Physiological evaluation of the severity of pancreatic exocrine dysfunction during endoscopy

Staging chronic pancreatitis with exocrine function tests: Are we better?

Chronic pancreatitis (CP) is an inflammatory disease of the pancreas evolving in progressive fibrotic disruption of the gland with exocrine and endocrine pancreatic insufficiency. Although imaging features of CP are well known, their correlation with exocrine pancreatic function tests are not obvious, particularly in the early stage of the disease. There are many clinical classification of CP, all suggested for better distinguish and manage different forms based on etiological and clinical factors, and severity of the disease. Recently, a new classification of CP has been suggested: the M-ANNHEIM multiple risk factor classification that includes etiology, stage classification and degree of clinical severity. However, more accurate determination of clinical severity of CP requires a correct determination of exocrine function of the pancreas and fecal fat excretion. Recently, Kamath et al demonstrated that the evaluation of exocrine pancreatic function by acid steatocrit and fecal elastase-1 (EF-1) was helpful, but EF-1 was able to detect exocrine pancreatic insufficiency in more patients, upgrading some patients in higher stage of disease according to M-ANNHEIM classification. So, EF-1 is a more accurate test to determine exocrine pancreatic insufficiency and to stage chronic pancreatitis in the M-ANNHEIM classification. On the contrary, EF-1 determination shows low sensitivity in detecting exocrine pancreatic insufficiency in early stage of the disease.

Pancreatic and Intestinal Function Post Roux-en-Y Gastric Bypass Surgery for Obesity

OBJECTIVES

Despite the fact that the most effective treatment for morbid obesity today is gastric bypass surgery, some patients develop life-threatening nutritional complications associated with their weight loss.

METHODS

Here we examine the influence of the altered anatomy and digestive physiology on pancreatic secretion and fat absorption. Thirteen post Roux-en-Y gastric bypass (RYGB) patients who had lost >100 lbs in the first year following surgery and who gave variable histories of gastrointestinal (GI) dysfunction, were selected for study. Food-stimulated pancreatic enzyme secretion and GI hormone responses were measured during 2 h perfusions of the Roux limb with a standard polymeric liquid formula diet and polyethylene glycol marker, with collections of secretions from the common channel distal to the anastomosis and blood testing. Fat absorption was then measured during a 72 h balance study when a normal diet was given containing ~100 g fat/d.

RESULTS

Result showed that all patients had some fat malabsorption, but eight had coefficients of fat absorption <80%, indicative of steatorrhea. This was associated with significantly lower feed-stimulated secretion rates of trypsin, amylase, and lipase, and higher plasma peptide-YY concentrations compared with healthy controls. Five steatorrhea patients were subsequently treated with low quantities of pancreatic enzyme supplements for 3 months, and then retested. The supplements were well tolerated, and fat absorption improved in four of five patients accompanied by an increase in lipase secretion, but body weight increased in only three. Postprandial breath hydrogen concentrations were elevated with some improvement following enzyme supplementation suggesting persistent bacterial overgrowth and decreased colonic fermentation.

CONCLUSIONS

Our investigations revealed a wide spectrum of gastrointestinal abnormalities, including fat malabsorption, impaired food stimulated pancreatic secretion, ileal brake stimulation, and bacterial overgrowth, in patients following RYGB which could be attributed to the breakdown of the normally highly orchestrated digestive anatomy and physiology.

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

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

Chronic pancreatitis

PURPOSE OF REVIEW

As in previous reviews in this journal, this review is focused on the most important new observations in chronic pancreatitis made in the last year.

RECENT FINDINGS

Important observations included the search for biomarkers and alternative methods for the detection of early chronic pancreatitis; stellate cell activation and their role in fibrogenesis; the natural history of chronic pancreatitis; reports outlining the complexity in diagnosis of autoimmune pancreatitis; emerging roles of endoscopic ultrasound and magnetic resonance cholangiopancreatography in chronic pancreatitis diagnosis; a better understanding of neurobiology of chronic pancreatitis pain; and the potential role of surgery as first-line therapy in advanced chronic pancreatitis.

SUMMARY

In 2007, major advances were made in our understanding of central processing in chronic pancreatitis pain. New techniques are being utilized in search of a better means to diagnose early chronic pancreatitis. Important prospective studies are emerging, which compare endoscopic and surgical interventions. Furthermore, the complexities of diagnosing autoimmune pancreatitis are being recognized. Overall, the future is promising as advances in genomic and proteomic techniques are applied to improve our understanding of chronic pancreatitis.