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Barkin JA, Delk TB, Powell VJ. Symptoms, burden, and unmet needs of patients living with exocrine pancreatic insufficiency: a narrative review of the patient experience. BMC Gastroenterol 2024; 24:101. [PMID: 38481137 PMCID: PMC10938721 DOI: 10.1186/s12876-024-03188-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/26/2024] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Jodie A Barkin
- University of Miami Miller School of Medicine, 1120 NW 14th St., Clinical Research Building, Suite 1188 (D-49), 33136, Miami, FL, USA.
| | - Trudi B Delk
- Aimmune Therapeutics, a Nestlé Health Science Company, Brisbane, CA, USA
| | - Valerie J Powell
- CorEvitas, LLC, part of Thermo Fisher Scientific, Waltham, MA, USA
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2
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Abu-El-Haija M, Hornung L, Ellery K, Fishman DS, Gonska TY, Gariepy C, Lowe M, Larson Ode K, Maqbool A, Mascarenhas M, Morinville VD, Ooi CY, Perito ER, Schwarzenberg SJ, Sellers ZM, Zemel BS, Yuan Y, Wang F, Uc A, Kalkwarf HJ. Bone health in children with recurrent and chronic pancreatitis: A multi-center cross sectional analysis. Pancreatology 2023; 23:755-760. [PMID: 37723006 PMCID: PMC10843133 DOI: 10.1016/j.pan.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 08/02/2023] [Accepted: 08/25/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND/OBJECTIVES Bone health of children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) is not well studied. METHODS This retrospective study was performed at three sites and included data from INSPPIRE-2. RESULTS Of the 87 children in the study: 46 had ARP (53%), 41 had CP (47%). Mean age was 13.6 ± 3.9 years at last DXA scan. The prevalence of low height-for-age (Z-score < -2) (13%, 10/78) and low bone mineral density (BMD) adjusted for height (Z-score < -2) (6.4%, 5/78) were higher than a healthy reference sample (2.5%, p < 0.0001 and p = 0.03, respectively). CONCLUSION Children with ARP or CP have lower height and BMD than healthy peers. Attention to deficits in growth and bone mineral accrual in children with pancreatic disease is warranted.
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Affiliation(s)
- Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kate Ellery
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | | | | | - Mark Lowe
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Katie Larson Ode
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA; Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA, USA
| | - Asim Maqbool
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maria Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Chee Y Ooi
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, University of New South Wales and Department of Gastroenterology, Sydney Children's Hospital Randwick, Sydney, Australia
| | - Emily R Perito
- University of California San Francisco, San Francisco, CA, USA
| | | | - Zachary M Sellers
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Palo Alto, CA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ying Yuan
- Department of Biostatistics, University of Texas MD, Anderson Cancer Center, Huston, TX, USA
| | - Fuchenchu Wang
- Department of Biostatistics, University of Texas MD, Anderson Cancer Center, Huston, TX, USA
| | - Aliye Uc
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA; Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, IA, USA; Radiation Oncology, University of Iowa, Iowa City, IA, USA
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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4
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Sankararaman S, Schindler T. Exocrine Pancreatic Insufficiency in Children - Challenges in Management. Pediatric Health Med Ther 2023; 14:361-378. [PMID: 37908317 PMCID: PMC10615098 DOI: 10.2147/phmt.s402589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Abstract
Cystic fibrosis (CF) is the leading etiology for exocrine pancreatic insufficiency (EPI) in children, followed by chronic pancreatitis, Shwachman-Diamond syndrome, and other genetic disorders. Management of EPI in children poses several unique challenges such as difficulties in early recognition, lack of widespread availability of diagnostic tests and limited number of pediatric-specific pancreatic centers. Pancreatic enzyme replacement therapy is the cornerstone of EPI management and in young children difficulties in administering pancreatic enzymes are frequently encountered. Patients with EPI also should be screened for fat-soluble vitamin deficiencies and receive appropriate supplementation. Among disorders with EPI in children, CF is the relatively well-studied condition, and most management recommendations for EPI in children come from expert consensus and conventional practice guidelines. The impact of EPI can be greater in children given their high metabolic demands and rapid growth. Early diagnosis and aggressive management of EPI prevent consequences of complications such as malnutrition, fat-soluble vitamin deficiencies, and poor bone health and improve outcomes. Management by multi-disciplinary team is the key to success.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital / Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
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5
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Koh A, Oyende O, Humes DJ, Lobo DN. Risk of osteopaenia, osteoporosis and osteoporotic fractures in patients with chronic pancreatitis: A systematic review and meta-analysis. Clin Nutr 2023; 42:1086-1094. [PMID: 37271708 DOI: 10.1016/j.clnu.2023.05.019] [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: 02/14/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND & AIMS Chronic pancreatitis results in irreversible pancreatic dysfunction and malnutrition which, alongside excess alcohol intake, can increase the risk of low bone density. Osteoporosis increases the risk of fractures and chronic bone pain, reduces quality of life, and poses considerable costs to healthcare. Despite this, there remains a paucity of literature evaluating bone health in this patient population. This systematic review and meta-analysis evaluated the prevalences of osteopaenia, osteoporosis and fractures in patients with chronic pancreatitis. METHODS A comprehensive search of Medline, Embase, ClinicalTrials.gov, and CENTRAL databases was undertaken to identify eligible studies from January 2000 to May 2022. The prevalences of osteopenia, osteoporosis and fragility fractures were extracted from the included studies. Where available, a subgroup analysis was performed to compare the likelihood of developing osteoporosis in patients with chronic pancreatitis compared with control. RESULTS Nineteen studies reporting on 2,027,764 participants (20,460 with chronic pancreatitis and 2,007,304 controls) were included. The pooled prevalence of osteoporosis was 19% (95% CI 13 to 26%; I2 = 94%). Patients with chronic pancreatitis were more likely to have osteoporosis when compared with those in the control group (OR 2.80, 95% CI 1.86 to 4.21; I2 = 21%). The prevalences of osteopaenia and fractures in patients with chronic pancreatitis were 37% (95% CI 31 to 44%; I2 = 81%) and 14% (95% CI 7 to 22%; I2 = 99%) respectively. CONCLUSION The prevalences of osteopenia and osteoporosis are significant in patients with chronic pancreatitis and can increase the risk of developing fractures. Further population-based studies are required to evaluate the disease burden of osteoporotic fractures and associated morbidity and mortality in chronic pancreatitis.
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Affiliation(s)
- Amanda Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Olamide Oyende
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - David J Humes
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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6
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Zheng Y, Mostamand S. Nutrition in children with exocrine pancreatic insufficiency. Front Pediatr 2023; 11:943649. [PMID: 37215591 PMCID: PMC10196508 DOI: 10.3389/fped.2023.943649] [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] [Received: 05/14/2022] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
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.
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Affiliation(s)
- Yuhua Zheng
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shikib Mostamand
- Gastroenterology, Hepatology, and Nutrition, Stanford Children’s Health & Stanford University School of Medicine, Palo Alto, CA, United States
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Chhoda A, Hernandez-Woodbine MJ, Addo NAA, Nasir SA, Grimshaw A, Gunderson C, Ahmed A, Freedman SD, Sheth SG. Burden of bone disease in chronic pancreatitis: A systematic review and meta-analysis. World J Gastroenterol 2023; 29:1374-1394. [PMID: 36925454 PMCID: PMC10011962 DOI: 10.3748/wjg.v29.i8.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/15/2023] [Accepted: 02/15/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Bone disease is an under-recognized cause of morbidity in chronic pancreatitis (CP). Over the past decade, publications of original studies on bone disease in CP has warranted synthesis of the evidence to ascertain the true burden of the problem.
AIM To quantify the prevalence of osteopenia, osteoporosis, and fragility fractures in CP patients and investigate the associated clinical features and outcomes.
METHODS A systematic search identified studies investigating bone disease in CP patients from Cochrane Library, Embase, Google Scholar, Ovid Medline, PubMed, Scopus, and Web of Science, from inception until October 2022. The outcomes included prevalence of osteopenia, osteoporosis, and fragility fractures, which were meta-analyzed using a random-effects model and underwent metaregression to delineate association with baseline clinical features.
RESULTS Twenty-one studies were included for systematic review and 18 studies were included for meta-analysis. The pooled prevalence of osteopenia and osteoporosis in CP patients was 41.2% (95%CI: 35.2%-47.3%) and 20.9% (95%CI: 14.9%-27.6%), respectively. The pooled prevalence of fragility fractures described among CP was 5.9% (95%CI: 3.9%-8.4%). Meta-regression revealed significant association of pancreatic enzyme replacement therapy (PERT) use with prevalence of osteoporosis [coefficient: 1.7 (95%CI: 0.6-2.8); P < 0.0001]. We observed no associations with mean age, sex distribution, body mass index, alcohol or smoking exposure, diabetes with prevalence of osteopenia, osteoporosis or fragility fractures. Paucity of data on systemic inflammation, CP severity, and bone mineralization parameters precluded a formal meta-analysis.
