Diagnosis and treatment of pancreatic exocrine insufficiency

Hydrophobic solid lipid-based microparticles for the protection of gastric-sensitive hydrophilic active biomolecules for oral administration in the treatment of EPI

Exocrine Pancreatic Insufficiency (EPI), induced by conditions such as cystic fibrosis, chronic pancreatitis, and Crohn's disease, is a frequently overlooked and underdiagnosed gastrointestinal disorder. It leads to inadequate intestinal digestion due to insufficient secretion of pancreatic juice, resulting in discomfort, pain, and ultimately severe malnutrition. Despite numerous treatments proving ineffective over the past three decades, a strictly hydrophobic solid lipid formulation, administered orally, is proposed in this study to restore digestive function. This technology relies on the hydrophobic nature of the matrix to physically protect the hydrophilic active principle from the gastric environment while enabling its immediate release in the duodenum by targeting the amphiphilic nature of bile salts. Results demonstrate that this formulation effectively protects an acid-sensitive active ingredient during gastric passage (Simulated Gastric Fluid or SGF), facilitating its rapid release upon entering an artificial duodenal environment (Simulated Intestinal Fluid or SIF). Furthermore, it has been demonstrated that the preservation of a protein-based active ingredient extends beyond its primary protein structure to include its functional aspects, such as enzymatic activity. This drug delivery technology could enable the protection of hydrophilic active biomolecules, such as pancreatin, which are sensitive to gastric acidity, while promoting their immediate release upon contact with bile salts in the proximal duodenum, with the ultimate goal of correcting the digestive defect induced by EPI.

Pancreas and pancreatitis: Exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is highly prevalent among individuals with cystic fibrosis (CF). Individuals diagnosed with EPI are often labeled as having "pancreas insufficient cystic fibrosis (PI-CF)" while those with normal exocrine function are labeled as "pancreas sufficient CF (PS-CF)." This diagnosis of EPI relies on clinical and laboratory features and management involves consumption of pancreas enzyme replacement therapy. In this review, we discuss the nuances of diagnosis and management of EPI in CF. We also present emerging evidence on the effects of CFTR modulating agents on the management of EPI, and speculate that these medications may lead to greater heterogeneity in management of EPI in CF moving forward.

Validity and Diagnostic Ability of Pancreatic Exocrine Insufficiency Questionnaire in Turkish Patients

Pancreatic exocrine insufficiency (PEI) is a prevalent disease that is often underdiagnosed and undertreated, leading to resulting in diminished health-related quality of life. The PEI questionnaire (PEI-Q), a patient-reported outcome questionnaire developed to diagnose and evaluate PEI, is available only in English. The study aimed to provide a Turkish translation of PEI-Q and validate its reliability and diagnostic performance in a Turkish-speaking population with PEI. This study included 161 participants: 98 patients with PEI and 63 healthy controls. Participants underwent the PEI-Q test, and the results were statistically analyzed for reliability and validity. The diagnostic value of PEI-Q was determined using receiver operating characteristic (ROC) curves. Cronbach's alpha was used to assess internal consistency, while exploratory factor analysis was performed to determine construct validity and reveal the factor structure. The mean age of participants was 45.0 years, and 60.2% were male. Participants with PEI were significantly older than those without. Scores for abdominal, bowel movement, and total symptoms were significantly higher in patients with PEI than in controls. ROC analysis revealed good diagnostic value for PEI-Q, with areas under the curve ranging from 0.798 to 0.851 for different symptom scores. Cronbach's alpha coefficients were above 0.70, indicating good internal consistency, and exploratory factor analysis supported a 4-factor structure, accounting for 68.9% of the total variance. The Turkish version of the PEI-Q is a reliable, easy-to-use, and valid screening tool for diagnosing PEI. It consistently assesses symptoms and quality of life in patients with PEI, helping to inform diagnosis and treatment.

Developing the EPI Symptom Questionnaire (EPI-SQ): a qualitative study to understand the symptom experience of patients with exocrine pancreatic insufficiency (EPI)

BACKGROUND

Symptom assessment is the key factor in determining disease status and optimal management of exocrine pancreatic insufficiency (EPI). There is a need for a standardized patient-reported outcome (PRO) questionnaire to assess symptoms in patients diagnosed with EPI. The purpose of this qualitative study was to increase understanding of the EPI symptom experience from the patients' perspective, and to develop and evaluate the content validity of the EPI Symptom Questionnaire (EPI-SQ) in US patients with EPI.

METHODS

Concept elicitation interviews (Phase I) were conducted to understand the symptom experience in patients with a clinical diagnosis of EPI (i.e., fecal pancreatic elastase value of ≤ 200 mcg/g based on most recent value) due to chronic pancreatitis or pancreatectomy. The EPI-SQ was developed based on the data extracted from Phase I interviews and feedback from clinical experts. Next, separate cognitive interviews (Phase II) were conducted to evaluate participants' understanding of the instructions, items, response scales, and recall periods of the instrument.

RESULTS

During Phase I interviews (n = 21), 19 participants (90%) reported abdominal pain as the most frequent EPI symptom and lifestyle changes were the most frequently endorsed impacts (n = 18; 86%). Phase II results indicated that all participants (n = 7) felt the 12-item EPI-SQ was relevant to their symptom experience and that they understood the items, instructions, and response options as intended.

CONCLUSION

The qualitative data from this study support the content validity of the EPI-SQ in measuring EPI symptom severity in US patient populations diagnosed with EPI.

Pancreatic enzyme replacement therapy and resource utilization in patients with chronic pancreatitis in a US healthcare system: a retrospective study

OBJECTIVE

To assess the association between pancreatic enzyme replacement therapy (PERT) and resource utilization among patients with chronic pancreatitis (CP) in a large Midwestern US healthcare system.

METHODS

This retrospective cohort study used electronic medical record data. Eligible patients (N = 2445) were aged ≥18 years and diagnosed with non-cystic fibrosis CP between January 2005 and December 2018, with ≥6 months' follow-up; study initiation was first encounter with the healthcare system. Patients in the PERT group were prescribed PERT at ≥1 encounter; patients in the non-PERT group were not prescribed PERT at any encounter.

RESULTS

In total, 62,899 encounters were reviewed (PERT, n = 22,935; non-PERT, n = 39,964). More patients in the PERT group were younger, male, White, married/partnered and with private insurance than those in the non-PERT group. They also received longer care and had more overall encounters, fewer outpatient and day surgery/24-hour observation encounters, and more inpatient encounters. Emergency room encounters were similar between groups. Average cost by encounter was similar between groups ($225 and $213, respectively).

CONCLUSIONS

Despite similar average costs per encounter, the groups had very different encounter types. More inferential research on PERT use among patients with CP is needed, particularly regarding resource utilization and long-term outcomes.

Screening for undiagnosed pancreatic exocrine insufficiency (PEI) in a cohort of diabetic patients using faecal elastase testing and PEI scoring system

INTRODUCTION

Type 1 and type 2 diabetes mellitus (DM) are often accompanied by mild forms of pancreatic exocrine insufficiency (PEI). The prevalence rates of PEI in diabetic patients are unclear and variable depending on the testing modality and the studies published. The clinical consequences of PEI in diabetics are also not well defined.

AIM

We aimed to determine the prevalence of PEI in a diabetic cohort using the faecal elastase-1 (FE-1) assay as a screening test and to validate a patient-reported symptom-based scoring system, the (PEI-S) for diagnosing PEI within this patient population.

