, pancreatic cancer and pancreatic surgery. The main symptoms of PEI are steatorrhoea or diarrhoea, abdominal pain, bloating and weight loss. These symptoms are non-specific and often go undetected and untreated. PEI diagnosis is predominantly based on clinical findings and the presence of underlying disease. The likelihood of PEI in suspected patients has been categorised into three groups: definite, possible and unlikely. If left untreated, PEI may lead to complications related to fat malabsorption and malnutrition, and have an impact on quality of life. Pancreatic enzyme replacement therapy (PERT) remains the mainstay of PEI treatment with the recommended adult initial enzyme dose being 25 000-40 000 units of lipase per meal, titrating up to a maximum of 75 000-80 000 units of lipase per meal. Adjunct acid-suppressing therapy may be useful when patients still experience symptoms of PEI on high dose PERT. Nutritional management by an experienced dietitian is essential. Changes in management as a result of these guidelines: These are the first guidelines to classify PEI as being definite, possible or unlikely, and provide a diagnostic algorithm to facilitate the early diagnosis of PEI and appropriate use of PERT.
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Affiliation(s)
| | - Jeremy S Wilson
- South Western Sydney Clinical School, Liverpool Hospital, UNSW, Sydney, NSW
| | - Ross C Smith
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW
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Kamath MG, Pai CG, Kamath A, Kurien A. Comparing acid steatocrit and faecal elastase estimations for use in M-ANNHEIM staging for pancreatitis. World J Gastroenterol 2017; 23:2217-2222. [PMID: 28405150 PMCID: PMC5374134 DOI: 10.3748/wjg.v23.i12.2217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/14/2017] [Accepted: 03/06/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare two tests for exocrine pancreatic function (EPF) for use in M-ANNHEIM staging for pancreatitis.
METHODS One hundred and ninety four consecutive patients with acute pancreatitis (AP; n = 13), recurrent acute pancreatitis (RAP; n = 65) and chronic pancreatitis (CP; n = 116) were enrolled. EPF was assessed by faecal elastase-1 (FE-1) estimation and stool fat excretion by the acid steatocrit method. Patients were classified as per M-ANNHEIM stages separately based on the results of the two tests for comparison. Independent Student’s t-test, χ2 test, Kruskal-Wallis test, Mann-Whitney U test and McNemar’s test were used as appropriate.
RESULTS Sixty-one (52.5%) patients with CP had steatorrhoea when assessed by the acid steatocrit method; 79 (68.1%) with CP had exocrine insufficiency by the FE-1 test (χ2 test, P < 0.001). The results of acid steatocrit and FE-1 showed a significant negative correlation (Spearman’s rho = -0.376, P < 0.001). A statistically significant difference was seen between the M-ANNHEIM stages as classified separately by acid steatocrit and the FE-1. Thirteen (6.7%), 87 (44.8%), 89 (45.8%) and 5 (2.5%) patients were placed in M-ANNHEIM stages 0, I, II, and III respectively, with the use of acid steatocrit as against 13 (6.7%), 85 (43.8%), 75 (38.6%), and 21 (10.8%) respectively by FE-1 in stages 0, I, II, and III thereby altering the stage in 28 (14.4%) patients (P < 0.001, McNemar’s test).
CONCLUSION FE-1 estimation performed better than the acid steatocrit test for use in the staging of pancreatitis by the M-ANNHEIM classification since it diagnosed a higher proportion of patients with exocrine insufficiency.
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Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol. Pancreas 2016; 45:1092-103. [PMID: 27171509 DOI: 10.1097/mpa.0000000000000606] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This systemic review summarizes the current literature and general consensus on secretin-stimulated magnetic resonance imaging (s-MRI) of the benign pancreatic disorders and discusses important aspects on how s-MRI is optimally performed. The aim is to provide an overview, for clinicians and radiologist, of the s-MRI protocols and the range of clinical applications. Furthermore, the review will summarize the criteria for evaluation of pancreatic morphology and function based on s-MRI.The literature search indentified 69 original articles and 15 reviews. Chronic pancreatitis was the disease that was most frequently assessed by s-MRI (33%), followed by acute pancreatitis (9%). Dynamic thick-slab 2-dimensional magnetic resonance cholangiopancreatography was the most used imaging sequence (86%). The diameter of the main pancreatic duct (75%) and pancreatic exocrine function based on visual grading of duodenal filling (67%) were the most evaluated pancreatic features. Sufficient similarities between studies were identified to propose the most agreeable standardized s-MRI protocol for morphological and functional assessment of the pancreas. In the future, more research and increased collaboration between centers is necessary to achieve more consensus and optimization of s-MRI protocols.
