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Valente R, Coppola A, Scandavini CM, Halimi A, Magnusson A, Lauro A, Sotirova I, Arnelo U, Franklin O. Interactions between the Exocrine and the Endocrine Pancreas. J Clin Med 2024; 13:1179. [PMID: 38398492 PMCID: PMC10890016 DOI: 10.3390/jcm13041179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 02/25/2024] Open
Abstract
The pancreas has two main functions: to produce and secrete digestive enzymes (exocrine function) and to produce hormones that regulate blood glucose and splanchnic secretion (endocrine function). The endocrine and exocrine portions of the pancreas are central regulators in digestion and metabolism, with continuous crosstalk between their deeply interconnected components, which plays a role in disease. Pancreatic neoplasms, inflammation, trauma, and surgery can lead to the development of type 3c diabetes when an insult simultaneously damages both acini and islets, leading to exocrine and endocrine dysfunction. In diabetes mellitus patients, pancreatic exocrine insufficiency is highly prevalent, yet little is known about the associations between diabetes mellitus and pancreatic exocrine function. This review aims to provide an overview of the physiology of the pancreas, summarize the pathophysiology and diagnostic work-up of pancreatic exocrine insufficiency, and explore the relationships between exocrine pancreatic insufficiency and diabetes mellitus.
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Affiliation(s)
- Roberto Valente
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | | | - Chiara Maria Scandavini
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
| | - Asif Halimi
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
| | - Annelie Magnusson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
| | - Augusto Lauro
- Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy;
| | - Ira Sotirova
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
| | - Urban Arnelo
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
| | - Oskar Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, 90185 Umeå, Sweden; (R.V.); (C.M.S.); (A.H.); (A.M.); (I.S.); (U.A.); (O.F.)
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Luo Q, Dong Y, Liu P, He C, Chen L, Zhang K, Pan C, Gao Y, Qin T. Inhibition Effect of Pancreatic Exocrine Insufficiency on Immune Checkpoint Inhibitor Treatment in Pancreatic Cancer: A Retrospective Study. Immunotargets Ther 2024; 13:45-54. [PMID: 38317658 PMCID: PMC10840537 DOI: 10.2147/itt.s442247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/26/2024] [Indexed: 02/07/2024] Open
Abstract
Introduction Chemotherapy combined with immune checkpoint inhibitors (ChIM) is used to treat advanced pancreatic ductal adenocarcinoma (PDAC). However, the efficacy of ChIM is similar to that of chemotherapy alone. Methods To assess potential factors affecting the effectiveness of ChIM, we analyzed the clinical data of 359 patients with PDAC who visited the hospital during June 2017 to December 2022. Results Surgical resection, diabetes, and ChIM were risk factors for pancreatic exocrine insufficiency (PEI). The adjusted odds ratio of ChIM was 2.63 (95% confidence interval (CI) 1.492-4.626) (P = 0.001). The incidence of PEI in the ChIM group (76.9%) was significantly higher than that of the chemotherapy group (60.2%) (P = 0.004). Survival analysis showed that ChIM did not improve the survival rate of patients with PDAC (hazard ratio (HR) 0.92, 0.707-1.197) (P = 0.534) in comparison with that of the chemotherapy group. However, in patients without PEI, those receiving ChIM showed a higher 1-year overall survival (OS) rate of 70.8% (two-sided, P = 0.045) and a median OS of 22.0 months (95% CI 11.5-32.5). Moreover, pancreatic enzyme replacement therapy significantly improved the OS of patients with PDAC (HR = 0.73, 95% CI = 0.561-0.956) (P = 0.022). Conclusion Immune checkpoint inhibitors (ICIs) increased the incidence of PEI in patients with PDAC. The OS was not different between patients receiving chemotherapy and ChIM due to irregular PERT treatment. The finding show that pancreatic enzyme replacement therapy may improve the response rate of patients with PDAC to ICIs.
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Affiliation(s)
- Qiankun Luo
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Yifei Dong
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Pan Liu
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Chao He
- Department of Hepatobiliary and Pancreatic Surgery, Henan University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Lei Chen
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Kailun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Changjie Pan
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Yahui Gao
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Tao Qin
- Department of Hepatobiliary and Pancreatic Surgery, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, Henan, People’s Republic of China
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Jalal M, Leeds JS, Ching HL, Oprescu A, Tunbridge A, Greig J, Tesfaye S, Hopper AD. Are we missing pancreatic exocrine insufficiency in 'at-risk' groups? Prospective assessment of the current practice and yield of faecal elastase testing in patients with diabetes mellitus, HIV and/or high alcohol intake. Clin Med (Lond) 2023; 23:588-593. [PMID: 38065607 DOI: 10.7861/clinmed.2023-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
There is cumulative evidence that pancreatic exocrine insufficiency (PEI) is under-recognised and can occur in patients with 'at-risk' conditions. Thus, we aimed to assess the current practice and yield of requesting faecal elastase (FEL-1), an indicator of PEI, in patients with 'at-risk' conditions. We prospectively recruited patients attending secondary care clinics with diabetes mellitus (DM), people living with HIV (PLHIV) and inpatients admitted to hospital with high alcohol intake (HAI). All patients underwent testing with FEL-1. Those patients with PEI (FEL-1 <200 μg/g) were contacted and offered a follow-up review in gastroenterology clinic. In total, 188 patients were recruited (HAI, n=78; DM, n=64; and PLHIV, n=46). Previous FEL-1 testing had not been performed in any of the patients. The return rate of samples was 67.9% for patients with HAI, 76.6% for those with DM and 56.5% for those with PLHIV. The presence of PEI was shown in 20.4% of patients with DM, 15.4% of patients with PLHIV and 22.6% in those with HAI. Diarrhoea and bloating were the most reported symptoms in followed-up patients with low FEL-1 (31.8% and 22.7% of patients, respectively). Follow-up computed tomography (CT) scans in those patients with PEI identified chronic pancreatitis changes in 13.6% and pancreatic atrophy in 31.8% of patients. These results suggest that there is a lack of testing for PEI in 'at-risk' groups. Our findings also suggest that using FEL-1 to test for PEI in patients with DM, PLHIV and HAI has a significant impact, although further studies are required to validate these findings.
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Affiliation(s)
- Mustafa Jalal
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, and consultant gastreoenterologist, Royal Bournemouth Hospital, Bournemouth, UK
| | - John S Leeds
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Hey-Long Ching
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrei Oprescu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ann Tunbridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Julia Greig
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew D Hopper
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, and University of Sheffield, Sheffield, UK
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Halle-Smith JM, Hall LA, Powell-Brett SF, Merali N, Frampton AE, Beggs AD, Moss P, Roberts KJ. Pancreatic Exocrine Insufficiency and the Gut Microbiome in Pancreatic Cancer: A Target for Future Diagnostic Tests and Therapies? Cancers (Basel) 2023; 15:5140. [PMID: 37958314 PMCID: PMC10649877 DOI: 10.3390/cancers15215140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) is common amongst pancreatic cancer patients and is associated with poorer treatment outcomes. Pancreatic enzyme replacement therapy (PERT) is known to improve outcomes in pancreatic cancer, but the mechanisms are not fully understood. The aim of this narrative literature review is to summarise the current evidence linking PEI with microbiome dysbiosis, assess how microbiome composition may be impacted by PERT treatment, and look towards possible future diagnostic and therapeutic targets in this area. Early evidence in the literature reveals that there are complex mechanisms by which pancreatic secretions modulate the gut microbiome, so when these are disturbed, as in PEI, gut microbiome dysbiosis occurs. PERT has been shown to return the gut microbiome towards normal, so called rebiosis, in animal studies. Gut microbiome dysbiosis has multiple downstream effects in pancreatic cancer such as modulation of the immune response and the response to chemotherapeutic agents. It therefore represents a possible future target for future therapies. In conclusion, it is likely that the gut microbiome of pancreatic cancer patients with PEI exhibits dysbiosis and that this may potentially be reversible with PERT. However, further human studies are required to determine if this is indeed the case.
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Affiliation(s)
- James M. Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2GW, UK;
| | - Lewis A. Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Sarah F. Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Nabeel Merali
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
- Minimal Access Therapy Training Unit (MATTU), Leggett Building, University of Surrey, Guildford GU2 7WG, UK
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Adam E. Frampton
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
- Minimal Access Therapy Training Unit (MATTU), Leggett Building, University of Surrey, Guildford GU2 7WG, UK
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Andrew D. Beggs
- Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2GW, UK;
- Colorectal Surgery Department, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Paul Moss
- Section of Oncology, Department of Clinical & Experimental Medicine, University of Surrey, Guildford GU2 7WG, UK (A.E.F.); (P.M.)
| | - Keith J. Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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Takata K, Nagata T, Matsumoto K, Miyayama T, Shibata K, Fukuda H, Yamauchi R, Fukunaga A, Tanaka T, Yokoyama K, Shakado S, Sakisaka S, Hirai F. Two Cases of Rapidly Progressive Fatty Liver Disease due to Pancreatic Exocrine Insufficiency without a History of Surgery. Intern Med 2023; 62:2667-2673. [PMID: 36754408 PMCID: PMC10569931 DOI: 10.2169/internalmedicine.0775-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/26/2022] [Indexed: 02/10/2023] Open
Abstract
We herein report two cases of rapidly progressive fatty liver (FL) disease due to pancreatic exocrine insufficiency (PEI) without a surgical history. Two women, 59 and 72 years old, with no history of abdominal surgery presented to our hospital with severe anorexia and nausea persisting for one week. Examinations revealed progressive, marked FL disease with hepatomegaly and PEI, for which pancreatic enzyme replacement therapy was effective. Commonly known causes of PEI include chronic pancreatitis, abdominal surgery (e.g. pancreaticoduodenectomy), pancreatic cancer, and obstruction of the pancreatic duct, none of which were present in either of these two cases.
