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Stern L, Schuette M, Goetz MR, Nitschke C, Bardenhagen J, Scognamiglio P, Stüben BO, Calavrezos L, Amin T, Heumann A, Lohse AW, de Heer G, Izbicki JR, Uzunoglu FG. Perioperative management of pancreatic exocrine insufficiency-evidence-based proposal for a paradigm shift in pancreatic surgery. HPB (Oxford) 2024; 26:117-124. [PMID: 37770362 DOI: 10.1016/j.hpb.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/07/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Despite exocrine pancreatic insufficiency (EPI) being a significant consequence of pancreatic surgery, there is still no consensus on its perioperative management. This study aimed to evaluate unselective pancreatic enzyme replacement therapy (PERT). METHODS A prospective, observational study of patients undergoing partial pancreatectomy was conducted. EPI status was assessed pre- and postoperatively, based on three fecal-elastase measurements each. Characteristic symptoms were evaluated by questionnaire. In 85 post-surgical patients, the subjective burden of PERT was measured. RESULTS 101 patients were followed prospectively. Preoperative EPI screening was available for 83 patients, of which 48% were diagnosed with preexisting EPI. Of those patients with regular exocrine function, 54% developed EPI de novo; this rate being higher following pancreatic head resections (72%) compared to left-sided pancreatectomies (LP) (20%) (p = 0.016). Overall postoperative EPI prevalence was significantly greater following pancreatic head resections (86%) than LP (33%) (p < 0.001). Only young and female patients described a significant burden related to PERT. CONCLUSION For all patients undergoing pancreatic head resection PERT should be considered beginning prior to surgery, due to the subgroup's high EPI rate and the comparatively low burden of PERT. Patients with LP are at lower risk and should be pre- and postoperatively screened and supplemented accordingly.
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Affiliation(s)
- Louisa Stern
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Miriam Schuette
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Mara R Goetz
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Christine Nitschke
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jan Bardenhagen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Björn-Ole Stüben
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lenika Calavrezos
- Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tania Amin
- Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Asmus Heumann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Geraldine de Heer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Valla FV, Uberti T, Henry C, Slim K. Perioperative nutritional assessment and support in visceral surgery. J Visc Surg 2023; 160:356-367. [PMID: 37587003 DOI: 10.1016/j.jviscsurg.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.
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Affiliation(s)
- Frederic V Valla
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France.
| | - Thomas Uberti
- Anesthesiology and Critical Care Department, Hôpital E.-Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France
| | - Caroline Henry
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France
| | - Karem Slim
- Digestive Surgery Department and Ambulatory Surgery Unit, 63003 Clermont-Ferrand, France
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3
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Brenner DM, Domínguez-Muñoz JE. Differential Diagnosis of Chronic Diarrhea: An Algorithm to Distinguish Irritable Bowel Syndrome With Diarrhea From Other Organic Gastrointestinal Diseases, With Special Focus on Exocrine Pancreatic Insufficiency. J Clin Gastroenterol 2023:00004836-990000000-00152. [PMID: 37115854 DOI: 10.1097/mcg.0000000000001855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Chronic diarrhea, defined as diarrhea persisting for more than 4 weeks, affects up to 5% of the population regardless of patient age, sex, race, or socioeconomic status. The impact on patient health and quality of life is substantial, and diagnosis and management of these patients have significant economic consequences for health care services. The differential diagnosis of chronic diarrhea is broad, with etiologies including infections, endocrinopathies, maldigestive/malabsorptive conditions, and disorders of gut-brain interaction. The considerable overlap of symptoms across this spectrum makes accurate diagnosis problematic and may lead to delays in diagnosis or misdiagnosis. In this narrative review, we consider the differential diagnosis of chronic diarrhea, focusing on irritable bowel syndrome with diarrhea and exocrine pancreatic insufficiency, two conditions that may present similarly but have very different underlying causes and require significantly different management strategies. We outline a 4-step diagnostic strategy and propose a straightforward algorithm to assist in efficiently differentiating irritable bowel syndrome from exocrine pancreatic insufficiency and other causes of chronic diarrhea. We anticipate that these aids will improve diagnostic accuracy, which ultimately should lead to improvements in patients' health-related quality of life and reduce the societal burden on health care services.
