Comparing the urinary pancreolauryl ratio and faecal elastase-1 as indicators of pancreatic insufficiency in clinical practice

Assessment of exocrine pancreatic function in children and adolescents with direct and indirect testing

The exocrine pancreas plays an important role in digestion. Understanding of the physiology and regulation of exocrine function provides insight into disease processes and basis of functional testing. Specifically, exocrine pancreatic insufficiency (EPI) can cause maldigestion and thus a proper assessment of exocrine pancreatic function is important. There are indirect and direct methods for evaluating pancreatic function. Indirect methods are varied and include stool, serum, urine, and breath tests. Fecal elastase is a commonly used indirect test today. Direct methods involve stimulated release of pancreatic fluid that is collected from the duodenum and analyzed for enzyme activity. The most used direct test today is the endoscopic pancreatic function test. Indirect pancreatic function testing is limited in identifying cases of mild to moderate EPI, and as such in these cases, direct testing has higher sensitivity and specificity in diagnosing EPI. This review provides a comprehensive guide to indirect and direct pancreatic function tests as well as an in-depth look at exocrine pancreatic function including anatomy, physiology, and regulatory mechanisms.

Which factors determine exocrine pancreatic dysfunction in diabetes mellitus?

The exocrine structure is significantly affected by diabetes because of endocrine structure-function disorder within the pancreas. Exocrine pancreatic dysfunction (EPD) is the general name of the malabsorption process resulting from inadequate production, release, decreased activation, and/or insufficient degradation of enzymes required for digestion from pancreatic acinar cells. It is important to diagnose patients early and correctly, since there may be both macro- and micro-nutrient deficiency in EPD. In this paper, EPD, the diabetes-EPD relationship, and the predictive, effective factors affecting the emergence of EPD are briefly explained and summarized with contemporary literature and our experienced based on clinical, lab, and radiological findings.

Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition

Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

Pancreatic exocrine insufficiency in type 1 and type 2 diabetics of Indian origin

BACKGROUND

Pancreatic exocrine insufficiency has been frequently described in both type 1 and type 2 diabetes. Fecal elastase test has been demonstrated to have good correlation with direct tests for exocrine function, especially in moderate to severe cases. There are no data on the prevalence of pancreatic exocrine insufficiency in Indian patients with diabetes utilizing FEC concentrations. The objective of our study is to evaluate the prevalence of pancreatic exocrine insufficiency (PEI) in type 1 and type 2 diabetes and study the impact of PEI on glycemic control and metabolic parameters in diabetes.

METHODS AND MATERIALS

We conducted a cross sectional study on 89 T1D, 95 T2D patients and 90 healthy controls. Biochemical parameters including FBS, HbA1c, serum albumin and serum calcium were estimated. Fecal elastase concentrations (FEC) were estimated by ELISA. Patients with FEC <200 μg/g were considered to have pancreatic exocrine insufficiency.

RESULTS

The prevalence of PEI was 31.4% in T1D, 29.4% in T2D and 4.4% in controls (P < 0.01). A significant negative correlation was observed between FEC levels and, both FBS and HbA1c in diabetic patients. There was also a significant positive correlation between BMI and FEC. There was no significant association between low FEC and other biochemical parameters.

CONCLUSION

Nearly one third of patients with both T1D and T2D showed evidence of impaired exocrine function utilizing FEC test. Presence of PEI correlated with lower BMI and higher HbA1c.

ESPGHAN and NASPGHAN Report on the Assessment of Exocrine Pancreatic Function and Pancreatitis in Children

The purpose of this clinical report is to discuss several recent advances in assessing exocrine pancreatic insufficiency (EPI) and pancreatitis in children, to review the array of pancreatic function tests, to provide an update on the inherited causes of EPI, with special emphasis on newly available genetic testing, and to review newer methods for evaluating pancreatitis.

