Study of the gastrointestinal bioavailability of a pancreatic extract product (Zenpep) in chronic pancreatitis patients with exocrine pancreatic insufficiency

INTRODUCTION

The Food and Drug Administration in 2006 required that all pancreatic enzyme products demonstrate bioavailability of lipase, amylase, and protease in the proximal small intestine.

METHODS

In this phase I open-label, randomized, crossover trial, 17 adult chronic pancreatitis (CP) patients with severe exocrine pancreatic insufficiency (EPI) underwent two separate gastroduodenal perfusion procedures (Dreiling tube suctioning and [¹⁴C]-PEG instillation by an attached Dobhoff tube in the duodenal bulb). Patients received Ensure Plus® alone and Ensure Plus with Zenpep (75,000 USP lipase units) in random order. The bioavailability of Zenpep was estimated by comparing the recovery of lipase, amylase, chymotrypsin activity in two treatment conditions. ¹⁴C-PEG was used to correct duodenal aspirates volume. The primary efficacy endpoint was lipase delivery in the duodenum after Zenpep administration under fed conditions. Secondary efficacy endpoints included chymotrypsin and amylase delivery, serum CCK levels, and measuring duodenal and gastric pH.

RESULTS

Zenpep administration with a test meal was associated with significant increase in duodenal aspiration of lipase (p = 0.046), chymotrypsin (p = 0.008), and amylase (p = 0.001), compared to the test meal alone, indicating release of enzymes to the duodenum. Lipase delivery was higher in the pH subpopulation (the efficacy population with acid hypersecretors excluded) (p = 0.01). Recovery of [¹⁴C]-PEG was 61%. Zenpep was generally well tolerated. All adverse events were mild and transient.

CONCLUSIONS

In CP patients with severe EPI, lipase, chymotrypsin and amylase were released rapidly into the duodenum after ingestion of Zenpep plus meal compared to meals alone. Results also reflected the known pH threshold for enzyme release from enteric coated products.

Predisposing factors for positive D-Xylose breath test for evaluation of small intestinal bacterial overgrowth: A retrospective study of 932 patients

AIM: To investigate, in the largest cohort to date, patient characteristics and associated risk factors for developing small intestinal bacterial overgrowth (SIBO) using the D-Xylose breath test (XBT).

METHODS: We performed a retrospective cross-sectional study to analyze patient characteristics who underwent the XBT for evaluation of SIBO. Diagnostic testing with the XBT was performed based on a clinical suspicion for SIBO in patients with symptoms of bloating, abdominal pain, abdominal distension, weight loss, diarrhea, and/or constipation. Consecutive electronic medical records of 932 patients who completed the XBT at the University of Florida between 2005 and 2009 were reviewed. A two-way Analysis of Variance (ANOVA) was used to test for several associations including age, gender, and body mass index (BMI) with a +XBT. A two-way ANOVA was also performed to control for the differences and interaction with age and between genders. A similar analysis was repeated for BMI. Associations between medical conditions and prior surgical histories were conducted using the Mantel-Haenszel method for 2 by 2 contingency tables, stratified for gender. Reported odds ratio estimates reflect the odds of the prevalence of a condition within the +XBT group to that of the -XBT group. P values of less than 0.05 (two-sided) were considered statistically significant.

RESULTS: In the 932 consecutive eligible subjects studied, 513 had a positive XBT. A positive association was found between female gender and a positive XBT (P = 0.0025), and females with a positive test were, on average, greater than 5 years older than those with a negative test (P = 0.024). The mean BMI of positive XBT subjects was normal (24.5) and significantly lower than the subjects with a negative XBT (29.5) (P = 0.0050). A positive XBT was associated with gastroesophageal reflux disease (GERD) (OR = 1.35; 95%CI: 1.02-1.80, P = 0.04), peptic ulcer disease (PUD) (OR = 2.61; 95%CI: 1.48-4.59, P < 0.01), gastroparesis (GP) (OR = 2.04; 95%CI: 1.21-3.41, P < 0.01) and steroid use (OR = 1.35; 95%CI: 1.02-1.80, P = 0.01). Irritable bowel syndrome, independent proton-pump inhibitor (PPI) usage, or previous abdominal surgery was not significantly associated with a positive XBT. No single subdivision by gender or PPI use was associated with a significant difference in the odds ratios between any of the subsets.

CONCLUSION: Female gender, lower BMI, steroid use, PUD, GERD (independent of PPI use), and GP were more prevalent in patients with SIBO, determined by a positive XBT. Increasing age was associated with SIBO in females, but not in males.

A pilot retrospective study of the relationship between estrogen use and pancreatitis/pancreatic function in women with chronic abdominal pain

CONTEXT

Estrogens are thought to cause pancreatitis by raising triglyceride levels but whether there are other effects on the pancreas is debatable.

OBJECTIVE

To better elucidate the relationship between estrogens and pancreatitis and pancreatic function in a pilot study.

DESIGN/SETTING/PATIENTS

Our retrospectively collected database of 224 patients who had undergone secretin stimulation testing was queried for females with available medication histories, who were then divided into two groups: those taking estrogens (E) and those not on estrogens (N). Mann Whitney U and Fisher's exact tests were used.

RESULTS

Seventy of the patients in the database were females with available medication histories. Thirty-five (50.0%) were taking estrogens. Twenty-nine (82.9%) of the E patients experienced any type of pancreatitis (i.e., acute pancreatitis, acute relapsing pancreatitis, chronic pancreatitis) while only 19 (54.3%) of the N patients did (P=0.019). During secretin stimulation testing, the peak bicarbonate levels for E and N patients were 80±18 and 90±23 mEq/L, respectively (P=0.058). When patients with any type of pancreatitis were excluded, E patients still displayed decreased peak bicarbonate levels in response to secretin (90±18 vs. 104±19 mEq/L; P=0.021). Weight, age, triglyceride levels, frequency of patients with cholecystectomy and biliary stones did not significantly differ between the two groups (E and N respectively).

