Exocrine pancreatic disease and the malabsorption syndrome in tropical Africa

Protein intakes of pregnant women and children in India-protein quality implications

The recent National Family Health Survey (NFHS-4, 2016) reports a national average of 18% for low birthweight (LBW) and 38% for stunting in children <5 years. Nutrition and environmental influences (chronic enteric pathogenic exposure through poor water, sanitation, and hygiene) are two critical factors that impact the health outcomes of the populxation. This is particularly relevant for vulnerable age groups such as pregnant women and children <5 years, who bear long-lasting and intergenerational consequences of impoverished nutrition and suboptimal living conditions. The present review provides, for the first time, an analysis of indispensable amino acid (IAA) requirements for pregnant women, separately for the second and third trimesters, using protein accretion data from a recent Indian study. Furthermore, using these estimates for pregnancy, and the current IAA requirements for young children, the quality of protein was assessed in Indian diets consumed by pregnant women and children (1-3 and 4-6 years) from national representative rural National Nutrition Monitoring Bureau survey. The assessment was considered in the context of an adverse environment and in relation to outcomes such as LBW, stunting, and underweight. Finally, an assessment was made of the proportion of the surveyed population at risk of dietary quality protein inadequacy and implications for planning nutrition intervention programmes. Specifically, state-wise estimates of the risk of quality protein inadequacy are provided, in addition to evaluations of additional dietary supplementation, which could inform the policy of supplementary nutrition programmes to improve health outcomes.

Effectivity of Pancreatic Enzyme Replacement Therapy in Malnourished Children

OBJECTIVE

Malnutrition is commonly seen in children with exocrine pancreatic insufficiency (EPI). Pancreatic enzyme replacement therapy (PERT) is the mainstay treatment of acute malnutrition in children detected with a disease closely associated with EPI (eg, cystic fibrosis). The effectiveness of PERT in children with malnutrition without any chronic disease, however, remains unclear. The aim of this study was to investigate the effectiveness of PERT on weight gain and EPI in children classified as moderately and severely malnourished according to the World Health Organization (WHO) classification.

MATERIALS AND METHODS

The study included a total of 40 children aged 2-16 years who were classified as moderately and severely malnourished according to the WHO classification. The patients were randomly divided into 2 groups: PERT group (n = 20) received 2000 U lipase/kg/day (in 4 doses) in addition to hypercaloric enteral supplements and control group received hypercaloric enteral supplements only. In both groups, anthropometric measurements and the assessment of fecal elastase-1 (FE-1) levels were performed both at first admission and at the end of the 8-week treatment period.

RESULTS

On the basis of WHO classification, 10 (25%) children were classified as severely malnourished and 30 (75%) children as moderately malnourished. EPI was detected in all the patients, among whom 24 (60%) patients had severe EPI. At the end of the treatment, body weight, height, and body mass index (BMI) increased significantly in both groups compared to their pre-treatment values, whereas no significant difference was found with regard to waist circumference (WC) and FE-1 levels. Similarly, no significant difference was found between pre- and posttreatment measurements of PERT and control groups (P > 0.05) and between pre- and posttreatment measurements of patients with moderate and severe malnutrition (P > 0.05).

CONCLUSIONS

Malnutrition remains a serious public health problem, and thus, the development of novel treatment methods is highly essential. PERT is one of the most commonly considered alternatives, although there is little documentation of PERT in the literature. In the present study, although PERT resulted in higher weight gain, it established no significant difference between the 2 groups.

The Relation Between Malnutrition and the Exocrine Pancreas: A Systematic Review

OBJECTIVE

The relation between malnutrition and exocrine pancreatic insufficiency (EPI) has been described previously, but it is unclear if malnutrition leads to EPI or vice versa. We systematically synthesized current evidence evaluating the association between malnutrition and EPI in children.

METHODS

Pubmed, Embase, and Cochrane databases were searched from inception until February 2017. We included cohort or case-controlled studies in children reporting on prevalence or incidence of EPI and malnutrition. Data generation was performed independently by 2 authors. Quality was assessed by using quality assessment tools from the National Heart, Lung, and Blood Institute.

RESULTS

Nineteen studies were divided into 2 groups: 10 studies showing EPI leading to malnutrition, and 9 studies showing malnutrition leading to EPI. Because of heterogeneity in design, definitions, and outcome measures, pooling of results was impossible. Quality was good in 4 of 19 studies. Pancreatic insufficiency was linked to decreased nutritional status in 8 of 10 articles, although this link was not specified properly in most articles. In malnourished children, improvement was seen in pancreatic function in 7 of 9 articles after nutritional rehabilitation. The link between the 2 was not further specified. Heterogeneity exists with respect to definitions, outcome measures, and study design.