CONCLUSION This meta-analysis confirms significant bone disease in patients with CP. Other than PERT use, we observed no patient or study-specific factor to be significantly associated with CP-related bone disease. Further studies are needed to identify confounders, at-risk population, and to understand the mechanisms of CP-related bone disease and the implications of treatment response.
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Affiliation(s)
- Ankit Chhoda
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | | | - Nana Afua Akkya Addo
- Department of Medicine, Norwalk Hospital, Yale School of Medicine, Norwalk, CT 06850, United States
| | - Syed Alishan Nasir
- Department of Medicine, Norwalk Hospital, Yale School of Medicine, Norwalk, CT 06850, United States
| | - Alyssa Grimshaw
- Cushing/Whitney Medical Library, Yale University, New Haven, CT 06510, United States
| | - Craig Gunderson
- General Internal Medicine, Yale School of Medicine, New Haven, CT 06510, United States
| | - Awais Ahmed
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Steven D. Freedman
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Sunil G. Sheth
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
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8
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Campagnola P, de Pretis N, Zorzi A, Caldart F, Frulloni L. Chronic pancreatitis and nutritional support. Best Pract Res Clin Gastroenterol 2023; 62-63:101823. [PMID: 37094906 DOI: 10.1016/j.bpg.2023.101823] [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] [Received: 01/13/2023] [Accepted: 01/29/2023] [Indexed: 04/26/2023]
Abstract
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.
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Affiliation(s)
| | | | - Alberto Zorzi
- Department of Medicine, University of Verona, Verona, Italy
| | | | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
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Cai F, Hu C, Chen CJ, Han YP, Lin ZQ, Deng LH, Xia Q. Vitamin D and Pancreatitis: A Narrative Review of Current Evidence. Nutrients 2022; 14:nu14102113. [PMID: 35631254 PMCID: PMC9143310 DOI: 10.3390/nu14102113] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 12/10/2022] Open
Abstract
Emerging research indicates that vitamin D metabolic disorder plays a major role in both acute pancreatitis (AP) and chronic pancreatitis (CP). This has been demonstrated by studies showing that vitamin D deficiency is associated with pancreatitis and its anti-inflammatory and anti-fibrotic effects by binding with the vitamin D receptor (VDR). However, the role of vitamin D assessment and its management in pancreatitis remains poorly understood. In this narrative review, we discuss the recent advances in our understanding of the molecular mechanisms involved in vitamin D/VDR signaling in pancreatic cells; the evidence from observational studies and clinical trials that demonstrate the connection among vitamin D, pancreatitis and pancreatitis-related complications; and the route of administration of vitamin D supplementation in clinical practice. Although further research is still required to establish the protective role of vitamin D and its application in disease, evaluation of vitamin D levels and its supplementation should be important strategies for pancreatitis management according to currently available evidence.
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Affiliation(s)
- Fei Cai
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
| | - Cheng Hu
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
| | - Chan-Juan Chen
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
| | - Yuan-Ping Han
- The Center for Growth, Metabolism and Aging, College of Life Sciences, Sichuan University, Chengdu 610017, China;
| | - Zi-Qi Lin
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
| | - Li-Hui Deng
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
- Correspondence:
| | - Qing Xia
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu 610041, China; (F.C.); (C.H.); (C.-J.C.); (Z.-Q.L.); (Q.X.)
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10
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Tang XY, Ru N, Li Q, Qian YY, Sun H, Zhu JH, He L, Wang YC, Hu LH, Li ZS, Zou WB, Liao Z. Prevalence and Risk Factors for Osteopathy in Chronic Pancreatitis. Dig Dis Sci 2021; 66:4008-4016. [PMID: 33433813 DOI: 10.1007/s10620-020-06732-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 11/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The high incidence of osteopathy among patients with chronic pancreatitis (CP) has garnered increased attention over recent years. The aims of this study were to assess the prevalence and risk factors for osteopathy in Chinese patients with CP. METHODS This was a cross-sectional study of CP patients from a large center in China; patients were recruited between 31 January 2017 and 31 January 2018. Bone density and laboratory tests, including bone-related biochemical, inflammatory, and hormone parameters, were assessed prospectively. Differences between patients with and without osteopathy were analyzed. Logistic regression analysis was used to investigate associations between variables. RESULTS In total, 104 CP patients were enrolled in this study (68.3% idiopathic and 31.7% alcoholic). According to the M-ANNHEIM classification, 87.5% of the patients were at an early stage (0-II). Osteopenia was diagnosed in 30.8% of patients and osteoporosis in 5.8%; thus, a total of 36.5% of patients presented with osteopathy. In multivariate analysis, the independent risk factors for osteopathy in CP patients were age (OR = 1.04; 95% CI = 1.00-1.08; P = 0.030), BMI (OR = 0.72; 95% CI = 0.58-0.89; P = 0.003), and PTH (OR = 0.96; 95% CI = 0.93-1.00; P = 0.022). CONCLUSIONS This study is the first to report the prevalence of osteopathy in Chinese patients with CP. It found that age and low BMI are significant risk factors for osteopathy. Low PTH (but within the normal range) showed a weak association with osteopathy, which warrants further exploration.
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Affiliation(s)
- Xin-Ying Tang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Prevention and Health Care, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Nan Ru
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai, 200433, China
| | - Qing Li
- Department of Gastroenterology, Taicang Affiliated Hospital of Soochow University, The First People's Hospital of Taicang, Taicang, Jiangsu Province, China
| | - Yang-Yang Qian
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Sun
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jia-Hui Zhu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Lin He
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Department of Gastroenterology and Endocrinology, PLA 969 Hospital, Inner Mongolia, China
| | - Yuan-Chen Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai, 200433, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.,Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai, 200433, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China. .,Shanghai Institute of Pancreatic Diseases, 168 Changhai Road, Shanghai, 200433, China.
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Won H, Jeong DH, Shin HS, Lee JH, Lee JP, Yang JY, Jung K, Jeong J, Oh JH. Toxicological Assessment of Bromochlorophene: Single and Repeated-Dose 28-Day Oral Toxicity, Genotoxicity, and Dermal Application in Sprague-Dawley Rats. Front Pharmacol 2021; 12:690141. [PMID: 34335256 PMCID: PMC8316990 DOI: 10.3389/fphar.2021.690141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Bromochlorophene (BCP) has shown good properties in sterilization and antibacterial activity and is widely used as a household chemical. We evaluated the genotoxicity, single and repeated-dose 28-day oral toxicity, and dermal application of a BCP suspension in Sprague–Dawley (SD) rats. For the single-dose toxicity study, a dose of 25–1,000 mg per kg of bodyweight (mg/kg b.w.) of BCP was given once orally to SD rats. Mortality and clinical signs were observed and recorded for the first 30 min after treatment, at 4 h post-administration, and then at least once daily for 14 days after administration. For the repeated-dose 28-day toxicity study, the high dose was set at 1,000 mg/kg b.w. and the middle, middle-low, and low dose were set to 500, 250, and 125 mg/kg, respectively. Hematology and biochemistry parameters were examined. Gross pathologic and histopathologic examinations were performed on selected tissues from all animals. A bacterial reverse mutation assay, in vitro chromosomal aberration assay, and in vivo micronucleus assay were performed to assess genotoxicity-dermal application exposure assessment of BCP in rats. A high oral approximate lethal dose (ALD) of 1,000 mg/kg was observed in the single-dose toxicity test. During the repeated-dose 28-day time period, most animal deaths after administration occurred during the first 3 weeks. The 1,000 mg/kg b.w. oral dose caused the death of six male rats (6/7) and four female rats (4/7). At 500 mg/kg b.w., the female rats showed mortality (1/7). For the biochemistry assays, cholesterol was increased significantly compared to vehicle in both sexes in the 250 and 500 mg/kg groups. Histopathological changes with treatment-related findings were observed in the pancreas in female rats treated with a high dose of BCP compared with the vehicle group. BCP showed no genotoxic effect. These data suggested that the ALD of BCP, estimated as a non-genotoxic substance, was over 1,000 mg/kg b.w. in the single-dose toxicity study, and the NOAEL of BCP was considered to be 250 mg/kg b.w. for male and female rats after repeated oral administration for 28 days under the present study conditions.