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Liu Y, Zheng X, Huang Z, Chen J, Song B. Secretin-stimulated magnetic resonance imaging/magnetic resonance cholangiopancreatography for the detection of chronic pancreatitis: A meta-analysis. Pancreatology 2016. [DOI: 10.1016/j.pan.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
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Smits MM, Tonneijck L, Muskiet MHA, Kramer MHH, Diamant M, Pieters-van den Bos IC, van Raalte DH, Cahen DL. Glucagon-like peptide-1 receptor agonist exenatide has no acute effect on MRI-measured exocrine pancreatic function in patients with type 2 diabetes: a randomized trial. Diabetes Obes Metab 2016; 18:281-8. [PMID: 26640129 DOI: 10.1111/dom.12612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/14/2015] [Accepted: 11/30/2015] [Indexed: 12/13/2022]
Abstract
AIMS To investigate the effect of infusion of the glucagon-like peptide-1 (GLP-1) receptor agonist exenatide on exocrine pancreatic function. METHODS This was a randomized, placebo-controlled, double-blind, crossover study in 12 male patients with type 2 diabetes, treated with oral glucose-lowering agents. On two separate occasions, exenatide or placebo (saline 0.9%) were administered intravenously, in randomized order. Exocrine pancreatic function was measured using secretin-enhanced magnetic resonance cholangiopancreatography. The primary outcome measure was defined as secretin-stimulated pancreatic excretion volume. Secondary outcome measures were maximum secretion speed and the time to reach this maximum. In addition, changes in pancreatic duct (PD) diameter were measured. RESULTS Exenatide did not change secretin-stimulated pancreatic excretion volume, as compared with placebo (mean ± standard error of the mean 142.2 ± 15.6 ml vs 142.6 ± 8.5 ml, respectively; p = 0.590). Also, exenatide did not change the maximum secretion speed (33.1 ± 1.4 vs 36.9 ± 2.2; p = 0.221), nor the time to reach this maximum (both 4 min 30 s). No differences in PD diameter were observed between the two groups. CONCLUSIONS Infusion of exenatide did not directly influence MRI-measured exocrine pancreatic excretion in patients with type 2 diabetes. Although long-term studies are warranted, these findings suggest that potential adverse pancreatic effects of GLP-1 receptor agonists are not mediated by changes in exocrine pancreatic secretion.
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Affiliation(s)
- M M Smits
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - L Tonneijck
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - M H A Muskiet
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - M H H Kramer
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - M Diamant
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - I C Pieters-van den Bos
- Department of Radiology and Nuclear Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - D H van Raalte
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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18
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Smith RC, Smith SF, Wilson J, Pearce C, Wray N, Vo R, Chen J, Ooi CY, Oliver M, Katz T, Turner R, Nikfarjam M, Rayner C, Horowitz M, Holtmann G, Talley N, Windsor J, Pirola R, Neale R. Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency. Pancreatology 2016; 16:164-80. [PMID: 26775768 DOI: 10.1016/j.pan.2015.12.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/01/2015] [Accepted: 12/10/2015] [Indexed: 02/06/2023]
Abstract
AIM Because of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI). METHODS A working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category. RESULTS AND CONCLUSIONS Recent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the 'unlikely' PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000-40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy.
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Affiliation(s)
| | - Ross C Smith
- Department of Surgery, University of Sydney, NSW, Australia; Australasian Pancreatic Club, Australia.