CONCLUSIONS

There is sufficient evidence for an association between EPI and malnutrition. We could not confirm whether there is a correlation or causality between EPI or malnutrition. It was therefore not possible to draw firm conclusions from this systematic review on underlying pathophysiological mechanisms between EPI and malnutrition. More observational clinical trials are crucially needed.

Pancreatic Enzyme Replacement Therapy in Children with Severe Acute Malnutrition: A Randomized Controlled Trial

OBJECTIVE

To assess the benefits of pancreatic enzyme replacement therapy (PERT) in children with complicated severe acute malnutrition.

STUDY DESIGN

We conducted a randomized, controlled trial in 90 children aged 6-60 months with complicated severe acute malnutrition at the Queen Elizabeth Central Hospital in Malawi. All children received standard care; the intervention group also received PERT for 28 days.

RESULTS

Children treated with PERT for 28 days did not gain more weight than controls (13.7 ± 9.0% in controls vs 15.3 ± 11.3% in PERT; P = .56). Exocrine pancreatic insufficiency was present in 83.1% of patients on admission and fecal elastase-1 levels increased during hospitalization mostly seen in children with nonedematous severe acute malnutrition (P <.01). Although the study was not powered to detect differences in mortality, mortality was significantly lower in the intervention group treated with pancreatic enzymes (18.6% vs 37.8%; P < .05). Children who died had low fecal fatty acid split ratios at admission. Exocrine pancreatic insufficiency was not improved by PERT, but children receiving PERT were more likely to be discharged with every passing day (P = .02) compared with controls.

CONCLUSIONS

PERT does not improve weight gain in severely malnourished children but does increase the rate of hospital discharge. Mortality was lower in patients on PERT, a finding that needs to be investigated in a larger cohort with stratification for edematous and nonedematous malnutrition. Mortality in severe acute malnutrition is associated with markers of poor digestive function.

TRIAL REGISTRATION

ISRCTN.com: 57423639.

Both Exocrine Pancreatic Insufficiency and Signs of Pancreatic Inflammation Are Prevalent in Children with Complicated Severe Acute Malnutrition: An Observational Study

OBJECTIVES

To assess whether pancreatic function is impaired in children with severe acute malnutrition, is different between edematous vs nonedematous malnutrition, and improves by nutritional rehabilitation.

STUDY DESIGN

We followed 89 children with severe acute malnutrition admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Stool and blood samples were taken on admission and 3 days after initial stabilization to determine exocrine pancreatic function via fecal elastase-1 (FE-1) and serum trypsinogen and amylase levels.

RESULTS

A total of 33 children (37.1%) had nonedematous severe acute malnutrition, whereas 56 (62.9%) had edematous severe acute malnutrition. On admission, 92% of patients showed evidence of pancreatic insufficiency as measured by FE-1 <200 μg/g of stool. Patients with edematous severe acute malnutrition were more likely to have low FE-1 (98% vs 82.8%, P = .026). FE-1 levels remained low in these individuals throughout the assessment period. Serum trypsinogen was elevated (>57 ng/mL) in 28% and amylase in 21% (>110 U/L) of children, suggesting pancreatic inflammation.

CONCLUSION

Exocrine pancreatic insufficiency is prevalent in children with severe acute malnutrition and especially in children with edematous severe acute malnutrition. In addition, biochemical signs suggestive of pancreatitis are common in children with severe acute malnutrition. These results have implications for standard rehabilitation treatment of children with severe acute malnutrition who may benefit from pancreatic enzyme replacement therapy.

TRIAL REGISTRATION

ISRCTN.com: 13916953.

Tropical pancreatitis

Tropical pancreatitis is an uncommon cause of acute, and often chronic, relapsing pancreatitis. Patients present with abdominal pain, weight loss, pancreatic calcifications, and glucose intolerance or diabetes mellitus. Etiologies include a protein-calorie malnourished state, a variety of exogenous food toxins, pancreatic duct anomalies, and a possible genetic predisposition. Chronic cyanide exposure from the diet may contribute to this disease, seen often in India, Asia, and Africa. The pancreatic duct of these patients often is markedly dilated, and may contain stones, with or without strictures. The risk of ductal carcinoma with this disease is accentuated. Treatment may be frustrating, and may include pancreatic enzymes, duct manipulations at endoscopic retrograde cholangiopancreatography, octreotide, celiac axis blocks for pain control, or surgery via drainage and/or resection.