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Affiliation(s)
- Hansol Won
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Da Hye Jeong
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Hyo-Sook Shin
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Jin Hee Lee
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Jeong Pyo Lee
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Jun-Young Yang
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Kikyung Jung
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Jayoung Jeong
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
| | - Jae Ho Oh
- Division of Toxicological Research, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, South Korea
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Vujasinovic M, Nezirevic Dobrijevic L, Asplund E, Rutkowski W, Dugic A, Kahn M, Dahlman I, Sääf M, Hagström H, Löhr JM. Low Bone Mineral Density and Risk for Osteoporotic Fractures in Patients with Chronic Pancreatitis. Nutrients 2021; 13:nu13072386. [PMID: 34371899 PMCID: PMC8308495 DOI: 10.3390/nu13072386] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: Chronic pancreatitis (CP) can lead to malnutrition, an established risk factor for low bone mineral density (BMD) and fractures. This study aims to determine the prevalence of low BMD, assess fracture incidence and explore risk factors for fractures in patients with CP. Patients and methods: We performed a retrospective analysis of all patients treated for CP at Karolinska University Hospital between January 1999 and December 2020. Electronic medical records were retrieved to assess demographic, laboratory and clinical data. Patients subjected to dual-energy X-ray absorptiometry (DXA) were categorised as either low BMD or normal BMD. We investigated whether the rate of fractures, defined by chart review, differed between these groups using Cox regression, adjusting the model for age, sex and body mass index (BMI). Additional within-group survival analysis was conducted to identify potential risk factors. Results: DXA was performed in 23% of patients with definite CP. Some 118 patients were included in the final analysis. Low BMD was present in 63 (53.4%) patients. Mean age at CP diagnosis in the total cohort was 53.1 years and was significantly lower in patients with normal BMD than in patients with low BMD (45.5 vs. 59.8, p < 0.001). Significant differences were observed in smoking status and disease aetiology, i.e., a higher proportion of patients with low BMD were current or former smokers, with nicotine or alcohol being a more common cause of CP (p < 0.05). Total follow-up time was 898 person-years. Fractures were found in 33 (28.0%) patients: in 5 of 55 patients (16.7%) with normal DXA and in 28 of 63 patients (44.4%) with low BMD (adjusted hazard ratio = 3.4, 95% confidence interval (CI) = 1.2-9.6). Patients with at least 3 months of consecutive pancreatic enzyme replacement therapy (PERT) or vitamin D treatment had a longer median time to fracture after CP diagnosis. Conclusion: DXA was only performed in 23% of patients with definite CP in this study, indicating a low adherence to current European guidelines. A low BMD was found in 53.4% of patients with CP, and 44% of the patients with a low BMD experienced a fracture during follow-up. Moreover, the fracture rate in patients with low BMD increased compared to those with normal BMD.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (W.R.); (H.H.); (J.-M.L.)
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
- Correspondence: ; Tel.: +46-(0)-72-469-49-38; Fax: +46-(0)-8-5858-2335
| | - Lorena Nezirevic Dobrijevic
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
| | - Ebba Asplund
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
| | - Wiktor Rutkowski
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (W.R.); (H.H.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
| | - Ana Dugic
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
| | - Mashroor Kahn
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
| | - Ingrid Dahlman
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
| | - Maria Sääf
- Endocrine and Diabetes Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Hannes Hagström
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (W.R.); (H.H.); (J.-M.L.)
- Department of Medicine, Huddinge, Karolinska Institutet, 171 76 Stockholm, Sweden; (L.N.D.); (E.A.); (A.D.); (M.K.); (I.D.)
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Johannes-Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden; (W.R.); (H.H.); (J.-M.L.)
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
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Difference in Performance of EPI Pigs Fed Either Lipase-Predigested or Creon®-Supplemented Semielemental Diet. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6647734. [PMID: 34307664 PMCID: PMC8282365 DOI: 10.1155/2021/6647734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/25/2021] [Indexed: 11/17/2022]
Abstract
Pancreatic enzyme replacement therapy (PERT) and fat predigestion are key in ensuring the optimal growth of patients with cystic fibrosis. Our study attempted to highlight differences between fat predigestion and conventional PERT on body composition of young pigs with exocrine pancreatic insufficiency (EPI). EPI and healthy pigs were fed with high-fat diet for six weeks. During the last two weeks of the study, all pigs received additional nocturnal alimentation with Peptamen AF (PAF) and were divided into three groups: H—healthy pigs receiving PAF; P—EPI pigs receiving PAF+PERT; and L—EPI pigs receiving PAF predigested with an immobilized microbial lipase. Additional nocturnal alimentation increased the body weight gain of EPI pigs with better efficacy in P pigs. Humerus length and area in pigs in groups L and P were lower than that observed in pigs in group H (p value 0.005-0.088). However, bone mineral density and strength were significantly higher in P and L as compared to that of H pigs (p value 0.0026-0.0739). The gut structure was improved in P pigs. The levels of neurospecific proteins measured in the brain were mainly affected in P and less in L pigs as compared to H pigs. The beneficial effects of the nocturnal feeding with the semielemental diet in the prevention of EPI pigs' growth/development retardation are differently modified by PERT or fat predigestion in terms of growth, bone properties, neurospecific protein distribution, and gut structure.
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Srivoleti P, Yang AL, Jin DX, Banks PA, McNabb-Baltar J. Does Provider Type Affect Bone Health Surveillance in Chronic Pancreatitis? Dig Dis Sci 2021; 66:2235-2239. [PMID: 32816216 DOI: 10.1007/s10620-020-06542-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/06/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bone density screening (DEXA) and vitamin D serum assay (Vit-D) are recommended in chronic pancreatitis, but adherence by providers is unknown. AIMS Assess DEXA/Vit-D testing according to provider type. METHODS A retrospective cohort study of chronic pancreatitis patients followed in a tertiary hospital (August 2017-2018) was conducted. Provider type was primary care (PCP), gastroenterologist, and pancreas specialist. Chi-square test and multivariable analysis were conducted to assess the relation between provider type and DEXA/Vit-D testing. Subset analyses were performed among patients with fecal elastase < 200 mcg/g. RESULTS A total of 478 charts were reviewed, and 256 (53.6%) met diagnosis of chronic pancreatitis; 184 (71.9%) definite, 45 (17.6%) probable, and 27 (10.6%) borderline chronic pancreatitis. DEXA was tested in 112/256 (43%) patients; 16/57(28%) patients followed by PCP, 11/38 (28.9%) by gastroenterologists, and 85/161(52.2%) by pancreas specialists (p = 0.001). Vit-D was tested in 210/256 (82.0%) patients; 42/57(73.7%) followed by PCP, 29/38 (76.3%) by gastroenterologists, and 139/161(86.3%) by pancreas specialists (p = 0.06). Multivariate analysis assessing DEXA/Vit-D testing showed pancreas specialists were more likely to test compared to PCP (DEXA: OR 3.70, CI 1.77-7.74, p = 0.001. Vit-D: OR 3.24, CI 1.43-7.38, p = 0.005), but gastroenterologists were not. In patients with low fecal elastase, pancreas specialists were more likely to test DEXA (pancreas specialists: 62.1%, PCP: 40.0%, Gastroenterologists: 11.1%, p = 0.01) and all patients received Vit-D testing. CONCLUSIONS Chronic pancreatitis patients often do not receive optimal preventive care. Pancreas specialists were more likely to perform DEXA and Vit-D testing compared to PCP and gastroenterologists. More physician education is needed.
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Affiliation(s)
- Padmavathi Srivoleti
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Allison L Yang
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine College, New York, NY, USA
| | - David X Jin
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter A Banks
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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15
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Pancreatic cancer cachexia: three dimensions of a complex syndrome. Br J Cancer 2021; 124:1623-1636. [PMID: 33742145 PMCID: PMC8110983 DOI: 10.1038/s41416-021-01301-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/18/2021] [Accepted: 02/02/2021] [Indexed: 02/08/2023] Open
Abstract
Cancer cachexia is a multifactorial syndrome that is characterised by a loss of skeletal muscle mass, is commonly associated with adipose tissue wasting and malaise, and responds poorly to therapeutic interventions. Although cachexia can affect patients who are severely ill with various malignant or non-malignant conditions, it is particularly common among patients with pancreatic cancer. Pancreatic cancer often leads to the development of cachexia through a combination of distinct factors, which, together, explain its high prevalence and clinical importance in this disease: systemic factors, including metabolic changes and pathogenic signals related to the tumour biology of pancreatic adenocarcinoma; factors resulting from the disruption of the digestive and endocrine functions of the pancreas; and factors related to the close anatomical and functional connection of the pancreas with the gut. In this review, we conceptualise the various insights into the mechanisms underlying pancreatic cancer cachexia according to these three dimensions to expose its particular complexity and the challenges that face clinicians in trying to devise therapeutic interventions.
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16
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Srivastava A, Saini N, Mathias A, Arya A, Jain S, Yachha SK. Prevalence and predictive factors of undernutrition and low bone mineral density in children with chronic pancreatitis. Pancreatology 2021; 21:74-80. [PMID: 33262050 DOI: 10.1016/j.pan.2020.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/19/2020] [Accepted: 11/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malnutrition and bone disease are common in adults with chronic pancreatitis (CP). We studied the nutritional status and bone mineral density (BMD) of children with CP and the factors predicting them. METHODS CP children were prospectively evaluated with a detailed questionnaire, anthropometry, 25-hydroxy vitamin D, fecal elastase and BMD [total body less head (TBLH), spine and hip] by dual energy x-ray absorptiometry. Body mass index (BMI) Z score of -1 to -1.9, -2 to -2.9 and <-3 was taken as mild, moderate and severe malnutrition respectively. Low BMD and osteoporosis were defined as per International Society for Clinical Densitometry. RESULTS 83 children (46 boys, 14[4.3-21]years) with CP were enrolled. Majority had Cambridge IV (51,62.2%) or III (15,18.3%) changes. 34(41%) had undernutrition (mild-37.3%, moderate-2.4%, severe-1.2%). Overweight and obesity were present in 3.6% and 1.2% cases. BMI had a significant correlation with haemoglobin, serum albumin, percentage body fat and BMD. A majority had low fecal elastase (69 [84.1%], <100 μg/g) and vitamin D deficiency (70[84.3%],<20 ng/ml). 9 cases had a history of fractures. 14/75(18.6%) cases had low TBLH-BMD and this group had a lower BMI (-1.3[-1.9 to 0.34] vs 0.8 [-2.1 to 5.50; p = 0.03) than patients with normal BMD. There was no difference in age, disease duration, vitamin D, fecal elastase and Cambridge grade between normal and low BMD. CONCLUSIONS 41% CP children have undernutrition with a majority having mild undernutrition. Nearly 20% have low BMD, with osteoporosis in none. Subjects with low BMI have lower BMD and percentage body fat.