| | | | | | - Callum Pearce
- Institute for Immunology and Infectious Diseases, Murdoch University, WA, Australia; Fremantle Hospital, WA, Australia
| | - Nick Wray
- Nutrition & Dietetics, School of Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Ruth Vo
- Liverpool Hospital, University of NSW, Australia
| | - John Chen
- South Australian Liver Transplant & HPB Unit, RAH & Flinders Medical Centre, SA, Australia
| | - Chee Y Ooi
- School of Women's and Children's Health, Dept. of Medicine, University of NSW, Australia; Department of Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Mark Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, VIC, Australia
| | - Tamarah Katz
- Sydney Children's Hospital, Randwick, NSW, Australia
| | - Richard Turner
- Hobart Clinical School and Dept. Surgery, University of Tasmania, Australia
| | - Mehrdad Nikfarjam
- Dept. Surgery, University of Melbourne, VIC, Australia; Australasian Pancreatic Club, Australia
| | - Christopher Rayner
- School of Medicine, University of Adelaide, SA, Australia; Centre for Digestive Diseases, Royal Adelaide Hospital, SA, Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, University of Adelaide and Royal Adelaide Hospital, SA, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Australia; Translational Research Institute, Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Qld, Australia
| | - Nick Talley
- Faculty of Health and Medicine, University of Newcastle, NSW, Australia; Royal Australasian College of Physicians, Australia
| | - John Windsor
- Dept. of Surgery, University of Auckland, New Zealand
| | - Ron Pirola
- Faculty of Medicine, SW Sydney Clinical School, University of NSW, Australia
| | - Rachel Neale
- Cancer Control Laboratory, Queensland Institute of Medical Research, Qld, Australia
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Vujasinovic M, Tepes B, Volfand J, Rudolf S. Exocrine pancreatic insufficiency, MRI of the pancreas and serum nutritional markers in patients with coeliac disease. Postgrad Med J 2015; 91:497-500. [PMID: 26253920 DOI: 10.1136/postgradmedj-2015-133262] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 07/23/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To determine whether exocrine pancreatic function is impaired in patients with coeliac disease (CD) in our population and to evaluate its clinical importance. METHODS Pancreatic exocrine function was determined by measuring faecal elastase-1 (FE) concentration. CD was diagnosed by serological testing using IgA anti-tissue transglutaminase antibody (IgAtTg) and small bowel biopsy using the Marsh classification. MRI of the pancreas was performed to evaluate any morphological changes. The study took place from January 2012 to December 2013. RESULTS 90 patients (73 women and 17 men) of mean age 43.8±17.7 years (range 20-80) were included in the study. Mean time from CD confirmation was 5.8±0.7 years (range 1-25). Exocrine pancreatic insufficiency (EPI) was diagnosed in four (4.4%) patients (one with mild EPI and three with severe EPI). MRI showed no morphological changes in any of the four patients. In all patients with EPI at least one serological nutritional marker was below the lower limit of normal. CONCLUSIONS EPI is present in a small number of patients with CD. EPI should be excluded in all patients with CD in the presence of overt malnutrition or in cases of persistent gastrointestinal symptoms despite a gluten-free diet. Measurement of a serum nutritional panel, regardless of the presence of clinical symptoms of EPI, can be of clinical importance. MRI should be performed to exclude any morphological change in the pancreas.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Internal Medicine, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia
| | - Bojan Tepes
- Abakus Medico Diagnostic Centre, Rogaska Slatina, Slovenia
| | | | - Sasa Rudolf
- Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
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Engjom T, Erchinger F, Tjora E, Lærum BN, Georg D, Gilja OH. Diagnostic accuracy of secretin-stimulated ultrasonography of the pancreas assessing exocrine pancreatic failure in cystic fibrosis and chronic pancreatitis. Scand J Gastroenterol 2015; 50:601-10. [PMID: 25623422 DOI: 10.3109/00365521.2015.1004363] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Volume output failure is a feature of decreasing exocrine pancreatic function. This parameter is assessed by secretin-stimulated MRI in several studies. Our purpose was to evaluate ultrasonography of the fluid in the descending duodenum and Wirsung duct (WD) after secretin stimulation as a measure of pancreatic fluid flow in patients expected to have severe output failure. MATERIAL AND METHODS We included subjects with chronic pancreatitis (CP), cystic fibrosis (CF) and a group of healthy controls in a prospective observation study. Transabdominal ultrasonography was performed before and during 15 min after secretin i.v. duodenal juice was collected by endoscopic short test (EST), and bicarbonate concentration measured. Patient groups were classified according to exocrine pancreatic function. RESULTS Pancreatic insufficient CF (CFI) patients and CP insufficient (CPI) patients showed less duodenal fluid filling compared to other groups (p < 0.001). Measures of the WD diameter could only identify the most severe failure in the CFI group (p < 0.001). CONCLUSION Secretin-stimulated ultrasonography can be used to assess pancreatic fluid flow and may be combined with EST in the evaluation of exocrine pancreatic function. Fluid filling in the descending part of duodenum was the most accurate predictor of pancreatic insufficiency in both patient groups. The test demonstrated better diagnostic accuracy diagnosing exocrine pancreatic failure in the CF patients than in CP patients.