William Hillary and sprue in the Caribbean: 230 years later

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Etiology of chronic calcifying pancreatitis in Brazil: a report of 329 consecutive cases

The authors observed 329 consecutive cases of chronic calcifying pancreatitis (CCP) from January 1963 to January 1986. Alcoholism was the etiological agent in 282 cases (86%). In 34 patients (10%) no cause was detectable (idiopathic). Malnutrition was responsible for 10 cases (3%) and chronic familial pancreatitis was diagnosed in 3 cases (0.9%). The mean age at the apparent onset of symptoms was 36.5 +/- 10.5 for the alcoholics, 22.6 +/- 15.4 in the idiopathic cases and 7.3 +/- 3.0 for the nutritional etiology patients. Mean age differences are statistically significant for the 3 groups. Pancreatic calcifications were found in 224 alcohol-induced cases (79%), in 32 idiopathic cases (94%), in 8 patients with malnutrition (80%) and in one patient with familial pancreatitis (33%). All cases of nutritional etiology presented severe protein-caloric deficiencies with edema, and none complained of pain, but 9 had pancreatic insufficiency. Mean daily ethanol intake for the alcohol-addicted patients was 396.6 +/- 286 g (range 80-1664 g) with the onset of alcoholism at 19.1 +/- 6.8 yr old and 20.8 +/- 8.3 (4-44) yr of alcohol indulgence. Pancreatic carcinoma developed in 7 cases. Six cases of chronic pancreatitis were seen among relatives in the group with CCP of alcoholic etiology.

Tropical or malnutrition-related diabetes: a real syndrome?

The syndrome known as tropical diabetes seems to be distinct from the two main types common in developed countries. Major pancreatic exocrine disease may or may not be present, and within these two groups there are clinical and biochemical variants. For these conditions the term malnutrition-related diabetes has been proposed. Although malnutrition is a plausible unifying factor, there is a good case for retaining the term tropical diabetes until there is more information on clinical and biochemical features and on aetiology.

Nutritional data and etiology of chronic pancreatitis in Mexico

Alcoholism and malnutrition have been implicated commonly in the etiology of chronic pancreatitis (CP). The geographical distribution and clinical and nutritional features differ between the alcoholic and tropical forms of CP. This work presents the etiology and nutritional characteristics of CP in Mexico, a country in which both alcoholism and childhood malnutrition are common. Two well-defined groups of patients have been identified: an alcoholic group composed mainly of males with a mean age at clinical onset of 41 years and a high dietary intake of fat, protein, carbohydrates, and calories; and a nonalcoholic group with a female preponderance, a mean age at onset of 23 years, and a higher intake of protein than controls. We conclude that alcoholic chronic pancreatitis in Mexico is similar to that reported in other temperate countries. Although the nonalcoholic group resembles that observed in tropical countries in many ways, our patients are not malnourished, further questioning the role of childhood malnutrition in the pathogenesis of this type of chronic pancreatitis.

Elevated serum immunoreactive pancreatic cationic trypsinogen in acute malnutrition: evidence of pancreatic damage

We used a sensitive probe of pancreatic dysfunction, serum immunoreactive cationic trypsinogen, to study 50 infants and children with varying degrees of malnutrition. Patients were classified into subgroups according to the severity of malnutrition. Mean serum trypsinogen concentration was significantly elevated in 25 patients with "severe" malnutrition (77.4 +/- 42.0 ng/ml, P less than 0.001) and in 23 with "moderate" malnutrition (55.2 +/- 16.1 ng/ml, P less than 0.02) compared with the mean value (32.5 +/- 10.4 ng/ml) for well-nourished controls. The level of circulating trypsinogen tended to rise with increasing severity of malnutrition. There was no relationship between serum trypsinogen and other variables such as age, specific diagnosis, or mode of feeling. Elevated serum trypsinogen levels could not be attributed to renal disease or cystic fibrosis. In patients who showed an improvement in nutritional status, serum trypsinogen tended to revert toward normal. Elevated serum trypsinogen values in acutely malnourished infants and children may result from pancreatic acinar cell damage or regurgitation of enzymes from obstructed pancreatic ducts.

Immunodeficiency and cryptosporidiosis. Demonstration at the Royal College of Physicians of London

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Pathogenesis of juvenile tropical pancreatitis syndrome

The name juvenile tropical pancreatitis syndrome (JTPS) is proposed for a disease which affects young people of both sexes in certain parts of the tropics and which is characterised by abdominal pain, diabetes, steatorrhoea, and pancreatic calcification. The condition seems to start with blockage of the pancreatic ducts by laminated secretions or inspissated mucus plugs which later calcify. Chronic pancreatitis follows. The hypothesis is that plugs are the result of pancreatic stasis due to prolonged lack of food in the stomach and/or gastroenteritis and dehydration. Most plugs are probably dislodged during convalescence when protein-containing foods are eaten and stimulate vigorous flow of pancreatic juice. The sluggish pancreatic flow produced by very-low-protein diets may not dislodge plugs. Repeated infection and anorexia can enlarge the plugs which ultimately calcify. JTPS therefore occurs in Third-World areas with a high rate of childhood infections, and where low-protein staples are taken. Cereal staples seem to reduce the incidence of JTPS in endemic areas because of their protein content.