CONCLUSIONS

These pilot data suggest exogenous estrogens may be related to the development of acute pancreatitis and acute relapsing pancreatitis, and probably to a lesser degree chronic pancreatitis, perhaps through a triglyceride independent mechanism. During secretin stimulation testing, peak bicarbonate production may be diminished in women on estrogens (even in those who have never had pancreatitis). Further study is necessary to better define the relationship between estrogen use, pancreatitis, and pancreatic function.

Effect of azithromycin on small bowel motility in patients with gastrointestinal dysmotility

OBJECTIVE

To investigate the effect of azithromycin (AZI) on small bowel activity in patients with gastrointestinal dysmotility (GID).

MATERIAL AND METHODS

Manometric data on a consecutive series of 21 patients was reviewed. Only those patients with gastroparesis and small bowel dysmotility as defined by antroduodenal manometric criteria were included. Pressure profiles were recorded in three stages: baseline period, fed state and postprandial after administration of erythromycin (ERY) and AZI. The measured parameters included the number and characteristics of activity fronts and migrating motor complexes (MMCs) including duration, amplitude and frequency of contractions. The data were analyzed using repeated measures analysis of variance for comparison of each medication.

RESULTS

AZI induced more MMCs in the duodenum with origin of activity fronts in the antrum than did ERY (18 patients with AZI, 10 patients with ERY). No significant difference between AZI and ERY was seen with respect to the amplitude of MMCs or number of cycles per minute. The average duration of activity fronts was longer with AZI compared with ERY (AZI mean 18.5 min, ERY mean 9.7 min, p < 0.02).

CONCLUSIONS

AZI induces activity fronts in the antrum followed by duodenal contractions more frequently than ERY in patients with GID. AZI potentially promises to be a prokinetic for treatment of small bowel dysmotility.

A new 13C breath test to detect vitamin B12 deficiency: a prevalent and poorly diagnosed health problem

Vitamin B12 deficiency is emerging as a growing public health problem. The most commonly used diagnostic tests are limited in accuracy, sensitivity, and are non-specific for B12 deficiency. The aim of this study was to develop a simple B12 breath test (BBT) to more accurately evaluate vitamin B12 status as an alternative to the most common diagnostic test, serum B12 levels. The breath test is based on the metabolism of sodium 1-(13)C-propionate to (13)CO(2) which requires B12 as a cofactor. We initially compared the BBT to current B12 diagnostic methods in 58 subjects. Subjects also received a second BBT 1-3 days after initial testing to evaluate reproducibility of results. Propionate dosage, fasting times, and collection periods were compared, respectively. The dose of sodium 1-(13)C-propionate (10-50 mg) gave equivalent results while an 8 h fast was essential. Statistical analysis revealed that breath collection times could be reduced to just a baseline and 10 and 20 min following propionate dosing. We also measured the incidence of B12 deficiency with the BBT in 119 patients with chronic pancreatitis, Crohn's disease, small intestinal bacterial overgrowth, and subjects over 65 years of age. The BBT results agreed with previous publications showing a higher incidence of B12 deficiency in these patients. The BBT may provide clinicians with a non-invasive, accurate, reliable, and reproducible diagnostic test to detect vitamin B12 deficiency.

Pancrelipase for pancreatic disorders: An update

Pancrelipase is a porcine pancreatic extract which contains the digestive enzymes lipases, proteases and amylases. In patients with pancreatic exocrine insufficiency (PEI) from conditions such as chronic pancreatitis, pancreatectomy and cystic fibrosis, pancrelipase can be used as pancreatic enzyme replacement therapy (PERT). Pancrelipase can reverse steatorrhea, prevent weight loss, control pain and correct other nutritional deficiencies resulting from exocrine insufficiency. Various forms of pancreatic enzymes were being marketed as over-the-counter medications prior to the recent FDA declaration that all pancreatic enzyme products had to obtain approval as new drugs before marketing. On the basis of evidence from recent randomized controlled trials, three pancrelipase formulations (Creon®, Zenpep® and Pancreaze®) have been approved by the FDA as effective treatments for PEI. Although several tests exist for the detection of PEI, early diagnosis still remains a challenge. Individualization of the timing of treatment initiation and dosage requirements is needed to achieve optimal effectiveness. When used at recommended doses, pancrelipase is a safe medication. Appropriate use of pancrelipase in patients with pancreatic exocrine insufficiency can achieve symptomatic relief, prevent morbidity/mortality and also improve quality of life.

Advantages of azithromycin over erythromycin in improving the gastric emptying half-time in adult patients with gastroparesis

Background/Aims

Current therapy for gastroparesis with prokinetic agents is limited by options and side effects. One macrolide, erythromycin (ERY), is associated with possible sudden cardiac death from QT prolongation due to P450 iso-enzyme inhibition. An alternative, azithromycin (AZI), lacks P450 inhibition. We compared the effect on gastric emptying half-times (t½) between AZI and ERY in patients diagnosed with gastroparesis by gastric emptying scintigraphy.

Methods

Patients stopped medications known to affect gastric emptying prior to the study, and then ingested 1 scrambled egg meal labeled with 18.5-37 MBq of technetium-99m sulfur colloid followed by continuous imaging for 120 minutes, at 1 minute per frame. A simple linear fit was applied to the rate of gastric emptying, and gastric emptying t½ was calculated (normal = 45-90 minutes). At 75-80 minutes, if the stomach had clearly not emptied, patients were given either ERY (n = 60) or AZI (n = 60) 250 mg IV and a new post-treatment gastric emptying t½ was calculated.