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Affiliation(s)
- Kazuhide Takata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takahiro Nagata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Keisuke Matsumoto
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Miyayama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Kumiko Shibata
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Atsushi Fukunaga
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Japan
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Izumi H, Yoshii H, Fujino R, Takeo S, Nomura E, Mukai M, Makuuchi H. Factors contributing to nonalcoholic fatty liver disease (NAFLD) and fat deposition after pancreaticoduodenectomy: A retrospective analysis. Ann Gastroenterol Surg 2023; 7:793-799. [PMID: 37663962 PMCID: PMC10472401 DOI: 10.1002/ags3.12673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 09/05/2023] Open
Abstract
Aim Nonalcoholic fatty liver disease (NAFLD) can occur due to various reasons after pancreaticoduodenectomy (PD). This study examined the risk and perioperative determinants of NAFLD and fat deposition after PD. Methods A total of 101 patients who had undergone computed tomography 6 months after PD were included. We compared perioperative factors between patients who developed NAFLD and those who developed fatty deposits after PD. Results In the NAFLD group, pancreatic cancer was significantly more prevalent among patients who developed postoperative NAFLD (p = 0.024) and had a lower postoperative body mass index (BMI; p = 0.008). Multivariate analysis revealed that pancreatic carcinoma (hazard ratio [HR] 4.42, 95% confidence interval [CI] 1.118-17.442, p = 0.034) and lower postoperative BMI (HR 0.51, 95% CI 0.274-0.954, p = 0.0355) were risk factors for fatty liver. Pancreatic leakage (p = 0.024) and postoperative BMI (p = 0.002) were significantly lower in the fat deposition group than those in the NAFLD group. Multivariate analysis also revealed that a lower postoperative BMI was a risk factor for fat deposition (HR 0.56, 95% CI 0.523-0.982, p = 0.042). Moreover, multivariate analysis revealed that the fat deposition group had significantly lower pancreatic leakage than the NAFLD group (HR 7.944, 95% CI 1.993-63.562, p = 0.049). Conclusion The findings of this study suggest that postoperative BMI and pancreatic cancer are associated with a higher risk of NAFLD after PD, possibly because of pancreatic exocrine insufficiency and impaired fat absorption.
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Affiliation(s)
- Hideki Izumi
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Hisamichi Yoshii
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Rika Fujino
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Shigeya Takeo
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Eiji Nomura
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Masaya Mukai
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
| | - Hiroyasu Makuuchi
- Department of Gastrointestinal SurgeryTokai University Hachioji HospitalHachioji, TokyoJapan
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Hasebe Y, Karasawa Y, Nozawa K. Dietary therapy for patients with chronic pancreatitis in Japan: a cross-sectional online survey of physicians and registered dietitians. Drugs Context 2023; 12:2023-2-4. [PMID: 37521108 PMCID: PMC10378997 DOI: 10.7573/dic.2023-2-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023] Open
Abstract
Background This study was aimed towards understanding the current status of dietary therapy for patients with pancreatic exocrine insufficiency (PEI) in Japan and its alignment with Japanese recommendations for high-fat intake and concomitant high-potency pancreatic enzyme replacement therapy (PERT) by surveying treating physicians and registered dietitians. Methods The 19-item physicians' online questionnaire collected data about the number of patients with PEI treated, methods used to assess PEI and nutritional status in patients with PEI, as well as provision of dietary guidance and details of treatment with PERT. The 10-item registered dietitians' online questionnaire captured data about the provision of dietary guidance, including setting (inpatient or outpatient) and details of nutritional guidance provided to patients. Results Overall, 35 physicians and 23 dietitians completed the respective questionnaires. The primary cause of PEI in patients treated by physicians during the previous month was chronic pancreatitis (80.5%). Of 30 (86%) physicians who reported implementing dietary guidance for patients with PEI, less than half (43%) followed national guidelines and most (83%) implemented a low-fat diet. The use of PERT in recently treated patients with PEI was low. Amongst 11 (48%) dietitians who reported providing dietary guidance to patients with chronic pancreatitis and PEI, 7 (64%) recommended restricting fat intake in patients with uncompensated chronic pancreatitis. Dietitians overall were more likely to provide guidance about alcohol avoidance (91%) than smoking cessation (48%) to appropriate patients. Conclusion This survey suggests that additional educational efforts are required to align the management practices of physicians and registered dietitians with evidence-based clinical practice guidelines for Japanese patients with chronic pancreatitis and PEI.
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Affiliation(s)
| | | | - Kazutaka Nozawa
- Mylan EPD G.K., Tokyo, Japan
- Viatris Pharmaceuticals Japan Inc., Tokyo, Japan
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Maetzel H, Rutkowski W, Panic N, Mari A, Hedström A, Kulinski P, Stål P, Petersson S, Brismar TB, Löhr JM, Vujasinovic M. Non-alcoholic fatty pancreas disease and pancreatic exocrine insufficiency: pilot study and systematic review. Scand J Gastroenterol 2023; 58:1030-1037. [PMID: 37088949 DOI: 10.1080/00365521.2023.2200452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION The prevalence of non-alcoholic fatty pancreas disease (NAFPD) is estimated as 2-46% among patients without known pancreatic diseases. An association between NAFPD and non-alcoholic fatty liver disease (NAFLD) has been proposed, as well as an association between NAFPD and pancreatic exocrine insufficiency (PEI). PATIENTS AND METHODS Patients with histologically confirmed NAFLD were included in the study. The control group consisted of individuals included in a surveillance screening program. Magnetic resonance imaging (MRI) of the pancreas was performed in all patients and fat measurement was made using 2-point Dixon imaging. Fecal elastase-1 (FE-1) was performed to evaluate pancreatic exocrine function. Additionally, a 13C-mixed triglyceride breath test (13 C-MTG-BT) was performed in patients with FE-1 < 200 μg/g. RESULTS Imaging signs of NAFPD were present in 17 (71%) patients; 11 (85%) from the NAFLD group and 6 (55%) from the control group. FE-1 < 200 μg/g was found in six (25%) patients (four in the NAFLD group and two in the control group); however, none of them had clinical symptoms of PEI. Therefore, in five out of six patients with low FE-1, a 13C-MTG-BT was performed, showing normal results (>20.9%) in all tested patients. Furthermore, the serum nutritional panel was normal in all patients with low FE-1. A systematic review identified five studies relevant to the topic. CONCLUSION NAFPD was found in 85% of patients with NAFLD and in 55% of control patients. We did not diagnose PEI in either group. A literature review showed PEI in 9-56% of patients with NAFPD.
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Affiliation(s)
- Hartwig Maetzel
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Wiktor Rutkowski
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Nikola Panic
- Digestive Endoscopy Unit, University Clinic "Dr Dragisa Misovic-Dedinje", Belgrade, Serbia
| | - Amir Mari
- Gastroenterology Institute, The Nazareth Hospital EMMS, Nazareth, Israel
- The Azreili Faculty of Medicine, Bar-Ilan University, Israel
| | - Aleksandra Hedström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Paula Kulinski
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Per Stål
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sven Petersson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - J Matthias Löhr
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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Hall LA, Powell-Brett S, Thompson O, Smith D, Bradley E, Smith S, Vickrage S, Kemp-Blake J, Roberts KJ, Shah T. Casting a Wider NET: Pancreatic Exocrine Insufficiency Induced by Somatostatin Analogues among Patients with Neuroendocrine Tumours? Cancers (Basel) 2023; 15:cancers15071933. [PMID: 37046594 PMCID: PMC10093494 DOI: 10.3390/cancers15071933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Somatostatin-analogues (SSAs) are a first-line treatment of unresectable neuroendocrine tumours (NETs). However, SSAs inhibit pancreatic secretions, which could lead to pancreatic exocrine insufficiency (PEI). PEI is known to be detrimental to patient quality of life and nutritional status. This study aimed to evaluate the effect of SSAs on pancreatic exocrine function in patients with NETs, using the 13C-mixed triglyceride breath test (13C-MTGT). Exocrine function was assessed using the 13C-MTGT at baseline and after a third SSA injection (two months). A quotient of 13CO2/12CO2 was measured by mass spectrometry, and the cumulative percent dose recovered at 6 h (cPDR) is reported. The secondary endpoints investigated were change in weight, HbA1C, and vitamin D levels. Ten patients completed the study. Exocrine function reduced in all patients (n = 10) following SSA therapy (median reduction from baseline: -23.4% (range: -42.1-0.5%, p = 0.005)). vitamin D levels decreased in all but one patient (median decrease from baseline: -26.5%, (-44.7-10%; p = 0.038)), and median HbA1C levels increased by 8.0% (0-59.3%; p = 0.008). Change in weight was not significant (median decrease from baseline: -0.21% (-4.5-3.5%, p = 1.000)). SSA therapy has a consistent impact on exocrine function from early in the treatment course, but the long-term clinical effects of this remain to be defined. Further studies are required to determine the clinical relevance of this observation and optimise the management of PEI in this cohort.