METHODS

Two hundred and three diabetic patients attending diabetic and gastroenterology outpatients of a university hospital without previously known PEI were recruited for the study. Demographic parameters, PEI score (PEI-S), and glycated hemoglobin (HBA1c) were documented in standardized data sheets, and a stool sample was obtained. A FE-1 value < 200 μg/g and or a PEIS of > 0.6 was used as the screening cut-off for PEI.

RESULTS

One hundred sixty-six patients returned faecal samples. The prevalence of PEI, as measured by low FE-1, was 12%. Smoking was associated with an increased risk of developing PEI in this diabetic population. No other independent risk factors were identified. The PEI-S system did not differentiate between people with diabetes having a normal and low FE1.

CONCLUSION

12% of this mixed, real-life cohort of type 1 and 2 DM patients had undiagnosed PEI, as defined by an FE-1 score of less than 200 μg/g. While this may appear low, given the rising prevalence of type 2 DM worldwide, there is likely an unrecognized burden of PEI, which has long-term health consequences for those affected. The PEI-S, a symptom-scoring system for patients with PEI, did not perform well in this patient group.

Fat malabsorption in pancreatic cancer: Pathophysiology and management

Exocrine pancreatic insufficiency (EPI) is common in pancreatic ductal adenocarcinoma (PDAC) and may lead to significant nutrition compromise. In the setting of cancer cachexia and gastrointestinal toxicities of cancer treatments, untreated (or undertreated) EPI exacerbates weight loss, sarcopenia, micronutrient deficiencies, and malnutrition. Together, these complications contribute to poor tolerance of oncologic therapies and negatively impact survival. Treatment of EPI in PDAC involves the addition of pancreatic enzyme replacement therapy, with titration to improve gastrointestinal symptoms. Medical nutrition therapies may also be applicable and may include fat-soluble vitamin replacement, medium-chain triglycerides, and, in some cases, enteral nutrition. Optimizing nutrition status is an important adjunct treatment approach to improve quality of life and may also improve overall survival.

Symptoms, burden, and unmet needs of patients living with exocrine pancreatic insufficiency: a narrative review of the patient experience

Exocrine pancreatic insufficiency (EPI) stems from a deficiency of functional pancreatic enzymes with consequent maldigestion and malnutrition. EPI shares clinical symptoms and manifestations with other disorders and is a considerable burden to individuals affected. In this narrative review, we analyzed the literature to identify relevant publications on living with EPI with the scope of individuating evidence gaps, including those related to symptoms, health-related quality of life (HRQoL), emotional functioning, disease burden, presence of comorbidities, and the use of pancreatic enzyme replacement therapy (PERT). Abdominal pain emerged as one of the most prominent symptoms. HRQoL was affected in EPI, but no articles examined emotional functioning. Comorbidities reported involved other pancreatic disorders, diabetes, gastrointestinal disorders, sarcopenia and osteopenia, cardiovascular disorders, bacterial overgrowth, and nutritional deficiencies. PERT was found to be effective in improving EPI symptoms and was well tolerated by most individuals. Our review revealed a dearth of literature evidence on patients' experience with EPI, such as emotional functioning and disease burden. We also revealed that studies on long-term effects of PERT are missing, as are studies that would help advance the understanding of the disease and its progression, risk/mitigating factors, and comorbidities. Future studies should address these identified gaps.

High hand grip strength is a significant risk factor and a useful predictor of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most critical complications of pancreaticoduodenectomy (PD). Studies on predictive factors for POPF that can be identified preoperatively are limited. Recent reports have highlighted the association between the preoperative nutritional status, including sarcopenia, and postoperative complications. We examined preoperative risk factors for POPF after PD, focusing on nutritional indicators.

METHODS

A total of 153 consecutive patients who underwent PD at our institution were enrolled in this study. Preoperative nutritional parameters, including hand grip strength (HGS) and skeletal muscle mass as components of sarcopenia, were incorporated into the analysis. POPFs were categorized according to the International Study Group of Pancreatic Fistula (ISGPF) definition as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C).

RESULTS

Thirty-seven of the 153 patients (24.1%) fulfilled the ISGPF definition of CR-POPF postoperatively. In the univariate analysis, the incidence of CR-POPF was associated with male sex, non-pancreatic tumor diseases, a high body mass index, a high HGS and a high skeletal muscle mass index. In the multivariate analysis, non-pancreatic tumor diseases and an HGS ≥23.0 kg were selected as independent risk factors for CR-POPF (P <0.05).

CONCLUSIONS

A high HGS, a screening tool for sarcopenia, was a risk factor for CR-POPF. It can accurately serve as a useful predictor of POPF risk in patients undergoing PD. These results highlight the potential of sarcopenia to reduce the incidence of POPF and highlight the need to clarify the mechanism of POPF occurrence.

Nonallergic Diseases Associated With Foods

Clinicians are faced with evaluating real and alleged reactions to foods that may be allergic or nonallergic. Pathogenesis, diagnosis, and treatment of various non-IgE-mediated diseases are discussed in this review. These food-related conditions range from mild to severe. Referral for an allergy workup may be pursued despite the lack of IgE-mediated symptoms. Diagnostic testing is available for defined non-IgE-mediated food diseases that are either immunologic or nonimmunologic. These include celiac disease and related disorders, carbohydrate maldigestion, pancreatic insufficiency, and histamine intolerance. In contrast, there is a paucity of definitive studies to prove food intolerance diseases. There are no definitive diagnostic criteria or testing for nonceliac gluten sensitivity. Functional gastrointestinal disorders, such as irritable bowel syndrome, are better stratified diagnostically but still lack reliable testing. Both nonceliac gluten sensitivity and irritable bowel syndrome are linked to dietary triggers including fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Therefore, dietary alteration alone may be diagnostic and therapeutic when all other conditions are ruled out. These conditions are important considerations when evaluating a patient with history of a food reaction. There is little evidence that foods are causative in other ailments such as acne, migraines, and nasal congestion and hypersecretion.

Predictive Insights Into Exocrine Pancreatic Insufficiency in Chronic Pancreatitis and Autoimmune Pancreatitis: A Decision Tree Approach

OBJECTIVE

Exocrine pancreatic insufficiency (EPI) is a common manifestation of chronic pancreatitis (CP) and autoimmune pancreatitis (AIP). This study aimed to estimate the presence of EPI in patients with CP or AIP using alternative clinical markers.

MATERIALS AND METHODS

A machine learning analysis employing a decision tree model was conducted on a retrospective training cohort comprising 57 patients with CP or AIP to identify EPI, defined as fecal elastase-1 levels less than 200 μg/g. The outcomes were then confirmed in a validation cohort of 26 patients.

RESULTS

Thirty-nine patients (68%) exhibited EPI in the training cohort. The decision tree algorithm revealed body mass index (≤21.378 kg/m 2 ) and total protein level (≤7.15 g/dL) as key variables for identifying EPI. The algorithm's performance was assessed using 5-fold cross-validation, yielding area under the receiver operating characteristic curve values of 0.890, 0.875, 0.750, 0.625, and 0.771, respectively. The results from the validation cohort closely replicated those in the training cohort.

CONCLUSIONS

Decision tree analysis revealed that EPI in patients with CP or AIP can be identified based on body mass index and total protein. These findings may help guide the implementation of appropriate treatments for EPI.