Fecal elastase-1 is useful in the detection of steatorrhea in patients with pancreatic diseases but not after pancreatic resection

BACKGROUND

Fecal elastase-1(FE-1) has been suggested as an alternative to steatorrhea quantification to evaluate pancreatic insufficiency, but its diagnostic performance has not been compared with steatorrhea in chronic pancreatitis or after pancreatic resection.

METHODS

The relationship between steatorrhea and FE-1 was studied in patients with chronic pancreatic disorders or pancreatic resection. Student's t test and ANOVA were used for statistical analysis, accepting 0.05 as limit for significance.

RESULTS

Eighty-two patients were studied (42 non-operated; 40 previously submitted to pancreatic resection). Fat output was higher in operated than non-operated patients (29.2 ± 3.1 vs 9.9 ± 2.2 g/day, p < 0.001) FE-1 was more severely reduced in operated patients (202 ± 32.3 μg/g in non operated vs 68.6 ± 18.2 in operated patients; p < 0.001). Steatorrhea was significantly more severe in operated patients across different levels of FE-1. The relationship between FE-1 and steatorrhea was described by a power regression model, with a regression line significantly different in operated and non-operated patients (p < 0.001). A steatorrhea of 7 g (upper limit of normal range) was calculated by this regression line when FE-1 is 15 μg/g in non-operated, but as high as 225 μg/g in operated patients.

CONCLUSION

FE-1 is useful to identify pancreatic insufficiency. Steatorrhea is anticipated in non-operated patients only when FE-1 is below the limit for a confident measurement of our assay. In operated patients, steatorrhea may be present even if FE-1 is only slightly reduced, that suggests a role for non pancreatic factors. FE1 is not useful to identify operated patients at risk of malabsorption.

Partial pancreatic resection for pancreatic malignancy is associated with sustained pancreatic exocrine failure and reduced quality of life: a prospective study

OBJECTIVES

Pancreatic resection for cancer may produce pancreatic exocrine insufficiency (PEI), which is poorly understood. This study examined the coefficient of fat absorption (CFA), symptoms, quality of life (QoL) and the accuracy of faecal elastase-1 (FE-1) measurement to predict PEI.

METHODS

Forty patients were analysed following resection for pancreatic malignancy. The primary endpoint was PEI diagnosis defined by CFA <93%; secondary endpoints were PEI diagnosis using FE-1 <200 μg/g, body mass index (BMI), and symptom and QoL analysis. Interventions were 3-day stool collection, EORTC QLQ-C30 (version 1) questionnaire and patient's diary, at 6 weeks and 3, 6 and 12 months after surgery.

RESULTS

CFA <93% was present in 67% of patients at 6 weeks and in 55% at 12 months. PEI using FE-1 was present in 77 and 83% of patients, respectively. No significant changes between time-points were observed. Sensitivity, specificity, PPV, NPV and accuracy for FE-1 in detecting CFA <93% were 91, 35, 70, 71 and 70%, respectively. CFA and FE-1 levels were uncorrelated. Overall, QoL increased at 6 (p = 0.0212) and 12 (p < 0.0001) months after surgery, mainly driven by physical, role and social functioning, and by appetite. Importantly, however, BMI and symptoms were unaffected by PEI, which suggests a subclinical presentation; such patients had attributes indicating poorer QoL (notably insomnia, p = 0.0012).

CONCLUSIONS

PEI was common and sustained following resection and not associated with significant symptoms. These patients had a tendency toward poorer QoL. FE-1 is a poor surrogate for diagnosing impaired fat absorption. Postoperative pancreatic enzyme replacement should be considered more routinely. and IAP.

Pancreatic insufficiency in adult celiac disease: do patients require long-term enzyme supplementation?

BACKGROUND

Celiac disease is associated with exocrine pancreatic insufficiency. We previously reported that in 30% (20/66) of adult celiac patients with current or persistent diarrhea the underlying cause was exocrine pancreatic insufficiency. Of these 20 patients, 19 initially improved on pancreatic supplementation. To date, there are no published longitudinal studies.