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Affiliation(s)
- Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sarah Powell-Brett
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Oscar Thompson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Daniel Smith
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Elizabeth Bradley
- Department of Nutrition and Dietetics, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Joanne Kemp-Blake
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Keith J Roberts
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- The Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
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10
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Guo Y, Wang X, Wang S, Li A, Cao F, Li F. Predictive Risk Factors of Pancreatic Exocrine Insufficiency Developed After Acute Pancreatitis: A Retrospective Cohort Study. J Inflamm Res 2023; 16:1157-1167. [PMID: 36950051 PMCID: PMC10025014 DOI: 10.2147/jir.s392932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/25/2023] [Indexed: 03/17/2023] Open
Abstract
Purpose The aim of this study was to compare the clinical characteristics of acute pancreatitis (AP) patients between those who developed pancreatic exocrine insufficiency (PEI) and those who did not, and to investigate the predictive factors of PEI. Patients and Methods From October 1st 2019 to July 30th 2021, AP patients admitted at our center were included. The fecal elastase-1 assay was adopted for PEI diagnosis. The clinical characteristics, treatments, and outcomes between the patients with and without PEI were analyzed. Results In total, 63 males and 42 females were included. There were 27 patients with mild AP, 54 with moderately severe AP, and 24 with severe AP. The median modified computed tomography severity index (MCTSI) was 6.000(4.000, 8.000). During the follow-up, 38 patients developed PEI after AP. The univariate analysis showed that higher ASA grade (P = 0.006), more severe AP (P = 0.000), the presence of multiple organ dysfunction syndrome (P = 0.030), higher MCTSI (P = 0.000), the development of infected pancreatic necrosis (P = 0.002) and local complications (P = 0.000), higher levels of triacylglycerol (P = 0.022), video-assisted retroperitoneal debridement intervention (P = 0.015), and longer intensive care unit stay (P = 0.044) were correlated with PEI development. Furthermore, the logistic regression analyses showed that MCTSI during hospitalization is an independent risk factor for PEI development during the AP recovery period. Conclusion ASA grade, severity of AP, multiple organ dysfunction syndrome, MCTSI, infected pancreatic necrosis, local complications, higher levels of triacylglycerol, video-assisted retroperitoneal debridement intervention, and longer intensive care unit stay were potentially associated with PEI development during the AP recovery period. High MCTSI was independently associated with the development of PEI during the AP recovery period, which may help alert to the possibility of PEI to help with its early detection and treatment.
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Affiliation(s)
- Yulin Guo
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
| | - Xiaohui Wang
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
| | - Shuo Wang
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
| | - Feng Cao
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, Beijing, People’s Republic of China
- Acute Pancreatitis Clinical Center of Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Fei Li; Feng Cao, Department of General Surgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, People’s Republic of China, Tel/Fax +86-10-83198835, Email ;
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11
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Ud-Din M, Karout B, Torbé WM, Lunding J, Wegeberg AM, Drewes AM, Brock C, Hellström PM. DIgestive COmplications in DIabetes - the DICODI population study. Scand J Gastroenterol 2023; 58:3-6. [PMID: 35961288 DOI: 10.1080/00365521.2022.2106149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diabetes type 1 and type 2 may develop gastrointestinal complications e.g., gastroparesis and gastroenteropathy. Concomitant celiac disease and pancreatic exocrine insufficiency occur with high prevalence in diabetes and with symptomatic overlap. Consequently, it is a challenge to disentangle symptoms of these conditions and separate them from functional dyspepsia. We aim to develop a clinical decision-support tool to differentiate the underlying disease in a plethora of gastrointestinal symptoms. METHODS An internet-based computerized survey will collect basic characteristics (diabetes type, age, gender, duration, HbA1c, treatment) and patient reported outcomes by validated questionnaires focusing on (1) gastroparesis using Gastroparesis Cardinal Symptom Index; (2) gastroenteropathy using Gastrointestinal Symptom Rating Scale; (3) celiac disease using Celiac Symptom Index and (4) pancreatic exocrine insufficiency with Pancreatic Exocrine Insufficiency Questionnaire. Logistic regression and multiple regression analyses will identify risk factors and gastrointestinal complications. Cluster analyses and machine learning will classify different symptoms and co-existing presentations, into a likely diagnosis. We seek biomarkers for autonomic neuropathy by characterizing development of retinopathy using the Visual Function Questionnaire-25 and peripheral neuropathy by the Michigan neuropathy questionnaire. Participants are re-examined yearly for disease progression over time. RESULTS From focus group studies gastrointestinal symptoms are of major concern in diabetes. Potentially, estimates of symptom prevalence, risk factor identification and classifications of gastrointestinal complications can be unraveled for feedback to health care providers. CONCLUSION The web-based DICODI project will open up possibilities to detect gastrointestinal complications of diabetes in a societal setting, benefitting people living with diabetes, health care professionals, and society.
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Affiliation(s)
- Moeen Ud-Din
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | - Johan Lunding
- Diakonhjemmet Hospital, Oslo University, Oslo, Norway
| | - Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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12
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Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients 2022; 14:4570. [PMID: 36364832 PMCID: PMC9656643 DOI: 10.3390/nu14214570] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 08/13/2023] Open
Abstract
This review summarizes the main pancreatic diseases from a nutritional approach. Nutrition is a cornerstone of pancreatic disease and is sometimes undervalued. An early identification of malnutrition is the first step in maintaining an adequate nutritional status in acute pancreatitis, chronic pancreatitis and pancreatic cancer. Following a proper diet is a pillar in the treatment of pancreatic diseases and, often, nutritional counseling becomes essential. In addition, some patients will require oral nutritional supplements and fat-soluble vitamins to combat certain deficiencies. Other patients will require enteral nutrition by nasoenteric tube or total parenteral nutrition in order to maintain the requirements, depending on the pathology and its consequences. Pancreatic exocrine insufficiency, defined as a significant decrease in pancreatic enzymes or bicarbonate until the digestive function is impaired, is common in pancreatic diseases and is the main cause of malnutrition. Pancreatic enzymes therapy allows for the management of these patients. Nutrition can improve the nutritional status and quality of life of these patients and may even improve life expectancy in patients with pancreatic cancer. For this reason, nutrition must maintain the importance it deserves.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, Martínez de Velasco Avenue 36, 22004 Huesca, Spain
| | - Guillermo García-Rayado
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
| | - Enrique Alfaro-Almajano
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
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13
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Erchinger F, Tjora E, Nordaas IK, Dimcevski G, Olesen SS, Jensen N, Dahl EE, Borch A, Nøjgaard C, Novovic S, Barauskas G, Ignatavicius P, Vujasinovic M, Lőhr M, Laukkarinen J, Parhiala M, Drewes AM, Engjom T. Pancreatic enzyme treatment in chronic pancreatitis: Quality of management and adherence to guidelines-A cross-sectional observational study. United European Gastroenterol J 2022; 10:844-853. [PMID: 35981311 PMCID: PMC9557959 DOI: 10.1002/ueg2.12276] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/17/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives Pancreatic exocrine insufficiency (PEI) is a common complication in patients with chronic pancreatitis (CP), leading to increased morbidity and mortality if not treated adequately. Pancreatic enzyme replacement therapy|pancreas enzyme replacement therapy (PERT) is the cornerstone in treatment of patients with PEI. In the present study, we use data from the Scandinavian Baltic Pancreatic Club database to examine adherence of PERT according to United European Gastroenterology evidence‐based guidelines treatment of CP. Patients and methods Patients with definitive or probable CP according to M‐ANNHEIM diagnostic criteria were included. We collected information on exposures, exocrine function, intake of pancreatic enzymes, and markers of nutrition. Fecal elastase <200 μg/g was defined as a marker for PEI. Enzyme replacement therapy of 100,000 lipase units or more was defined as adequate treatment. Results We included 1006 patients from 8 centers in five countries. Sixty‐four percent of the patients were correctly treated. Twenty‐five per cent of PEI patients were not taking enzymes at all, and 20% of PEI patients were undertreated with insufficient PERT doses according to the guidelines. Fourteen percent of patients with sufficient pancreatic function were receiving enzymes despite normal exocrine pancreatic function. There were center differences. Current smoking was associated with lack of treatment and alcohol abuse was associated with under‐treatment. There were no associations between “no treatment” or “under‐treatment” for underweight or vitamin D deficiency. Conclusion In our CP expert centers, the adherence to guidelines for enzyme treatment is insufficient. Both patient factors and center differences have influence on treatment adherence.
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Affiliation(s)
| | - Erling Tjora
- Pediatric Department, Haukeland University Hospital, Bergen, Norway
| | | | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Søren Schou Olesen
- Department of Gastroenterology and Hepatology, Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna Jensen
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Eva Efsen Dahl
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Anders Borch
- Department of Gastroenterology, Herlev University Hospital, Herlev, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Herlev, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Herlev, Denmark
| | - Giedrus Barauskas
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Ignatavicius
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Matthias Lőhr
- Department of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, University Hospital, Tampere, Finland
| | - Mikael Parhiala
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, University Hospital, Tampere, Finland
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Trond Engjom
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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14
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Siuka D, Kumer K, Stabuc B, Stubljar D, Drobne D, Jansa R. Abbreviated (13)C-mixed triglyceride breath test for detection of pancreatic exocrine insufficiency performs equally as standard 5-hour test in patients after gastrectomy performed for gastric cancer. Radiol Oncol 2022; 56:390-7. [PMID: 35962951 DOI: 10.2478/raon-2022-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND 13C-mixed triglyceride breath test (13C-MTGT) is a non-invasive test for the detection of moderate and severe pancreatic exocrine insufficiency (PEI), but it requires prolonged breath sampling. The aim of this study was to determine the diagnostic power of abbreviated 13C-MTGT in detecting PEI in patients after subtotal and total gastrectomy performed due to gastric cancer. SUBJECTS AND METHODS This cross-sectional observational study included 3 groups of subjects; healthy controls, patients with subtotal and patients with total gastrectomy. Demographic and clinical data of patients were collected. Stool samples to determine faecal elastase (Fe-1) and chymotrypsin were collected and measured by ELISA. All subjects performed 5-hour 13C-MTGT breath test. The concentration and relative content of 13C in exhaled air was measured by isotope ratio mass spectrometer (IRMS). PEI was confirmed as values of 13C-exhalation < 26.8% after 5 hours. RESULTS Overall, 65 participants were included into analysis, 22 having PEI (n = 11 after subtotal and n = 11 after total gastrectomy, both performed for gastric cancer). 13C-MTGT breath test showed difference in percent of exhaled 13C between PEI and non-PEI patients already after 60 minutes (p = 0.034). Receiver operating characteristic (ROC) curve analysis showed that cut-off value of 13.74% after 150 minutes is showing equivalent diagnostic power to the longer test with sensitivity and specificity both above 90% for the exclusion of PEI in patients after subtotal and/or total gastrectomy. CONCLUSIONS In this study abbreviated 13C-MTGT test could be shortened from 5 to 2.5 hours without decrease in its diagnostic accuracy for detection of PEI in patients with subtotal or total gastrectomy performed for gastric cancer. This allows significant time savings in the diagnostics of PEI in this subgroup of patients.