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Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Nidhi Saini
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Asmita Arya
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sunil Jain
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - S K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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17
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Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
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Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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18
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Ahmed A, Deep A, Kothari DJ, Sheth SG. Bone disease in chronic pancreatitis. World J Clin Cases 2020; 8:1574-1579. [PMID: 32432135 PMCID: PMC7211537 DOI: 10.12998/wjcc.v8.i9.1574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 04/18/2020] [Indexed: 02/05/2023] Open
Abstract
Bone disease (osteopenia or osteoporosis) is a highly prevalent condition in society and presents a tremendous, preventable public health burden. Screening procedures, such as, dual-energy X-ray absorptiometry scans, have allowed early identification and intervention to improve bone health, and reduce the risk of osteoporotic fractures, which carry significant morbidity and mortality. The association of bone disease has been recognized in several diseases of the gastrointestinal tract, resulting in established guidelines for screening in patients with malabsorptive disorders such as inflammatory bowel disease and celiac disease. Increasingly, the risk of bone disease has been recognized in patients with chronic pancreatitis (CP), who share similar risk factors as patients with other high gastrointestinal disorders. As a result, there have been a number of studies examining the prevalence and risks of bone disease and fractures in patients with CP. This review aims to summarize the recent literature and current recommendations related to bone disease in CP.
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Affiliation(s)
- Awais Ahmed
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Aman Deep
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
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Abstract
OBJECTIVES A few past studies have found increased utilization of 25-hydroxyvitamin D and prevalence of osteoporosis in acute pancreatitis (AP). Our aim was to obtain a survey of bone diseases after a sentinel episode of AP. METHODS A database (Explorys), an aggregate of electronic health record from 26 integrated United States healthcare systems, was queried. A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms diagnosis of AP between 2014 and 2019, after excluding patients with selected medical conditions and medications that are associated with poor bone health, was identified. The prevalence of new diagnoses of vitamin D deficiency (VDD), osteoporosis, and fractures in the study cohort was evaluated. Age-, race-, and sex-based distributions and risk factors were determined through univariate and multivariate analyses. RESULTS Of the 36,087,380 individuals in the database, we identified 256,580 (0.71%) with AP. In multivariate analysis, patients with AP were more likely to develop VDD (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.24-1.26; P < 0.0001), osteoporosis (OR, 1.89; CI, 1.81-1.85; P < 0.0001), and fractures (OR, 1.58; 95% CI, 1.57-1.59; P < 0.0001). CONCLUSIONS Acute pancreatitis was associated with increased risk of VDD, osteoporosis, and fractures.
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20
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ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
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21
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Jalal M, Campbell JA, Hopper AD. Practical guide to the management of chronic pancreatitis. Frontline Gastroenterol 2019; 10:253-260. [PMID: 31288255 PMCID: PMC6583580 DOI: 10.1136/flgastro-2018-101071] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/19/2018] [Indexed: 02/04/2023] Open
Abstract
Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.
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Affiliation(s)
- Mustafa Jalal
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Andrew D Hopper
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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22
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Waldthaler A, Valente R, Arnelo U, Löhr JM. Endoscopic and Conservative Management of Chronic Pancreatitis and Its Complications. Visc Med 2019; 35:98-108. [PMID: 31192243 DOI: 10.1159/000499611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/14/2019] [Indexed: 12/15/2022] Open
Abstract
Chronic pancreatitis is a progressive inflammatory disease of the pancreas potentially giving rise to several complications. For this reason, patients need long-term care and treatment by medical, interventional, and sometimes surgical measures. This article reviews current state-of-the-art strategies and guidelines for treating chronic pancreatitis with conventional and endoscopic measures.
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Affiliation(s)
- Alexander Waldthaler
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Valente
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases at Karolinska University Hospital, and Clinical Science, Intervention and Technology (CLINTEC), Karolinska University Hospital, Stockholm, Sweden
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Abstract
OBJECTIVES Patients with chronic pancreatitis (CP) are at increased risk of low bone mineral density (BMD), although the prevalence of low BMD in patients with CP in the United States is lacking. We aimed to determine the prevalence of low BMD and identify potential risk factors, including hypogonadism and use of opioid medications, in subjects with CP in the United States. METHODS This was a prospective, observational study. Subjects with CP underwent dual-energy x-ray absorptiometry scan. Blood was assayed for vitamin D, sex hormones, and a metabolic panel. History was obtained for fractures, menopause, hypogonadal symptoms, and opioid medication doses. Low BMD was defined by both World Health Organization and the International Society for Clinical Densitometry criteria. RESULTS Depending on criteria used, 37% to 55% of our cohort had low BMD. Subjects with low and normal BMD had similar vitamin D levels. Hypogonadism was present in 27% of nonmenopausal subjects and was associated with reduced lumbar spine BMD in subjects 30 years or older. CONCLUSIONS Patients with CP are at increased risk of low BMD, which is likely multifactorial. Hypogonadism, possibly related to opioid pain medications, may be an independent risk factor for low BMD in CP.
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Vitamins D and K as Factors Associated with Osteopathy in Chronic Pancreatitis: A Prospective Multicentre Study (P-BONE Study). Clin Transl Gastroenterol 2018; 9:197. [PMID: 30323223 PMCID: PMC6189068 DOI: 10.1038/s41424-018-0066-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/21/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023] Open
Abstract
Background Osteopathy is common in patients with chronic pancreatitis (CP), but previous studies carry several limitations. Vitamin K is essential for bone metabolism, but its role in this setting has never been investigated. Our aim is to assess the prevalence of osteoporosis and osteopenia in CP patients, and to investigate the association between osteopathy and CP features and nutritional parameters, especially vitamin D and K levels. Methods Multicentre cross-sectional study on CP patients diagnosed according to M-ANNHEIM criteria. Bone density was evaluated by dual-energy X-ray absorptiometry and pancreatic function by faecal elastase. Nutritional evaluation included vitamin D and vitamin K. Differences between patients with or without osteopathy were evaluated. The association between investigated variables and bone density were analysed with logistic regression analysis. Results In total, 211 CP patients were enrolled at eight Centres (67% men; mean age 60). In total, 18% had advanced-marked CP, 56% suffered from pancreatic exocrine insufficiency and disease aetiology was alcoholic in 43%. Vitamin D and K were deficient in 56% and 32%, respectively. Osteopenia was diagnosed in 42% and osteoporosis in 22%. In the multivariate analysis, female sex (OR 2.78), age (OR 1.07 per year) and higher BMI (OR 0.84) were associated with the presence of osteoporosis. In male patients, the only factor associated with osteoporosis was vitamin K deficiency (OR 4.23). Conclusion The present data confirm a high rate of osteopathy in CP patients and highlight the relevance of vitamin K deficiency as only factor associated with osteoporosis in male patients for the first time.
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Parambeth JC, Fosgate GT, Suchodolski JS, Lidbury JA, Steiner JM. Randomized placebo controlled clinical trial of an enteric coated micro-pelleted formulation of a pancreatic enzyme supplement in dogs with exocrine pancreatic insufficiency. J Vet Intern Med 2018; 32:1591-1599. [PMID: 30221800 PMCID: PMC6189344 DOI: 10.1111/jvim.15235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/09/2018] [Accepted: 05/08/2018] [Indexed: 11/30/2022] Open
Abstract
Background Pancreatic enzyme supplements for the treatment of exocrine pancreatic insufficiency (EPI) in dogs can be uncoated or enteric coated. Enteric coated supplements might be advantageous. Hypothesis/Objectives Enteric coated enzyme supplements are superior to uncoated supplements in dogs with clinical EPI. Animals Eleven dogs with naturally occurring EPI that were apparently free from other diseases. Methods Randomized, blinded, controlled cross‐over clinical trial comparing a novel micro‐encapsulated enteric coated enzyme supplement to a commercially available uncoated product in dogs with clinical EPI. Search of serum canine serum trypsin‐like immunoreactivity concentration ≤ 2.5 µg/L in the Gastrointestinal Laboratory database was used to identify dogs with EPI. Results There was no difference −4.46% (95% CI: −7.97%‐–0.96%; P = .15) in the % acid hydrolysis fecal fat (primary outcome) between the enteric coated formulation (median: 11.8%; range 6.4%‐17.0%) and the uncoated pancreatic enzyme replacement product (median: 17.5%; range: 5.2%‐24.9%) in the 11 dogs that completed the study. Other variables did not differ between treatments. Conclusions and Clinical Importance This study, which had low statistical power, did not detect a difference between formulations.