Results

Comparison of gastric emptying t½ showed a similar positive effect (mean gastric emptying t½ for AZI = 10.4 ± 7.2 minutes; mean gastric emptying t½ for ERY = 11.9 ± 8.4 minutes; p = 0.30).

Conclusions

AZI is equivalent to ERY in accelerating the gastric emptying of adult patients with gastroparesis. Given the longer duration of action, better side effect profile and lack of P450 interaction for AZI as compared with ERY, further research should evaluate the long term effectiveness and safety of AZI as a gastroparesis treatment.

Screening and therapy for malnutrition and related gastro-intestinal disorders in systemic sclerosis: recommendations of a North American expert panel

OBJECTIVES

To develop a set of recommendations for clinicians caring for patients with systemic sclerosis (SSc) to guide their approach to the patient with malnutrition and possible malabsorption.

METHODS

The Canadian Scleroderma Research Group convened a meeting of experts in the areas of nutrition, speech pathology, oral health in SSc, SSc and gastroenterology to discuss the nutrition-GI paradigm in SSc. This meeting generated a set of recommendations based on expert opinion.

RESULTS

Physicians should screen ALL patients with SSc for malnutrition. The physician should ask a series of questions that pertain to GI involvement. Patients who screen positive for malnutrition should be referred to a dietitian and gastroenterologist. Referral to a patient support group should be considered and if screening reveals oral health problems, referral to a dentist, preferably with expertise in treating patients with SSc, should be done. All SSc patients should weigh themselves monthly and report any sudden significant changes in weight. They should be assessed by a rheumatologist once a year for signs of malnutrition.

CONCLUSIONS

Malnutrition may be common in SSc and a multidisciplinary approach is important.

The management of acute and chronic pancreatitis

Pancreatitis, which is most generally described as any inflammation of the pancreas, is a serious condition that manifests in either acute or chronic forms. Chronic pancreatitis results from irreversible scarring of the pancreas, resulting from prolonged inflammation. Six major etiologies for chronic pancreatitis have been identified: toxic/ metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, and obstruction. The most common symptom associated with chronic pancreatitis is pain localized to the upper-to-middle abdomen, along with food malabsorption, and eventual development of diabetes. Treatment strategies for acute pancreatitis include fasting and short-term intravenous feeding, fluid therapy, and pain management with narcotics for severe pain or nonsteroidal anti-inflammatories for milder cases. Patients with chronic disease and symptoms require further care to address digestive issues and the possible development of diabetes. Dietary restrictions are recommended, along with enzyme replacement and vitamin supplementation. More definitive outcomes may be achieved with surgical or endoscopic methods, depending on the role of the pancreatic ducts in the manifestation of disease.

A pilot study of Octreotide LAR vs. octreotide tid for pain and quality of life in chronic pancreatitis

CONTEXT

Chronic abdominal pain is the most difficult management issue in patients with chronic pancreatitis. Recently, a long-acting depo-formulated version of octreotide has been developed that can be given as a once monthly intramuscular injection, Octreotide LAR(R) (O-LAR) rather than as a thrice daily subcutaneous injection (octreotide short-acting, O-SA).

OBJECTIVE

To see if O-LAR is similar in efficacy to O-SA in the treatment of painful chronic pancreatitis in a small open-label, unblinded pilot study.

PATIENTS

Seven advanced chronic pancreatitis patients with daily, severe abdominal pain who had previously responded to O-SA were recruited from the pancreas clinics of the University of Florida and monitored for one month on O-SA and for four months while on O-LAR. Each patient served as his/her own control as this was a paired data set.

MAIN OUTCOME MEASURES

1) Daily VAS scores; 2) daily morphine equivalents; 3) monthly health related quality of life chronic pancreatitis surveys; 4) daily diaries of work/pleasurable activities missed or hospitalization/Emergency Department visits.

RESULTS

Average daily VAS scores for patients during O-SA therapy were 4.50+/-2.28 and during the fourth month of O-LAR therapy, 3.86+/-2.11, difference -0.64+/-0.80 (P=0.078). Average daily morphine equivalents were not dissimilar at 124.3+/-177.3 mg during O-SA therapy and 131.6+/-194.3 mg during O-LAR therapy; difference 7.3+/-17.5 mg P=0.310. Health related quality of life chronic pancreatitis scores were not significantly changed when moving from O-SA to O-LAR. Adverse events were rare.

CONCLUSIONS

Octreotide LAR(R) may be a reasonable substitute for tid octreotide in treating chronic pancreatitis pain. Further, larger studies would be useful to better characterize the role of Octreotide LAR(R) in the management of chronic pancreatitis pain.

The effects of oral pancreatic enzymes (Creon 10 capsule) on steatorrhea: a multicenter, placebo-controlled, parallel group trial in subjects with chronic pancreatitis

OBJECTIVES

Creon 10 Minimicrospheres is an enteric-coated, delayed-release pancrelipase preparation designed to deliver active pancreatic enzymes to the small intestine. The primary objective of this study was to compare the effect of Creon 10 with placebo in the control of steatorrhea in chronic pancreatitis patients. Secondary objectives included evaluation of stool parameters and global improvement of symptoms scales.

METHODS

The study was a randomized, double-blind, placebo-controlled, 2-week trial. After a placebo run-in ("washout") phase, the effect on coefficient of fat absorption (%), daily fat excretion before and after treatment, and stool frequency and consistency were assessed.