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Affiliation(s)
- Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL
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4
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Chang VT, Sandifer C, Zhong F. GI Symptoms in Pancreatic Cancer. Clin Colorectal Cancer 2023; 22:24-33. [PMID: 36623952 DOI: 10.1016/j.clcc.2022.12.002] [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: 08/30/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022]
Abstract
This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.
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Affiliation(s)
- Victor T Chang
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ.
| | | | - Fengming Zhong
- Section Hematology Oncology (111), VA New Jersey Health Care System, East Orange, NJ; Department of Medicine, Rutgers - New Jersey Medical School, Newark, NJ
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5
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Mathew A, Fernandes D, Andreyev HJN. What is the significance of a faecal elastase-1 level between 200 and 500μg/g? Frontline Gastroenterol 2023; 14:371-376. [PMID: 37581180 PMCID: PMC10423608 DOI: 10.1136/flgastro-2022-102271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/26/2023] [Indexed: 08/16/2023] Open
Abstract
Background Pancreatic exocrine insufficiency is a cause of malabsorption. It is generally diagnosed if faecal elastase-1 (FE-1) levels are below 200 µg/g. Pancreatic function is assumed to be normal when faecal elastase levels are >500 µg/g. The significance of faecal elastase levels above 200 µg/g but less than 500 µg/g is unclear. Methods This retrospective study reports the response to treatment in patients who had an FE-1 level between 200 and 500 µg/g. Results Of these 82 patients, 28 were offered pancreatic enzyme replacement therapy (PERT). A clinical response, defined as an improvement in their initial symptoms after commencing PERT, was seen in 20 patients (71%), 7 with potentially predisposing conditions and 13 with functional diarrhoea. PERT particularly abolished or improved diarrhoea, steatorrhoea and flatulence. Conclusion Clinicians should, therefore, be aware that a trial of PERT given to patients with FE-1 levels between 200 and 500 µg/g may lead to improvement in gastrointestinal symptoms.
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Affiliation(s)
| | - Darren Fernandes
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- School of Health and Social Care, Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - H Jervoise N Andreyev
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln, UK
- The Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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6
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Muftah AA, Pecha RL, Riojas Barrett M, Abidi WM, Patel KK, Keihanian T, Othman MO. Pancreatic parenchymal changes seen on endoscopic ultrasound are dynamic in the setting of fatty pancreas: A short-term follow-up study. Pancreatology 2022; 22:1187-1194. [PMID: 36402715 DOI: 10.1016/j.pan.2022.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/17/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The impact of fatty pancreas on pancreatic parenchymal changes is unclear. The aim of this study is to assess parenchymal alterations over time in patients with fatty pancreas (FP). METHODS This is a retrospective study (2014-2021) of patients with FP identified on endoscopic ultrasound (EUS). Subjects with follow up imaging studies including Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI), and EUS at least two years after the initial EUS were included. RESULTS A total of 39 patients with a mean age of 51.21 ± 12.34 years were included. Mean initial weight was 80.17 ± 17.75 kg. Diabetes, hepatic steatosis, and EPI were present in 15%, 46% and 33% of the patients at baseline, respectively. In 25 patients with available follow up EUS over 2.4 ± 0.76 years, 16% progressed to chronic pancreatitis (CP) and 24% had progressive parenchymal changes without meeting the criteria for CP. One patient progressed from focal to diffuse FP, while one patient had resolution of FP. In multivariate analysis, progressive parenchymal changes on EUS were associated with an increase in weight over time (p-value 0.04), independent of the effects of gender, alcohol, or tobacco. CONCLUSION Progressive parenchymal changes were noted in 44%. Our result suggests that FP is a dynamic process with the possibility of progression or regression over time.