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Affiliation(s)
- Joseph Cyrus Parambeth
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Geoffrey T Fosgate
- Department of Production Animal Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, South Africa
| | - Jan S Suchodolski
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Jonathan A Lidbury
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Jörg M Steiner
- Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
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Increased Risk of Mortality Associated With Pancreatic Exocrine Insufficiency in Patients With Chronic Pancreatitis. J Clin Gastroenterol 2018; 52:e63-e72. [PMID: 28858943 DOI: 10.1097/mcg.0000000000000917] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) is a common serious complication in chronic pancreatitis (CP); however, little is known about its effect on mortality in these patients. In this study, we assessed the mortality risk of PEI in patients with CP. STUDY A prospective, longitudinal cohort study conducted in patients with CP under long-term follow-up. CP and PEI were diagnosed using pancreatic imaging and the C-labeled mixed triglyceride breath test, respectively. Multivariate analysis was performed to evaluate the impact of PEI and other clinical features on mortality risk. RESULTS Patients (N=430) were analyzed (79.1% male; mean age, 47.8 y) during a mean follow-up of 8.6±4.6 years. PEI prevalence was 29.3% and mortality was 10.9%. Most frequent causes of death were cancer (40.4%), infection (21.3%), and acute cardiovascular event (14.9%). Multivariate analyses showed associations between increased mortality and presence of PEI [hazard ratio (HR), 2.59; 95% confidence interval (CI), 1.42-4.71; P<0.003], liver cirrhosis (HR, 3.87; 95% CI, 1.95-7.69; P<0.001), age at diagnosis (HR, 1.05; 95% CI, 1.03-1.09; P<0.001), toxic etiology of CP (HR, 3.11; 95% CI, 1.11-8.70; P<0.05) and respiratory comorbidity (HR, 2.19; 95% CI, 1.12-4.31; P<0.03). Nutritional markers were significantly lower in patients with PEI versus those without PEI (P<0.001) and in those who died versus survivors (P<0.001). CONCLUSIONS PEI was a significant independent risk factor for mortality in patients with CP. These results support further research into the optimal treatment of PEI to reduce mortality in this population.
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Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group. J Pediatr Gastroenterol Nutr 2018; 67:131-143. [PMID: 29927872 PMCID: PMC6020697 DOI: 10.1097/mpg.0000000000002023] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed. METHODS This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified. RESULTS AND DISCUSSION The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies. CONCLUSIONS This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.
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Löhr JM, Panic N, Vujasinovic M, Verbeke CS. The ageing pancreas: a systematic review of the evidence and analysis of the consequences. J Intern Med 2018; 283:446-460. [PMID: 29474746 DOI: 10.1111/joim.12745] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Senior people constitute the fastest growing segment of the population. The elderly are at risk for malnutrition, thought to be caused by reduced food intake or involution of the physiological capacity of the GI tract. Age-related changes are well known in other secretory organs such as liver, kidney and intestine. The pancreas, representing a metabolically active organ with uptake and breakdown of essential nutritional components, changes its morphology and function with age. During childhood, the volume of the pancreas increases, reaching a plateau between 20 and 60 years, and declines thereafter. This decline involves the pancreatic parenchyma and is associated with decreased perfusion, fibrosis and atrophy. As a consequence of these changes, pancreatic exocrine function is impaired in healthy older individuals without any gastrointestinal disease. Five per cent of people older than 70 years and ten per cent older than 80 years have pancreatic exocrine insufficiency (PEI) with a faecal elastase-1 below 200 μg g-1 stool, and 5% have severe PEI with faecal elastase-1 below 100 μg g-1 stool. This may lead to maldigestion and malnutrition. Patients may have few symptoms, for example steatorrhoea, diarrhoea, abdominal pain and weight loss. Malnutrition consists of deficits of fat-soluble vitamins and is affecting both patients with PEI and the elderly. Secondary consequences may include decreased bone mineral density and results from impaired absorption of fat-soluble vitamin D due to impaired pancreatic exocrine function. The unanswered question is whether this age-related decrease in pancreatic function warrants therapy. Therapeutic intervention, which may consist of supplementation of pancreatic enzymes and/or vitamins in aged individuals with proven exocrine pancreas insufficiency, could contribute to healthy ageing.
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Affiliation(s)
- J-M Löhr
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - N Panic
- University Hospital Dr. Dragisa Misovic-Dedinje, Belgrade, Serbia
| | - M Vujasinovic
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - C S Verbeke
- Department of Pathology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Durie P, Baillargeon JD, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin 2018; 34:25-33. [PMID: 28985688 DOI: 10.1080/03007995.2017.1389704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release. PURPOSE To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI. METHODS For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? FINDINGS The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist. CONCLUSIONS In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.
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Affiliation(s)
- P Durie
- a Hospital for Sick Children and University of Toronto , Toronto , ON , Canada
| | - J-D Baillargeon
- b Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke , Sherbrooke , QC , Canada
| | - S Bouchard
- c Centre Hospitalier de l'Université de Montréal , Montréal , QC , Canada
| | - F Donnellan
- d Vancouver General Hospital , Vancouver , BC , Canada
| | | | - C Teshima
- f St. Michael's Hospital and University of Toronto , Toronto , ON , Canada
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Talley NJ, Holtmann G, Nguyen QN, Gibson P, Bampton P, Veysey M, Wong J, Philcox S, Koloski N, Bunby L, Jones M. Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain. J Gastroenterol Hepatol 2017; 32:1813-1817. [PMID: 28332731 DOI: 10.1111/jgh.13791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/19/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM A previous UK study showed that 6.1% of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had evidence of severe pancreatic exocrine insufficiency (PEI), but these findings need replication. We aimed to identify the prevalence of PEI based on fecal elastase stool testing in consecutive outpatients presenting with chronic unexplained abdominal pain and/or diarrhea and/or IBS-D. METHODS Patients aged over 40 years presenting to hospital outpatient clinics from six sites within Australia with unexplained abdominal pain and/or diarrhea for at least 3 months and/or IBS-D were studied. Patients completed validated questionnaires and donated a stool sample in which elastase concentration was measured by ELISA. A concentration of < 100 mcg/g stool represented severe and < 200 mcg/g mild to moderate PEI. Patients whose fecal elastase was < 200 mcg/g underwent testing for pancreatic pathology with an endoscopic ultrasound or abdominal CT. RESULTS Two hundred eighteen patients (mean age of 60 years, 29.4% male) were studied. PEI was found in 4.6% (95% CI 2.2-8.3%) (n = 10), with five patients (2.3% (95% CI 0.8-5.3%) having severe PEI. Only male sex and heavy alcohol use were significantly associated with abnormal versus normal pancreatic functioning. Of seven patients who underwent endoscopic ultrasound or CT, two had features indicative of chronic pancreatitis. CONCLUSION One in 50 patients with IBS-D or otherwise unexplained abdominal pain or diarrhea have an abnormal fecal elastase, but unexpected pancreatic insufficiency was detected in only a minority of these. This study failed to confirm the high prevalence of PEI among patients with unexplained GI symptoms previously reported.
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Affiliation(s)
- Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Quoc Nam Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter Gibson
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Martin Veysey
- Teaching & Research Unit, Gosford & Wyong Hospital, Gosford, New South Wales, Australia
| | - James Wong
- Mylan EPD, Macquarie, New South Wales, Australia
| | - Stephen Philcox
- Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Natasha Koloski
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia.,Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Lisa Bunby
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Michael Jones
- Department of Psychology, Macquarie University, Ryde, New South Wales, Australia
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Kumar KVSH, Sharma R, Manrai M, Sood AK. Visceral Adipose Tissue as a Risk Factor for Diabetes Mellitus in Patients with Chronic Pancreatitis: A Cross-sectional, Observational Study. Diabetes Ther 2017; 8:1057-1064. [PMID: 28895079 PMCID: PMC5630559 DOI: 10.1007/s13300-017-0304-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Visceral adipose tissue (VAT) is a risk factor for diabetes and we investigated the amount of VAT in patients with chronic pancreatitis (CP). METHODS Serial patients with CP seen between January 2015 and June 2016 were included in this cross-sectional, observational study. The study population was divided into alcoholic CP (group 1; N = 67) and tropical CP (group 2; N = 35). VAT was estimated using bioelectric impedance analysis (BIA) and dual energy X-ray absorptiometry (DEXA) methods. The results were analyzed by appropriate statistical methods. RESULTS The study participants (85 male, 17 female) had a mean (SD) age of 40.8 (12.6) years, CP duration of 3.7 (4.7) years, and body mass index of 22.5 (3.2) kg/m2. Pancreatogenic diabetes was seen in 54 patients and the total body fat percentage was lower in the alcoholic CP group. VAT mass was similar in both the groups (p = 0.8749). CP patients with diabetes had a higher VAT mass (436 vs. 341 g) than those without diabetes (p = 0.0132). DEXA and BIA correlated in estimation of total body fat (p < 0.0001) but not in VAT (p = 0.0922). CONCLUSION VAT is a determinant in the development of diabetes, even in patients with CP. DEXA is a better modality for VAT estimation in comparison to BIA.