METHODS

The 20 patients who had initially received therapy for exocrine pancreatic insufficiency were prospectively followed-up for 4 years. Gastrointestinal symptoms, dietary adherence, celiac antibody status, and dose of enzyme supplementation were recorded. Fecal elastase-1 (Fel-1) was repeated to reassess exocrine pancreatic function.

RESULTS

In the study, 19/20 patients were reviewed, as one had died (mean age 59.7 years, 7 males). The mean duration of celiac disease was 13.2 years. Eleven out of nineteen were still taking enzyme supplementation at a mean dose of 45,000 units of lipase per day. Only 1/11 reported no symptomatic benefit and 8/19 patients had discontinued supplementation because their diarrhea had improved. In the whole group there was a significant increase in Fel-1 levels over time, with median values of 90 μg/g at 0 months, 212 μg/g at 6 months, and 365 μg/g at follow-up (45-66 months)(p < 0.0001).

CONCLUSIONS

Fecal elastase-1 is useful in identifying exocrine pancreatic insufficiency in adult celiac patients with diarrhea. Our longitudinal data suggests that pancreatic enzyme supplementation could be discontinued in a substantial proportion of patients as symptoms improve.

Diagnosing exocrine pancreatic insufficiency after surgery: when and which patients to treat

Exocrine pancreatic insufficiency (EPI) is a common problem after surgery of the pancreas and stomach. It is usually caused by inadequate pancreatic enzyme activity resulting from insufficient enzyme production, insufficient enzyme activation or disturbed enzyme deactivation. A variety of direct and indirect pancreatic function tests such as the secretin-cerulein test, the faecal elastase test and the (13)C-mixed triglyceride breath test are used to assess exocrine pancreatic function. Few studies have addressed pancreatic enzyme replacement therapy (PERT) following pancreatic surgery. These studies suggest beneficial effects of enzyme replacement after pancreatic resections. A number of studies have been performed to assess post-gastrectomy maldigestion and PERT. The treatment options remain controversial, although the published evidence is in favour of PERT leading to an overall improvement of symptoms. In conclusion, EPI following pancreatic surgery and total or partial gastrectomy remains a common clinical challenge. As a result of the lack of solid evidence, more clinical trials, particularly randomized, controlled clinical trials, are urgently needed.

Determinants of Exocrine Pancreatic Function as Measured by Fecal Elastase-1 Concentrations (FEC) in Patients with Diabetes mellitus

OBJECTIVE

Recently it has been shown that there is not only endocrine insufficiency in diabetic patients, but a frequent co-morbidity of both, the endocrine and exocrine pancreas. The present study was performed to further analyse the determinants of exocrine pancreatic function in patients with diabetes mellitus.

METHODS

The records of 1992 patients with diabetes mellitus who had been treated in our hospital during a 2-year period were re-evaluated. Defined parameters were documented in standardized data sheets. Records were further checked for the results of imaging procedures of the pancreas. In 307 patients FEC had been performed and documented. Only these patients were included in further evaluation.

RESULTS

FEC was inversely correlated with diabetes duration and HbA1c-levels but not with age. C-peptide levels correlated positively with FEC. BMI and FEC were also significantly correlated. There was no correlation between diabetes therapy and exocrine pancreatic function as there was no correlation with any concomitant medication. The presence of diabetes-associated antibodies was not related to FEC. According to the documented data 38 were classified as type-1 diabetes (12.4%), 167 as type-2 (54.4%), and 88 patients met the diagnostic criteria of type-3 (28.7%). Fourteen patients could not be classified because of lacking information (4.6%).

CONCLUSIONS

Exocrine insufficiency might be explained as a complication of diabetes mellitus. However, it is more likely that type-3 diabetes is much more frequent than previously believed. Consequently the evaluation of exocrine function and morphology should be included into the clinical workup of any diabetic patient at least at the time of manifestation.