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Affiliation(s)
- Abdullah A Muftah
- Department of Internal Medicine, Baylor College of Medicine, Houston, Tx, USA
| | - Robert L Pecha
- Department of Internal Medicine, Baylor College of Medicine, Houston, Tx, USA
| | - Margarita Riojas Barrett
- Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Tx, USA
| | - Wasif M Abidi
- Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Tx, USA
| | - Kalpesh K Patel
- Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Tx, USA
| | - Tara Keihanian
- Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Tx, USA
| | - Mohamed O Othman
- Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Tx, USA.
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7
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Roeyen G, Berrevoet F, Borbath I, Geboes K, Peeters M, Topal B, Van Cutsem E, Van Laethem JL. Expert opinion on management of pancreatic exocrine insufficiency in pancreatic cancer. ESMO Open 2022; 7:100386. [PMID: 35124465 PMCID: PMC8819032 DOI: 10.1016/j.esmoop.2022.100386] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- G Roeyen
- Department of Hepatobiliary Transplantation and Endocrine Surgery, Antwerp University Hospital and University of Antwerp, Edegem.
| | - F Berrevoet
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent
| | - I Borbath
- Hepato-Gastroenterology Unit, Cliniques Universitaires Saint-Luc, Brussels
| | - K Geboes
- Department of Gastroenterology, Division of Digestive Oncology, Ghent University Hospital, Ghent
| | - M Peeters
- Department of Oncology, Antwerp University Hospital and University of Antwerp, Edegem
| | - B Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Leuven
| | - E Van Cutsem
- Department of Gastroenterology/Digestive Oncology, University Hospital Leuven, University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven
| | - J-L Van Laethem
- Department of Digestive Oncology, University Hospital Erasmus Brussels, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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8
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Kunovský L, Dítě P, Jabandžiev P, Eid M, Poredská K, Vaculová J, Sochorová D, Janeček P, Tesaříková P, Blaho M, Trna J, Hlavsa J, Kala Z. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021; 10:jcm10245779. [PMID: 34945075 PMCID: PMC8708123 DOI: 10.3390/jcm10245779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malnutrition, results from primary pancreatic disease or is secondary to impaired exocrine pancreatic function. Although chronic pancreatitis is the most common cause of EPI, several additional causes exist. These include pancreatic tumors, pancreatic resection procedures, and cystic fibrosis. Other diseases and conditions, such as diabetes mellitus, celiac disease, inflammatory bowel disease, and advanced patient age, have also been shown to be associated with EPI, but the exact etiology of EPI has not been clearly elucidated in these cases. The causes of EPI can be divided into loss of pancreatic parenchyma, inhibition or inactivation of pancreatic secretion, and postcibal pancreatic asynchrony. Pancreatic enzyme replacement therapy (PERT) is indicated for the conditions described above presenting with clinically clear steatorrhea, weight loss, or symptoms related to maldigestion and malabsorption. This review summarizes the current literature concerning those etiologies of EPI less common than chronic pancreatitis, the pathophysiology of the mechanisms of EPI associated with each diagnosis, and treatment recommendations.
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Affiliation(s)
- Lumír Kunovský
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Petr Dítě
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Petr Jabandžiev
- Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, 61300 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 62500 Brno, Czech Republic
| | - Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic;
| | - Karolina Poredská
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Jitka Vaculová
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavel Janeček
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavla Tesaříková
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
| | - Martin Blaho
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Jan Trna
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute Brno, 60200 Brno, Czech Republic
- Correspondence: (J.T.); (J.H.)
| | - Jan Hlavsa
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
- Correspondence: (J.T.); (J.H.)