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Affiliation(s)
| | - Rahul Sharma
- Department of Gastroenterology, Army Hospital (R&R), Delhi, India
| | - Manish Manrai
- Department of Gastroenterology, Army Hospital (R&R), Delhi, India
| | - A K Sood
- Department of Gastroenterology, Army Hospital (R&R), Delhi, India
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Petzel MQB, Hoffman L. Nutrition Implications for Long-Term Survivors of Pancreatic Cancer Surgery. Nutr Clin Pract 2017; 32:588-598. [DOI: 10.1177/0884533617722929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Maria Q. B. Petzel
- Department of Clinical Nutrition and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Leah Hoffman
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Lin SY, Hsu WH, Lin CC, Lin CL, Tsai CH, Kao CH. Effect of acute pancreatitis on the risk of developing osteoporosis: A nationwide cohort study. PLoS One 2017; 12:e0179358. [PMID: 28604838 PMCID: PMC5467899 DOI: 10.1371/journal.pone.0179358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/27/2017] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Chronic exocrine pancreatic insufficiency can lead to osteoporosis. However, the incidence and risk of osteoporosis after acute inflammation of pancreas remained known. Thus, we conducted a population-based cohort study to clarify the association between acute pancreatitis (AP) and osteoporosis. METHODS Patients newly diagnosed with AP with index date between 2000 and 2011 were identified from the National Health Insurance Research Database. Osteoporosis were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied age-, sex-, and comorbidities-adjusted variable Cox proportional hazard models for assessing the association between AP and osteoporosis. Moreover, these models were used to adjust for the influences of patient characteristics and comorbidities. RESULTS In this study, 4,016 patients were included in the AP cohort (males, 67.9%; mean age, 51.8 years) and 4,016 matched controls in the non-AP cohort. After a mean follow-up period of 4.97 and 5.21 years in the AP and non-AP cohorts, respectively, the incidence of osteoporosis was 8.22 per 1000 person-years in the AP cohort. The AP cohort had a higher risk [adjusted hazard ratio (aHR) = 1.27, 95% confidence interval (CI) = 1.02-1.58] of osteoporosis than did the non-AP cohort. The risk of osteoporosis was highest in the female patients of the AP cohort (aHR = 2.26, 95% CI = 1.85-2.76) and patients aged 50-64 years (aHR = 4.14, 95% CI = 3.13-5.47). CONCLUSION AP patients are at a risk of osteoporosis, especially female gender and age 50-64 years. Those with > 3 episodes of AP had highest significant risk of developing osteoporosis.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chung-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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Shintakuya R, Uemura K, Murakami Y, Kondo N, Nakagawa N, Urabe K, Okano K, Awai K, Higaki T, Sueda T. Sarcopenia is closely associated with pancreatic exocrine insufficiency in patients with pancreatic disease. Pancreatology 2016; 17:70-75. [PMID: 27743711 DOI: 10.1016/j.pan.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 10/06/2016] [Accepted: 10/09/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The loss of skeletal muscle mass (sarcopenia) is associated with the poor prognosis of pancreatic cancer. It has been reported pancreatic exocrine insufficiency (PEI) is associated with serum nutritional markers in chronic pancreatitis. However, there has been no report about the relationship between sarcopenia and PEI. The aim of this study is to determine whether body composition, including skeletal muscle (SM), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), intramuscular adipose tissue content (IMAC), and serum nutritional markers are associated with pancreatic exocrine function in patients with pancreatic disease. METHODS Data were collected prospectively on 132 patients with pancreatic disease. SM, SAT, VAT and IMAC were assessed by computed tomography. Patients underwent a 13C-labeled mixed triglyceride breath test to measure pancreatic exocrine function. Serum nutritional markers were measured at the same time of 13C-labeled mixed triglyceride breath test. Patients were stratified by quartiles according to each body component, and for each component the lowest group was defined as the lowest quartile, treating men and women separately. The lowest group for SM was defined as sarcopenia. PEI was defined as a percentage 13CO2 cumulative dose at 7 h below 5%. RESULTS Sarcopenia was associated with PEI in both men (P < 0.001) and women (P = 0.012). Serum albumin was associated with PEI in men only (P = 0.005). Among all patients, sarcopenia (P = 0.001) and serum albumin (P = 0.058) were associated with PEI. On multivariate analysis, only sarcopenia remained independently associated with PEI (P < 0.001). CONCLUSIONS Sarcopenia is independently associated with PEI in patients with pancreatic disease.
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Affiliation(s)
- Ryuta Shintakuya
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kenichiro Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naru Kondo
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoya Nakagawa
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuhide Urabe
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keisuke Okano
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Toru Higaki
- Department of Diagnostic Radiology, Institute of Biomedical & Health Science, Hiroshima University, Hiroshima, Japan
| | - Taijiro Sueda
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Abstract
OBJECTIVES There is increasing evidence that chronic pancreatitis (CP) is a risk factor for osteoporotic fracture, but data on males with CP and fracture prevalence are sparse. We determined the association of sex and age using a large Veterans Administration database. METHODS This was a retrospective analysis (1998-2007). Patients with CP (International Classification of Diseases code 577.1) and control subjects (without CP) were identified after exclusions and fracture prevalence (vertebral, hip, and wrist) were recorded. RESULTS 453,912 Veterans Administration patients were identified (control subjects: 450,655 and patients with CP: 3257). Mean ages of control subjects and CP were 53.6 and 54.2 years (P < 0.014). Patients with CP had higher odds ratios of total fractures (2.35; 95% confidence interval [CI], 2.00-2.77), vertebral fracture 2.11 (95% CI, 1.44-3.01), hip fracture 3.49 (95% CI, 2.78-4.38), and wrist fracture 1.68 (95% CI, 1.29-2.18) when compared with control subjects. After adjusting for age group and etiology, patients with CP had increased odds of total fractures, vertebral fractures, and hip fractures (P < 0.05). CONCLUSIONS In this male-predominate Veterans Administration study, patients with CP were at increased risk of osteoporotic fractures. The risk was higher for hip fracture (>3 times) in patients with CP compared with control subjects. All patients with CP older than 45 years, irrespective of sex, should be screened for bone mineral density loss.
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Maev IV, Kucheryavyi YA, Andreev DN, Bideeva TV. Nutritional status in patients with chronic pancreatitis. TERAPEVT ARKH 2016; 88:81-89. [DOI: 10.17116/terarkh201688281-89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Margulies SL, Kurian D, Elliott MS, Han Z. Vitamin D deficiency in patients with intestinal malabsorption syndromes--think in and outside the gut. J Dig Dis 2015; 16:617-33. [PMID: 26316334 DOI: 10.1111/1751-2980.12283] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/26/2015] [Accepted: 08/04/2015] [Indexed: 12/11/2022]
Abstract
There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.
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Affiliation(s)
- Samantha L Margulies
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Divya Kurian
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Mark S Elliott
- Department of Biochemistry and Molecular Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Zhiyong Han
- Department of Biochemistry and Molecular Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Lindkvist B, Phillips ME, Domínguez-Muñoz JE. Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: Prevalence and diagnostic use. Pancreatology 2015; 15:589-97. [PMID: 26243045 DOI: 10.1016/j.pan.2015.07.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 12/11/2022]
Abstract
Pancreatic exocrine insufficiency (PEI) frequently occurs secondary to exocrine pancreatic disease (e.g. chronic pancreatitis, cystic fibrosis, cancer) or pancreatic/gastrointestinal surgery, resulting in the maldigestion of nutrients and consequently malnutrition. Pancreatic enzyme replacement therapy (PERT) is the cornerstone of PEI management. Despite its clinical relevance, the diagnosis of PEI in clinical practice is challenging, as the current gold standard test is cumbersome, and alternatives have limited availability or accuracy. There is a need for accurate and easily applicable diagnostic modalities. We review the prevalence of clinical symptoms and changes in anthropometric measurements and laboratory nutritional markers indicative of malnutrition in patients with PEI, and the relevance of these findings in diagnosing PEI and monitoring PERT efficacy. Based on limited available evidence, assessment of clinical symptoms, body weight, body mass index and other anthropometric parameters are not sensitive methods for PEI diagnosis, owing to high variability and multiple confounding factors, but appear useful in monitoring PERT efficacy. Limited evidence precludes strong recommendations but suggests that serum levels of vitamin E, magnesium, and plasma proteins, notably retinol binding protein, albumin, and prealbumin, may have diagnostic utility in PEI. Studies show that assessment of changes in these and other nutritional parameters is helpful in monitoring PERT efficacy. Further research is needed to confirm the diagnostic accuracy of these parameters for PEI. Until such data are available, a nutritional evaluation including circulating vitamin E, magnesium, retinol binding protein, albumin, and prealbumin may be used to evaluate the probability of PEI in clinical practice when reliable pancreatic function tests are not available.