Comprehensive, long-term evaluation of pancreatic exocrine insufficiency after pancreatoduodenectomy

AIMS

Treatment of pancreatic exocrine insufficiency (PEI) following pancreatoduodenectomy (PD) improves quality of life, clinical outcomes, and survival. However, diagnosing PEI following PD is challenging owing to the difficulties with current tests and often non-specific symptoms. This work aims to quantify the true rate of long-term PEI in patients following a PD.

METHODS

Patients underwent a PEI screen approximately one to two years following PD for oncologic indication, including the 13C Mixed triglyceride breath test (13CMTGT), faecal elastase 1 (FE-1) and the PEI Questionnaire (PEI-Q). Four reviewers with expertise in PEI reviewed the results blinded to other decisions to classify PEI status; disagreements were resolved on consensus.

RESULTS

26 patients were recruited. Of those with valid test results, these were indicative of PEI based on pre-specified thresholds for 60 % (15/25) for the 13CMTGT, 82 % (18/22) for FE-1, and 88 % (22/25) for the PEI-Q. After discussion between reviewers, the consensus PEI prevalence was 81 % (95 % CI: 61-93 %; 21/26), with 50 % (N = 13) classified as having severe, 23 % (N = 6) moderate, and 8 % (N = 2) mild PEI.

DISCUSSION

Since no ideal test exists for PEI, this collation of diagnostic modalities and blinded expert review was designed to ascertain the true rate of long-term PEI following PD. This required our cohort to survive a year, travel to hospital, and undergo a period of starvation and PERT hold, and therefore there is likely to be recruitment bias towards fitter, younger patients with less aggressive pathology. Despite this, over 80 % were deemed to have PEI, with over 90 % of these being considered moderate or severe.

A case report of pancreatic exocrine insufficiency in a patient with Parkinson's disease: A coincidence or is there more to it than meets the eye?

Pancreatic exocrine insufficiency (PEI) is an under-diagnosed condition. Untreated PEI can result in developing gastrointestinal symptoms and long-term complications including weight loss, nutrient deficiencies, sarcopenia and osteoporosis. Current best practice recommends testing for PEI in certain disorders including chronic pancreatitis, cystic fibrosis, pancreatic cancer and post-pancreatic surgery. However, there is increasing evidence that PEI is associated with a number of conditions in addition to the aforementioned diseases. These 'at-risk' conditions are a heterogeneous group of diseases, for example, diabetes mellitus, people living with human immunodeficiency virus, high alcohol intake, and coeliac disease. The pathophysiology of some of 'at-risk' conditions is becoming increasingly recognised; therefore, the list of associated conditions are in evolving process. We present a case of a 60-year-old male with Parkinson's disease and persistent abdominal pain who was found to have low faecal elastase levels indicative of severe PEI. His past medical history included none of the known risk factors for PEI. After examining the literature, we report a similar pathophysiological process underlying the development of pancreatitis and Parkinson's disease which is dysfunction of the Unfolded Protein Response. We suggest further research to assess the prevalence of PEI in the population of patients with Parkinson's disease.

What is the clinical significance of low serum amylase? Systematic review of the conditions associated with low serum amylase

Objective

Most studies have assessed the impact of elevated serum amylase levels in clinical practice, but only a few have investigated the significance of low serum amylase. We therefore, aimed to review the literature to understand the conditions associated with low serum amylase and its clinical relevance.

Method

This systematic review was performed in accordance with the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on Medline and Embase databases until November 2022. After identifying relevant titles, abstracts were read and data of eligible articles retrieved. The conditions associated with low serum amylase were evaluated. The quality of the studies was assessed using the Newcastle-Ottawa Score.

Results

Our search strategy identified 19 studies including a total of 15 097 patients for systematic review. All the studies were observational including two studies which used secretin-induced test. The main conditions associated with low serum amylase were diabetes mellitus (n=9), metabolic syndrome (n=3), chronic pancreatitis (CP) (n=3), non-alcoholic fatty liver disease (n=2) and obesity (n=1). Low serum amylase showed a high specificity (94%) with low sensitivity (38.7%-59%) in diagnosing chronic pancreatitis.

Conclusion

This systematic review revealed a unique insight into the relevance of low serum amylase in clinical practice. Low serum amylase can be a useful adjunct test in the assessment of patients with CP, pancreatic exocrine insufficiency, diabetes mellitus and metabolic syndrome.

Interactions between the Exocrine and the Endocrine Pancreas

The pancreas has two main functions: to produce and secrete digestive enzymes (exocrine function) and to produce hormones that regulate blood glucose and splanchnic secretion (endocrine function). The endocrine and exocrine portions of the pancreas are central regulators in digestion and metabolism, with continuous crosstalk between their deeply interconnected components, which plays a role in disease. Pancreatic neoplasms, inflammation, trauma, and surgery can lead to the development of type 3c diabetes when an insult simultaneously damages both acini and islets, leading to exocrine and endocrine dysfunction. In diabetes mellitus patients, pancreatic exocrine insufficiency is highly prevalent, yet little is known about the associations between diabetes mellitus and pancreatic exocrine function. This review aims to provide an overview of the physiology of the pancreas, summarize the pathophysiology and diagnostic work-up of pancreatic exocrine insufficiency, and explore the relationships between exocrine pancreatic insufficiency and diabetes mellitus.

Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types

BACKGROUND

Pancreatic enzyme replacement therapy (PERT) is the standard treatment for exocrine pancreatic insufficiency (EPI). However, many individuals are inadequately treated, with gaps in clinical dosing, guidelines, and tools to aid individual titration.

METHODS

A systematic review identified research and guidelines on PERT dosing recommendations across conditions, systematically reviewing and synthesizing total PERT intake, meal/snack guidelines, and changes over time to provide an up-to-date look at the most common doses used in studies and guidelines.

RESULTS

This review of 257 articles found wide variability in PERT dosing guidelines within and across conditions. Many patients with EPI are underdosed, with guidelines differing globally and by disease type, and clinician prescribing may also play a role. The most common dosing guidelines focus on starting doses at 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies. Guidelines and studies typically focus only on fat digestion, and comparison by total daily dose shows underdosing is common. Most PERT studies are on safety and efficacy rather than optimal titration.

CONCLUSION

The current guidelines for PERT in EPI demonstrate substantial variability in dosing recommendations, both within and across disease types. This variation highlights the need for further research to optimize PERT dosing and improve patient outcomes. Healthcare providers should consider individualizing PERT dosing based on nutritional status and response to therapy, ensuring regular follow-up with patients for dose titrations with consideration that most guidelines are framed as initial doses rather than upper limits.

Pancreatic exocrine insufficiency after non-pancreatic upper gastrointestinal surgery: meta-analysis

BACKGROUND

Untreated pancreatic exocrine insufficiency (PEI) results in substantial patient harm. Upper gastrointestinal surgery (bariatric metabolic surgery and oesophagogastric resection) affects the delicate physiology of pancreatic exocrine function and may result in PEI. The aim of this study was to assimilate the literature on incidence, diagnosis, and management of PEI after bariatric metabolic surgery and oesophagogastric resection.

METHODS

A systematic review of PubMed, MEDLINE, and Embase databases identified studies investigating PEI after non-pancreatic upper gastrointestinal surgery. Meta-analyses were undertaken for incidence of PEI and benefit of pancreatic enzyme replacement therapy.