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
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Moore JV, Tom S, Scoggins CR, Philips P, Egger ME, Martin RCG. Exocrine Pancreatic Insufficiency After Pancreatectomy for Malignancy: Systematic Review and Optimal Management Recommendations. J Gastrointest Surg 2021; 25:2317-2327. [PMID: 33483914 DOI: 10.1007/s11605-020-04883-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/12/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Exocrine pancreatic insufficiency (EPI) occurs when pancreatic enzyme activity in the intestinal lumen is insufficient for normal digestion to occur. The true incidence and diagnosis of EPI after pancreatectomy has not been fully understood and optimized. The aim of this study was to present incidence and diagnostic criteria for EPI after pancreatectomy for cancer and provide a guide for management and optimal therapy in pancreatectomy patients with cancer. METHODS A comprehensive review of the literature with publication dates from 2014 to 2019 was performed. A comprehensive diagnostic and treatment algorithm was then created based on literature review and current treatment options. RESULTS In total, 30 studies were included, 19 combined both pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), 9 for central pancreatectomy, and 2 others. EPI was defined subjectively without definitive testing using any of the established diagnostic studies in the majority of studies 23 (76%). Preoperative EPI was calculated to be 11.52%. Most studies assessed exocrine function at least 6 months postoperatively with four studies extending the follow-up period beyond 12 months. EPI diagnosed postoperatively at 1 month (40.27%), 3 months (30.94%), 6 months (36.06%), and 12 months (34.69%). After PD, the median prevalence of postoperative EPI was 43.14%, CP, the median prevalence was 4.85%, DP, median prevalence of postoperative EPI of 11.94%. CONCLUSION EPI is a frequent outcome that is often misdiagnosed or under-reported by the patient post-pancreatectomy. Given the increasing overall survival in pancreatectomy patients for cancer, surgeon awareness and assessment is critical to improving patients' overall quality of life.
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Affiliation(s)
| | - Stephanie Tom
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Prejesh Philips
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Michael E Egger
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA
| | - Robert C G Martin
- Division of Surgical Oncology, The Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway #311, Louisville, KY, 40202, USA.
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10
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Robbins AJ, Lusczek E, Bellin MD, Alwan FS, Hodges JS, Chapman SA, Beilman GJ. Gastrointestinal Bleed After Total Pancreatectomy With Islet Autotransplant. Pancreas 2021; 50:841-846. [PMID: 34347732 PMCID: PMC8373743 DOI: 10.1097/mpa.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB. METHODS Prospectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes. RESULTS Sixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055). CONCLUSIONS Twelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).
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Affiliation(s)
| | | | | | | | - James S Hodges
- Division of Biostatistics, University of Minnesota School of Public Health
| | - Scott A Chapman
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
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11
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Barkin JA, Barkin JS. Effect of Pancrelipase Therapy on Exocrine Pancreatic Insufficiency Symptoms and Coefficient of Fat Absorption Associated With Chronic Pancreatitis. Pancreas 2021; 50:176-182. [PMID: 33560089 DOI: 10.1097/mpa.0000000000001733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether improvement in coefficient of fat absorption (CFA) with pancreatic enzyme replacement therapy correlates with clinical symptoms in patients with chronic pancreatitis with moderate to severe exocrine pancreatic insufficiency. METHODS Data were pooled from 2 randomized double-blind trials of the effects of 1 week of pancrelipase (n = 59) versus placebo (n = 57) on CFA and stool frequency, stool consistency, abdominal pain, and flatulence; 1 trial included a 51-week open-label pancrelipase treatment period (n = 34). RESULTS Compared with placebo, significantly more patients receiving pancrelipase reported decreased stool frequency at week 1 (72% vs 38%; P < 0.001). Although 30% of patients receiving pancrelipase and 20% receiving placebo reported improved stool consistency, changes in stool consistency, abdominal pain, and flatulence were not different between groups. Mean CFA absolute change from baseline was significantly greater with pancrelipase versus placebo (24.7% vs 6.4%; P < 0.001). Improvements in stool consistency and frequency correlated with CFA improvement. Symptom improvements persisted or further improved through 52 weeks of treatment. CONCLUSIONS Pancrelipase significantly improved exocrine pancreatic insufficiency maldigestive symptoms. Improvements in objective stool symptoms with pancreatic enzyme replacement therapy correlated with CFA improvement at 1 week.