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Affiliation(s)
- Björn Lindkvist
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - J Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.
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Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part I: epidemiology, etiology, risk factors, genetics, pathophysiology, and clinical features. Dis Mon 2015; 60:530-50. [PMID: 25510320 DOI: 10.1016/j.disamonth.2014.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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An association between abnormal bone turnover, systemic inflammation, and osteoporosis in patients with chronic pancreatitis: a case-matched study. Am J Gastroenterol 2015; 110:336-45. [PMID: 25623657 DOI: 10.1038/ajg.2014.430] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 12/01/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Because of deteriorating exocrine function, malabsorption renders chronic pancreatitis (CP) patients at risk of osteoporosis and fracture. However, the pathogenesis of low bone mineral density (BMD) has not been characterized. We hypothesized that bone turnover is elevated in CP, and we sought to investigate an association between bone metabolism and systemic inflammation. METHODS Twenty-nine CP patients and twenty-nine matched controls were recruited. Bone-turnover markers procollagen 1 amino-terminal propeptide (P1NP), OC (osteocalcin; bone formation markers), and carboxy-terminal telopeptide of type I collagen (CTX-I; bone resorption marker) were measured along with vitamin D (25-hydroxyvitamin D, 25OHD), parathyroid hormone (PTH), interleukin 6 (IL-6), high-sensitivity (hs) C-reactive protein (CRP), and sex/thyroid hormones. BMD was measured by dual-energy X-ray absorptiometry. Smoking status was noted. RESULTS Of the CP patients, 31% had osteoporosis and 44.8% osteopenia (controls: 6.9 and 51.7%, respectively; P=0.019). BMD was lower for patients at the lumbar spine (P=0.014) and femoral neck (P=0.029). Patients had elevated bone formation (P1NP (P=0.0068), OC (P=0.033)) and bone resportion (CTX-I (P=0.016)) compared with controls. Patients had lower 25OHD compared with controls (P=0.0126) and higher inflammatory markers (hsCRP, P=0.0013). Sex and thyroid hormone levels were similar. Patients with lowest 25OHD levels had highest P1NP. In a multivariable model, age, PTH, and smoking were predictive of 25OHD. Patients with osteoporosis had higher P1NP, PTH, and IL-6 and lower 25OHD. Using analysis of variance, inflammation (hsCRP) was highest in those with lowest 25OHD and lowest BMD. CONCLUSIONS For the first time, bone turnover was shown to be abnormal in CP, and importantly, an association between low 25-OHD, smoking, and systematic inflammation was identified. Moreover, those with osteoporosis had the highest systemic inflammation. Together these factors provide an avenue for potential modification of risk factors, which may ultimately reduce bone loss and avert fractures in this group.
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Gaddini GW, Grant KA, Woodall A, Stull C, Maddalozzo GF, Zhang B, Turner RT, Iwaniec UT. Twelve months of voluntary heavy alcohol consumption in male rhesus macaques suppresses intracortical bone remodeling. Bone 2015; 71:227-36. [PMID: 25451322 PMCID: PMC4291183 DOI: 10.1016/j.bone.2014.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 10/19/2014] [Accepted: 10/31/2014] [Indexed: 12/25/2022]
Abstract
Chronic heavy alcohol consumption is a risk factor for cortical bone fractures in males. The increase in fracture risk may be due, in part, to reduced bone quality. Intracortical (osteonal) bone remodeling is the principle mechanism for maintaining cortical bone quality. However, it is not clear how alcohol abuse impacts intracortical bone remodeling. This study investigated the effects of long-duration heavy alcohol consumption on intracortical bone remodeling in a non-human primate model. Following a 4-month induction period, male rhesus macaques (Macaca mulatta, n=21) were allowed to voluntarily self-administer water or alcohol (4% ethanol w/v) for 22h/d, 7 d/wk for 12months. Control monkeys (n=13) received water and an isocaloric maltose-dextrin solution. Tetracycline hydrochloride was administered orally 17 and 3days prior to sacrifice for determination of active mineralization sites. Animals in the alcohol group consumed 2.7±0.2g alcohol/kg/d (mean±SE) during the 12months of self-administration, resulting in a mean daily blood alcohol concentration of 77±9mg/dl from samples taken at 7h after the start of a daily session. However, blood alcohol concentration varied widely from day to day, with peak levels exceeding 250mg/dl, modeling a binge-drinking pattern of alcohol consumption. The skeletal response to alcohol was determined by densitometry, microcomputed tomography and histomorphometry. Significant differences in tibial bone mineral content, bone mineral density, and cortical bone architecture (cross-sectional volume, cortical volume, marrow volume, cortical thickness, and polar moment of inertia) in the tibial diaphysis were not detected with treatment. However, cortical porosity was lower (1.8±0.5 % versus 0.6±0.1 %, p=0.021) and labeled osteon density was lower (0.41±0.2/mm(2)versus 0.04±0.01/mm(2), p<0.003) in alcohol-consuming monkeys compared to controls, indicating a reduced rate of intracortical bone remodeling. In concordance, plasma CTx was lower (2.5±0.3ng/ml versus 1.7±0.1ng/ml, p=0.028) in the alcohol group. These results suggest that chronic heavy alcohol consumption may negatively impact bone health, in part, by suppressing intracortical bone remodeling.
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Affiliation(s)
- Gino W Gaddini
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA
| | - Kathleen A Grant
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, Beaverton, OR 97006, USA
| | - Andrew Woodall
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, Beaverton, OR 97006, USA
| | - Cara Stull
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health and Science University, Beaverton, OR 97006, USA
| | - Gianni F Maddalozzo
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA
| | - Bo Zhang
- Division of Biostatistics, Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Russell T Turner
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA; Center for Healthy Aging Research, Oregon State University, Corvallis, OR 97331, USA
| | - Urszula T Iwaniec
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA; Center for Healthy Aging Research, Oregon State University, Corvallis, OR 97331, USA.
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Kolodziejczyk E, Wejnarska K, Dadalski M, Kierkus J, Ryzko J, Oracz G. The nutritional status and factors contributing to malnutrition in children with chronic pancreatitis. Pancreatology 2014; 14:275-9. [PMID: 25062876 DOI: 10.1016/j.pan.2014.04.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/23/2014] [Accepted: 04/26/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND/OBJECTIVES The present study was undertaken to determine the prevalence of malnutrition among children with chronic pancreatitis (CP). Furthermore, we aimed to evaluate the relationship between etiological factors of CP, its clinical characteristics, and the severity of malnutrition. METHODS The study included 208 children with CP (113 girls and 95 boys; mean age: 10.8 years, range: 1.6-18 years), hospitalized at our center between 1988 and 2012. The severity of malnutrition was graded on the basis of Cole's ratios, and its prevalence was analyzed according to the etiological factors of pancreatitis. Moreover, the analysis of discrimination was performed to identify the factors contributing to malnutrition among the following variables: age at CP onset, duration of CP, number of CP exacerbations, the number of ERCPs performed, the grade of pancreatic damage documented on imaging, co-occurrence of diabetes, and the results of 72-h fecal fat quantification. RESULTS We documented features of malnutrition in 52 (25%) children with CP, including 36 (17.3%) patients with moderate malnutrition, and 2 (0.96%) with severe malnutrition. There was no significant difference in the prevalence of malnutrition between groups of patients with various etiological factors of chronic pancreatitis. The age at CP onset showed the best discrimination ability of malnourished patients: the mean age at disease onset in a subgroup of malnourished children was significantly higher than in children with Cole's index >85%. CONCLUSIONS A considerable percentage of children with CP can suffer from clinically significant malnutrition. Later age at CP onset predisposes to development of malnutrition.
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Affiliation(s)
- E Kolodziejczyk
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - K Wejnarska
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - M Dadalski
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - J Kierkus
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland.
| | - J Ryzko
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - G Oracz
- Department of Gastroenterology, Hepatology and Feeding Disorders, The Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
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Duggan SN, Smyth ND, O'Sullivan M, Feehan S, Ridgway PF, Conlon KC. The prevalence of malnutrition and fat-soluble vitamin deficiencies in chronic pancreatitis. Nutr Clin Pract 2014; 29:348-54. [PMID: 24727205 DOI: 10.1177/0884533614528361] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with chronic pancreatitis are at risk of malnutrition and nutrient deficiency due to malabsorption, pain, and poor diet. We sought to examine fat-soluble vitamin levels and malnutrition parameters in patients with chronic pancreatitis. MATERIALS AND METHODS In a prospective controlled cohort study, 128 subjects (62 chronic pancreatitis patients and 66 age-/sex-matched controls) were recruited. Body mass index (BMI), handgrip strength (measure of functional capacity), fat stores (triceps skin fold), muscle stores (mid-arm muscle circumference), exocrine function, and serum levels of fat-soluble vitamins (A, D, E) were measured. RESULTS Half of patients in the chronic pancreatitis group were overweight or obese, although the mean BMI was lower in patients than in controls (P = .007). Handgrip strength (P = .048), fat stores (P = .000), and muscle stores (P = .001) were lower in patients than in controls. Of the patients, 14.5% and 24.2% were deficient in vitamins A and E, respectively. Nineteen percent of patients had excess serum vitamin A levels. CONCLUSIONS Despite the prevalence of overweight and obesity, patients had lower muscle stores, strength, and abnormal vitamin levels. Detailed nutrition assessment including anthropometry and vitamin status is warranted in chronic pancreatitis.