RESULTS

In Creon 10-treated subjects, the change in mean coefficient of fat absorption (%) from run-in to double-blind phase was significantly higher compared with placebo-treated subjects (+36.7 vs. +12.1, P = 0.0185). Stool consistency improved significantly more with Creon 10 than with placebo (P = 0.0102) resulting in more subjects with formed stool; stool frequency decreased significantly more with Creon 10 than with placebo (P = 0.0015) from 10.8 during placebo run-in to 5.2 stools per day during double-blind treatment; and daily mean fat excretion in stool decreased significantly more (-56.5 vs. -11.4 g/d, P = 0.0181) in Creon 10-treated subjects compared with placebo-treated subjects. Global disease symptom scores showed greater improvement for both physicians and subjects in the Creon 10 group relative to those receiving placebo. Between treatment difference reached statistical significance for Creon 10 (P = 0.0435) for physician score and showed a trend (P = 0.0634) favoring Creon for subject score.

CONCLUSIONS

This randomized, placebo-controlled trial found that Creon 10 treatment controlled steatorrhea, as reflected in reduced fat excretion, decreased stool frequency and improved stool consistency. Creon 10 treatment was safe and well tolerated.

Diagnosis and management of chronic pancreatitis

Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.

Evaluation of the Ez-HBT Helicobacter blood test to establish Helicobacter pylori eradication

BACKGROUND

The urea blood test (Ez-HBT) has been shown to compare favourably with the urea breath test in the diagnosis of active Helicobacter pylori infection.

AIM

To examine the performance characteristics of the Ez-HBT Helicobacter blood test in establishing success or failure of therapy in H. pylori-infected adults using the 13C urea breath test as the reference method.

METHODS

13C urea breath test and Ez-HBT Helicobacter blood test were performed 4-6 weeks after completion of treatment in H. pylori positive subjects. Basal urea breath samples were collected; basal Ez-HBT Helicobacter blood test samples were not. Ez-HBT Helicobacter blood test results were reported as positive, negative, or indeterminate.

RESULTS

Seventy patients generated 126 measurable sets of urea breath and blood tests. The H. pylori cure rate was 93%. The sensitivity, specificity, and accuracy of the Ez-HBT Helicobacter blood test were 100%, 97%, and 97%, respectively. Six of eight false positive and indeterminate Ez-HBT Helicobacter blood test results could be attributed to incomplete fasting or a 13C enriched diet. After correcting for the non-fasting state, the positive predictive value of the Ez-HBT Helicobacter blood test improved from 56% to 86%.

CONCLUSION

The performance characteristics of the Ez-HBT Helicobacter blood test are comparable with that of 13C-urea breath test in establishing H. pylori eradication after therapy. Errors related to incomplete fasting can be mitigated by collection of a basal blood sample.

Comparative analysis of direct pancreatic function testing versus morphological assessment by endoscopic ultrasonography for the evaluation of chronic unexplained abdominal pain of presumed pancreatic origin

OBJECTIVES

The diagnosis of "minimal change" chronic pancreatitis (MCCP) is often considered when conventional imaging studies are unrevealing in a patient population with abdominal pain of presumed pancreatic origin. Direct pancreatic function testing using secretin as a secretagogue (ST) has been considered the most sensitive method to diagnose MCCP but is not widely available to clinicians. Endoscopic ultrasound (EUS) allows detailed imaging of pancreatic architecture, but the sensitivity and specificity for MCCP remain to be determined. We sought to compare the accuracy of EUS and ST in patients with presumed MCCP.

METHODS

Seventy-four patients referred to our pancreas clinic with unexplained abdominal pain and previously negative imaging studies underwent an ST for evaluation of possible MCCP. Twenty-one of these also underwent EUS. EUS images were read by 1 of 2 experts blinded to ST results.

RESULTS

Using ST as the "gold standard," EUS had a maximum sensitivity of 71% when the cut-off for diagnosis was set at at least 3 EUS features. Conversely, maximum specificity (92%) was seen when the cut-off value was set at at least 6 EUS criteria. Diagnostic certainty was only 50% (positive predictive value = 0.5) when at least 6 criteria were used as the cut-off. MCCP was excluded with greater than 70% certainty when less than 3 criteria were present. At the best cut-off value of at least 4 features, EUS had a sensitivity of 57% and a specificity of 64%.

CONCLUSIONS

In this patient population with abdominal pain of presumed pancreatic origin, EUS and standard pancreatic function testing are often discordant. If ST is assumed to be the reference against which other tests are compared, EUS is less accurate than ST in diagnosing MCCP.

Chronic pancreatitis: controversies in etiology, diagnosis and treatment

The pathogenesis of idiopathic chronic pancreatitis remains poorly understood despite the high expectations for ascribing the pancreatic damage in affected patients to genetic defects. Mutations in the cationic trypsinogen gene, pancreatic secretory trypsin inhibitor, and the cystic fibrosis conductance regulator gene do not account for the chronic pancreatitis noted in most patients with idiopathic chronic pancreatitis. Small duct chronic pancreatitis can be best diagnosed with a hormone stimulation test. Endoscopic ultrasonography can detect abnormalities in both the parenchyma and ducts of the pancreas. The true value of endoscopic ultrasonography in diagnosing small duct chronic pancreatitis remains to be fully defined and is under active investigation. It is not clear whether endoscopic ultrasonography is more sensitive for early structural changes in patients with small duct disease or is over diagnosing chronic pancreatitis. Pancreatic enzyme supplementation with non-enteric formulation along with acid suppression (H2 blockers or proton pump inhibitors) is an effective therapy for pain in patients with small duct chronic pancreatitis. The role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities. Total pancreatectomy followed by autologous islet cell autotransplantation appears to be potential therapeutic approach but for now should be considered experimental.