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Affiliation(s)
- Jodie A Barkin
- From the Division of Gastroenterology, Department of Medicine, University of Miami, Leonard M. Miller School of Medicine, Miami, FL
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12
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Soytürk M, Bengi G, Oğuz D, Kalkan İH, Yalnız M, Tahtacı M, Demir K, Kasap E, Oruç N, Ünal NG, Sezgin O, Özdoğan O, Altıntaş E, Yaraş S, Parlak E, Köksal AŞ, Saruç M, Ünal H, Ünsal B, Günay S, Duman D, Yurçi A, Kacar S, Filik L. Turkish Gastroenterology Association, Pancreas Study Group, Chronic Pancreatitis Committee Consensus Report. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2020; 31:S1-S41. [PMID: 33210608 PMCID: PMC7752168 DOI: 10.5152/tjg.2020.220920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Müjde Soytürk
- Department of Gastroenterology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Göksel Bengi
- Department of Gastroenterology, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Dilek Oğuz
- Department of Gastroenterology, Kırıkkale University School of Medicine, Kırıkkale, Turkey
| | - İsmail Hakkı Kalkan
- Department of Gastroenterology, TOBB University of Economics and Technology School of Medicine, Ankara, Turkey
| | - Mehmet Yalnız
- Department of Gastroenterology, Fırat University School of Medicine, Elazığ, Turkey
| | - Mustafa Tahtacı
- Department of Gastroenterology, Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
| | - Kadir Demir
- Department of Gastroenterology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Elmas Kasap
- Department of Gastroenterology, Celal Bayar University School of Medicine, Manisa, Turkey
| | - Nevin Oruç
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Nalan Gülşen Ünal
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Orhan Sezgin
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Osman Özdoğan
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Engin Altıntaş
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Serkan Yaraş
- Department of Gastroenterology, Mersin University School of Medicine, Mersin, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aydın Şeref Köksal
- Department of Gastroenterology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Murat Saruç
- Department of Gastroenterology, Acibadem University School of Medicine, İstanbul, Turkey
| | - Hakan Ünal
- Department of Gastroenterology, Acibadem University School of Medicine, İstanbul, Turkey
| | - Belkıs Ünsal
- Health Sciences University, Katip Çelebi Training and Research Hospital, İzmir, Turkey
| | - Süleyman Günay
- Health Sciences University, Katip Çelebi Training and Research Hospital, İzmir, Turkey
| | - Deniz Duman
- Department of Gastroenterology, Marmara University School of Medicine, İstanbul, Turkey
| | - Alper Yurçi
- Department of Gastroenterology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Sabite Kacar
- Health Sciences University, Ankara State Hospital, Ankara, Turkey
| | - Levent Filik
- Health Sciences University, Ankara Training and Research Hospital, Ankara, Turkey
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13
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Siener R, Machaka I, Alteheld B, Bitterlich N, Metzner C. Effect of Fat-Soluble Vitamins A, D, E and K on Vitamin Status and Metabolic Profile in Patients with Fat Malabsorption with and without Urolithiasis. Nutrients 2020; 12:nu12103110. [PMID: 33053816 PMCID: PMC7601514 DOI: 10.3390/nu12103110] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
Patients with intestinal fat malabsorption and urolithiasis are particularly at risk of acquiring fat-soluble vitamin deficiencies. The aim of the study was to evaluate the vitamin status and metabolic profile before and after the supplementation of fat-soluble vitamins A, D, E and K (ADEK) in 51 patients with fat malabsorption due to different intestinal diseases both with and without urolithiasis. Anthropometric, clinical, blood and 24-h urinary parameters and dietary intake were assessed at baseline and after ADEK supplementation for two weeks. At baseline, serum aspartate aminotransferase (AST) activity was higher in stone formers (SF; n = 10) than in non-stone formers (NSF; n = 41) but decreased significantly in SF patients after supplementation. Plasma vitamin D and E concentrations increased significantly and to a similar extent in both groups during intervention. While plasma vitamin D concentrations did not differ between the groups, vitamin E concentrations were significantly lower in the SF group than the NSF group before and after ADEK supplementation. Although vitamin D concentration increased significantly in both groups, urinary calcium excretion was not affected by ADEK supplementation. The decline in plasma AST activity in patients with urolithiasis might be attributed to the supplementation of ADEK. Patients with fat malabsorption may benefit from the supplementation of fat-soluble vitamins ADEK.
