Malnutrition by GLIM criteria in chronic pancreatitis: Prevalence, predictors, and its impact on quality of life

Significance of the modified global leadership initiative on malnutrition (GLIM) criteria malcondition for patients with biliary tract cancer

PURPOSE

This study investigated the significance of the Global Leadership Initiative on Malnutrition (GLIM) for patients with resected biliary tract cancers.

METHODS

The subjects of this retrospective analysis were 114 patients who underwent radical surgery for cholangiocarcinoma between 2018 and 2023. We analyzed both handgrip force and skeletal muscle area and classified patients as having GLIM malnutrition or modified GLIM malcondition. We also evaluated clinicopathological factors, short-term outcomes, and prognoses.

RESULTS

The GLIM criteria identified 47 patients (41.2%) with malnutrition and 13 patients (11.4%) with modified GLIM malcondition. Overall survival (P = 0.009) and recurrence-free survival (P = 0.016) were significantly different between the well-nourished and malnourished patients according to the GLIM criteria. Furthermore, modified GLIM criteria malcondition was a significant prognostic factor for both recurrence-free and overall survival (P = 0.002 and P < 0.001, respectively). Multivariate analysis identified a higher carcinoembryonic antigen level and modified GLIM malcondition as predictors of overall and recurrence-free survival. Pathological stage ≥ III was also a predictor of recurrence-free survival. On comparing the prognoses of modified GLIM malcondition and GLIM malnutrition using the Akaike Information Criteria, the modified GLIM malcondition was identified as a stronger prognostic factor.

CONCLUSION

A modified GLIM malcondition can be a highly useful prognostic marker for patients with resected biliary tract cancer.

Investigation and quality evaluation of Internet videos related to diet therapy for chronic pancreatitis

Diet therapy can help alleviate chronic pancreatitis symptoms. The quality of diet therapy content in Internet videos varies markedly. Evaluating and assessing these videos is crucial for providing reliable patient education. This study aims to analyze 102 Internet videos regarding dietary therapy for chronic pancreatitis on media platforms in China (Bilibili, Weibo, and Tiktok) and rate their content, reliability, and quality. Videos were categorized into 3 sources: hospital or university officials, medical doctors, and independent users. An 8-point scale was used to score content (smoking, drinking, eating frequency, overeating, and nutrient intake [high-quality protein, low fat, nutrition, and dietary fiber]). An adapted DISCERN tool was used to assess reliability, with the Global Quality Scale employed to measure quality. Among the 102 videos analyzed, 34 (4, 9, and 21 from hospital or university officials, medical doctors, and independent users, respectively) were rated as low quality, 37 (8, 12, and 17 from hospital or university officials, medical doctors, and independent users, respectively) were rated as moderate quality, and 31 (7, 19, and 6 from hospital or university officials, medical doctors, and independent users, respectively) were rated as high quality. Thus, among 102 videos from TikTok, Weibo, and Bilibili, only 31 (30.4%) were considered high quality based on reliability and quality assessments, and some were misleading. Our findings suggest nearly 70% of health videos fail to meet high-quality standards, highlighting critical needs for improved content moderation across media platforms. Medical professionals and institutions should be encouraged to produce more high-quality Internet videos with comprehensive content to better guide and support patients with pancreatitis in adopting effective dietary therapy.

[Prevalence and risk of malnutrition in patients with chronic pancreatitis: A systematic review and meta-analysis]

AIM

To systematize data on the prevalence and risk of malnutrition in patients with chronic pancreatitis (CP).

MATERIALS AND METHODS

MEDLINE/PubMed, EMBASE, Cochrane, Google Scholar, Scopus, and the Russian Science Citation Index were searched for studies published between January 1, 1985, and October 23, 2024 (inclusive) based on an analysis of the titles and abstracts of articles in these databases. The study included relevant publications in peer-reviewed periodicals in English or Russian, publications with data on the prevalence of malnutrition in patients with CP and control subjects (if any), studies on adult patients with CP, and publications with detailed descriptive statistics that allow using the data in the meta-analysis.