Small Bowel Bacterial Overgrowth: Presentation, Diagnosis, and Treatment

Small bowel bacterial overgrowth (SBBO) syndrome is associated with excessive numbers of bacteria in the proximal small intestine. The pathology of this condition involves competition between the bacteria and the human host for ingested nutrients. This competition leads to intraluminal bacterial catabolism of nutrients, often with production of toxic metabolites and injury to the enterocyte. A complex array of clinical symptoms ensues, resulting in chronic diarrhea, steatorrhea, macrocytic anemia, weight loss, and less commonly, protein-losing enteropathy. Therapy is targeted at correction of underlying small bowel abnormalities that predispose to SBBO and appropriate antibiotic therapy. The symptoms and signs of SBBO can be reversed with this approach.

Is a 15-minute collection of duodenal secretions after secretin stimulation sufficient to diagnose chronic pancreatitis?

BACKGROUND

Standard hormonal stimulation tests of pancreatic function use a 60- to 90-minute collection of pancreatic secretions. A shorter 15-minute collection time has been proposed to increase the feasibility of the secretin stimulation test. The accuracy of this brief collection period for the diagnosis of chronic pancreatitis has not been well defined.

METHODS

We retrospectively evaluated the accuracy of a 15-minute collection period by comparing the results of 633 complete standard secretin tests (60 minutes) to the result using only the first 15-minute collection of the same test. The gold standard used for the diagnosis of chronic pancreatitis was the final result of the complete 60-minute secretin stimulation test.

RESULTS

The specificity of the first 15-minute collection was 34.6% (95% CI, 30.03%-39.21%). The positive predictive value was 44.9% (95% CI, 40.5%-49.3%). The accuracy was 57.3% (95% CI, 53.01% 59.34%).

CONCLUSIONS

Using only the first 15-minute collection period in a standard 60-minute secretin test is inaccurate in the diagnosis of chronic pancreatitis.

Small bowel bacterial overgrowth: presentation, diagnosis, and treatment

Small bowel bacterial overgrowth (SBBO) syndrome is associated with excessive numbers of bacteria in the proximal small intestine. The pathology of this condition involves competition between the bacteria and the human host for ingested nutrients. This competition leads to intraluminal bacterial catabolism of nutrients, often with production of toxic metabolites and injury to the enterocyte. A complex array of clinical symptoms ensues, resulting in chronic diarrhea, steatorrhea, macrocytic anemia, weight loss, and less commonly, protein-losing enteropathy. Therapy is targeted at correction of underlying small bowel abnormalities that predispose to SBBO and appropriate antibiotic therapy. The symptoms and signs of SBBO can be reversed with this approach.

Comparison of biologic porcine secretin, synthetic porcine secretin, and synthetic human secretin in pancreatic function testing

BACKGROUND AND AIMS

Due to the unavailability of biologic porcine secretin (BPS), 2 synthetic forms of secretin were developed. Our aim is to determine the bioequivalency of the 3 forms of secretin in pancreatic function testing.

METHODS

In a randomized, crossover design, synthetic porcine (SPS) and synthetic human secretin (SHS) were compared in a group of 12 subjects with chronic pancreatitis undergoing secretin stimulation test (SST). The 2 synthetic forms of secretin were then compared with BPS in 12 subjects utilizing a similar design. Finally, 18 healthy subjects underwent secretin stimulation testing with SHS.

RESULTS

There was excellent correlation of peak bicarbonate measurements in the comparison of SPS to SHS (R = 0.967) as well as in the comparison of all 3 forms of secretin (P = 0.08, ANOVA for correlated samples). In the SST, each of the synthetic forms of secretin were 100% accurate in diagnosing chronic pancreatitis in disease subjects and in excluding chronic pancreatitis in normal controls. The synthetic forms of secretin were associated with fewer side effects when compared with BPS with the exception of transient tachycardia which occurred in up to 19% of subjects.

CONCLUSIONS

The synthetic porcine and human forms of secretin are equivalent to one another and to biologic porcine secretin and can be used interchangeably in pancreatic function testing.

A new synthetic porcine secretin for facilitation of cannulation of the dorsal pancreatic duct at ERCP in patients with pancreas divisum: a multicenter, randomized, double-blind comparative study

BACKGROUND

Secretin, a 27 amino acid polypeptide released in response to duodenal luminal acidification, stimulates secretion of water and bicarbonate from pancreatic ductal cells. To date the only secretin available for clinical use has been a biologically derived compound extracted from porcine duodenums. Although used to facilitate pancreatic duct cannulation, secretin has not been approved for this indication. In this study, a new synthetic porcine secretin with an identical amino acid composition was compared with saline solution for the facilitation of minor papilla cannulation in patients with pancreas divisum.

METHODS

A multicenter, prospective, randomized, placebo-controlled, double-blind, comparative trial was conducted at 4 centers with expertise in pancreaticobiliary endoscopy. Patients with pancreas divisum in whom minor papilla cannulation initially was unsuccessful were enrolled. Either saline solution (placebo) or synthetic porcine secretin was administered. If the minor papilla orifice and/or pancreatic juice flow was noted, cannulation was attempted and success or failure was documented (phase 1), as well as the time taken for successful cannulation. If cannulation was unsuccessful, no juice flow was noted, or the orifice was not seen, the alternate agent was administered (phase 2).

RESULTS

Twenty-nine patients (7 men, 22 women; mean age 51 years, range 21-76 years) were enrolled. In phase 1, cannulation was achieved in 1 of 13 patients (7.7%) after the placebo was given and in 13 of 16 patients (81.3%) after synthetic porcine secretin was given (p < 0.0001). In phase 2, cannulation was achieved in 12 of 12 patients (100%) after synthetic porcine secretin was given and in 0 of 3 patients (0%) after the placebo was given (p = 0.0022). Overall, cannulation was successful in 25 of 28 patients (89.3%) who received synthetic porcine secretin and in 1 of 16 (6.3%) who received the placebo (p < 0.0001). Mean time to cannulation was significantly greater for the placebo than for the synthetic porcine secretin (4.75 min vs. 2.63 min; p = 0.0001). No adverse events directly attributable to synthetic porcine secretin administration were documented.