RESULTS

Among 1620 patients from 24 studies included in quantitative synthesis, 36.0% developed PEI. The incidence of PEI was 23.0 and 50.4% after bariatric metabolic surgery and oesophagogastric resection respectively. Notably, the incidence of PEI was 44% after biliopancreatic diversion with duodenal switch and 66.2% after total gastrectomy. The most common diagnostic test used was faecal elastase 1 (15 of 31 studies), with less than 200 µg/g being diagnostic of PEI. A total of 11 studies considered the management of pancreatic exocrine insufficiency, with 78.6% of patients responding positively to pancreatic enzyme replacement when it was prescribed.

CONCLUSION

PEI is common after non-pancreatic upper gastrointestinal surgery and patients may benefit from enzyme replacement therapy.

Apolipoprotein A2 isoforms associated with exocrine pancreatic insufficiency in early chronic pancreatitis

BACKGROUND AND AIM

Apolipoprotein A2 (apoA2) isoforms have been reported to undergo the aberrant processing in pancreatic cancer and pancreatic risk populations compared with that in healthy subjects. This study aimed to clarify whether apoA2 isoforms were as useful as N-benzoyl-p-aminobenzoic acid (BT-PABA) test for exocrine pancreatic dysfunction markers in patients with early chronic pancreatitis (ECP).

METHODS

Fifty consecutive patients with functional dyspepsia with pancreatic enzyme abnormalities (FD-P) (n = 18), with ECP (n = 20), and asymptomatic patients with pancreatic enzyme abnormalities (AP-P) (n = 12) based on the Rome IV classification and the Japan Pancreatic Association were enrolled in this study. The enrolled patients were evaluated using endoscopic ultrasonography and endoscopic ultrasonography elastography. Five pancreatic enzymes were estimated. Pancreatic exocrine function was analyzed using the BT-PABA test. Lighter and heavier apoA2 isoforms, AT and ATQ levels were measured by enzyme-linked immunosorbent assay methods.

RESULTS

There were no significant differences in clinical characteristics such as age, gender, body mass index, alcohol consumption and smoking among patients with AP-P, FD-P, and ECP. The BT-PABA test and lighter apoA2 isoform, AT level in the enrolled patients had a significant correlation (P < 0.01). The BT-PABA test in patients with ECP was significantly lower (P = 0.04) than that in AP-P. ApoA2-AT level in patients with ECP was lower than that in AP-P, albeit, insignificantly. Interestingly, apo A2-AT level was significantly (P = 0.041) associated with exocrine pancreatic insufficiency by multiple logistic regression analysis.

CONCLUSIONS

ApoA2-AT level is a useful tool to evaluate exocrine pancreatic insufficiency in the early stage of chronic pancreatitis.

Are we missing pancreatic exocrine insufficiency in 'at-risk' groups? Prospective assessment of the current practice and yield of faecal elastase testing in patients with diabetes mellitus, HIV and/or high alcohol intake

There is cumulative evidence that pancreatic exocrine insufficiency (PEI) is under-recognised and can occur in patients with 'at-risk' conditions. Thus, we aimed to assess the current practice and yield of requesting faecal elastase (FEL-1), an indicator of PEI, in patients with 'at-risk' conditions. We prospectively recruited patients attending secondary care clinics with diabetes mellitus (DM), people living with HIV (PLHIV) and inpatients admitted to hospital with high alcohol intake (HAI). All patients underwent testing with FEL-1. Those patients with PEI (FEL-1 <200 μg/g) were contacted and offered a follow-up review in gastroenterology clinic. In total, 188 patients were recruited (HAI, n=78; DM, n=64; and PLHIV, n=46). Previous FEL-1 testing had not been performed in any of the patients. The return rate of samples was 67.9% for patients with HAI, 76.6% for those with DM and 56.5% for those with PLHIV. The presence of PEI was shown in 20.4% of patients with DM, 15.4% of patients with PLHIV and 22.6% in those with HAI. Diarrhoea and bloating were the most reported symptoms in followed-up patients with low FEL-1 (31.8% and 22.7% of patients, respectively). Follow-up computed tomography (CT) scans in those patients with PEI identified chronic pancreatitis changes in 13.6% and pancreatic atrophy in 31.8% of patients. These results suggest that there is a lack of testing for PEI in 'at-risk' groups. Our findings also suggest that using FEL-1 to test for PEI in patients with DM, PLHIV and HAI has a significant impact, although further studies are required to validate these findings.

The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions

Background

The finding of pancreatic cystic lesions (PCL) on incidental imaging is becoming increasingly common. International studies report a prevalence of 2.2-44.7% depending on the population, imaging modality and indication for imaging, and the prevalence increases with age. Patients with PCL are at risk of developing pancreatic cancer, a disease with a poor prognosis. This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency (PEI) from a group of local specialists.

Methods

Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022. The expert panel included gastroenterologists, hepatobiliary surgeons, oncologists, radiologists, and endocrinologists.

Results

Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions. They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient. Where indicated, patients should undergo pancreatectomy to excise PCL. Following pancreatectomy, patients are at risk of PEI, leading to gastrointestinal dysfunction and malnutrition. Therefore, such patients should be monitored for symptoms of PEI, and promptly treated with pancreatic enzyme replacement therapy (PERT). Patients with poor response to PERT may require increases in dose, addition of a proton pump inhibitor, and/or further investigation, including tests for pancreatic function. Patients are also at risk of new-onset diabetes mellitus after pancreatectomy; they should be screened and treated with insulin if indicated.

Conclusions

These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.

A Systematic Review of Exocrine Pancreatic Insufficiency Prevalence and Treatment in Type 1 and Type 2 Diabetes

Type 1 diabetes and type 2 diabetes have high rates of associated exocrine pancreatic insufficiency (EPI). This review evaluated the current evidence on prevalence and treatment of EPI in type 1 and type 2 diabetes and compared general population prevalence rates of EPI and prevalence of other common gastrointestinal conditions such as celiac disease and gastroparesis based on within-diabetes rates of common gastrointestinal (GI) conditions. Prevalence of EPI in type 1 diabetes ranges from 14% to 77.5% (median 33%), while EPI in type 2 diabetes ranges from 16.8% to 49.2% (median 29%), and where type of diabetes is not specified in studies, ranges from 5.4% to 77%. In studies with control groups of the general population, prevalence of EPI overall in those without diabetes ranged from 4.4% to 18%, median 13%, which is comparable with other estimated general population prevalence rates of EPI (10%-20%). Cumulatively, this suggests there may be significant numbers of people with diabetes with EPI who are undiagnosed. People with diabetes (both type 1 and type 2) who present with gastrointestinal symptoms, such as steatorrhea or changes in stool, bloating, and/or abdominal pain, should be screened for EPI. Both diabetes specialists and gastroenterologists and primary care providers should be aware of the high rates of prevalence of diabetes and EPI and recommend fecal elastase-1 screening for people with diabetes and GI symptoms.

Pancreatic exocrine insufficiency in diabetes mellitus

Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).

Pancreatic exocrine insufficiency in diabetes mellitus

Diabetes is disease of both the endo- and exocrine parts of the pancreas. Pancreatic exocrine insufficiency (PEI) can occur in every 2–3 patients with diabetes and affect not only the quality, but also life expectancy. At the same time, the diagnosis and treatment of PEI is not getting enough attention. The endocrinologist, as the main specialist leading patients with diabetes, can diagnose and treat patients with pancreatic exocrine insufficiency and diabetes using adequate doses of pancreatic enzyme replacement therapy (PERT).