A rapid, endoscopic exocrine pancreatic function test and the Lundh test: a comparative study

BACKGROUND/AIMS

The diagnosis of chronic pancreatitis is often difficult in the early stages of the disease. Morphological tests may be normal, and reliable methods for the evaluation of the exocrine pancreatic function are time-consuming and troublesome. A new test for exocrine pancreatic function, using endoscopic aspiration of secretin-stimulated pancreatic juice, has been developed. We evaluated the test using the Lundh meal test as reference.

METHODS

The endoscopic secretin stimulation test (ESST) was performed in a consecutive row of 24 patients referred for pancreatic function testing because of clinical suspicion of chronic pancreatitis and in 23 healthy volunteers. The participants fasted overnight and secretin was given intravenously (1 CU/kg) as a bolus the following morning. Thirty minutes after administration of secretin, the tip of the duodenoscope was placed close to the ampulla of Vater and duodenal aspirate was drawn for 10 min. Intraduodenal concentrations of lipase, bicarbonate, elastase and zinc were measured. The concentration of lipase during the Lundh test (4 x 20 min aspiration) was used as reference test in the patients.

RESULTS

Judged from the Lundh test, the exocrine pancreatic function was nearly abolished in 5 patients (<10% of lower normal limit), reduced in 6 patients and normal in 13 patients. ESST failed in 1 patient (no aspirate). Lipase concentrations (KU/l) were significantly lower in the patients with nearly abolished function compared to patients with reduced or normal exocrine pancreatic function (NEPF; Mann-Whitney U test: p < 0.01), but an overlap was found between patients with reduced exocrine pancreatic function [100.1 (median); 60.0-225.0 (range)] patients with NEPF (145.7; 44.6-268.0) and healthy controls (175.0; 84.8-381.0). Bicarbonate concentrations (mEq/l) were significantly lower in patients with reduced exocrine pancreatic function (51.2; 32.5-69.6) compared to patients with NEPF (80.0; 48.1-101.8; Mann-Whitney U test: p < 0.05). Pancreatic elastase concentration was significantly lower in the group with nearly abolished exocrine function compared to patients with NEPF (Mann-Whitney U test: p < 0.05), but there was no difference between elastase concentrations among the other groups. We found significant correlation between lipase and bicarbonate concentrations during ESST and lipase concentrations during the Lundh test in all 23 patients (Spearman's Rank test: rho = 0.597 and 0.683, respectively, p < 0.01). By using receiver operating characteristic curves, best cut-off point for bicarbonate was estimated. Lipase and bicarbonate results in the healthy volunteers were not statistically different from results in patients with NEPF. No side effects were observed except for worsening of nausea and abdominal pain in 2 of the patients.

CONCLUSION

The ESST is safe, and by combining the estimation of lipase and bicarbonate concentrations this test is a rapid, easy and useful diagnostic test for exocrine pancreatic function.

Correlation of MRCP quantification (MRCPQ) with conventional non-invasive pancreatic exocrine function tests

PURPOSE

To correlate MRCP quantification (MRCPQ) of pancreatic fluid output following secretin with steatorrhoea, urinary pancreo-lauryl (PL) or fecal elastase 1 (FE1) tests.

METHODS AND MATERIALS

Sixty-one patients, 36 male, median age 51 years (23-78) with known or suspected pancreatic disease who had undergone both MRCPQ and FE1 or PL were included. Twenty-nine patients had chronic pancreatitis, five acute pancreatitis, seven normal, five pancreas divisum, four pancreatic atrophy, three pancreatic duct obstruction, two post-surgical and six miscellaneous diagnoses. Clinical assessment of steatorrhoea was available in 29. MRCP was performed before and at 2 min intervals after 0.1 ml/kg IV Secretin. Changes in signal intensity in the imaging volume were plotted against time and the flow rate derived from the gradient. Scatter plots, Pearson correlation coefficient, and the Fisher Exact test were performed.