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Affiliation(s)
- Roswitha Siener
- Department of Urology, University Stone Center, University Hospital Bonn, 53127 Bonn, Germany;
- Correspondence: ; Tel.: +49-228-2871-9034
| | - Ihsan Machaka
- Department of Urology, University Stone Center, University Hospital Bonn, 53127 Bonn, Germany;
| | - Birgit Alteheld
- Department of Nutrition and Food Sciences, Nutritional Physiology, University of Bonn, 53115 Bonn, Germany;
| | - Norman Bitterlich
- Department of Biostatistics, Medicine and Service Ltd., 09117 Chemnitz, Germany;
| | - Christine Metzner
- Bonn Education Association for Dietetics r. A., 50935 Cologne, Germany; or
- Clinic for Gastroenterology, Metabolic Disorders and Internal Intensive Medicine (Medical Clinic III), RWTH Aachen, 52074 Aachen, Germany
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14
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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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15
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Barkin JA, Barkin JS. Chronic Pancreatitis and Bone Disease. J Clin Densitom 2020; 23:237-243. [PMID: 31558406 DOI: 10.1016/j.jocd.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022]
Abstract
Patients with chronic pancreatitis (CP) may have a higher prevalence of osteoporosis than the general population thereby increasing the risk of bone fracture. The pathophysiology of bone disease in CP is multifactorial. Their risk factors for secondary osteoporosis include increasing age, low body mass index from sitophobia, maldigestion due to exocrine pancreatic insufficiency (EPI) with resulting low vitamin D, as well as smoking and alcohol abuse. An obvious association of bone disease with CP is from EPI with maldigestion of fat-soluble vitamins including vitamin-D, which has a significant role in the process of bone formation. Vitamin-D deficiency may be higher in CP patients vs controls, and it is especially so in CP patients with EPI. Screening for CP-associated osteopathy, including osteopenia and osteoporosis, should be initiated early in the course of CP, as the overall prevalence of bone disease is approximately two-thirds of CP patients. Our initial approach in the treatment of osteoporosis should include correction of maldigestion resulting from EPI with use of pancreatic enzyme replacement therapy (PERT). PERT, which is the treatment for EPI is associated with improvement in Dual energy X-ray absorptiometry (DXA) values and vitamin-D levels compared to those who are not treated. This should improve, in addition to body mass index, vitamin-D deficiency and calcium absorption as well as improve overall nutritional status. Osteopathy is common in CP patients, has significant associated morbidity, should be screened for regularly, and corrected with fat soluble vitamin supplementation and PERT to prevent clinical sequelae. In this article, we review the epidemiology, pathophysiology, and treatment of bone disease in patients with CP.
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Affiliation(s)
- Jodie A Barkin
- University of Miami, Leonard M. Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL USA.
| | - Jamie S Barkin
- University of Miami, Leonard M. Miller School of Medicine, Department of Medicine, Division of Gastroenterology, Miami, FL USA
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16
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Bellomo TL. Exocrine pancreatic insufficiency: Can this be the cause of your patient's GI symptoms? Nursing 2020; 50:41-45. [PMID: 32068705 DOI: 10.1097/01.nurse.0000615080.53435.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Exocrine pancreatic insufficiency (EPI) prevents the pancreas from making enough of the exocrine pancreatic enzymes that help the body digest food. EPI can be challenging to recognize and diagnose because many of its signs and symptoms overlap with other gastrointestinal disorders. This article offers practical advice to nurses for patient assessment and nursing interventions.