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Affiliation(s)
- Trond Engjom
- Department of Medicine, Haukeland University Hospital, Haukeland University Hospital , 5021 Bergen , Norway
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Mascarenhas MR, Mondick J, Barrett JS, Wilson M, Stallings VA, Schall JI. Malabsorption blood test: Assessing fat absorption in patients with cystic fibrosis and pancreatic insufficiency. J Clin Pharmacol 2015; 55:854-65. [PMID: 25689042 DOI: 10.1002/jcph.484] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/12/2015] [Indexed: 12/19/2022]
Abstract
The malabsorption blood test (MBT), consisting of pentadecanoic acid (PA), a free fatty acid, and triheptadecanoic acid (THA), a triglyceride that requires pancreatic lipase for absorption of the heptadecanoic acid (HA), was developed to assess fat malabsorption in patients with cystic fibrosis (CF) and pancreatic insufficiency (PI). The objective was to construct a population pharmacokinetic (PK) model to describe PA and HA disposition in healthy subjects and CF subjects. A model was simultaneously fit to PA and HA concentrations, consisting of 1-compartment disposition and a transit model to describe absorption. PA bioavailability estimates for CF subjects without pancreatic enzyme administration (1.07 [0.827, 1.42]) and with enzymes (0.88 [0.72, 1.09]) indicated PA absorption comparable to healthy subjects. HA bioavailability in CF without enzyme administration was 0.0292 (0.0192, 0.0459) and with enzymes increased to 0.606 (0.482, 0.823). In CF, compared with taking enzymes with the MBT, HA bioavailability was further decreased by factors of 0.829 (0.664, 0.979) and 0.78 (0.491, 1.13) with enzymes taken 30 and 60 minutes after MBT, respectively. The MBT detected differences in fat absorption in subjects with CF with and without enzyme administration and with changes in enzyme timing. Future studies will address application of the MBT in CF and other malabsorption diagnoses.
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Affiliation(s)
- Maria R Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Jeffrey S Barrett
- Division of Clinical Pharmacology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Sanofi-US, Bridgewater, NJ, USA
| | - Martha Wilson
- Department of Pathology and Lipid Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Virginia A Stallings
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joan I Schall
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Age-related change of the secretory flow of pancreatic juice in the main pancreatic duct: evaluation with cine-dynamic MRCP using spatially selective inversion recovery pulse. AJR Am J Roentgenol 2014; 202:1022-6. [PMID: 24758654 DOI: 10.2214/ajr.13.10852] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate age-related changes in the secretory flow of pancreatic juice in the main pancreatic duct noninvasively by means of nonpharmacologic cine-dynamic MRCP using spatially selective inversion recovery (IR) pulse. MATERIALS AND METHODS Fifty-three subjects without a history of pancreatic disease were included. Four-second breath-hold MRCP using spatially selective IR pulse was performed every 15 seconds during 5 minutes (acquiring a total of 20 images) in cine-dynamic fashion. The secretion grade was classified into five grades by the distance of pancreatic juice inflow within the tagged area. The mean secretion grade and the frequency of secretion in cine-dynamic MRCP were compared among three age-range groups (group 1, < 40 years; group 2, 40-70 years; and group 3, > 70 years). Statistical analysis was performed using Spearman rank correlation coefficient and Kruskal-Wallis and Mann-Whitney U tests. RESULTS The secretion grade and the frequency of secretion were significantly reduced with aging (r = -0.77, p < 0.001; and r = -0.74, p < 0.001, respectively). The mean secretion grade and the frequency of secretion were significantly lower in group 3 than in group 2 (mean grade, 0.36 vs 1.48, p = 0.001; and 4.8 vs 11.9 times, p = 0.001) and were lower in group 2 than in group 1 (mean grade, 1.48 vs 2.48, p < 0.001; and 11.9 vs 16.2 times, p = 0.011). CONCLUSION Cine-dynamic MRCP using spatially selective IR pulse was able to show the age-related decrease of the secretory flow of pancreatic juice in the main pancreatic duct visually and noninvasively.
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Abstract
Magnetic resonance (MR) imaging of the pancreas is useful as both a problem-solving tool and an initial imaging examination of choice. With newer imaging sequences such as diffusion-weighted imaging, MR offers improved ability to detect and characterize lesions and identify and stage tumors and inflammation. MR cholangiopancreatography can be used to visualize the pancreatic and biliary ductal system. In this article, the use of MR to evaluate the pancreas, including recent advances, is reviewed and the normal appearance of the pancreas on different imaging sequences, as well as inflammatory diseases, congenital abnormalities, and neoplasms of the pancreas, are discussed.
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Affiliation(s)
- Erin O'Neill
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA
| | - Nancy Hammond
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA
| | - Frank H Miller
- Department of Radiology, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, 676 North Saint Clair Street, Suite 800, Chicago, IL 60611, USA.