Nutrition in children with exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a condition defined as pancreatic loss of exocrine function, including decreased digestive enzymes and bicarbonate secretion, which leads to maldigestion and malabsorption of nutrients. It is a common complication in many pancreatic disorders. If left undiagnosed, EPI can cause poor digestion of food, chronic diarrhea, severe malnutrition and related complications. Nutritional status and fat-soluble vitamins should be carefully assessed and monitored in patients with EPI. Early diagnosis of EPI is clinically important for appropriate nutritional support and initiating pancreatic enzyme replacement therapy (PERT) which could significantly improve patient outcomes. The evaluation of nutritional status and related unique management in children with EPI will be discussed in this review.

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

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.

Prospective Observational Study of Prevalence, Assessment and Treatment of Pancreatic Exocrine Insufficiency in Patients with Inoperable Pancreatic Malignancy (PANcreatic Cancer Dietary Assessment-PanDA)

INTRODUCTION

Pancreatic exocrine insufficiency (PEI) in patients with advanced pancreatic cancer (aPC) is well documented, but there is no consensus regarding optimal screening.

METHODS AND ANALYSIS

Patients diagnosed with aPC referred for palliative therapy were prospectively recruited. A full dietetic assessment (including Mid-Upper Arm Circumference (MUAC), handgrip and stair-climb test), nutritional blood panel, faecal elastase (FE-1) and ¹³C-mixed triglyceride breath tests were performed.

PRIMARY OBJECTIVE

prevalence of dietitian-assessed PEI (demographic cohort (De-ch)); design (diagnostic cohort (Di-ch)) and validation (follow-up cohort (Fol-ch)) of a PEI screening tool. Logistic and Cox regressions were used for statistical analysis.

RESULTS

Between 1 July 2018 and 30 October 2020, 112 patients were recruited (50 (De-ch), 25 (Di-ch) and 37 (Fol-ch)). Prevalence of PEI (De-ch) was 64.0% (flatus (84.0%), weight loss (84.0%), abdominal discomfort (50.0%) and steatorrhea (48.0%)). The derived PEI screening panel (Di-ch) included FE-1 (normal/missing (0 points); low (1 point)) and MUAC (normal/missing (>percentile 25) (0 points); low (2 points)) and identified patients at high-risk (2-3 total points) of PEI [vs. low-medium risk (0-1 total points)]. When patients from the De-ch and Di-ch were analysed together, those classified by the screening panel as "high-risk" had shorter overall survival (multivariable Hazard Ratio (mHR) 1.86 (95% CI 1.03-3.36); p-value 0.040). The screening panel was tested in the Fol-ch; 78.4% patients classified as "high-risk", of whom 89.6% had dietitian-confirmed PEI. The panel was feasible for use in clinical practice (64.8% patients completed all assessments), with high acceptability (87.5% would repeat it). Most patients (91.3%) recommended dietetic input for all patients with aPC.

CONCLUSIONS

PEI is present in most patients with aPC; early dietetic input provides a holistic nutritional overview, including, but not limited to, PEI. This proposed screening panel may help to prioritise those at higher risk of PEI, requiring urgent dietitian input. Its prognostic role needs further validation.

Casting a Wider NET: Pancreatic Exocrine Insufficiency Induced by Somatostatin Analogues among Patients with Neuroendocrine Tumours?

Somatostatin-analogues (SSAs) are a first-line treatment of unresectable neuroendocrine tumours (NETs). However, SSAs inhibit pancreatic secretions, which could lead to pancreatic exocrine insufficiency (PEI). PEI is known to be detrimental to patient quality of life and nutritional status. This study aimed to evaluate the effect of SSAs on pancreatic exocrine function in patients with NETs, using the ¹³C-mixed triglyceride breath test (¹³C-MTGT). Exocrine function was assessed using the ¹³C-MTGT at baseline and after a third SSA injection (two months). A quotient of ¹³CO₂/¹²CO₂ was measured by mass spectrometry, and the cumulative percent dose recovered at 6 h (cPDR) is reported. The secondary endpoints investigated were change in weight, HbA1C, and vitamin D levels. Ten patients completed the study. Exocrine function reduced in all patients (n = 10) following SSA therapy (median reduction from baseline: -23.4% (range: -42.1-0.5%, p = 0.005)). vitamin D levels decreased in all but one patient (median decrease from baseline: -26.5%, (-44.7-10%; p = 0.038)), and median HbA1C levels increased by 8.0% (0-59.3%; p = 0.008). Change in weight was not significant (median decrease from baseline: -0.21% (-4.5-3.5%, p = 1.000)). SSA therapy has a consistent impact on exocrine function from early in the treatment course, but the long-term clinical effects of this remain to be defined. Further studies are required to determine the clinical relevance of this observation and optimise the management of PEI in this cohort.

Replacing secretin-enhanced MRCP with MRI radiomics model based on a fully automated pancreas segmentation for assessing pancreatic exocrine function in chronic pancreatitis

OBJECTIVES

To develop and validate a radiomics nomogram based on a fully automated pancreas segmentation to assess pancreatic exocrine function. Furthermore, we aimed to compare the performance of the radiomics nomogram with the pancreatic flow output rate (PFR) and conclude on the replacement of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) by the radiomics nomogram for pancreatic exocrine function assessment.

METHODS

All participants underwent S-MRCP between April 2011 and December 2014 in this retrospective study. PFR was quantified using S-MRCP. Participants were divided into normal and pancreatic exocrine insufficiency (PEI) groups using the cut-off of 200 µg/L of fecal elastase-1. Two prediction models were developed including the clinical and non-enhanced T1-weighted imaging radiomics model. A multivariate logistic regression analysis was conducted to develop the prediction models. The models' performances were determined based on their discrimination, calibration, and clinical utility.

RESULTS

A total of 159 participants (mean age [Formula: see text] standard deviation, 45 years [Formula: see text] 14;119 men) included 85 normal and 74 PEI. All the participants were divided into a training set comprising 119 consecutive patients and an independent validation set comprising 40 consecutive patients. The radiomics score was an independent risk factor for PEI (odds ratio = 11.69; p < 0.001). In the validation set, the radiomics nomogram exhibited the highest performance (AUC, 0.92) in PEI prediction, whereas the clinical nomogram and PFR had AUCs of 0.79 and 0.78, respectively.

CONCLUSION

The radiomics nomogram accurately predicted pancreatic exocrine function and outperformed pancreatic flow output rate on S-MRCP in patients with chronic pancreatitis.

KEY POINTS

• The clinical nomogram exhibited moderate performance in diagnosing pancreatic exocrine insufficiency. • The radiomics score was an independent risk factor for pancreatic exocrine insufficiency, and every point rise in the rad-score was associated with an 11.69-fold increase in pancreatic exocrine insufficiency risk. • The radiomics nomogram accurately predicted pancreatic exocrine function and outperformed the clinical model and pancreatic flow output rate quantified by secretin-enhanced magnetic resonance cholangiopancreatography on MRI in patients with chronic pancreatitis.

What is the significance of a faecal elastase-1 level between 200 and 500μg/g?

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.

Oral Endothelium Corneum Gigeriae Galli Therapy for Pancreatic Duct Stones: A Prospective Cohort Study

BACKGROUND

Pancreatic duct stones obstruct the pancreatic ducts and aggravate clinical symptoms of chronic pancreatitis. Only isolated case reports have shown that some drugs may be useful in dissolving pancreatic duct stones. Endothelium corneum gigeriae galli is a Chinese medicine widely used to cure multifarious lithiasis and maldigestion. This study aimed to evaluate the efficacy of endothelium corneum gigeriae galli oral therapy in the dissolution of stones and evaluate the improvement of clinical symptoms in patients with pancreatic duct stones.