RESULTS

The final analysis included 13 studies involving 3,812 subjects (3,401 patients with CP and 411 controls). The overall prevalence of malnutrition in patients with CP was 43.43% (95% confidence interval [CI] 32.419-54.780), whereas in controls, it was 10.843% (95% CI 1.360-27.698). When analyzing the association in the overall pool of studies, a significant risk of malnutrition in CP patients compared to controls was shown (relative risk [RR] 3.635, 95% CI 1.409-9.373; p=0.008). The analysis used a random effect model, as there was high heterogeneity between the groups (I2=88.09%, 95% CI 74.76-94.38). A review of studies that used only validated instrumental methods for the diagnosis of malnutrition (criteria of the Global Leadership Initiative on Malnutrition) showed a total prevalence of malnutrition of 38.348% (95% CI 14.975-65.047) in patients with CP and 12.22% (95% CI 5.985-67.238) in control subjects.

CONCLUSION

This meta-analysis demonstrated that malnutrition is a common complication of CP and occurs in approximately 40% of CP patients. A modern clinician should promptly assess malnutrition markers in a CP patient and correct them using enzyme replacement therapy if detected.

S3-Leitlinie Klinische Ernährung bei Pankreaserkrankungen

Sowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen, die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen, endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte Säule der multimodalen Therapie darstellt.

Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet werden, und entsprechende Präventivmaßnahmen erwogen werden.

An intensified trans-sectoral nutritional intervention in malnourished patients with chronic pancreatitis improves diseases prognosis and identifies potential biomarkers of nutritional status

Background

Malnutrition is a common complication in chronic pancreatitis and associated with reduced quality of life and life expectancy. Nutritional support is considered mandatory in malnourished patients with chronic pancreatitis but there is only scarce evidence on optimal treatment modalities and the efficacy of nutrition therapy. Here, we investigated the feasibility and efficacy of an intensified nutritional intervention in malnourished patients with chronic pancreatitis and aimed to identify suitable indicators for monitoring nutritional status.

Methods

We performed a single-arm feasibility study, in which malnourished patients with chronic pancreatitis received an intensified trans-sectoral nutritional intervention for 6 months. Multimodal treatment comprised face-to-face dietary counseling, oral nutritional supplementation, and a complementary telephone-based nutrition and exercise coaching. Patients underwent follow-up examinations after 28, 90, and 180 days, when we assessed changes in anthropometric and body composition measures, muscle function, Chronic Pancreatitis Prognosis Score (COPPS), as well as blood parameters and intestinal microbiota composition.

Results

Eleven out of 73 patients initially screened for study participation were enrolled in the trial of which 9 subjects (age (mean ± SD): 56.2 (±14.8) years; male: 67%; alcoholic etiology: 44%) underwent the complete intervention. Patients gained a median of 5.3 kg (8.6%) body weight, including 1.6 kg skeletal muscle mass, and significantly increased gait speed (p < 0.001). Ameliorated nutritional status and muscle function were associated with increased blood levels of IGF-1 and cholinesterase as well as altered gut microbiota composition on the phyla and genera level. Moreover, significant improvements in COPPS indicated reduced disease severity after 90 and 180 days.

Conclusion

Malnourished patients with chronic pancreatitis benefit from intensified nutritional therapy. Besides ameliorated nutritional status, a multimodal intervention can improve muscle function as well disease prognosis. Future studies are needed to prove superiority to standard-of-care and to validate potential biomarkers for prospective monitoring of nutritional status.

Clinical trial registration

https://clinicaltrials.gov/study/NCT04476056, NCT04476056.

Progress in treatment of chronic pancreatitis: A review based on the ClinicalTrials.gov database

Chronic pancreatitis (CP) is a chronic progressive fibro-inflammatory disease of the pancreas caused by various etiologies, characterized by recurrent upper abdominal pain and pancreatic exocrine dysfunction. ClinicalTrials.gov is the most commonly used clinical trial database, including information of clinical trials which have been completed or are ongoing, or upcoming. Based on the ClinicalTrials.gov database, we retrieved all clinical studies registered before June 30, 2024, screened out recent clinical studies related to CP, and summarized and integrated highlights and directions of these studies from the perspectives of nutritional support, medication, endoscopy, etc., aiming to provide new ideas for the design of CP clinical studies in the future.