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15
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Dams OC, Vijver MAT, van Veldhuisen CL, Verdonk RC, Besselink MG, van Veldhuisen DJ. Heart Failure and Pancreas Exocrine Insufficiency: Pathophysiological Mechanisms and Clinical Point of View. J Clin Med 2022; 11:jcm11144128. [PMID: 35887892 PMCID: PMC9324511 DOI: 10.3390/jcm11144128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/28/2022] [Accepted: 07/14/2022] [Indexed: 01/27/2023] Open
Abstract
Heart failure is associated with decreased tissue perfusion and increased venous congestion that may result in organ dysfunction. This dysfunction has been investigated extensively for many organs, but data regarding pancreatic (exocrine) dysfunction are scarce. In the present review we will discuss the available data on the mechanisms of pancreatic damage, how heart failure can lead to exocrine dysfunction, and its clinical consequences. We will show that heart failure causes significant impairment of pancreatic exocrine function, particularly in the elderly, which may exacerbate the clinical syndrome of heart failure. In addition, pancreatic exocrine insufficiency may lead to further deterioration of cardiovascular disease and heart failure, thus constituting a true vicious circle. We aim to provide insight into the pathophysiological mechanisms that constitute this reciprocal relation. Finally, novel treatment options for pancreatic dysfunction in heart failure are discussed.
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Affiliation(s)
- Olivier C. Dams
- Department of Cardiology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (M.A.T.V.); (D.J.v.V.)
- Correspondence:
| | - Marlene A. T. Vijver
- Department of Cardiology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (M.A.T.V.); (D.J.v.V.)
| | - Charlotte L. van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; (C.L.v.V.); (M.G.B.)
- Amsterdam Gastroenterology Endocrinology Metabolism, 1100 DD Amsterdam, The Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands;
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1100 DD Amsterdam, The Netherlands; (C.L.v.V.); (M.G.B.)
- Amsterdam Gastroenterology Endocrinology Metabolism, 1100 DD Amsterdam, The Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (M.A.T.V.); (D.J.v.V.)
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Tanaka E, Ogawa T, Tsutsumi K, Kobayashi S, Nawa T, Ueki T, Okada H. Pancreatic Exocrine Insufficiency in Intraductal Papillary Mucinous Carcinoma Presenting with Leg Edema Treated with Pancreatic Exocrine Replacement Therapy. Intern Med 2022; 61:1963-1967. [PMID: 34840231 PMCID: PMC9334247 DOI: 10.2169/internalmedicine.8611-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
An 89-year-old woman underwent examinations for leg edema. Blood tests indicated low nutrition and low pancreatic enzymes, and a stool examination indicated fatty stool. Computed tomography showed pleural effusion, ascites, and cystic lesions in the pancreatic head and mural nodules within the cysts. Pancreatic juice cytology revealed adenocarcinoma. The diagnosis was pancreatic exocrine insufficiency caused by intraductal papillary mucinous carcinoma. The patient did not wish to undergo surgery. Therefore, diuretics, component nutrients, and pancreatic exocrine replacement therapy using pancrelipase were initiated. After starting treatment, her leg edema, pleural effusion, and ascites disappeared, and her activities of daily living improved markedly.
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Affiliation(s)
- Emi Tanaka
- Department of Internal Medicine, Fukuyama City Hospital, Japan
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | | | - Koichiro Tsutsumi
- Department of Internal Medicine, Fukuyama City Hospital, Japan
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Sayo Kobayashi
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Toru Nawa
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
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17
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Hwang H, Kim H, Sohn HJ, Lee M, Kim HS, Han Y, Kwon W, Jang JY. Stool Elastase as an Independent Prognostic Factor in Patients with Pancreatic Head Cancer. J Clin Med 2022; 11. [PMID: 35807003 DOI: 10.3390/jcm11133718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/22/2022] [Accepted: 06/25/2022] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Patients with pancreatic exocrine insufficiency (PEI) have an increased risk of malnutrition, which in turn increases morbidity and mortality and is frequent in pancreatic head cancer. This study aimed to analyze the utility of PEI measured using the stool elastase (SE) level to predict the prognosis of patients with pancreatic head cancer. (2) Methods: Patients who underwent pancreaticoduodenectomy for pancreatic cancer at our institution between 2011 and 2015 were included. Only patients with data on preoperative SE levels were analyzed. Patients were classified into low and high SE groups based on preoperative SE levels (low < 100 µg/g < high). (3) Results: The median preoperative SE level was 67.2 µg/g, and 84 of 143 (58.7%) patients were included in the low SE group. The two groups had significantly different overall survival (OS) and disease-free survival (DFS), and the low SE group had a worse prognosis. In multivariate analysis, SE level < 100 µg/g and lymph node metastasis were independent poor prognostic factors for OS and DFS. (4) Discussion: PEI measured using SE levels is an independent prognostic factor in patients with pancreatic head cancer undergoing pancreaticoduodenectomy. Since poor nutritional status may be related to prognosis in patients with low levels of stool elastase preoperatively, aggressive treatment may be required.
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18
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Ciochina M, Balaban DV, Manucu G, Jinga M, Gheorghe C. The Impact of Pancreatic Exocrine Diseases on the β-Cell and Glucose Metabolism-A Review with Currently Available Evidence. Biomolecules 2022; 12:biom12050618. [PMID: 35625546 PMCID: PMC9139037 DOI: 10.3390/biom12050618] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 02/07/2023] Open
Abstract
Pancreatic exocrine and endocrine dysfunctions often come together in the course of pancreatic diseases as interdependent manifestations of the same organ. However, the mechanisms underlying the bidirectional connection of the exocrine and endocrine pancreas are not fully understood. In this review, we aimed to synthetize the current knowledge regarding the effects of several exocrine pancreatic pathologies on the homeostasis of β-cells, with a special interest in the predisposition toward diabetes mellitus (DM). We focused on the following pancreatic exocrine diseases: chronic pancreatitis, acute pancreatitis, cystic fibrosis, pancreatic cancer, pancreatic resections, and autoimmune pancreatitis. We discuss the pathophysiologic mechanisms behind the impact on β-cell function and evolution into DM, as well as the associated risk factors in progression to DM, and we describe the most relevant and statistically significant findings in the literature. An early and correct diagnosis of DM in the setting of pancreatic exocrine disorders is of paramount importance for anticipating the disease's course and its therapeutical needs.
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Affiliation(s)
- Marina Ciochina
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Correspondence:
| | - Daniel Vasile Balaban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - George Manucu
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Mariana Jinga
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Cristian Gheorghe
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.V.B.); (M.J.); (C.G.)
- Gastroenterology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
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Capurso G, Pecorelli N, Burini A, Orsi G, Palumbo D, Macchini M, Mele R, de Cobelli F, Falconi M, Arcidiacono PG, Reni M. The impact of nutritional status on pancreatic cancer therapy. Expert Rev Anticancer Ther 2022; 22:155-167. [PMID: 34989653 DOI: 10.1080/14737140.2022.2026771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/05/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pancreatic Ductal Adenocarcinoma (PDAC) is an aggressive disease with poor outcomes. One of the reasons for the dismal prognosis resides in its impressive ability to alter the nutritional status of patients who develop malnutrition, cachexia, anorexia, and sarcopenia in most cases. The ideal way to measure such changes in PDAC patients, in order to readily identify them and avoid complications or discontinuations of treatment is a relatively unexplored area. In addition, most PDAC patients experience pancreatic exocrine insufficiency (PEI) that contributes to the complex puzzle of malnutrition and that can be treated with Pancreatic Enzyme Replacement Therapy (PERT). AREAS COVERED We review current knowledge on the impact of nutritional status on both surgical and medical treatments for PDAC, reporting available data on the causes of malnutrition, characteristics, and advantages of different tools to investigate nutritional status and possible strategies to improve patient outcomes. EXPERT OPINION All PDAC patients should receive a careful nutritional assessment at diagnosis, and this should be repeated alongside their treatment path. Screening tools and biochemical variables or scores are associated with prognosis, but bioimpedance vector analysis (BIVA) and radiological assessment of body composition seem more accurate in predicting clinical outcomes and postoperative complications.