Light microscopic and ultrastructural changes of the exocrine pancreas in magnesium deficient rats

In magnesium deficient rats with a clinical picture of protein malnutrition, pancreatic changes typical of protein malnutrition were expected. However, in rats fed for four weeks on a low magnesium diet (protein content 25%), light and electron microscopic studies revealed that the acinar cells of the pancreas were packed with zymogen granules, suggesting a disturbance in the discharge (rather than in the production) of the pancreatic enzymes. The mitochondria and the lumina of the RER were swollen. The nuclei had an irregular outline, the chromatin was aggregated into irregular granules and the nucleolemma of the nucleolus was fibrillar. It was suggested that the disturbance in the release of pancreatic enzymes might cause a maldigestion of the dietary protein, which eventually would lead to the condition of protein malnutrition in the magnesium deficient rats. The disturbance of exocytosis in the pancreas of magnesium deficient rats might be due to the preferential use of all the available magnesium for protein (enzymes) synthesis so that there were no magnesium ions left for the energy dependent discharge of the zymogen granules.

Pancreatic response to secretion+CCK-PZ in European and North African adults and children

Pancreatic response to intravenous secretin GIH (1CU/kg) +CCK-PZ (3CHRU/kg) was investigated in European and North African normal subjects. The pancreatic responses were compared in two groups of 38 normal male adults and in two groups of nine normal nurslings (less than 1 year). Body weight and age were similar in the two adult groups and in the two nursling groups. The peaks of volume, electrolytes, and enzymes were determined in samples of duodenal aspirate after hormonal stimulation. In adult subjects the flow rate and electrolytes were not statistically different in the two groups, while enzyme outputs were lower in the North African group -73% for lipase (P less than 0.001), -54% for phospholipase (P less than 0.01), and -35% for chymotrypsin (P less than 0.05). On the other hand, in both groups of nursling subjects all parameters of pancreatic secretion were identical. The difference in the pattern of the pancreatic response to exogenous hormonal stimulation observed between the two groups of adult subjects could be related to genetic or acquired differences. The second hypothesis is, however, the most probable because the pancreatic secretion was similar in both groups of nursling subjects.

Endemic tropical sprue in Rhodesia

The existence of tropical sprue in Africa is controversial. In this paper we present 31 cases seen in Rhodesia over a 15 month period. They have the clinical features, small intestinal morphology, malabsorption pattern, and treatment response of tropical sprue. Other causes of malabsorption, and primary malnutrition, have been excluded. The severity of the clinical state and intestinal malabsorption distinguish these patients from those we have described with tropical enteropathy. The previous work on tropical sprue in Africa is reviewed and it is apparent that, when it has been adequately looked for, it has been found. It is clear that the question of tropical sprue in Africa must be re-examined and that it existence may have hitherto been concealed by the assumption that primary malnutrition is responsible for the high prevalence of deficiency states.

Subclinical intestinal malabsorption in developing countries

Asymptomatic small intestinal disease characterized by abnormalities of structure and function has been reported from many developing countries. Abnormalities of structure include changes in villus architecture and in appearance under both the light and the electron microscope. Changes in function include abnormalities in the absorption of xylose, fat, vitamin B(12), amino acids, and dipeptides and excessive faecal losses of nitrogen and energy. The etiology of the condition is unknown but appears to be closely related to exposure to the environment. The nutritional consequences of this condition have not been fully explored but for people living on marginally sufficient dietary intakes they may be extremely important.

Pancreatic pseudocysts in children: 4 cases from Uganda

Four cases of pancreatic pseudocyst in African children are described. There is some evidence that they followed pancreatitis of unknown aetiology. None had a history of trauma. Three were treated by cystogastrostomy, and the fourth by excision of the cyst.

Chronic pancreatitis in African diabetics

Steatorrhea due to chronic pancreatitis was found in 23 percent of a consecutive series of 107 new african diabetics; 3 had pancreatic calcification. Of 16, 14 had definitely abnormal exocirne secretion function testing using secreation pancreozymin stimultion. Themorphology and function of the small intestine were normal by local standards. When compared with diabetics without steatorrhea they weighed less, their fasting blood sugars were lower, and their insulin requirements were greater. High alcoholic intake might be significant cause, but the incidence was similar in the diabetics without steatorrhea. No evidence of childhood or adult malnutrition was established. The etiology of this high incidence of chronic pancreatitis among african diabetics remains unexplained.