Management of chronic pancreatitis: recent advances and future prospects

As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.

Fat-soluble vitamin deficiency and exocrine pancreatic insufficiency among adults with chronic pancreatitis: Is routine monitoring necessary for all patients?

Chronic pancreatitis (CP) is often associated with exocrine pancreatic insufficiency (EPI), which may increase risk for fat-soluble vitamin depletion. Although vitamin D deficiency is widespread among the general population, vitamins A, E, and K deficiencies may more uniquely present in patients with CP. Yet, it is unclear whether fat-soluble vitamin status should be routinely monitored in all patients with CP or limited to those with EPI. The purpose of this review is to describe the laboratory status of vitamins A, E, and K in adult patients with CP and their association with exocrine pancreatic function. Five primary, observational studies met the inclusion criteria for qualitative synthesis. Biochemical deficiencies in fat-soluble vitamins were observed across trials but results varied with respect to whether EPI increased risk. Challenges related to the diagnosis and treatment of EPI along with potential confounders may contribute to the heterogeneity among study results. Although more studies are needed to determine the influence of pancreatic enzyme replacement therapy on fat-soluble vitamin status as well as effective vitamin repletion strategies, clinicians should consider periodically screening for deficiencies in all patients with CP regardless of EPI to avoid associated health effects of vitamin depletion.

Opportunistic screening for osteopathy with routine abdominal computed tomography scan in chronic pancreatitis

BACKGROUND AND AIMS

Lumbar vertebral bone attenuation, measured in Hounsfield units (HU) can indirectly indicate the bone mineral density (BMD). The aim of this study is to determine the optimal HU threshold on abdominal computed tomography (CT) scans to detect osteopathy in patients with chronic pancreatitis (CP).

METHODS

This cross-sectional study included patients with CP who underwent CT scans to measure HU at L1 to L4 vertebrae. The mean lumbar vertebral attenuation of female renal transplant donors, aged 20-30 years was utilized to calculate the T-scoreHU of all patients at each vertebral level. Receiver operator characteristic analysis was used to determine the HU and T-scoreHU for diagnosis of osteopathy in patients with CP. Dual-energy X-ray absorptiometry value was used to categorize osteopenia and osteoporosis.

RESULTS

A total of 175 patients (mean age, 34.5 ± 10.9 years; 72 % males) and 33 female renal transplant donors (mean age, 28 ± 2.4 years) were included. A threshold HU value 212 or T scoreHU of -1.80 at L1 vertebra was found to have a 78 % sensitivity and 70 % specificity for differentiating between osteoporosis and non-osteoporosis (osteopenia and normal BMD). Similarly, a threshold HU value of 254 or a T-scoreHU of -0.46 at L1 vertebra had 78 % sensitivity and 71 % specificity for distinguishing between normal and low BMD (osteoporosis and osteopenia).

CONCLUSION

Abdominal CT images, which are routinely performed in chronic pancreatitis, can be used for opportunistic screening of osteoporosis and osteopenia without additional cost or radiation exposure.

Managing complications of chronic pancreatitis: a guide for the gastroenterologist

INTRODUCTION

Chronic pancreatitis is a heterogeneous and complex syndrome that, in most cases, causes pain as a cardinal symptom and affects both the morphology and function of the pancreas, leading to several serious complications.

AREAS COVERED

The present review, based on a non-systematic PubMed search updated to June 2023, aims to present the current available evidence on the role of gastroenterologists in the diagnosis and treatment of both local and systemic complications by either endoscopic or medical treatments.