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Affiliation(s)
- Tamara L Bellomo
- Tamara Bellomo is an associate professor at Kingsborough Community College in Brooklyn, N.Y
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17
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Ru N, Zou WB, Wu H, Hu LH, Li XB, Liu GF, Li ZS, Liao Z. Chinese guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency (2018 edition). J Dig Dis 2019; 20:567-571. [PMID: 31006979 DOI: 10.1111/1751-2980.12753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nan Ru
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Wen Bin Zou
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Hao Wu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China
| | - Xiao Bin Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Gai Fang Liu
- Department of Gastroenterology, Hebei People's Hospital, Shijiazhuang, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Naval Medical University (Second Military Medical University), Shanghai, China.,Department of Gastroenterology, Shanghai Institute of Pancreatic Diseases, Shanghai, China
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18
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Johnston PC, Thompson J, Mckee A, Hamill C, Wallace I. Diabetes and Chronic Pancreatitis: Considerations in the Holistic Management of an Often Neglected Disease. J Diabetes Res 2019; 2019:2487804. [PMID: 31687406 PMCID: PMC6800932 DOI: 10.1155/2019/2487804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/13/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
Diabetes secondary to chronic pancreatitis (CP) or type 3cDM refers to a brittle form of diabetes and is often characterised by hypoglycaemic episodes, erratic glycaemic control, and impaired quality of life. It differs from other forms of diabetes and is typically characterised by concurrent pancreatic endocrine and exocrine insufficiency which can present as malabsorption and nutritional deficiencies. In this review, we discuss the pathogenesis, epidemiology, and the practicalities of diagnosis, screening, and management of this condition.
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Affiliation(s)
| | - Judith Thompson
- Dietetics Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Allison Mckee
- Dietetics Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Connor Hamill
- Diabetes Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
| | - Ian Wallace
- Diabetes Department, 51 Lisburn Road, BT9 7AB Belfast City Hospital, UK
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19
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Sankararaman S, Schindler T, Sferra TJ. Management of Exocrine Pancreatic Insufficiency in Children. Nutr Clin Pract 2019; 34 Suppl 1:S27-S42. [DOI: 10.1002/ncp.10388] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Cleveland Ohio USA
| | - Thomas J. Sferra
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
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20
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Barkin JA, Westermann A, Hoos W, Moravek C, Matrisian L, Wang H, Shemanski L, Barkin JS, Rahib L. Frequency of Appropriate Use of Pancreatic Enzyme Replacement Therapy and Symptomatic Response in Pancreatic Cancer Patients. Pancreas 2019; 48:780-786. [PMID: 31210656 PMCID: PMC6749961 DOI: 10.1097/mpa.0000000000001330] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/20/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Pancreatic cancer (PC) and its treatments can result in pancreatic exocrine insufficiency that requires pancreatic enzyme replacement therapy (PERT). Appropriate PERT usage is during meals and snacks. The aim was to determine the frequency of appropriate use of PERT and its impact on symptom alleviation in PC through a patient-reported outcomes online platform. METHODS Users in the Pancreatic Cancer Action Network's Patient Registry were prompted to answer a standalone questionnaire about their experience with PERT. RESULTS Two hundred sixty-two users completed the PERT questionnaire (January 2016-January 2018). Patients who reported taking PERT with meals had higher alleviation of symptoms compared with those taking PERT prior to or after meals. Specifically, "feeling of indigestion," "light-colored or orange stools," and "visible food particles in stool" were significantly decreased. Patients taking PERT with meals reported weight gain and less weight loss. CONCLUSIONS Of the 89% of PC patients prescribed PERT, 65% were prescribed PERT appropriately with all meals and snacks. Overall compliance with PERT administration guidelines was low (50% [105/208]). Improvement in symptoms significantly correlated with appropriate use of PERT. Increase in PC patient and provider education about appropriate PERT usage and administration is warranted.