RESULTS

MRCPQ was significantly different (p = 0.012) between those with/without steatorrhoea; mean +/- SD (95% CI) were 4.0 +/- 1.5 (3.1:4.9, n = 16) and 6.3 +/- 2.9 (4.7:7.8, n = 13). Fifty-one paired FE1-MRCPQ and 24 PL-MRCPQ data sets were analysed. Both the Pearson correlation coefficient (FE1 p = 0.001 and %TK p = 0.003) and the Fisher Exact test were significant (FE1 p = 0.016 and %T/K 0.03).

CONCLUSIONS

MRCPQ correlated with steatorrhoea, PL and FE1.

Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms?

BACKGROUND

Patients with coeliac disease may have diarrhoea despite being on a gluten-free diet.

AIM

To assess whether exocrine pancreatic insufficiency causes persisting symptoms compared with controls, we determined whether pancreatic enzyme supplementation provided symptomatic benefit in coeliac patients with chronic diarrhoea.

METHODS

Patients (n = 259) were subdivided into four groups: (a) new coeliac disease (n = 57), (b) coeliac disease patients on a gluten-free diet without gastrointestinal symptoms (n = 86), (c) coeliac disease patients on a gluten-free diet with chronic diarrhoea (n = 66) and (d) patients with chronic diarrhoea without coeliac disease (n = 50). Stool frequency and weight, before and after treatment with pancreatic enzyme supplementation were recorded.

RESULTS

The prevalence of a low faecal elastase-1 within the groups was: group (A) six of 57 (11%), group (B) five of 86 (6%), group (C) 20 of 66 (30%) and group (D) two of 50 (4%). Low faecal elastase-1 was more frequent in coeliac disease patients with chronic diarrhoea vs. other subgroups of coeliac disease (P < or = 0.0001) and controls (P < or = 0.0003). In 18 of 20 stool frequency reduced following pancreatic enzyme supplementation from four per day to one (P < or = 0.001). No weight increase (P = 0.3) was observed.

CONCLUSIONS

Low faecal elastase is common in patients with coeliac disease and chronic diarrhoea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.

Using faecal elastase-1 to screen for chronic pancreatitis in patients admitted with acute pancreatitis

BACKGROUND

Patients presenting with acute pancreatitis may have co-existing chronic pancreatitis, the accurate diagnosis of which would potentially guide appropriate management. Gold standard tests are often invasive, costly or time-consuming, but the faecal elastase-1 assay has been shown to be comparatively accurate for moderate and severe exocrine deficiency. This study aimed to evaluate fecal elastase-1 concentration [FE-1] against clinical criteria for chronicity in an acute setting.

PATIENTS AND METHODS

[FE-1] was performed on patients admitted with acute onset of epigastric pain and a serum lipase at least three times the upper limit of normal. Clinical diagnosis of chronic pancreatitis was defined by the presence of specific clinical, pathological or radiological criteria. A [FE-1] value of <200 microg/g was similarly considered indicative of chronic exocrine insufficiency. Thus a 2 x 2 table comparing [FE-1] and clinical diagnosis was constructed.

RESULTS

After exclusion of liquid stool specimens, 105 stool specimens from 87 patients were suitable for [FE-1] determination. [FE-1] was evaluated against the clinical diagnosis of chronic pancreatitis, initially for the whole sample, and then after exclusion of cases of moderate and severe acute pancreatitis (Ranson score >2). The latter analysis, based on an exocrine insufficiency threshold of 200 microg/g, yielded a sensitivity of 79.5%, specificity of 98.0%, positive predictive value of 96.9% and negative predictive value of 86.0%.

CONCLUSION

[FE-1] is an accurate screening tool for underlying chronic exocrine insufficiency when taken in the course of a hospital admission for mild acute pancreatitis.