METHODS

Sixty-eight patients with pancreatic duct stones were randomly divided into the endothelium corneum gigeriae galli and control groups. Endothelium corneum gigeriae galli was given orally to the endothelium corneum gigeriae galli group, and the placebo was given to the control group. Both groups were reviewed by computed tomography and magnetic resonance imaging; abdominal pain, exocrine and endocrine pancreatic function, and the nutritional status of patients were measured after the study.

RESULTS

The dissolution rate of the endothelium corneum gigeriae galli group was significantly higher than that of the control group (P = .002). The abdominal pain of the endothelium corneum gigeriae galli group was relieved more significantly compared to that of the control group (P < .001). The exocrine and endocrine pancreatic function of the endothelium corneum gigeriae galli group improved more significantly than that of the control group (P < .001). The nutritional status of the endothelium corneum gigeriae galli group was significantly higher than that of the control group (P = .003).

CONCLUSION

Overall, oral endothelium corneum gigeriae galli treatment could dissolve pancreatic duct stones, relieve abdominal pain, improve exocrine and endocrine pancreatic functions, and control the deterioration of nutritional status. Endothelium corneum gigeriae galli treatment should be useful in pancreatic duct stones therapy.

Genomic divergence during artificial selection by feed conversion ratio in Pekin ducks

Pekin ducks are world-famous for its fast growth and have become the majority of breeds rearing in duck industry. Feed conversion ratio (FCR) is an important trait in Pekin ducks breeding and production, and the underlying biological processes are complex. To gain an insight to the possible biological mechanism underlying the FCR in Pekin ducks, an artificial selection population (S) and a natural population (Z7) were used in this study. The FCR of S line decreased from 2.184 ± 0.057 in the first generation to 1.886 ± 0.063 in the eighth generation, which displays significantly low FCR (p = 0.0032) than that of the Z7 line (2.23 ± 0.046). Then, 9 samples from eighth generation of S line and 10 samples from Z7 were used for whole-genome resequencing. Analyses of F_ST, θπ and XP-EHH revealed 450, 479 and 356 candidate genes, which involved in 1,955, 1,933 and 1,964 candidate divergent regions (CDRs), respectively. And the integration of three approaches resulted in 30 overlapping genes. Functional analysis of 30 candidate genes revealed that variants of KCNQ1 and ADCY7, which were involved in the pancreatic secretion signal pathway, could be important molecular markers for high feed conversion efficiency in S line breeding.

Update in Advancing the Gastrointestinal Frontier in Cystic Fibrosis

Clinical complications of cystic fibrosis (CF) include a variety of gastrointestinal (GI) and hepatobiliary manifestations. Recent years have witnessed several advances in the understanding and management of these complications, in addition to opportunities for therapeutic innovations. Herein we review the current understanding of these disorders and also discuss the management of the GI and hepatobiliary complications experienced by persons with CF.

Fat-Soluble Vitamin Deficiencies and Disruption of the Immune System in Pancreatic Cancer: A Vicious Cycle

ABSTRACT

Pancreatic ductal adenocarcinoma (PDAC) is currently an increasing contributor to cancer-related mortality. Despite advances in cancer treatment, PDAC survival rates have remained roughly unchanged over the years. Specifically, late diagnosis and insensitivity to currently available therapeutic regimens have been identified as the main causes for its poor survival. Pancreatic exocrine insufficiency (PEI) is a typical complication associated with PDAC diagnosis and pancreatic surgery. Pancreatic exocrine insufficiency, a major contributor to maldigestion in PDAC, is often not treated because it remains undetected because of lack of overt signs and symptoms. In this review, we will focus on the major consequences of PEI, including the inadequacy of lipase excretion, which results in deficiency of fat-soluble vitamins. Because PDAC is known for its immune-high jacking mechanisms, we describe key features in which deficiencies of fat-soluble vitamins may contribute to the aggressive biological behavior and immune evasion in PDAC. Because PEI has been shown to worsen survival rates in patients with PDAC, detecting PEI and the related fat-soluble vitamin deficits at the time of PDAC diagnosis is critical. Moreover, timely supplementation of pancreatic enzymes and fat-soluble vitamins may improve outcomes for PDAC patients.

Pancreatic Exocrine Insufficiency in Intraductal Papillary Mucinous Carcinoma Presenting with Leg Edema Treated with Pancreatic Exocrine Replacement Therapy

An 89-year-old woman underwent examinations for leg edema. Blood tests indicated low nutrition and low pancreatic enzymes, and a stool examination indicated fatty stool. Computed tomography showed pleural effusion, ascites, and cystic lesions in the pancreatic head and mural nodules within the cysts. Pancreatic juice cytology revealed adenocarcinoma. The diagnosis was pancreatic exocrine insufficiency caused by intraductal papillary mucinous carcinoma. The patient did not wish to undergo surgery. Therefore, diuretics, component nutrients, and pancreatic exocrine replacement therapy using pancrelipase were initiated. After starting treatment, her leg edema, pleural effusion, and ascites disappeared, and her activities of daily living improved markedly.

Stool Elastase as an Independent Prognostic Factor in Patients with Pancreatic Head Cancer

(1) Background: Patients with pancreatic exocrine insufficiency (PEI) have an increased risk of malnutrition, which in turn increases morbidity and mortality and is frequent in pancreatic head cancer. This study aimed to analyze the utility of PEI measured using the stool elastase (SE) level to predict the prognosis of patients with pancreatic head cancer. (2) Methods: Patients who underwent pancreaticoduodenectomy for pancreatic cancer at our institution between 2011 and 2015 were included. Only patients with data on preoperative SE levels were analyzed. Patients were classified into low and high SE groups based on preoperative SE levels (low < 100 µg/g < high). (3) Results: The median preoperative SE level was 67.2 µg/g, and 84 of 143 (58.7%) patients were included in the low SE group. The two groups had significantly different overall survival (OS) and disease-free survival (DFS), and the low SE group had a worse prognosis. In multivariate analysis, SE level < 100 µg/g and lymph node metastasis were independent poor prognostic factors for OS and DFS. (4) Discussion: PEI measured using SE levels is an independent prognostic factor in patients with pancreatic head cancer undergoing pancreaticoduodenectomy. Since poor nutritional status may be related to prognosis in patients with low levels of stool elastase preoperatively, aggressive treatment may be required.

Harnessing the Potential of Enzymes as Inhaled Therapeutics in Respiratory Tract Diseases: A Review of the Literature

Respiratory tract diseases (RTDs) are a global cause of mortality and affect patient well-being and quality of life. Specifically, there is a high unmet need concerning respiratory tract infections (RTIs) due to limitations of vaccines and increased antibiotic resistance. Enzyme therapeutics, and in particular plant-based enzymes, represent an underutilised resource in drug development warranting further attention. This literature review aims to summarise the current state of enzyme therapeutics in medical applications, with a focus on their potential to improve outcomes in RTDs, including RTIs. We used a narrative review approach, searching PubMed and clinicaltrials.gov with search terms including: enzyme therapeutics, enzyme therapy, inhaled therapeutics, botanical enzyme therapeutics, plant enzymes, and herbal extracts. Here, we discuss the advantages and challenges of enzyme therapeutics in the setting of RTDs and identify and describe several enzyme therapeutics currently used in the respiratory field. In addition, the review includes recent developments concerning enzyme therapies and plant enzymes in (pre-)clinical stages. The global coronavirus disease 2019 (COVID-19) pandemic has sparked development of several promising new enzyme therapeutics for use in the respiratory setting, and therefore, it is timely to provide a summary of recent developments, particularly as these therapeutics may also prove beneficial in other RTDs.