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Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol 2013; 19:7258-7266. [PMID: 24259956 PMCID: PMC3831207 DOI: 10.3748/wjg.v19.i42.7258] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/22/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis. Normal digestion requires adequate stimulation of pancreatic secretion, sufficient production of digestive enzymes by pancreatic acinar cells, a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food. Failure in any of these steps may result in pancreatic exocrine insufficiency, which leads to steatorrhea, weight loss and malnutrition-related complications, such as osteoporosis. Methods evaluating digestion, such as fecal fat quantification and the 13C-mixed triglycerides test, are the most accurate tests for pancreatic exocrine insufficiency, but the probability of the diagnosis can also be estimated based on symptoms, signs of malnutrition in blood tests, fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging. Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption, dietary consultation, enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment. Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicrospheres during meals. The dose should be in proportion to the fat content of the meal, usually 40-50000 lipase units per main meal, and half the dose is required for a snack. In cases that do not respond to initial treatment, the doses can be doubled, and proton inhibitors can be added to the treatment. This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.
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Hansen TM, Nilsson M, Gram M, Frøkjær JB. Morphological and functional evaluation of chronic pancreatitis with magnetic resonance imaging. World J Gastroenterol 2013; 19:7241-7246. [PMID: 24259954 PMCID: PMC3831205 DOI: 10.3748/wjg.v19.i42.7241] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/13/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance imaging (MRI) techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pancreatitis (CP) patients. Standard MRI including fat-suppressed T1-weighted and T2-weighted imaging techniques reveal decreased signal and glandular atrophy of the pancreas in CP. In contrast-enhanced MRI of the pancreas in CP the pancreatic signal is usually reduced and delayed due to decreased perfusion as a result of chronic inflammation and fibrosis. Thus, morphological changes of the ductal system can be assessed by magnetic resonance cholangiopancreatography (MRCP). Furthermore, secretin-stimulated MRCP is a valuable technique to evaluate side branch pathology and the exocrine function of the pancreas and diffusion weighted imaging can be used to quantify both parenchymal fibrotic changes and the exocrine function of the pancreas. These standard and advanced MRI techniques are supplementary techniques to reveal morphological and functional changes of the pancreas in CP. Recently, spectroscopy has been used for assessment of metabolite concentrations in-vivo in different tissues and may have the potential to offer better tissue characterization of the pancreas. Hence, the purpose of the present review is to provide an update on standard and advanced MRI techniques of the pancreas in CP.
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Bian Y, Wang L, Chen C, Lu JP, Fan JB, Chen SY, Zhao BH. Quantification of pancreatic exocrine function of chronic pancreatitis with secretin-enhanced MRCP. World J Gastroenterol 2013; 19:7177-7182. [PMID: 24222963 PMCID: PMC3819555 DOI: 10.3748/wjg.v19.i41.7177] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 09/04/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To obtain reference values for pancreatic flow output rate (PFR) and peak time (PT) in healthy volunteers and chronic pancreatitis (CP); to correlate quantification of secretin enhanced magnetic resonance cholangiopancreatography (SMRCP) of pancreatic fluid output following secretin with fecal elastase-1 (FE-1) tests.
METHODS: The present study includes 53 subjects comprised of 17 healthy individuals and 36 patients with CP from April 2011 to January 2013. The 36 patients with CP were divided into three groups of mild CP (n = 14), moderate CP (n = 19) and advanced CP (n = 3) by M-ANNHEIM classification for CP.. Fifty-three cases underwent FE-1 test and magnetic resonance imaging using 3.0 T-device (Signa EXCITE, GE Healthcare). Coronal T2-weighted single-shot turbo spin-echo, spiratory triggered, covering the papillae, duodenum and small bowel. MRCP was performed with a heavily T2-weighted fat-suppressed long TE HASTE sequence (thick slab 2D MRCP sequence), repeated every 2 min up to 11 min after 0.1 mL/kg secretin injection (Secrelux, Sanochemia®, Germany). FE-1 test used sandwich enzyme-linked immunosorbent assay (ELISA) test (ScheBo. Tech®, Germany).
RESULTS: A good linear correlation showed between the calculated volume and the actual volume by Phantom experiments. Fifty-three paired Quantification of secretin enhanced magnetic resonance cholangiopancreatography (MRCPQ) and FE-1 data sets were analyzed. The mean FE-1 of 53 cases was 525.41 ± 94.44 μg/g for 17 healthy volunteers, 464.95 ± 136.13 μg/g for mild CP, 301.55 ± 181.55 μg/g for moderate CP, 229.30 ± 146.60 μg/g for advanced CP. Also, there was statistically significant difference in FE-1 (P = 0.0001) between health and CP. The mean values of PFR and PT were 8.18 ± 1.11 mL/min, 5.76 ± 1.71 min for normal; 7.27 ± 2.04 mL/min, 7.71 ± 2.55 min for mild CP; 4.98 ± 2.57 mL/min, 9.10 ± 3.00 min for moderate CP; 4.13 ± 1.83 mL/min, 12.33 ± 1.55 min for advanced CP. Further, statistically significant difference in PFR (P = 0.0001) and PT (P = 0.0001) was observed between health and CP. Besides, there was correlation (r = 0.79) and consistency (K = 0.6) between MRCPQ and ELISA Test. It was related between M-ANNHEIM classification and PFR (r = 0.55), FE-1 (r = 0.57).