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Affiliation(s)
- Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Nicolò Pecorelli
- Pancreas Translational & Clinical Research Center, Division of Pancreatic Surgery, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Alice Burini
- Nutrition Service, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Giulia Orsi
- Pancreas Translational & Clinical Research Center, Oncology Department, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Diego Palumbo
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Marina Macchini
- Pancreas Translational & Clinical Research Center, Oncology Department, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Roberto Mele
- Nutrition Service, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Francesco de Cobelli
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, Division of Pancreatic Surgery, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Reni
- Pancreas Translational & Clinical Research Center, Oncology Department, San Raffaele Scientific Institute IRCCS, Milan, Italy
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20
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Kaniel O, Sherf-Dagan S, Szold A, Langer P, Khalfin B, Kessler Y, Raziel A, Sakran N, Motro Y, Goitein D, Moran-Gilad J. The Effects of One Anastomosis Gastric Bypass Surgery on the Gastrointestinal Tract. Nutrients 2022; 14:nu14020304. [PMID: 35057486 PMCID: PMC8778673 DOI: 10.3390/nu14020304] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 02/05/2023] Open
Abstract
One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, yet data on its effect on the gastrointestinal tract are lacking. This study sought to evaluate the incidence of small-intestinal bacterial overgrowth (SIBO) following OAGB; explore its effect on nutritional, gastrointestinal, and weight outcomes; and assess post-OABG occurrence of pancreatic exocrine insufficiency (PEI) and altered gut microbiota composition. A prospective pilot cohort study of patients who underwent primary-OAGB surgery is here reported. The pre-surgical and 6-months-post-surgery measurements included anthropometrics, glucose breath-tests, biochemical tests, gastrointestinal symptoms, quality-of-life, dietary intake, and fecal sample collection. Thirty-two patients (50% females, 44.5 ± 12.3 years) participated in this study, and 29 attended the 6-month follow-up visit. The mean excess weight loss at 6 months post-OAGB was 67.8 ± 21.2%. The glucose breath-test was negative in all pre-surgery and positive in 37.0% at 6 months (p = 0.004). Positive glucose breath-test was associated with lower reported dietary intake and folate levels and higher vitamin A deficiency rates (p ≤ 0.036). Fecal elastase-1 test (FE1) was negative for all pre-surgery and positive in 26.1% at 6 months (p = 0.500). Both alpha and beta diversity decreased at 6 months post-surgery compared to pre-surgery (p ≤ 0.026). Relatively high incidences of SIBO and PEI were observed at 6 months post-OAGB, which may explain some gastrointestinal symptoms and nutritional deficiencies.
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Affiliation(s)
- Osnat Kaniel
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel;
| | - Shiri Sherf-Dagan
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel 40700, Israel; (S.S.-D.); (Y.K.)
- Department of Nutrition, Assuta Medical Center, Tel Aviv 69710, Israel
| | - Amir Szold
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
| | - Peter Langer
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
| | - Boris Khalfin
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (B.K.); (Y.M.)
| | - Yafit Kessler
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel 40700, Israel; (S.S.-D.); (Y.K.)
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
| | - Asnat Raziel
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
| | - Nasser Sakran
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
- Department of Surgery, Holy Family Hospital, Nazareth 16234, Israel
- The Azrieli Faculty of Medicine Safed, Bar-Ilan University, Ramat Gan 52900, Israel
| | - Yair Motro
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (B.K.); (Y.M.)
| | - David Goitein
- Assia Medical Group, Assuta Medical Center, Tel Aviv 69710, Israel; (A.S.); (P.L.); (A.R.); (N.S.); (D.G.)
- Department of Surgery C, Sheba Medical Center, Ramat Gan 52621, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (B.K.); (Y.M.)
- Correspondence: ; Tel.: +972-506-243-900
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21
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Kumar TK, Tewari M, Shukla SK, Mishra SP. Pancreatic exocrine insufficiency occurs in most patients following pancreaticoduodenectomy. Indian J Cancer 2022; 58:511-517. [PMID: 34975096 DOI: 10.4103/ijc.ijc_764_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Pancreatic exocrine insufficiency (PEI) is a well-defined complication of malignant diseases and pancreatic resection; however, study results of PEI are less consistent. Assessment of PEI by estimation of fecal elastase (FE)-1 in stool by enzyme-linked immunosorbent essay (ELISA) is a relatively inexpensive, noninvasive, and simple test. This study assessed exocrine function of pancreas following pancreaticoduodenectomy (PD) by estimating FE-1. Methods This prospective hospital-based study involved 30 patients who had undergone PD for malignancy. All 30 patients had an uneventful postoperative period under the unit's enhanced recovery after surgery (ERAS) protocol with no Grade B, C postoperative pancreatic fistula/postpancreatectomy hemorrhage as per the International Study Group of Pancreatic Surgery (ISGPS) definitions. Stool samples were collected postoperatively 3 months after surgery from all patients irrespective of clinical symptoms. The analysis was based on a solid phase ELISA used for the quantitative determination of human elastase 1 in feces. Fecal elastase was considered normal if >200 μg/gm stool, moderately reduced if 100-200 μg/gm stool, and severely reduced if <100 μg/gm stool. Results Among 30 patients included, fecal elastase levels were moderately reduced in 10 (33.33%) and severely reduced in 20 (66.67%) patients (P <0.0001). Mean (± standard deviation) of fecal elastase was 87.12 ± 38.76 with median of 74.6 μg/gm stool. There was no significant difference in the fecal elastase levels between men and women (P = 0.057), age (P = 0.48), pancreatic duct diameter (P = 0.609), pancreatic texture (P = 0.286), and presence or absence of clinical symptoms (P = 0.181). Conclusions PD was frequently associated with PEI. Unfortunately PEI is an under recognized and under treated long-term sequel of PD. Fecal elastase 1 should be performed routinely in both symptomatic and asymptomatic patients. Pancreatic enzyme replacement therapy should be considered in every patient after PD.
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Affiliation(s)
- Thogari K Kumar
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Mallika Tewari
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S K Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S P Mishra
- Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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22
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Vobugari N, Kim J, Gandhi KD, Lee ZE, Smith HP. Iron-Storage Disorder Presenting as Chronic Diarrhea. Cureus 2021; 13:e18864. [PMID: 34804717 PMCID: PMC8598083 DOI: 10.7759/cureus.18864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/15/2022] Open
Abstract
The involvement of the endocrine pancreas leading to bronze diabetes is well studied. However, little is known about the pathophysiology of iron dysregulation involving the exocrine pancreas. We present a unique association between the exocrine pancreas and iron dysregulation. A 45-year-old female presented with chronic diarrhea and low fecal elastase indicative of pancreatic exocrine dysfunction. MRI of the abdomen/pelvis showed iron deposition in the pancreas, suggesting an associated iron-storage disorder without features suggesting chronic pancreatitis. Association of an iron-storage disorder with pancreatic exocrine dysfunction has been reported only in one other case report. Pancreatic exocrine dysfunction can be directly associated with an iron-storage disorder that involves the pancreas. This should be included in the differential and diagnostic work-up of chronic diarrhea of unclear etiology. Based on the literature, we have highlighted the potential pathophysiology relevant to the case.
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Affiliation(s)
- Nikitha Vobugari
- Internal medicine, MedStar Washington Hospital Center, Washington, D.C., USA
| | - Jeffrey Kim
- Gastroenterology and Hepatology, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Kejal D Gandhi
- Internal Medicine, MedStar Washington Hospital Center, Washington, D.C., USA
| | - Zone-En Lee
- Gastroenterology and Hepatology, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Hedy P Smith
- Hematology and Medical Oncology, MedStar Washington Hospital Center, Washington, D.C., USA
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23
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Alshammari M, Aljohani MA, Hashash JM, Alsaedi HA, Alobaidi WY, Alhuzali NK, Alnumani MS, Alrashidi AH, Al-Battniji SA, Alotaibi NA, Alhumaidi NK, Alajaimi AN, Alqurashi RS, Albishri AT, Alshammari KH. Shwachman-Diamond Syndrome in a Child Presenting With Chronic Diarrhea: A Rare Case in Family Medicine Practice. Cureus 2021; 13:e19391. [PMID: 34925993 PMCID: PMC8654133 DOI: 10.7759/cureus.19391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/18/2022] Open
Abstract
Diarrhea remains an important cause of morbidity and mortality worldwide. Chronic diarrhea often represents a diagnostic challenge for family medicine and pediatric physicians because of its broad spectrum of possible etiologies. The differential diagnoses can be narrowed by taking a detailed history and performing an appropriate physical examination. In general, chronic diarrhea can be due to osmotic, secretory, inflammatory, or dysmotility-related pathologies. We present the case of a 30-month-old male who was brought to the family medicine clinic with a complaint of abdominal bloating and persistent diarrhea after every feeding for four months. His stools were foul-smelling and occurred more than four times a day. The patient was below the second standard deviations for weight and height. He appeared pale, and there was no scleral icterus. The patient underwent upper endoscopy, which showed no abnormal gross findings. A dedicated abdominal computed tomography scan was performed to evaluate the pancreas for any structural abnormalities. The scan demonstrated complete replacement of the pancreatic parenchyma by fatty tissue. The diagnosis of Shwachman-Diamond syndrome was established as the analysis revealed a mutation in the SBDS gene. The patient was treated with pancreatic enzyme replacement therapy. After two months of follow-up, the parents reported that the patient had significant improvement in diarrhea. Shwachman-Diamond syndrome is a very rare inherited disorder characterized by bone marrow failure, exocrine pancreatic dysfunction, and skeletal abnormalities. Despite its rarity, clinicians should keep a high index for this condition when they encounter a child with unexplained chronic diarrhea.