Risk factor analysis and nomogram development for steatorrhea in idiopathic chronic pancreatitis

OBJECTIVES

Steatorrhea, a sign of severe pancreatic exocrine insufficiency (PEI), is related to consequences caused by pancreatitis. This study aimed to identify predictors and to construct a nomogram for steatorrhea in idiopathic chronic pancreatitis (ICP).

METHODS

ICP patients admitted to our hospital from January 2000 to December 2013 were enrolled in this retrospective-prospective cohort study and randomly assigned to the training and validation cohorts. The cumulative rate of steatorrhea was calculated. A Cox proportional hazard regression model was used to identify predictors for steatorrhea and construct the nomogram. Internal and external validation of the nomogram was then performed.

RESULTS

There were 1633 ICP patients enrolled, with a median follow-up duration of 9.8 years and 20.8% (339/1633) of patients developed steatorrhea following onset of ICP. Steatorrhea was observed in 93, 115, and 133 patients at 1, 3, and 5 years following diagnosis of CP, with a cumulative rate of 6.5% (95% confidence interval [CI] 5.1%-7.9%), 8.0% (95% CI 6.2%-9.8%), and 9.3% (95% CI 6.6%-12.0%), respectively. Male sex (hazard ratio [HR] 2.479, P < 0.001), diabetes mellitus at/before diagnosis of ICP (HR 2.274, P = 0.003), and aged less than 18 years at onset of ICP (HR 0.095, P < 0.001) were identified risk factors for steatorrhea. Initial manifestations were associated with development of steatorrhea. The nomogram was proven to have good concordance indexes.

CONCLUSIONS

We identified predictors and developed a nomogram for predicting steatorrhea in ICP. It was recommended that high-risk populations be followed up closely, which might contribute to the early diagnosis and treatment of PEI.

Intestinal homeostasis and inflammation: gut microbiota at the crossroads of pancreas-intestinal barrier axis

The pancreas contains exocrine glands, which release enzymes (e.g., amylase, trypsin, and lipase) that are important for digestion and islets, which produce hormones. Digestive enzymes and hormones are secreted from the pancreas into the duodenum and bloodstream, respectively. Growing evidence suggests that the roles of the pancreas extend to not only the secretion of digestive enzymes and hormones but also to the regulation of intestinal homeostasis and inflammation (e.g., mucosal defense to pathogens and pathobionts). Organ crosstalk between the pancreas and intestine is linked to a range of physiological, immunological, and pathological activities, such as the regulation of the gut microbiota by the pancreatic proteins and lipids, the retroaction of the gut microbiota on the pancreas, the relationship between inflammatory bowel disease, and pancreatic diseases. We herein discuss the current understanding of the pancreas–intestinal barrier axis and the control of commensal bacteria in intestinal inflammation.

Surgical Outcomes and Trends for Chronic Pancreatitis: An Observational Cohort Study from a High-Volume Centre

Surgery for chronic pancreatitis (CP) is considered as a last resort treatment. The present study aims to determine the short- and medium-term outcomes of surgical treatment for CP with a comparison between duodenum-preserving pancreatic head resection (DPPHR) and pancreatoduodenectomy (PD). The trends in surgical procedures were also examined. This was a retrospective cohort study of patients who underwent surgery for CP between 2000 and 2019 at the Karolinska University Hospital. One hundred and sixty-two patients were included. Surgery performed included drainage procedures (n = 2), DPPHR (n = 35), resections (n = 114, of these PD in n = 65) and other procedures (n = 11). Morbidity occurred in 17%, and the 90-day mortality was 1%. Complete or partial pain relief was achieved in 65% of patients. No significant difference in morbidity was observed between the DPPHR and PD groups: 17% vs. 20% (p = 0.728). Pain relief did not differ between the groups (62% for DPPHR vs. 73% for PD, p = 0.142). The frequency of performed DPPHR decreased, whereas the rate of PD remained unaltered. Surgical treatment for CP is safe and effective. DPPHR and PD are comparable regarding post-operative morbidity and are equally effective in achieving pain relief. Trends over time revealed PD as more commonly performed compared to DPPHR.

The pancreatic exocrine function in patients with pancreatic endocrine insufficiency: the evaluation with cine-dynamic magnetic resonance cholangiopancreatography using a spatially selective inversion-recovery pulse and T1 mapping

Purpose

To evaluate the association of the pancreatic exocrine function estimated by cine-dynamic magnetic resonance cholangiopancreatography (MRCP) using a spatially selective inversion-recovery (IR) pulse with the pancreatic endocrine function estimated by the T1 relaxation time of the pancreatic parenchyma and HbA1c values.

Materials and methods

Forty-three patients with suspected hepatobiliary or pancreatic diseases were included. Patients were classified into three groups: HbA1c < 5.7% (normal group), 5.7% ≤ HbA1c < 6.5% (prediabetes group), and HbA1c ≥ 6.5% (diabetes group). The frequency of the secretory flow of the pancreatic juice was observed within the area of the IR pulse, and the moving distance (mean secretion grade) of the pancreatic juice inflow within the area of the IR pulse on cine-dynamic MRCP, and the T1 relaxation time of the pancreatic parenchyma on the T1 map images were assessed. The MR imaging measurements were compared using Spearman’s rank correlation coefficient analysis and the Kruskal–Wallis and Mann–Whitney U tests.

Results

Both the mean secretion grade and frequency of the pancreatic secretory inflow had a significant negative correlation with the T1 relaxation time of the pancreatic parenchyma (r = − 0.335, p = 0.028 and r = − 0.305, p = 0.047, respectively) and HbA1c values (r = − 0.308, p = 0.044 and r = − 0.313, p = 0.041, respectively). Both the mean secretion grade and frequency of the pancreatic secretory inflow in the elevated HbA1c (prediabetes and diabetes) group were significantly lower than those in the normal group (p = 0.030 and p = 0.029, respectively).

Conclusion

The pancreatic exocrine function estimated by cine-dynamic MRCP was significantly lower in patients with prediabetes and diabetes than in controls. Cine-dynamic MRCP with a spatially selective IR pulse may be useful for the early diagnosis of pancreatic exocrine insufficiency in patients with pancreatic endocrine insufficiency.

Gas chromatographic method with minimal sample consumption for quality control of 13C-mixed triglycerides used in clinical diagnosis

Exocrine pancreatic insufficiency (EPI) can be comfortably diagnosed by a breath test using the mixed triglyceride 2-octanoyl (1-¹³C)-1,3 distearoyl glycerol (¹³C-MTG). However, it is not fully accepted as a routine test yet as no vendor provides a certified product for clinical applications. Current recommended methods for quality control of triglycerides are not compatible with the produced expensive small batches of ¹³C-MTG. In this article, two procedures were miniaturized and optimized: one to confirm the structure by a regiospecific enzymatic reaction and another to check the purity via a methyl esterification. Both pretreated samples were then analyzed by gas chromatography coupled to mass spectrometry (GC-MS). The proposed methods showed good selectivity for the structure confirmation and good linearity with external standards for the purity control: R² values were higher than 0.995, accuracy was in the 98-100% range and excellent repeatability (RSD <1.4%) was achieved.