CONCLUSIONS

This study confirmed the use and safety of synthetic porcine secretin in facilitating cannulation of the minor papilla in patients with pancreas divisum in whom cannulation was difficult. Use of this agent has the potential to further increase the cannulation success rate in this group of patients.

Prevalence of gastroparesis in patients with small duct chronic pancreatitis

INTRODUCTION

The most common symptoms of chronic pancreatitis are abdominal pain, diarrhea, and weight loss. The abdominal pain has no consistent pattern, and nausea and vomiting commonly occur simultaneously. Gastroparesis may produce similar symptoms. These similar symptoms may cause diagnostic confusion, particularly with regard to patients with small-duct chronic pancreatitis, for whom diagnosis of chronic pancreatitis is most difficult. We have observed that coexistent gastroparesis may also interfere with the effectiveness of pancreatic enzyme therapy by failing to deliver proteases into the duodenum and therefore not restoring feedback control of pancreatic secretion.

AIM

To estimate the prevalence of gastroparesis in patients with minimal-change chronic pancreatitis.

METHODOLOGY

Patients with chronic pancreatitis diagnosed on the basis of secretin test results but with otherwise normal pancreatic imaging (ultrasonographic or computed tomographic) findings who had also undergone a gastric emptying study were retrospectively identified. An abnormal secretin test value was defined as a peak bicarbonate concentration in pancreatic secretions of <80 mEq/L after secretin stimulation. Gastroparesis was defined as an emptying half-time greater than 90 minutes.

RESULTS

Fifty-six patients were identified. Twenty-five of the 56 patients (44%) had concomitant gastroparesis and small-duct chronic pancreatitis. Twenty-four of these 25 were women, and 22 of the 25 had idiopathic small-duct chronic pancreatitis.

CONCLUSION

In our referral population, gastroparesis is frequently seen in patients with small-duct chronic pancreatitis. For patients with small-duct disease whose abdominal pain does not respond to pancreatic enzyme therapy, clinicians should consider an evaluation for gastroparesis.

Medical therapy for chronic pancreatitis pain

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.

Chronic pancreatitis

The pathogenesis of idiopathic chronic pancreatitis remains poorly understood despite the high expectations for ascribing the pancreatic damage in affected patients to genetic defects. Neither mutations in the cationic trypsinogen gene nor mutations of the cystic fibrosis conductance regulator gene account for the chronic pancreatitis noted in most patients with idiopathic chronic pancreatitis. Attempts to find an autoimmune basis for the pancreatitis in these patients have not been very successful. The diagnosis of small duct idiopathic chronic pancreatitis remains a great source of frustration for clinicians. Such patients with negative results of radiographic studies often cannot be diagnosed unless a hormone stimulation test such as a secretin test is performed. Although the porcine biologic form of secretin, which has been used to diagnose chronic pancreatitis, became unavailable because of widespread use in the treatment of children with autism, a synthetic form of porcine secretin has now been approved by the US Food and Drug Administration and is available. The true value of endoscopic ultrasonography in diagnosing small duct chronic pancreatitis remains to be fully defined. Endoscopic ultrasonography is becoming the test of choice in detecting radiographic abnormalities in both the parenchyma and ducts of the pancreas. Endoscopic ultrasonography-guided celiac plexus block can be performed relatively easily and very safely. It can provide excellent short-term pain relief in some patients, but reliable predictors of which patients will be successful with this therapy are not yet available. Because long-term follow-up data on the use of endoscopic ultrasonography in this respect are not available, and because the pain of chronic pancreatitis is, indeed, chronic, the role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities.

Synthetic porcine secretin is highly accurate in pancreatic function testing in individuals with chronic pancreatitis

The secretin stimulation test is the most sensitive and specific test for pancreatic function. It is usually performed using biologically derived porcine secretin. Several shortages of biologic porcine secretin have occurred in the past few years. The aim of this study was to compare synthetic porcine secretin to biologic porcine secretin in pancreatic function testing in subjects with chronic pancreatitis. Twelve patients with a previously abnormal secretin stimulation test were enrolled. After an overnight fast, each patient underwent a secretin stimulation test on 2 consecutive days using 1 CU/kg biologic porcine secretin or 0.2 [microg/kg synthetic porcine secretin in a randomized fashion. The peak bicarbonate concentration in duodenal juice was used as a measure of pancreatic function. The peak bicarbonate concentration (mean +/- SD) obtained by using biologic porcine secretin and synthetic porcine secretin were 70 +/- 25 mEq/L and 68 +/- 31 mEq/L, respectively (p = 0.58, paired t test; R = 0.964). The accuracy of synthetic porcine secretin in diagnosing pancreatic insufficiency was 100% when compared with biologic porcine secretin. We conclude that synthetic porcine secretin is highly accurate and safe in pancreatic function testing. The 100% purity, excellent diagnostic accuracy, and ready availability make synthetic porcine secretin an attractive choice for secretin stimulation testing.

Update on diagnosis and management of chronic pancreatitis

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. The importance of small duct disease without obvious radiographic abnormalities is an important new concept. It is meaningful for the clinician to define whether the patient with chronic pancreatitis has small duct or large duct disease. Diagnostic evaluations should begin with a simple, noninvasive, inexpensive test such as serum trypsinogen, to be followed by more complicated testing such as the secretin stimulation test, particularly in those patients with small duct disease. Non-enteric-coated pancreatic enzyme preparations are preferred for the treatment of pain whereas enteric-coated pancreatic enzyme preparations are the drugs of choice for treating steatorrhea. Octreotide may become an important therapy for treating abdominal pain unresponsive to pancreatic enzyme therapy. Endoscopic treatment of the pain of chronic pancreatitis should be used only in highly selected patients and may cause damage to the pancreas. Surgical ductal decompression is appropriate in selected patients.