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Affiliation(s)
- Jodie A. Barkin
- From the Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL
| | - Amy Westermann
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | - William Hoos
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | | | - Lynn Matrisian
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | | | | | - Jamie S. Barkin
- From the Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL
| | - Lola Rahib
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
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21
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Standardized clinical criteria and sweat test combined as a tool to diagnose Cystic Fibrosis. Heliyon 2018; 4:e01050. [PMID: 30582056 PMCID: PMC6299035 DOI: 10.1016/j.heliyon.2018.e01050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/29/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022] Open
Abstract
Context CF is under-diagnosed in Ecuador; one out of every 11,252 live births born in Ecuador could have CF. Aim To analyze the clinical findings, based on previously established criteria, with the results of the sweat test, in circumstances where we do not have the routine molecular study. Methods Epidemiological, observational, analytic, cross-sectional study. It analyzed 180 patients clinically suspected of CF. Inclusion criteria: children of both sexes older than 30 days and younger than 12 years, who meet at least three clinical criteria suggestive for CF, outpatient and referred by a specialist physician who made a preliminary diagnosis. This is a pilot study. Results The combination of criteria pneumonia, chronic cough and chronic obstructive bronchial syndrome is the most frequent, with not a significant relationship with a positive sweat test. On the contrary, a significant relationship was found between the clinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing, so it is recommended to perform the test in all these associations. The most frequent clinical criterion for the reference and performance of the electrolyte test in sweat is pneumonia to repeat for two or more episodes. Conclusion Clinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing are pathognomonic for CF and indication for the sweat test. The predictive performance in CF diagnosis, defined as compatible clinical presence plus high values of chloride in sweat test, was 91.1%.
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22
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Shandro BM, Nagarajah R, Poullis A. Challenges in the management of pancreatic exocrine insufficiency. World J Gastrointest Pharmacol Ther 2018; 9:39-46. [PMID: 30397535 PMCID: PMC6212541 DOI: 10.4292/wjgpt.v9.i5.39] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1 (FE-1) stool test is widely available and has been shown to be as effective as the 13C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.
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Affiliation(s)
- Benjamin Myles Shandro
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Rani Nagarajah
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
| | - Andrew Poullis
- Department of Gastroenterology, St George’s University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, United Kingdom
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23
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Othman MO, Harb D, Barkin JA. Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician. Int J Clin Pract 2018; 72:e13066. [PMID: 29405509 PMCID: PMC5873407 DOI: 10.1111/ijcp.13066] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022] Open
Abstract
AIMS In exocrine pancreatic insufficiency (EPI), the quantity and/or activity of pancreatic digestive enzymes are below the levels required for normal digestion, leading to maldigestion and malabsorption. Diagnosis of EPI is often challenging because the characteristic signs and symptoms overlap with those of other gastrointestinal conditions. Additionally, there is no single convenient, or specific diagnostic test for EPI. The aim of this review is to provide a framework for differential diagnosis of EPI vs other malabsorptive conditions. METHODS This is a non-systematic narrative review summarising information pertaining to the aetiology, diagnosis and management of EPI. RESULTS Exocrine pancreatic insufficiency may be caused by pancreatic disorders, including chronic pancreatitis, cystic fibrosis, pancreatic resection and pancreatic cancer. EPI may also result from extra-pancreatic conditions, including coeliac disease, Zollinger-Ellison syndrome and gastric surgery. Timely and accurate diagnosis of EPI is important, as delays in treatment prolong maldigestion and malabsorption, with potentially serious consequences for malnutrition, overall health and quality of life. Symptoms of EPI are non-specific; therefore, a high index of clinical suspicion is required to make a correct diagnosis.
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Affiliation(s)
- Mohamed O. Othman
- Division of GastroenterologyDepartment of MedicineBaylor College of MedicineHoustonTXUSA
| | - Diala Harb
- Global Medical AffairsAbbVie Inc.MettawaILUSA
| | - Jodie A. Barkin
- Division of GastroenterologyDepartment of MedicineLeonard M. Miller School of MedicineUniversity of MiamiMiamiFLUSA
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24
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Citrome L. Perspectives, Commentaries, Consensus Reports, Grand Rounds, Meta-Analyses, Systematic Reviews, Narrative Reviews: Collecting useful information in one place. Int J Clin Pract 2018; 72. [PMID: 29504664 DOI: 10.1111/ijcp.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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