CONCLUSION: SMRCP can provide a safe, non-invasive and efficient method to evaluate the exocrine function of the pancreas.
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Zhang TT, Wang L, Wang DB, Huang ZJ, Li YH, Lu JP. Correlation between secretin-enhanced MRCP findings and histopathologic severity of chronic pancreatitis in a cat model. Pancreatology 2013; 13:491-7. [PMID: 24075513 DOI: 10.1016/j.pan.2013.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES To evaluate the usefulness of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) in chronic pancreatitis (CP), we compared the severity of disease determined histopathologically with that indicated by S-MRCP imaging parameters in an induced CP cat model. MATERIALS AND METHODS An experimental group of randomly chosen cats (n = 24) underwent ligation of the pancreatic duct to induce CP, and cats in a similarly chosen control group (n = 8) were sham-operated. MRCP was performed prior to secretin stimulation, and 5 and 15 min afterward, noting in particular the pancreatic duct caliber change (PDC) and the increasing degree of fluid volume (IDFV). Histopathological changes were observed in pancreatic samples processed for hematoxylin-eosin and Sirius red staining, and CP was classified as normal, minimal, moderate, or advanced. Correlations were investigated between these groups and the PDC at 5 min and the IDFV at 15 min. RESULTS Between cats with minimal CP and the controls, the differences in mean IDFV and PDC were not significant although diseased cats showed a downward trend in both parameters. However, compared with the control group both the mean IDFV and PDC were significantly lower in cats with moderate (IDFV, P = 0.001; PDC, P = 0.013) or advanced (IDFV, P = 0.013; PDC, P = 0.001) CP. CONCLUSION The S-MRCP parameters IDFV and PDC correlated with the histopathological severity of induced CP. S-MRCP could be used to evaluate the severity of CP, although it is somewhat insensitive for depicting very early disease.
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Affiliation(s)
- Ting-Ting Zhang
- Department of Radiology, Xinhua Hospital, Shanghai Jiao Tong Medical University, Shanghai 200092, China
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Wathle GK, Tjora E, Ersland L, Dimcevski G, Salvesen ØO, Molven A, Njølstad PR, Haldorsen IS. Assessment of exocrine pancreatic function by secretin-stimulated magnetic resonance cholangiopancreaticography and diffusion-weighted imaging in healthy controls. J Magn Reson Imaging 2013; 39:448-54. [PMID: 23649590 DOI: 10.1002/jmri.24167] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 03/13/2013] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To characterize and quantify exocrine pancreatic function by secretin-stimulated magnetic resonance cholangiopancreaticography (s-MRCP) and diffusion-weighted imaging (DWI) in healthy subjects and compare these findings to morphological features, ie, pancreatic volume and secretin-stimulated peak bicarbonate concentration measured in pancreatic juice. MATERIALS AND METHODS Pancreatic magnetic resonance imaging (MRI) (1.5 T) was performed in 20 healthy volunteers among which 10 underwent gastroscopy with duodenal intubation. MRI included T2-weighted imaging and DWI acquired before and 1, 5, 9, and 13 minutes after secretin administration. Secreted pancreatic juice volumes were calculated based on the sequential T2-weighted images and pancreatic volumes and apparent diffusion coefficient (ADC) values were estimated. RESULTS The mean pancreatic secretion rate declined from 9.5 mL/min at 1-5 minutes (postsecretin) to 2.9 mL/min at 9-13 minutes. Pancreatic head ADC values significantly increased from baseline (1.29 × 10(-3) mm(2) /s) to 1 minute postsecretin (1.48 × 10(-3) mm(2) /s) (P = 0.003). Secreted pancreatic juice volume at 1 minute after secretin correlated positively with peak bicarbonate concentration (n = 10, P = 0.05). CONCLUSION Secretin-stimulated MRCP and DWI can characterize and quantify exocrine pancreatic function in healthy subjects. These imaging methods may prove relevant for patients with exocrine pancreatic dysfunction.
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Affiliation(s)
- Gaute K Wathle
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
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Martínez J, Abad-González Á, Aparicio JR, Aparisi L, Boadas J, Boix E, de las Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez Ó, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero EC, De-Madaria E. Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 1 (diagnóstico). GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:326-39. [DOI: 10.1016/j.gastrohep.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 12/14/2012] [Accepted: 12/27/2012] [Indexed: 12/20/2022]
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Martínez J, Abad-González A, Aparicio JR, Aparisi L, Boadas J, Boix E, de Las Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez O, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero E, de-Madaria E. The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis). Pancreatology 2012; 13:8-17. [PMID: 23395564 DOI: 10.1016/j.pan.2012.11.309] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 11/13/2012] [Accepted: 11/18/2012] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.