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Affiliation(s)
- Malak Alshammari
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Joud M Hashash
- College of Medicine, Batterjee Medical College, Jeddah, SAU
| | | | | | | | - Mohammed S Alnumani
- College of Medicine, King Saud bin Abdulaziz University For Health Sciences, Riyadh, SAU
| | - Asrar H Alrashidi
- College of Medicine, King Saud bin Abdulaziz University For Health Sciences, Riyadh, SAU
| | | | | | | | | | - Rawabi S Alqurashi
- College of Medicine, Princess Nourah Bint Abdul Rahman University, Riyadh, SAU
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24
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Abstract
OBJECTIVES Pancreatic exocrine insufficiency (PEI) is prevalent in diabetes. Pathophysiological theories imply autoimmune destruction, lack of trophic effects of insulin or impaired neuronal stimulation, but the relationship between PEI and autonomic dysfunction is largely unknown. In a pilot study, we aimed to investigate if patients with diabetes and PEI had impaired autonomic function. METHODS We measured faecal elastase in 59 patients with type 1 or 2 diabetes, using a cut-off-value <200 μg/g to define PEI. Based on faecal elastase results, patients were stratified into matched case (n = 8) and control groups (n = 13). We used heart rate variability, baroreflex sensitivity and orthostatic hypotension tests to assess autonomic dysfunction. RESULTS All baroreflex sensitivity parameters were reduced in cases with PEI compared with controls (all p < .05). The heart rate variability parameters root mean square of successive RR interval differences (p = .05) and high frequency (p = .04) were also reduced. We found no difference in orthostatic hypotension between the groups. CONCLUSIONS In this first-of-its-kind study, we found that diabetes patients with PEI had reduced autonomic function compared with matched controls. Although numbers are small, results support the hypothesis that autonomic dysfunction could be a contributor to PEI in diabetes.
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Affiliation(s)
- Dag André Sangnes
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | | | - Rose Marie Moss
- Department of Clinical Medicine, University of Bergen, Norway
| | - Trond Engjom
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | - Eirik Søfteland
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway.,Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
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25
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Ammar K, Leeds JS, Ratnayake CB, Sen G, French JJ, Nayar M, Oppong KW, Loveday BP, Pandanaboyana S. Impact of pancreatic enzyme replacement therapy on short- and long-term outcomes in advanced pancreatic cancer: meta-analysis of randomized controlled trials. Expert Rev Gastroenterol Hepatol 2021; 15:941-948. [PMID: 33522321 DOI: 10.1080/17474124.2021.1884544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objectives: We analyzed randomized controlled trials (RCTs) to assess the impact of PERT on weight change, quality of life, and overall survival (OS) in patients with advanced pancreatic cancer (APC).Methods: All RCTs indexed in PubMed, Medline and Scopus, databases reporting PEI in APC and the effect of PERT were included up to August 2020. The primary outcome measure was OS and the secondary outcome measures were weight change and quality of life.Results: Four RCTs including 194 patients (107 males) were analyzed. Ninety-eight (50.5%) patients received PERT treatment. Treatment with PERT did not show a significant effect on OS (SMD 0.12, 95% confidence interval -0.46-0.70, p = 0.46). There was no difference in change in body weight (SMD 0.53, 95% confidence interval -0.72-1.77, p = 0.21). Quality of life was not significantly different in those taking PERT compared to controls.Conclusions: This meta-analysis found no significant difference in OS, change in weight or quality of life with use of PERT in APC. However, non-uniform designs and different end points , along with smaller number of patients, limit a more in-depth analysis of outcomes. Further, RCTs are warranted to support evidence of routine use of PERT in APC.
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Affiliation(s)
- Khaled Ammar
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El Kom, Egypt
| | - John S Leeds
- Department of HPB Endoscopy, Freeman Hospital, Newcastle Upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Chathura Bb Ratnayake
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Gourab Sen
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Manu Nayar
- Department of HPB Endoscopy, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Kofi W Oppong
- Department of HPB Endoscopy, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Benjamin Pt Loveday
- Department of General Surgery, Royal Melbourne Hospital, Victoria, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK.,Population Health Sciences Institute, Newcastle University, Newcastle, UK
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26
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Khan M, Rutkowski W, Vujasinovic M, Löhr JM. Adherence to European Guidelines for Treatment and Management of Pancreatic Exocrine Insufficiency in Chronic Pancreatitis Patients. J Clin Med 2021; 10:jcm10122737. [PMID: 34205772 PMCID: PMC8233716 DOI: 10.3390/jcm10122737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 12/16/2022] Open
Abstract
European evidence-based guidelines for the treatment and management of chronic pancreatitis (CP) have been made available following the harmonizing diagnosis and treatment of CP across Europe (HaPanEU) initiative by the United European Gastroenterology (UEG). The aim of this study was to evaluate adherence to the guideline recommendations in the management of patients with pancreatic exocrine insufficiency (PEI) at Karolinska University Hospital in Stockholm. UEG guideline recommendations were evaluated and categorized into 55 different quality indicators (QIs). Data from a retrospective cohort of CP patients being treated at Karolinska University Hospital were evaluated with regard to overall adherence as well as adherence to specific QIs. A total number of 118 patients out of 956 patients diagnosed with CP were eligible for inclusion with mean overall adherence of 61.9% to the defined QIs. A significant difference in mean overall adherence was shown between patients diagnosed with CP prior to 1 January 2016 and following 1 January 2016 (59.3% and 67.7% respectively, p = 0.004), with linear regression analysis also demonstrating improvement correlating to date of diagnosis (p = 0.002). In conclusion, diagnosis and treatment of PEI improved after the HaPanEU guidelines became available and is continuously improving; however, there is room for further improvement.
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Affiliation(s)
- Mashroor Khan
- Department of Medicine Huddinge, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden; (M.K.); (M.V.)
| | - Wiktor Rutkowski
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, SE-141 86 Stockholm, Sweden;
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine Huddinge, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden; (M.K.); (M.V.)
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
| | - Johannes Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, SE-141 86 Stockholm, Sweden;
- Department of Clinical Science, Innovation and Technology, Karolinska Institutet, Huddinge, SE-141 86 Stockholm, Sweden
- Correspondence: ; Tel.: +46-8-5858-9591
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27
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Abstract
Acute inflammation of the pancreas, known as pancreatitis, can result in many complications ranging from acute distress respiratory syndrome to pancreatic necrosis. A relatively common vascular complication of pancreatitis is splenic vein thrombosis (SVT) due to intimal inflammation leading to platelet aggregation and thrombosis. The management of SVT with regard to anticoagulation (AC) might appear to be perplexing at first given the recommendation to withhold any sort of AC. Research studies have shown that these patients have an increased risk of gastrointestinal bleeding without AC. In this report, we discuss a case of hypertriglyceridemia-induced pancreatitis. During hospitalization, our patient complained of worsening abdominal pain with objective fevers and leukocytosis in which CT scan of the abdomen was significant for hemorrhagic pancreatitis with necrosis, acute SVT, and splenomegaly. The patient was managed conservatively with IV fluids, pain relief medications, and antibiotics.
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Affiliation(s)
- Chidinma Ejikeme
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - Sherif Elkattawy
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | | | - Abraheim Al-Nasseri
- Internal Medicine, St. George's University School of Medicine, Elizabeth, USA
| | - Arun Naik
- Gastroenterology, Trinitas Regional Medical Center, Elizabeth, USA
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28
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Keller J, Hammer HF, Afolabi PR, Benninga M, Borrelli O, Dominguez-Munoz E, Dumitrascu D, Goetze O, Haas SL, Hauser B, Pohl D, Salvatore S, Sonyi M, Thapar N, Verbeke K, Fox MR. European guideline on indications, performance and clinical impact of 13 C-breath tests in adult and pediatric patients: An EAGEN, ESNM, and ESPGHAN consensus, supported by EPC. United European Gastroenterol J 2021; 9:598-625. [PMID: 34128346 PMCID: PMC8259225 DOI: 10.1002/ueg2.12099] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction 13C‐breath tests are valuable, noninvasive diagnostic tests that can be widely applied for the assessment of gastroenterological symptoms and diseases. Currently, the potential of these tests is compromised by a lack of standardization regarding performance and interpretation among expert centers. Methods This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of 13C‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 43 experts from 18 European countries. Consensus on individual statements and recommendations was established if ≥ 80% of reviewers agreed and <10% disagreed. Results The guideline gives an overview over general methodology of 13C‐breath testing and provides recommendations for the use of 13C‐breath tests to diagnose Helicobacter pylori infection, measure gastric emptying time, and monitor pancreatic exocrine and liver function in adult and pediatric patients. Other potential applications of 13C‐breath testing are summarized briefly. The recommendations specifically detail when and how individual 13C‐breath tests should be performed including examples for well‐established test protocols, patient preparation, and reporting of test results. Conclusion This clinical practice guideline should improve pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, this guideline identifies areas of future clinical research involving the use of 13C‐breath tests.
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Affiliation(s)
- Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital University of Hamburg, Hamburg, Germany
| | - Heinz F Hammer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Paul R Afolabi
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK
| | - Enrique Dominguez-Munoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago, Spain
| | | | - Oliver Goetze
- Department of Medicine II, Division of Hepatology, University Hospital Würzburg, Würzburg, Germany
| | - Stephan L Haas
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussels, Brussels, Belgium
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Marc Sonyi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria.,Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK.,Department of Gastroenterology, Hepatology and Liver Transplantation, Queensland Children's Hospital, Brisbane, Australia
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Mark R Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
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Cañamares-Orbis P, Bernal-Monterde V, Sierra-Gabarda O, Casas-Deza D, Garcia-Rayado G, Cortes L, Lué A. Impact of Liver and Pancreas Diseases on Nutritional Status. Nutrients 2021; 13:1650. [PMID: 34068295 PMCID: PMC8153270 DOI: 10.3390/nu13051650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/02/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022] Open
Abstract
Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an adequate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow-up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and the efficacy of nutritional interventions in these settings.