Acid steatocrit: a simple, rapid gravimetric method to determine steatorrhea

OBJECTIVES

The detection and evaluation of steatorrhea in a rapid, quantitative fashion are clinically needed in patients with suspected steatorrhea. Our aim was to evaluate the acid steatocrit method, on random spot stools in adults with and without steatorrhea, relative to the qualitative (microscopic) and quantitative assessments for fecal fat.

METHODS

Stool samples were collected 72 h after a diet of 100 g of fat per day and randomly from 15 healthy controls, 14 patients with chronic pancreatitis, and seven patients with small bowel disease. All stools had quantitative, qualitative, and acid steatocrit analyses performed for fecal fat.

RESULTS

The sensitivity and specificity for the detection of steatorrhea by the spot stool qualitative fecal fat were 78 and 70%, respectively. The spot stool acid steatocrit correlated linearly with the 72-h stool quantitative fecal fat (g/24 h), r = 0.761 and p < 0.001. The acid steatocrit on random spot stools, compared with the 72-h stool quantitative fecal fat, revealed a sensitivity of 100%, a specificity of 95%, and a positive predictive value of 90% for the detection of steatorrhea. It also estimated the quantitative fecal fat.

CONCLUSIONS

The acid steatocrit can be performed accurately on random spot stools and can be used to detect the presence of steatorrhea and estimate the quantitative fecal fat. This assay can be done with readily available equipment for rapid evaluation. Use of a spot stool sample simplifies the acid steatocrit, further improving on the practicality of this test. This study also confirms the clinical usefulness of this simplified method to detect steatorrhea.

Fecal pancreatic elastase 1 is inaccurate in the diagnosis of chronic pancreatitis

Many tests are available to assess pancreatic function. The ideal test would be simple and have adequate sensitivity in mild to moderate chronic pancreatitis (MCP) and severe CP (SCP). Fecal pancreatic elastase 1 (FPE1) assay (ScheBo Tech) has been proposed as a reliable test to evaluate pancreatic exocrine function, with sensitivities of up to 100% in diagnosing CP. Cutoff values (microgram/g stool) of < 100 have been suggested as SCP, 100-200 as MCP, and > 200 as normal. The test's ability to detect MCP distinguished by the absence of steatorrhea, and its specificity among various etiologies of malabsorption, has not been fully evaluated. The aim of this study was to evaluate this assay in subjects including patients with SCP with steatorrhea, patients with MCP with no steatorrhea, healthy controls, and diseased controls with nonpancreatic malabsorption. Thirty-six subjects [15 healthy controls, 7 malabsorption controls, and 14 subjects with CP (7 MCP, 7 SCP)] had FPE1 assays. One hundred fifty-four assays for FPE1 were run for analysis. The intraassay and interassay intraclass correlation coefficients were 0.93 and 0.90, respectively. All SCP had values of < 100 micrograms/g but more than half of the MCP subjects had FPE1 levels within the normal range. The subjects with nonpancreatic malabsorption had FPE1 values ranging from 55 to > 500 micrograms/g of stool. Although the assay detected SCP with steatorrhea, it did not consistently separate the MCP patients from normals. The majority of those with nonpancreatic malabsorption had false-positive values. These results may differ from previously described data because of the purposeful inclusion of MCP subjects, documented by the lack of steatorrhea, and the inclusion of disease controls with nonpancreatic malabsorption. Although PE1 concentrates in the stool and is not significantly degraded, subtle changes in this enzyme, as in MCP, do not seem to be detectable by this assay. This group continues to be the most difficult group to diagnose clinically.

Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene

Hereditary pancreatitis (HP) is a rare, early-onset genetic disorder characterized by epigastric pain and often more serious complications. We now report that an Arg-His substitution at residue 117 of the cationic trypsinogen gene is associated with the HP phenotype. This mutation was observed in all HP affected individuals and obligate carriers from five kindreds, but not in individuals who married into the families nor in 140 unrelated individuals. X-ray crystal structure analysis, molecular modelling, and protein digest data indicate that the Arg 117 residue is a trypsin-sensitive site. Cleavage at this site is probably part of a fail-safe mechanism by which trypsin, which is activated within the pancreas, may be inactivated; loss of this cleavage site would permit autodigestion resulting in pancreatitis.

Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine

While fellowship training programs are being reduced in size to better conform to societal needs, the training of subspecialist basic scientists and clinical investigators must be protected to ensure continued discovery and the scholarly application of knowledge to patient care. Fewer subspecialist clinicians must be appropriately trained to serve as consultants, as principal care providers, and as scholarly leaders and educators in their subspecialties. This article describes the recommendations of the American Board of Internal Medicine for subspecialty training. To encourage physicians to choose careers as investigators, overlapping but different training paths are delineated for subspecialist clinicians and investigators. More didactic coursework is recommended for both paths. To maximize the contribution of fewer subspecialists, it is essential to provide rigorous training that is appropriately relevant and realistically matched with career opportunities.