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Affiliation(s)
- J Martínez
- Pancreatic Unit, University General Hospital of Alicante, Spain.
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Abstract
The present study was aimed to improve and simplify the 13C-mixed TAG (13C-MTG) breath test while keeping it acceptable for the patient. Healthy volunteers (ten women and eight men) were examined on four occasions, receiving in a random order 300 mg 13C-MTG: (1) contained in two wafers; (2) administered with a 50 g wheat roll; as well as given with either (3) 10 or (4) 30 g butter, spread onto a 50 g wheat roll, as the test meal, respectively. Samples of expiratory air were taken for 6 h postprandially for the mass spectroscopic measurement of 13CO2 enrichment. After intake of the sole 13C-MTG, the cumulative 13C recovery in breath air (AUC) appeared to be unsatisfactory, as after 6 h it did not exceed 10 %. Application of the substrate with the 50 g wheat roll did not bring about any improvement in this parameter. The addition of the unlabelled fat to the test meal dramatically increased the cumulative 13C recovery. However, we found higher values for the momentary 13C recovery and AUC with 10 g butter compared with 30 g. It can be concluded that: (1) addition of unlabelled fat is indispensable to obtain a proper course of the breath 13C elimination during the conduct of the 13C-MTG breath test and (2) it is possible to apply a considerably smaller amount of the unlabelled fat than has previously been recommended for this test.
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Abstract
The secretin-pancreozymin test is regarded as the most accurate of the pancreatic exocrine function tests but is cumbersome, time consuming, and invasive because it requires duodenal intubation and hormonal stimulation of the pancreas. Fecal analysis of fat, fecal elastase, or chymotrypsin are more practicable but far less sensitive to detect early stages of pancreatic exocrine insufficiency. Several (13)C-labeled substrates that are digested by pancreatic enzymes have been proposed for breath tests, thus assessing the intraluminal activity of pancreatic enzymes and therewith the pancreatic exocrine function. Particularly in pediatrics, (13)C breath tests are suited not only for diagnosis of pancreatic exocrine disorder, but also for therapy control under pancreatic enzyme substitution. However, the costs of substrates, the high time expenditure, and the lack of standardization still limit the clinical use of these breath tests. This review aims to place into perspective the traditional pancreatic exocrine function tests and the newer (13)C breath tests.
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Zuccaro P, Stevens T, Repas K, Diamond R, Lopez R, Wu B, Conwell DL. Magnetic resonance cholangiopancreatography reports in the evaluation of chronic pancreatitis: a need for quality improvement. Pancreatology 2010; 9:764-9. [PMID: 20110743 DOI: 10.1159/000201304] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 01/31/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Numerous publications from academic centers suggest that magnetic resonance cholangiopancreatography (MRCP) can diagnose early chronic pancreatitis (CP) and assess pancreatic secretory reserve/function. However, the rigorous composite interpretation methods and quantitative secretory dynamics reported in these studies are not routinely measured in clinical practice. Therefore, the utility of routine MRCP reports in the clinical setting is unknown. STUDY DESIGN Cross-sectional study of patients referred to a tertiary center who underwent both MRCP and endoscopic pancreas function testing (ePFT) for assessment of chronic pancreatitis and abdominal pain. AIMS To compare MRCP and sMRCP reports to a reference standard pancreas function test for diagnosis of chronic pancreatitis. METHODS Source population: patients seen within a pancreas clinic at a tertiary referral center. MRCP and sMRCP reports were reviewed to record pancreas duct (dilation, side-branch changes), parenchyma enhancement (T(1), T(2) signal) and physiologic response (duodenal filling, pancreas duct response) to secretin. ePFT was categorized based on previously published data (normal peak bicarbonate >80 mEq/l). Referent values were calculated for MRCP and sMRCP using secretin ePFT as gold standard. RESULTS A total of 69 patients were identified (mean age 43.5 +/- 12; 65.2% female). 28 (40.6%) patients had abnormal ePFT based on their peak bicarbonate level. The mean bicarbonate values in the abnormal PFT and normal PFT groups were 59 +/- 13.9 and 95.3 +/- 12.6 mEq/l, respectively. Peak bicarbonate decreased with severity of chronic pancreatitis on MRCP (p = 0.0016). There was fair agreement of MRCP and ePFT (kappa 0.335 [0.113, 0.557]). The pre-stimulation pancreas duct changes reported were found to be the only predictor of abnormal pancreas function (p = 0.002). The post-stimulation findings of duodenal filling (p = 0.47), T(2)enhancement (p = 0.21) or change in pancreas duct caliber (p = 0.3) reported did not improve MRCP agreement with ePFT. Overall diagnostic accuracy, sensitivity and specificity were 70, 85 and 46%, respectively, for MRCP reports using ePFT as the gold standard. CONCLUSIONS Pancreas ductal features described on routine MRCP reports correlate with abnormal pancreas function. Current MRCP reports should be standardized to include all radiologic information available in hopes of predicting early chronic pancreatitis.