Risk factors and assessment considerations for essential fatty acid deficiency in nonparenterally fed patients using a case example

Essential fatty acid deficiency (EFAD) has most commonly been reported in parenterally fed individuals but may also present in patients receiving fat-restricted diets and in patients with fat-malabsorption disorders. This article reviews the physical and biochemical assessment for EFAD in clinical practice and disorders of fat malabsorption as potential risk factors for EFAD. A case report is included to describe the fatty acid profile of a patient with exocrine pancreatic insufficiency receiving low-dose pancreatic enzyme replacement therapy after a self-imposed fat-restricted diet. The current challenges with laboratory interpretation of essential fatty acid status are also discussed.

Nutritional status disorders and methods of their correction in patients with advanced pancreatic cancer

Despite of achieved progress in advanced pancreatic cancer treatment, the disease outcomes remain far from satisfying. The peculiarity of malnutrition treatment in these patients is the result of its causes complexity and progressively growing manifestations extent. The review represents mechanisms of malnutrition and approaches to their treatment.

Nanocarriers targeting the diseases of the pancreas

Diseases of the pancreas include acute and chronic pancreatitis, exocrine pancreatic insufficiency, diabetes and pancreatic cancer. These pathologies can be difficult to treat due to the innate properties of the pancreas, its structure and localization. The need for effective targeting of the pancreatic tissue by means of nanoparticles delivering therapeutics is a major focus area covered and discussed in this review. Most common diseases of the pancreas do not have specific and direct medical treatment option, and existing treatment options are generally aimed at relieving symptoms. Diabetes has different treatment options for different subtypes based on insulin having stability problems and requiring injections reducing patient compliance. Pancreatic cancer progresses silently and can only be diagnosed in advanced stages. Therefore, survival rate of patients is very low. Gemcitabine and FOLFIRINOX treatment regimens, the most commonly used clinical standard treatments, are generally insufficient due to the chemoresistance that develops in cancer cells and also various side effects. Therefore new treatment options for pancreatic cancer are also under focus. Overcoming drug resistance and pancreatic targeting can be achieved with active and passive targeting methods, and a more effective and safer treatment regimen can be provided at lower drug doses. This review covers the current literature and clinical trials concerning pancreatic drug delivery systems in the nanoscale focusing on the challenges and opportunities provided by these smart delivery systems.

The Prevalence and Characteristics of Exocrine Pancreatic Insufficiency in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

Exocrine pancreatic insufficiency (EPI) is common in patients with type 2 diabetes. However, the prevalence of EPI varies significantly in different studies. Untreated EPI in these patients can adversely affect their nutrition and metabolism. The aim of this study is to estimate the pooled prevalence of EPI in patients with type 2 diabetes and to explore the potential risk factors.

METHODS

A systematic search was performed in PubMed, Web of Science, and Embase, which included studies meeting inclusion criteria from 1960 to 1 April 2022. Relevant articles were searched using the combination of Medical Subject Heading (MeSH) terms of "Type 2 diabetes" and "pancreatic exocrine insufficiency." The Stata 16.0 software was used for data analyses. The random-effects model was used to estimate the pooled prevalence rates and 95% CI using "metaprop program."

RESULTS

The pooled prevalence of EPI was 22% (95% CI: 15%-31%) in patients with type 2 diabetes and 8% (95% CI: 4%-14%) of them developed severe pancreatic insufficiency. In the subgroup analyses, the prevalence of EPI in type 2 diabetes was correlated with geographic location. The prevalence in Asian countries (35%, 95% CI: 22%-49%) is higher than in Europe (18%, 95% CI: 10%-29%) and Australia (9%, 95% CI: 4%-16%). Furthermore, patients with higher insulin requirements, who are more likely to be insulin-deficient, have a higher prevalence of EPI. The pooled prevalence was 27% (95% CI: 17%-37%) in type 2 diabetes with higher insulin requirement (1 group) and 15% (95% CI: 1%-40%) in patients with lower insulin requirement (2 group). In addition, the morbidity of severe EPI in the higher insulin requirement group (12%, 95% CI: 7%-19%) was sextuple as much as the lower insulin requirement group (2%, 95% CI: 0%-13%). EPI was more common in subjects younger than 60 compared with elderlies (25% vs. 19%).

CONCLUSION

The prevalence of EPI in type 2 diabetes may be overestimated. Furthermore, the higher prevalence may be closely related to β-cell function. Endocrine disease therapy would potentially represent a novel therapeutic approach for patients with type 2 diabetes and EPI.

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.

Yield of testing for micronutrient deficiencies associated with pancreatic exocrine insufficiency in a clinical setting: An observational study

BACKGROUND

Pancreatic exocrine insufficiency (PEI) can be difficult to diagnose and causes maldigestion symptoms and malabsorption. There has been a number of studies that have identified PEI associated micronutrient deficiencies (PEI-MD), however there is variation in both the frequency and type of PEI-MD reported, with the majority of studies including patients with PEI due to chronic pancreatitis (CP) or CP without PEI. There is a paucity of information regarding the prevalence of PEI-MD in patients with PEI without CP and the yield of testing for PEI-MD in a clinical setting in patients with suspected benign pancreatic diseases.

AIM

To prospectively assess the yield and type of PEI–MD in patients with and without PEI secondary to benign pancreatic disease.

METHODS

Patients investigated for maldigestion symptoms with Faecal Elastase-1 (FEL-1) and suspected or proven benign pancreatic disease were prospectively identified. At the time of FEL-1 testing, serum samples were taken for micronutrients identified by previous studies as PEI-MD: prealbumin, retinol binding protein, copper, zinc, selenium, magnesium and later in the study lipid adjusted vitamin E. FEL-1 was recorded, with a result < 200 µg/g considered diagnostic of PEI. Patients underwent computed tomography (CT) imaging when there was a clinical suspicion of CP, a new diagnosis of PEI recurrent, pancreatic type pain (epigastric abdominal pain radiating to back with or without previous acute pancreatitis attacks) or weight loss.

RESULTS

After exclusions, 112 patients were recruited that underwent testing for FEL-1 and PEI-MD. PEI was identified in 41/112 (36.6%) patients and a pancreatic CT was performed in 82 patients. Overall a PEI-MD was identified in 21/112 (18.8%) patients. The yield of PEI-MD was 17/41 (41.5%) if PEI was present which was significantly higher than those without 4/71 (5.6%) (P = 0.0001). The yield of PEI–MD was significantly higher when PEI and CP were seen together 13/22 (59.1%) compared to CP without PEI and PEI without CP (P < 0.03). Individual micronutrient assessment showed a more frequent occurrence of prealbumin 8/41 (19.5%), selenium 6/41 (14.6%) and magnesium 5/41 (12.2%) deficiency when PEI was present (< 0.02). The accuracy of using the significant micronutrients identified in our cohort as a predictor of PEI showed a positive predictive value of 80%-85.7% [95% confidence interval (CI): 38%-100%] and a low sensitivity of 9.8%-19.5% [95% CI: 3.3%-34.9%].

CONCLUSION

Testing for PEI-MD in patients with suspected pancreatic disease has a high yield, specifically when PEI and CP are found together. PEI-MD testing should include selenium, magnesium and prealbumin.