Acute pancreatitis. Medical management

The medical management of acute pancreatitis is primarily supportive and involves making the patient nulla per os, providing adequate intravenous hydration, and controlling pain with analgesics. Systems to identify patients with severe pancreatitis at risk for morbidity and mortality are available but require supplementation with frequent, experienced clinical observation. A number of modalities to inhibit pancreatic secretion or pancreatic proteases have not been successful in clinical trials, although larger studies in patients with more severe pancreatitis are required to ultimately assess their effectiveness. The empiric use of imipenem and long-term peritoneal lavage in patients with severe or necrotizing pancreatitis appear promising but further studies are needed. The removal of impacted gallstones in patients with severe pancreatitis or cholangitis is useful, provided an expert endoscopist is available. Improvements in our ability to document pancreatic infection early by CT-directed aspiration have markedly improved our ability to manage pancreatic infection.

Medical management of chronic pancreatitis

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. The importance of small duct disease without obvious radiographic abnormalities is an important new concept. Diagnostic evaluation should begin with simple, non-invasive, inexpensive tests (serum trypsinogen) to be followed by more complicated testing (hormone stimulation test) if needed. Enteric-coated pancreatic enzymes are the drugs of choice for treating steatorrhea, while conventional non-enteric coated enzymes are preferred for managing pain. The somatostatin analogue octreotide may become an important therapy for treating abdominal pain unresponsive to pancreatic enzyme therapy. Endoscopic approaches to the treatment of chronic pancreatitis are experimental and may cause damage to the pancreas. Surgical ductal decompression is appropriate in selected patients.

What does an abnormal pancreatogram mean?

The foregoing discussion emphasized the fact that pancreatography can document changes that are relatively specific for chronic pancreatitis but that similar changes can be seen in other clinical conditions and even as normal variants. In addition, the exact clinical implication of minor or equivocal changes is unclear and care should be taken not to overinterpret ERP findings. It also must be realized that ERP may miss a substantial number of patients with earlier or less advanced chronic pancreatitis. ERP also may document pancreas divisum, but is not helpful in explaining the patient's clinical condition in the absence of dorsal duct abnormalities. Finally, tests of pancreatic function--in particular, hormonal stimulation tests--are complementary to tests of pancreatic morphology and allow the diagnosis of less advanced or earlier chronic pancreatitis, as well as patients with divisum and normal dorsal ducts who nonetheless have obstruction to flow at the minor papilla. The evaluation of a patient with presumed chronic pancreatitis therefore should begin with simple, noninvasive tests that are able to detect advanced forms of chronic pancreatitis. These include plain abdominal radiograph and serum trypsin. If either of these is markedly abnormal, no further diagnostic testing is generally required. In patients in whom diagnostic uncertainty still exists, reasonable second-echelon tests include abdominal CT, bentiromide testing, or secretin stimulation testing. Of these, hormonal stimulation testing offers the most sensitivity but is not universally available. More invasive evaluations--in particular, ERP--should be reserved for patients in whom the diagnosis is still unclear or in whom therapeutic rather than diagnostic information is required (e.g., a patient classified a medical failure being considered for Peustow procedure).

Calcium polycarbophil compared with placebo in irritable bowel syndrome

Calcium polycarbophil was compared with placebo in 23 patients with irritable bowel syndrome in a six-month, randomized double-blind crossover study. Patients received polycarbophil tablets at a dosage of 6 g/day (twelve 0.5-g tablets) or matching placebo tablets. At study end, among patients expressing a preference, 15 of 21 (71%) chose polycarbophil over placebo for relief of the symptoms of irritable bowel syndrome. Statistically significant differences favouring polycarbophil were found among the following patient subgroups: 15 (79%) of 19 with constipation: all six with alternating diarrhoea and constipation; 13 (87%) of 15 with bloating: and 11 (92%) of 12 with two or more symptoms. Polycarbophil was rated better than placebo in monthly global responses to therapy. Patient diary entries showed statistically significant improvement for ease of passage with polycarbophil. Polycarbophil was rated better than placebo for relief of nausea, pain, and bloating. The data suggest that calcium polycarbophil can benefit irritable bowel syndrome patients with constipation or alternating diarrhoea and constipation and may be particularly useful in patients with bloating as a major complaint.

Hyperlipidemic pancreatitis

Marked elevation of triglyceride levels appears to be causally linked to acute pancreatitis and is found in 12% to 38% of patients presenting with acute pancreatitis. Elevated cholesterol levels are not associated with pancreatitis. The pathogenesis of pancreatitis associated with hypertriglyceridemia is not clear. Clinical recognition of this association is extremely important, because therapy with diet and lipid-lowering agents may prevent development of pancreatitis.

Systemic lupus erythematosus presenting initially with acute pancreatitis and a review of the literature

A patient with systemic lupus erythematosus is reported whose initial clinical presentation was that of acute pancreatitis, confirmed by pancreatic isoamylase elevation and pancreatic enlargement on computerized tomography. A lack of a correlation with steroid therapy and a need to document pancreatitis in a multisystem disease like lupus with radiographic evidence as well as pancreatic isoamylase elevations is emphasized.

Bentiromide test is not affected in patients with small bowel disease or liver disease

The bentiromide test reliably detects exocrine pancreatic insufficiency. The synthetic peptide attached to p-aminobenzoic acid (PABA) is cleaved by chymotrypsin, PABA is absorbed in the small intestine, partially conjugated in the liver, and excreted in the urine. It has been claimed that the bentiromide test is abnormal not only in patients with pancreatic insufficiency but also in patients with small bowel or liver disease because of impaired PABA absorption or conjugation, respectively. This study prospectively evaluates the bentiromide test in 12 patients with small bowel disease and 18 patients with biopsy-proven liver disease. One of 30 patients had an abnormal bentiromide test. Cumulative 6-h urinary arylamine excretion and plasma PABA concentration, 2 h after administration, were in the same range as healthy controls. We conclude that the bentiromide test is not affected by small bowel or liver disease. An abnormal test is virtually diagnostic for exocrine pancreatic insufficiency.