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Abstract
Magnetic resonance imaging (MRI) is a safe and universally available test that has much appeal to generalists and subspecialists evaluating patients with pancreatic disease. Testoni et al. report the clinical utility of magnetic resonance pancreaticocholangiography (MRCP) and secretin-enhanced MRCP in the evaluation of patients with asymptomatic abnormalities in pancreatic enzymes. The authors report that chronic pancreatitis changes will be seen in up to a third of patients with asymptomatic elevations in pancreas enzymes when compared with age-matched controls. The changes described on MRI and secretin-enhanced MRI are not in question, but the clinical significance of these changes is unknown. The authors rightly report that some of the changes seen may be age related, nonspecific, and of unknown clinical significance. Any new imaging and diagnostic test needs to be interpreted with caution until appropriate prospective clinical trials have been performed. It appears that secretin stimulation enhances the diagnostic accuracy of MRCP for the detection of minor changes in the pancreatic duct and parenchyma. Gastroenterologists are encouraged to proceed with cautious optimism when using MRI for the evaluation of early chronic pancreatitis.
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II JGL, Draganov PV. Pancreatic function testing: here to stay for the 21st century. World J Gastroenterol 2008; 14:3149-58. [PMID: 18506918 PMCID: PMC2712845 DOI: 10.3748/wjg.14.3149] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 03/09/2008] [Accepted: 03/16/2008] [Indexed: 02/06/2023] Open
Abstract
The diagnosis of Chronic Pancreatitis (CP) is based on the detection of abnormal structure or function of the diseased pancreas. The pancreatic function tests more accurately determine the presence of CP than tests of structure, especially for early stage disease. The function tests can be divided into two categories: non-invasive and invasive. The invasive "tube" tests can reliably detect mild, early CP, but are only available at a few referral centers and tend to be poorly tolerated by patients. The non-invasive tests are easy to obtain, but tend to perform poorly in patients with early, mild disease. Therefore, no one test is useful in all clinical situations, and a detailed understanding of the rational, pathophysiologic basis, strengths, and limitations of various tests is needed. This review highlights the role of various pancreatic function tests in the diagnosis of CP including fecal fat analysis, fecal elastase, fecal chymotrypsin, serum trypsin, the secretin stimulation test, the cholecystokinin (CCK) stimulation test, the combined secretin-CCK stimulation test, the intraductal and endoscopic secretin stimulation tests, and the functional magnetic resonance imaging of the pancreas after secretin stimulation.
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Kinney TP, Punjabi G, Freeman M. Technology insight: applications of MRI for the evaluation of benign disease of the pancreas. ACTA ACUST UNITED AC 2007; 4:148-59. [PMID: 17339852 DOI: 10.1038/ncpgasthep0760] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Accepted: 01/15/2007] [Indexed: 12/18/2022]
Abstract
This article reviews the role of MRI in the evaluation of benign pancreatic disease. Although MRI and magnetic resonance cholangiopancreatography (MRCP) are most often used to evaluate the liver and bile duct, technical advances such as the use of secretin stimulation also allow for high-quality imaging of the pancreas and pancreatic ductal system. Secretin-stimulated MRCP (S-MRCP) can aid the diagnosis of acute and chronic pancreatitis, and delineate ductal pathology such as benign strictures and duct leaks. There seems to be a role for S-MRCP in the assessment of pancreatic function and (possibly) sphincter of Oddi dysfunction. When endoscopic or surgical therapy is planned, S-MRCP can help to establish a diagnosis as well as offer a 'road map' to guide therapy. S-MRCP is noninvasive and almost entirely without risk to the patient, which gives it a distinct advantage over traditional endoscopic methods of diagnosis for conditions such as pancreas divisum and other ductal pathology. The information provided by S-MRCP, obtained before endoscopic or surgical therapy is attempted, can assist the patient and physician in making a fully informed decision with regard to the risks and probable benefits of any planned intervention.
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Affiliation(s)
- Timothy P Kinney
- Division of Gastroenterology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA.
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