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Affiliation(s)
- Pablo Cañamares-Orbis
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
| | - Vanesa Bernal-Monterde
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Olivia Sierra-Gabarda
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Diego Casas-Deza
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Guillermo Garcia-Rayado
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Luis Cortes
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Alberto Lué
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
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Sanjeevi R, Jamwal KD, Dhar Chowdhury S, Ramadass B, Gayathri R, Dutta AK, Joseph Joseph A, Ramakrishna BS, Chacko A. Assessment of small intestinal bacterial overgrowth in chronic pancreatitis patients using jejunal aspirate culture and glucose hydrogen breath test. Scand J Gastroenterol 2021; 56:588-593. [PMID: 33730978 DOI: 10.1080/00365521.2021.1900383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A subset of chronic pancreatitis patients respond poorly to pancreatic enzyme replacement therapy. Small intestinal bacterial overgrowth (SIBO) is considered to be one of the major reasons for this poor response. Previous studies have reported a wide range of prevalence of SIBO in patients with chronic pancreatitis. We aimed to assess the prevalence of SIBO in chronic pancreatitis using quantitative jejunal aspirate culture and glucose hydrogen breath test (GHBT). The sensitivity and specificity of GHBT for the diagnosis of SIBO in chronic pancreatitis were also estimated. METHODS Newly diagnosed chronic pancreatitis patients were recruited into the study. A detailed history and relevant laboratory tests were done. All patients underwent an endoscopy and jejunal fluid aspiration for bacterial cultures and GHBT to detect SIBO. The results of GHBT were compared with jejunal fluid aspirate culture. RESULTS The jejunal aspirate culture was positive in 18/48 (37.5%) patients while the GHBT showed that 14/48 (29%) patients had SIBO. The sensitivity, specificity, positive and negative predictive value of GHBT in our study was 44.4, 80, 57.14 and 70.59%, respectively. CONCLUSIONS SIBO is not uncommon in chronic pancreatitis patients. One-third of our study population had SIBO. GHBT has low sensitivity but had high specificity in the diagnosis of SIBO in chronic pancreatitis.
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Affiliation(s)
| | | | | | | | - R Gayathri
- Christian Medical College, Vellore, India
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Powell-Brett S, Pande R, Roberts KJ. Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:1669. [PMID: 33916294 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Liu Y, Zhang H, Zhou L, Li W, Yang L, Li W, Li K, Liu X. Immunotherapy-Associated Pancreatic Adverse Events: Current Understanding of Their Mechanism, Diagnosis, and Management. Front Oncol 2021; 11:627612. [PMID: 33732647 PMCID: PMC7959713 DOI: 10.3389/fonc.2021.627612] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) such as anti-programmed death-1 (PD-1) and its ligand PD-L1 and anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4) monoclonal antibodies, are involved in T cell-mediated immune response augmentation and promote anti-tumor immunity. Cancer patients treated with combination of immunotherapy, chemotherapy, radiotherapy, and targeted therapy exhibit superior clinical outcomes and tolerance compared with patients treated with monotherapies. However, immutherapy is associated with several concomitant immune-related adverse events (irAEs). For instance, IrAEs interferes with function of gastrointestinal tract, endocrine, dermatological, nervous system and musculoskeletal systems. ICIs-associated pancreatic injury might causes decrease in endocrine and exocrine pancreatic function, resulting in metabolic and nutritional disorders. Clinicians who administer immune checkpoint inhibitors to cancer patients are diagnosed with hyperglycemia, abdominal pain and steatorrhea. Currently, the precise mechanism of ICIs-associated pancreatic injury has not been fully explored. This paper summarizes incidence, diagnosis, clinical characteristics, potential mechanisms, and treatment management patterns of ICIs-associated pancreatic AEs based on previous studies. In addition, possible management approaches of these adverse effects are presented in this paper. in the findings summarized in this paper lay a basis for management of ICIs-associated pancreatic AEs and expanding future immunotherapy applications.
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Affiliation(s)
- Ya Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhou
- Core Facilities, West China Hospital, Sichuan University, Chengdu, China
| | - Weichun Li
- CAAC Academy, Civil Aviation Flight University of China, Guanghan, China
| | - Le Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Li
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kezhou Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Paragomi P, Phillips AE, Machicado JD, Lahooti A, Kamal A, Afghani E, Pothoulakis I, Reynolds SL, Mays M, Conwell DL, Lara LF, Singh VK, Papachristou GI. Post-Acute Pancreatitis Pancreatic Exocrine Insufficiency: Rationale and Methodology of a Prospective, Observational, Multicenter Cohort Study. Pancreas 2021; 50:147-152. [PMID: 33565790 PMCID: PMC9194920 DOI: 10.1097/mpa.0000000000001743] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We describe the methodology of Post-Acute Pancreatitis Pancreatic Exocrine Insufficiency (PAPPEI), a prospective, observational, multicenter cohort study. The objectives of PAPPEI are to estimate the incidence rate of post-acute pancreatitis (AP) pancreatic exocrine insufficiency (PEI), define factors that determine the development of post-AP PEI, and evaluate the impact of post-AP PEI on nutritional status and quality of life. METHODS Enrollment started in June 2017 in 3 expert academic centers in the United States. Data were collected during hospitalization (baseline) at 3 and 12 months after enrollment. Fecal elastase-1 was used to assess PEI. Study questionnaires are completed by patient interview and review of electronic medical records. Blood is obtained to evaluate vitamin deficiencies and nutritional markers. RESULTS As of August 2020, 77 subjects have completed the baseline evaluation. The median age was 58 years (interquartile range, 39-67 years), 38% were male, and 90% were white. The etiology of AP was biliary in 39 subjects (51%), and 51 subjects (66%) had mild AP. Three- and 12-month follow-up data have been collected in 29 and 13 subjects, respectively. CONCLUSION The PAPPEI study aims to expand our understanding of post-AP PEI incidence, including its impact on nutritional status and quality of life.
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Affiliation(s)
- Pedram Paragomi
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anna Evans Phillips
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jorge D. Machicado
- Department of Gastroenterology, Mayo Clinic Heath System, Eau Claire, WI
| | - Ali Lahooti
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Internal Medicine, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Ayesha Kamal
- Division of Gastroenterology, Department of Medicine, John Hopkins Medical Institutions, Baltimore, MD
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, John Hopkins Medical Institutions, Baltimore, MD
| | - Ioannis Pothoulakis
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC
- Division of Gastroenterology, Department of Medicine, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA
| | - Shari L. Reynolds
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melanie Mays
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Internal Medicine, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Luis F. Lara
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Internal Medicine, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Vikesh K. Singh
- Division of Gastroenterology, Department of Medicine, John Hopkins Medical Institutions, Baltimore, MD
| | - Georgios I. Papachristou
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Internal Medicine, Ohio State University, Wexner Medical Center, Columbus, OH
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Suzuki M, Minowa K, Isayama H, Shimizu T. Acute recurrent and chronic pancreatitis in children. Pediatr Int 2021; 63:137-149. [PMID: 32745358 DOI: 10.1111/ped.14415] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/27/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.
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Affiliation(s)
- Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kei Minowa
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
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Valente R, Waldthaler A, Scandavini CM, Vujasinovic M, Del Chiaro M, Arnelo U, Löhr JM. Conservative Treatment of Chronic Pancreatitis: A Practical Approach. Scand J Surg 2021; 109:59-68. [PMID: 32192418 DOI: 10.1177/1457496920905559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications. MATERIALS AND METHODS In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis. RESULTS Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers. CONCLUSIONS Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.
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Affiliation(s)
- R Valente
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A Waldthaler
- Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - C M Scandavini
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - M Vujasinovic
- CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - U Arnelo
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - J-M Löhr
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
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Suzuki M, Minowa K, Nakano S, Isayama H, Shimizu T. Genetic Abnormalities in Pancreatitis: An Update on Diagnosis, Clinical Features, and Treatment. Diagnostics (Basel) 2020; 11:E31. [PMID: 33375361 DOI: 10.3390/diagnostics11010031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/12/2020] [Accepted: 12/22/2020] [Indexed: 02/07/2023] Open
Abstract
Several pancreatitis susceptibility genes have been identified to date. A relationship between a mutation in the cationic trypsinogen (protease serine 1, PRSS1) gene and hereditary pancreatitis (HP) was first identified in 1996. Currently, HP has been defined as either two or more individuals within a family exhibiting pancreatitis for two or more generations, or pancreatitis linked to mutation of the PRSS1 gene. In 2000, a mutation in the serine protease inhibitor gene (Kazal type 1: SPINK1) was reported to be related to sporadic pancreatitis of unknown etiology. This paper reviews and summarizes the current published data on the pancreatitis susceptibility genes, mainly PRSS1 and SPINK1 genes, and introduces a diagnostic and therapeutic approach for dealing with patients with these gene mutations. Patients with these genetic predispositions, both children and adults, have often been initially diagnosed with idiopathic acute pancreatitis, in approximately 20-50% of pediatric cases and 28-80% of adult cases. In such patients, where the etiology is unknown, genetic testing, which requires pre-test and post-test genetic counselling, may prove helpful. Patients with chronic pancreatitis (CP) due to SPINK1 gene mutation and HP patients have a potentially high risk of pancreatic exocrine insufficiency, diabetes mellitus, and, of particular importance, pancreatic cancer. Thus, these patients require careful long-term follow-up and management. Specifically, symptomatic CP patients often need endoscopic therapy or surgery, often following a step-up approach beginning with endoscopic therapy and progressing to surgery if necessary, which is similar to the therapeutic approach for patients with CP due to other etiologies. It is important that clinicians are aware of the characteristics of patients with pancreatitis susceptibility genetic abnormalities.