EXPERT OPINION

At diagnosis and during chronic pancreatitis follow-up, particular care is needed to consider not only the clinically manifest signs and symptoms of the disease, such as pain, jaundice, gastrointestinal obstruction, and pseudocysts, which require multidisciplinary discussion to establish the best treatment option (endoscopic or surgical), but also less evident systemic complications. Pancreatic exocrine and endocrine insufficiency, together with chronic inflammation, addiction, and dysbiosis, contribute to malnutrition, sarcopenia, and osteopathy. These complications, in turn, increase the risk of infection, thromboembolic events, and death. Patients with chronic pancreatitis also have an increased risk of psychiatric disorders and pancreatic cancer onset. Overall, patients with chronic pancreatitis should receive a holistic evaluation, considering all these aspects, possibly through multidisciplinary care in dedicated expert centers.

Vascular complications of chronic pancreatitis and its management

Chronic pancreatitis is a chronic fibro-inflammatory disorder of the pancreas, resulting in recurrent abdominal pain, diabetes mellitus, and malnutrition. It may lead to various other complications such as pseudocyst formation, benign biliary stricture, gastric outlet obstruction; and vascular complications like venous thrombosis, variceal and pseudoaneurysmal bleed. Development of varices is usually due to chronic venous thrombosis with collateral formation and variceal bleeding can easily be tackled by endoscopic therapy. Pseudoaneurysmal bleed can be catastrophic and requires radiological interventions including digital subtraction angiography followed by endovascular obliteration, or sometimes with a percutaneous or an endoscopic ultrasound-guided approach in technically difficult situations. Procedure-related bleed is usually venous and mostly managed conservatively. Procedure-related arterial bleed, however, may require radiological interventions.

Utility of Fecal Elastase-1 to diagnose severe exocrine insufficiency in chronic pancreatitis: Real world experience

INTRODUCTION

Quantitative fecal fat estimation is the gold standard test to diagnose steatorrhea (fecal fat >7 g/day) in chronic pancreatitis (CP), but cumbersome and inconvenient. So, fecal elastase-1 (FE) is proposed as a good alternative but the data on the diagnostic utility of FE to diagnose steatorrhea is variable.

METHODS

This retrospective study included adult CP patients evaluated with both 24-h fecal-fat and FE tests within a 3-month period. The objective was to evaluate the diagnostic performance of FE to diagnose steatorrhea and to evaluate the FE progression over 9-month period.

RESULTS

Among the 147 included patients, the frequency of steatorrhea (fecal fat >7 g/day) was 34%. The sensitivity, specificity, and negative likelihood ratio (LR) of FE was 90%, 28.9% and 0.35 at cut-off of <100 μg/g stool to diagnose steatorrhea; and 96%, 11.3% and 0.35 at cut-off of <200 μg/g stool, respectively. The optimal cut-off of FE was <20 on receiver operating characteristic curve (sensitivity 66%; specificity 69%; positive LR 2.14). There was no statistically significant variation in FE levels over 9 months interval among a hundred patients.

CONCLUSION

Compared to FE ≥ 200 μg/g stool, FE ≥ 100 can used to exclude steatorrhea (better specificity and negative LR). FE < 20 alone cannot replace fecal fat estimation to confirm steatorrhea but to be interpreted with clinical features. Repeat FE testing for exocrine insufficiency progression can be done at least a year later.

Chronic pancreatitis and nutritional support

Malnutrition in patients with chronic pancreatitis is common, but its evaluation is often missed in clinical practice. Pancreatic exocrine insufficiency is the single most important cause of malnutrition; therefore, it needs to be screened for and treated appropriately. Specific diet regimens in patients suffering from chronic pancreatitis are rarely reported in the literature. Patients suffering from chronic pancreatitis have a higher demand for energy but a lower caloric intake secondary to pancreatic exocrine insufficiency, combined with the malabsorption of liposoluble vitamin and micronutrients, which needs be corrected by appropriate dietary counselling. Diabetes is frequently observed in chronic pancreatitis and classified as type 3c, which is characterized by low levels of both serum insulin and glucagon; therefore, there is a tendency towards hypoglycaemia in patients treated with insulin. Diabetes contributes to malnutrition in chronic pancreatitis. Strategies to treat exocrine and endocrine insufficiency are important to achieve better control of the disease.