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Kawka M, Lucas A, Riad AM, Hawkins D, de Madaria E, West H, Jakaityte I, Lee MJ, Kouli O, Ruanne R, Gujjuri RR, Brown S, Cambridge WA, Pandanaboyana S, Kamarajah SK, McLean KA. Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach. HPB (Oxford) 2024:S1365-182X(24)01260-7. [PMID: 38735815 DOI: 10.1016/j.hpb.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis. METHODS Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains. RESULTS From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment. CONCLUSION There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.
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Omer E, Chiodi C. Fat digestion and absorption: Normal physiology and pathophysiology of malabsorption, including diagnostic testing. Nutr Clin Pract 2024; 39 Suppl 1:S6-S16. [PMID: 38429963 DOI: 10.1002/ncp.11130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/06/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Fat digestion and absorption play crucial roles in maintaining energy homeostasis and supporting essential physiological functions. The initial stage of fat digestion occurs in the stomach, where gastric lipase begins the hydrolysis of triglycerides. However, most fat digestion takes place in the small intestine via pancreatic enzymes and bile salts. Emulsification of fat by bile acids facilitates enzymatic action, breaking down triglycerides into free fatty acids and monoglycerides, which are then able to be absorbed by enterocytes. Fat malabsorption can result from various underlying conditions, such as exocrine pancreatic insufficiency, bile acid disorders, or intestinal diseases. The clinical manifestations of fat malabsorption include steatorrhea, malnutrition, and deficiencies of fat-soluble vitamins. Diagnostic approaches involve assessing fecal fat levels, imaging studies, and various functional tests to identify the specific etiology. This review article will describe the normal physiologic process of fat digestion and absorption and discuss various pathophysiology that can lead to fat malabsorption within the gastrointestinal tract as well as their respective diagnostic testing modalities. Effective digestion of fat is essential for overall health, because it allows for absorption of many essential nutrients, plays an integral role in cellular and structural function, and supplies energy to the body. When this is dysfunctional, disorders of malabsorption can occur. This article will give a brief overview of the physiologic process of fat digestion and absorption in healthy individuals as well as review important pathophysiology that can lead to fat malabsorption within the gastrointestinal tract and current diagnostic testing modalities.
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Affiliation(s)
- Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Cristina Chiodi
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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Bejjani J, Ramsey ML, Lee PJ, Phillips AE, Singh VK, Yadav D, Papachristou GI, Hart PA. Alterations in exocrine pancreatic function after acute pancreatitis. Pancreatology 2024:S1424-3903(24)00063-2. [PMID: 38485543 DOI: 10.1016/j.pan.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Exocrine pancreatic dysfunction (EPD) is a malabsorptive complication of pancreatic disorders that can lead to a host of symptoms ranging from flatulence to diarrhea and contribute to weight loss and metabolic bone disease. It is increasingly recognized to occur after acute pancreatitis (AP), including episodes with mild severity. The risk of developing EPD after AP is influenced by a range of factors, including the degree of acinar cell destruction and inflammation during AP, and persistent structural derangements following AP. In this article, we discuss the epidemiology, pathophysiology, and clinical management of EPD after AP while highlighting key knowledge gaps.
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Affiliation(s)
- Joseph Bejjani
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anna Evans Phillips
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Lewis DM, Rieke JG, Almusaylim K, Kanchibhatla A, Blanchette JE, Lewis C. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci 2024; 69:615-633. [PMID: 38117426 DOI: 10.1007/s10620-023-08184-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
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.
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Affiliation(s)
| | - Jorden G Rieke
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA.
| | - Khaleal Almusaylim
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Anuhya Kanchibhatla
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Julia E Blanchette
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Claudia Lewis
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
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Borowitz D, Aronoff N, Cummings LC, Maqbool A, Mulberg AE. Coefficient of Fat Absorption to Measure the Efficacy of Pancreatic Enzyme Replacement Therapy in People With Cystic Fibrosis: Gold Standard or Coal Standard? Pancreas 2022; 51:310-318. [PMID: 35695742 PMCID: PMC9257055 DOI: 10.1097/mpa.0000000000002016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/02/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We sought data on the validity, reliability, responsiveness, and feasibility of the coefficient of fat absorption (CFA) as a measure of pancreatic enzyme replacement therapy (PERT) efficacy in people with cystic fibrosis (pwCF) and reviewed the literature for alternative measures. METHODS We searched PubMed for the Medical Subject Heading cystic fibrosis and the key words cystic fibrosis, fat absorption, CFA, and fecal fat imbalance; historical articles; and citations in bibliographies. RESULTS The lower the CFA, the greater its variability; thus, it is less variable in healthy individuals who have higher CFA than pwCF. In addition, the test-retest values for CFA are more variable in pwCF than the general population. There is no correlation between CFA and body mass index or PERT dose but CFA is related to gastrointestinal signs and symptoms. Research-quality CFA studies are expensive, time consuming, and odious to pwCF and research staff. Sparse stool tests, breath tests, and blood tests of fat absorption have been studied as potential alternatives to CFA to measure PERT efficacy. CONCLUSIONS Based on the evidence, we conclude that CFA as a measure of the efficacy of PERT is more of a "coal standard" than a gold standard; developing suitable alternatives should be a priority.
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Affiliation(s)
- Drucy Borowitz
- From the Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences
| | - Nell Aronoff
- University Libraries, University at Buffalo, Buffalo, NY
| | - Linda C. Cummings
- Department of Internal Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Asim Maqbool
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Genetic Variants, Fat Malabsorption, and Ancestral Background in a Small Chronic Pancreatitis Cohort. Pancreas 2020; 49:e76-e78. [PMID: 32833953 PMCID: PMC7450390 DOI: 10.1097/mpa.0000000000001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Measures of Dietary Fat and Energy Absorption in Healthy Adults. Pancreas 2020; 49:845-854. [PMID: 32590620 PMCID: PMC8335406 DOI: 10.1097/mpa.0000000000001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Existing reference ranges for stool fat and energy absorption were developed using subjects in controlled environments on precise diets. This study measured energy and fat absorption in healthy, community-dwelling adults eating a moderate-to-high fat American diet via stool- and serum-based methods. METHODS This was a secondary analysis of healthy subjects recruited as the comparison group in a chronic pancreatitis study. Subjects recorded dietary intake and collected stool over 3-day periods. Stool was analyzed for fat content using the coefficient of fat absorption and for energy content using bomb calorimetry. The malabsorption blood test (MBT) was used to measure dietary fat absorption. RESULTS Nineteen subjects had mean daily stool measures of 143 g wet weight, 4.1 g of fat, and 178 kcal. The mean coefficients of fat and energy absorption were 96% and 93%, respectively. The mean MBT area under the curve cut-point was greater than 8 mg·h/dL. CONCLUSIONS This study confirms the historical reference range for the coefficient of fat absorption in contemporary healthy, community-dwelling adults on a moderate-to-high fat diet. The study contributes to the development of reference range values for multiple bomb calorimetry-based outcomes of stool energy losses and to the serum-based MBT as a promising method for measuring fat absorption.
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