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High prevalence of osteoporosis in patients with chronic pancreatitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014; 12:219-28. [PMID: 23856359 DOI: 10.1016/j.cgh.2013.06.016] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/19/2013] [Accepted: 06/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with chronic pancreatitis may be at high risk for osteoporosis and osteopenia. We performed a systematic review and meta-analysis to determine the prevalence of osteoporosis and osteopenia in patients with chronic pancreatitis. METHODS Articles were identified from MEDLINE, EMBASE, and SCOPUS databases (through October 2012) and a manual search of the literature. The primary outcome measure was bone density, measured by dual-energy X-ray absorptiometry (T-score or Z-score). When available, data on the prevalence of osteopenia, bone mineral density, and bone mineral content also were recorded. RESULTS Ten studies including 513 patients were eligible for inclusion. Based on a random-effects model, the pooled prevalence rate for osteoporosis among patients with chronic pancreatitis was 23.4% (95% confidence interval, 16.6-32.0). The pooled prevalence for osteopenia was 39.8% (95% confidence interval, 29.1-51.6). The pooled prevalence rate for either osteoporosis or osteopenia was 65% (95% confidence interval, 54.7-74.0). CONCLUSIONS Based on meta-analysis, almost 1 of 4 patients with chronic pancreatitis have osteoporosis, and almost two-thirds of patients have either osteoporosis or osteopenia. Osteoporosis and osteopenia are underappreciated sources of morbidity in patients with chronic pancreatitis. Bone health management guidelines are urgently required in patients with chronic pancreatitis.
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Bang UC, Benfield T, Bendtsen F, Hyldstrup L, Beck Jensen JE. The risk of fractures among patients with cirrhosis or chronic pancreatitis. Clin Gastroenterol Hepatol 2014; 12:320-6. [PMID: 23644391 DOI: 10.1016/j.cgh.2013.04.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/18/2013] [Accepted: 04/08/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Cirrhosis and chronic pancreatitis (CP) are accompanied by inflammation and malnutrition. Both conditions can have negative effects on bone metabolism and promote fractures. We evaluated the risk of fractures among patients with CP or cirrhosis and determined the effect of fat malabsorption on fracture risk among patients with CP. METHODS We performed a retrospective cohort study using the Danish National Patient Register to identify patients diagnosed with CP or cirrhosis. We analyzed data collected from January 1, 1995, to December 31, 2010, on 20,769 patients (35.5% women with cirrhosis and 11,972 patients (33.5% women) with CP. Each patient was compared with 10 age- and sex-matched controls. We also assessed the risk of fractures among patients with CP who received pancreatic enzyme substitution (PES) for fat malabsorption. RESULTS During the study period, bone fractures occurred in 3954 patients with cirrhosis and 2594 patients with CP. The adjusted hazard ratio (HR) for any fracture was 2.4 in patients with cirrhosis (95% confidence interval [CI], 2.2-2.5) and 1.7 in patients with CP (95% CI, 1.6-1.8). The relative risk of low-trauma fractures was highest among individuals younger than 50 years old. Alcohol as an etiology was associated with an increased risk of fracture compared with patients with nonalcoholic cirrhosis (HR, 2.4 vs 1.5; P < .0001) and CP (HR, 2.0 vs 1.5; P < .0001). Patients with CP receiving PES for fat malabsorption had a lower risk of fractures than other CP patients (HR, 0.8; 95% CI, 0.7-0.9). However, increasing the duration of treatment with PES was associated with an increased risk of fracture. CONCLUSIONS Patients, especially younger patients, with cirrhosis or CP have an increased risk of fractures of all types.
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Affiliation(s)
| | - Thomas Benfield
- Department of Infectious Diseases, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bendtsen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Gastroenterology, University Hospital of Hvidovre, Hvidovre, Denmark
| | - Lars Hyldstrup
- Department of Endocrinology, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Erik Beck Jensen
- Department of Endocrinology, University Hospital of Hvidovre, Hvidovre, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Forsmark CE. Reply: To PMID 23622138. Gastroenterology 2013; 145:911-2. [PMID: 23973851 DOI: 10.1053/j.gastro.2013.08.044] [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: 12/02/2022]
Affiliation(s)
- Christopher E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
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Duggan SN, Conlon KC. Bone health guidelines for patients with chronic pancreatitis. Gastroenterology 2013; 145:911. [PMID: 23973854 DOI: 10.1053/j.gastro.2013.06.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 06/27/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Sinead N Duggan
- Centre for Pancreatico-Biliary Diseases, Department of Surgery, Trinity College Dublin, Dublin, Ireland
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Reddy SVB, Ramesh V, Bhatia E. Double blind randomized control study of intramuscular vitamin D3 supplementation in tropical calcific pancreatitis. Calcif Tissue Int 2013; 93:48-54. [PMID: 23564348 DOI: 10.1007/s00223-013-9726-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 02/10/2013] [Indexed: 11/30/2022]
Abstract
Vitamin D deficiency is prevalent in chronic pancreatitis (CP), but the optimal route and dose of vitamin D supplementation are unknown. We evaluated the relative efficacy of two different doses of intramuscular (i.m.) vitamin D(3) in patients with CP and vitamin D insufficiency. In a double-blind randomized study, 40 patients with tropical calcific pancreatitis with serum 25-hydroxyvitamin D (25OHD) <75 nmol/L (mean 27.0 ± 14.5 nmol/L, <50 nmol/L in 90 %) were divided into three groups. Groups 1 and 2 received 600,000 IU (15,000 μg) and 300,000 IU (7,500 μg) i.m. cholecalciferol, respectively, while group 3 received i.m. saline. All groups received 1 g calcium and 500 IU (12.5 μg) vitamin D(3) orally daily and were studied for 9 months. The primary outcome was the proportion of patients with vitamin D sufficiency (25OHD >75 nmol/L) at 6 months. Vitamin D sufficiency was significantly different in the three groups (85, 29, and 0 % in groups 1, 2, and 3, respectively; p < 0.001). Mean 25OHD remained >75 nmol/L in months 1-6 in group 1 but reached a lower level (50-75 nmol/L) at these time points in group 2. At 6 months, serum alkaline phosphatase decreased significantly only in group 1 (230 ± 73 vs 165 ± 39 IU/L, p = 0.004). No patient in any group developed hypervitaminosis D or hypercalcemia. In conclusion, in patients with CP, a single i.m. injection of 600,000 IU was more effective at achieving vitamin D sufficiency over 6 months compared with 300,000 IU vitamin D(3). (Clinical Trials.gov number NCT00956839).
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Affiliation(s)
- Sagili Vijaya Bhaskar Reddy
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
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Sikkens ECM, Cahen DL, Koch AD, Braat H, Poley JW, Kuipers EJ, Bruno MJ. The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis. Pancreatology 2013; 13:238-42. [PMID: 23719594 DOI: 10.1016/j.pan.2013.02.008] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/11/2013] [Accepted: 02/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES In chronic pancreatitis, malabsorption of fat is common due to loss of exocrine function. Consequently, these patients are at risk to acquire deficiencies of the fat-soluble vitamins, which may result in a decreased bone mineral density (BMD) and the development of osteopenia and osteoporosis. METHODS We prospectively enrolled all patients diagnosed with chronic pancreatitis, who visited our outpatient clinic between March and November 2011. Data were collected regarding demographic characteristics, symptoms, and pancreatic function. Serum concentrations of vitamins A, E, K, and D were determined, and BMD was assessed by means of bone densitometry. Results were analyzed according to pancreatic function status and enzyme use, and compared to reference data, when available. RESULTS Forty patients were included (43% female; mean age of 52). Alcohol abuse was the major cause of pancreatitis (50%). Twenty-eight patients were exocrine insufficient (70%), of whom 19 used pancreatic enzymes. Vitamin A, D, E, and K deficiencies were present in 3, 53, 10, and 63% of patients, respectively. Osteopenia and osteoporosis were observed in 45% and 10% of patients. A decreased BMD was more frequently observed than expected, based on reference data, even in exocrine sufficient patients. CONCLUSIONS Deficiencies of fat-soluble vitamins and a decreased BMD are frequently present in chronic pancreatitis, even in exocrine sufficient patients. Consequently, all patients with chronic pancreatitis should be routinely screened for fat-soluble vitamin deficiencies and a decreased BMD.
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Affiliation(s)
- Edmée C M Sikkens
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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