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de Rijk FE, Kempeneers MA, Bruno MJ, Besselink MG, van Goor H, Boermeester MA, van Geenen EJ, van Hooft JE, van Santvoort HC, Verdonk RC. Suboptimal care for chronic pancreatitis patients revealed by moderate to low adherence to the United European Gastroenterology evidence-based guidelines (HaPanEU): A Netherlands nationwide analysis. United European Gastroenterol J 2020; 8:764-774. [PMID: 32588790 PMCID: PMC7435004 DOI: 10.1177/2050640620937610] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and objective The 2016, United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU) provided evidence-based recommendations for the management of chronic pancreatitis and allowed for the objective evaluation of the quality of care in several domains of disease management through assessment of guideline adherence. Therefore, the aim of this study is to evaluate the current level and the variety of care for chronic pancreatitis patients in the Netherlands using the HaPanEU guidelines as a reference standard. The majority of these patients were diagnosed before the publication of these guidelines. Therefore, in most patients, the results of the present study with respect to those recommendations regarding the diagnostic process of chronic pancreatitis represent guideline correspondence and not adherence. Methods A subgroup of patients from the Dutch nationwide chronic pancreatitis registry (CARE) was included in a retrospective cross-sectional observational cohort study. A total of 39 recommendations concerning the non-invasive management of chronic pancreatitis were appointed as quality indicators (QIs). Per patient, the number of relevant QIs was determined and guideline adherence was assessed. Data were analyzed to identify factors associated with guideline adherence. Results Overall, 97 patients with chronic pancreatitis from 11 hospitals were included. Per patient, a mean number of 26 relevant QIs was applicable, with an average adherence rate of 53%. In 45% of the patients, guideline adherence was less than 50%. The majority of suboptimal managed QIs concerned the management of chronic pancreatitis complications. Guideline adherence was not associated with hospital type, sex, age or etiology of pancreatitis. Conclusion In the Netherlands, adherence to the HaPanEU recommendations for the management of chronic pancreatitis is moderate to low for all non-invasive domains, which may indicate suboptimal care for these patients. Closer guideline adherence could improve the level of care and the clinical outcomes of these patients. A nationwide approach to increase awareness of the key guideline recommendations among clinicians and patients is needed.
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Affiliation(s)
- Florence Em de Rijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Research and Development, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marc Gh Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Erwin Jm van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
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Ashihara N, Watanabe T, Kako S, Kuraishi Y, Ozawa M, Shigefuji S, Kanai K, Usami Y, Yamada A, Umemura T, Fujinaga Y. Correlation of Pancreatic T1 Values Using Modified Look-Locker Inversion Recovery Sequence (MOLLI) with Pancreatic Exocrine and Endocrine Function. J Clin Med 2020; 9:E1805. [PMID: 32531933 DOI: 10.3390/jcm9061805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023] Open
Abstract
Quantifying myocardial T1 values has been useful for detecting and characterizing fibrotic appearance in myocardial infarction, focal scars, and non-ischemic cardiomyopathies. Since pancreatic exocrine function decreases with chronic pancreatic fibrosis advancement, this study examined the correlation between pancreatic T1 values and pancreatic exocrine and endocrine insufficiency. METHODS Thirty-two patients underwent abdominal contrast-enhanced MRI in our department between October 2017 and February 2019. We evaluated the T1 values of the pancreas using a modified Look-Locker inversion recovery sequence (MOLLI), pancreatic exocrine insufficiency (PEI) by fecal elastase 1 (FE1) values, and pancreatic endocrine insufficiency using fasting insulin and blood glucose levels to calculate the HOMA-β. This trial is registered in the UMIN Clinical Trials Registry as UMIN 000030067. RESULTS The median cohort (9 males and 23 females) age was 71 (range: 49-84) years. Eighteen patients had pancreatic cysts, three had alcohol-induced chronic pancreatitis, three had pancreatic cancer, and eight possessed other pancreatic features (two patients each with autoimmune pancreatitis, acute pancreatitis, or a bile duct tumor, one with idiopathic chronic pancreatitis, and one healthy control with negative findings). The median pancreatic T1 value measured by the MOLLI was 857.5 ms (597-2569). A significant negative correlation was found between the T1 mapping and FE1 values (r = 0.69, p < 0.01), with none for the T1 with HOMA-β or serum albumin, triglycerides, or body mass index. CONCLUSIONS the pancreatic T1 values correlated significantly with pancreatic exocrine function and might be useful in PEI diagnosis.
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Dugic A, Nikolic S, Mühldorfer S, Bulajic M, Pozzi Mucelli R, Tsolakis AV, Löhr JM, Vujasinovic M. Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases. Scand J Gastroenterol 2020; 55:517-527. [PMID: 32393143 DOI: 10.1080/00365521.2020.1760345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear.Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019.Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant.Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted.
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Affiliation(s)
- Ana Dugic
- Department of Internal Medicine, Clinic for Gastroenterology, Endocrinology and Metabolic Disorders, Bayreuth, Germany.,Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Sara Nikolic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Steffen Mühldorfer
- Department of Internal Medicine, Clinic for Gastroenterology, Endocrinology and Metabolic Disorders, Bayreuth, Germany
| | - Milutin Bulajic
- Gastroenterology and Digestive Endoscopy Department, Mater Olbia Hospital, Olbia, Italy
| | - Raffaella Pozzi Mucelli
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Apostolos V Tsolakis
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna (MedS, K2), Division of Clinical Medicine, Karolinska Institute, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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40
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Pezzilli R, Caccialanza R, Capurso G, Brunetti O, Milella M, Falconi M. Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer. Cancers (Basel). 2020;12. [PMID: 31979186 DOI: 10.3390/cancers12020275] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.
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41
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Desbuissons G, Izzedine H, Bardier A, Dubreuil O, Vaillant JC, Frochot V, Mercadal L. Oxalate nephropathy is a major cause of kidney injury in surgically treated pancreatic adenocarcinoma patients. Clin Kidney J 2019; 12:821-828. [PMID: 31807294 PMCID: PMC6885689 DOI: 10.1093/ckj/sfz015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Indexed: 12/03/2022] Open
Abstract
Background Despite new therapeutics, the prognosis for pancreatic cancer remains poor. Pancreatic surgery is a therapeutic option in non-metastatic forms. The consequences for renal function are poorly described. Methods Patients who underwent surgery for pancreatic cancer between 1 January 2010 and 1 January 2017 and who experienced kidney biopsy in the Pitié-Salpêtrière Hospital were analysed. Results Two hundred and ninety-four patients had pancreatic surgery during the period of analysis and five of them had a kidney biopsy (mean ± SD 20 months ±13.6 months after surgery) during the post-operative follow-up. Among these patients, three exhibited oxalate nephropathy (ON), indicating that the prevalence of ON in patients with pancreatectomy is at least 1%. ON may be insidious, with chronic renal failure without urinary abnormalities. All patients had a high oxalate-to-creatinine ratio in urine sample. Renal function improved after specific management of ON in two patients. Pancreaticoduodenectomy may represent a higher risk of ON than left pancreatectomy. Conclusion Although rare and underestimated, ON appears to be a real risk after pancreatic resection. Early detection may preserve renal function.
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Affiliation(s)
- Geoffroy Desbuissons
- Nephrology Department, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France.,Division of Nephrology, RAMSAY-Générale de Santé, Hôpital privé de l'Ouest Parisien, Trappes, France
| | - Hassan Izzedine
- Nephrology Department, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France.,Division of Oncology, RAMSAY-Générale de Santé, Hôpital Privé Les Peupliers, Paris, France
| | - Armelle Bardier
- Pathology Department, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Olivier Dubreuil
- Oncology Department, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Jean Christophe Vaillant
- Department of Hepato Pancreato Biliary Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Vincent Frochot
- Physiology Unit, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Lucile Mercadal
- Nephrology Department, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
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42
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Andreasi V, Partelli S, Capurso G, Muffatti F, Balzano G, Crippa S, Falconi M. Long-Term Pancreatic Functional Impairment after Surgery for Neuroendocrine Neoplasms. J Clin Med 2019; 8:jcm8101611. [PMID: 31623399 PMCID: PMC6832294 DOI: 10.3390/jcm8101611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022] Open
Abstract
Radical surgery represents the only curative treatment for pancreatic neuroendocrine neoplasms (PanNEN). The aim of this study was to evaluate the postoperative onset of diabetes mellitus (DM) and/or pancreatic exocrine insufficiency (PEI) in surgically treated PanNEN. Consecutive PanNEN patients, without preoperative DM, who underwent partial pancreatic resection, were included. After a median follow-up of 72 months, overall 68/276 patients (24%) developed DM. Patients who developed DM were significantly older (p = 0.002) and they had a higher body mass index (BMI) (p < 0.0001) than those who did not; they were more frequently male (p = 0.017) and with nonfunctioning neoplasms (p = 0.019). BMI > 25 Kg/m2 was the only independent predictor of DM (p = 0.001). Overall, 118/276 patients (43%) developed a PEI, which was significantly more frequent after pancreaticoduodenectomy (p < 0.0001) and in patients with T3-T4 tumors (p = 0.001). Pancreaticoduodenectomy was the only independent predictor of PEI (p < 0.0001). Overall, 54 patients (20%) developed disease progression. Patients with and without DM had similar progression free survival (PFS), whereas patients without PEI had better five-year-PFS (p = 0.002), although this association was not confirmed in multivariate analysis. The risk of DM and PEI after surgery for PanNEN is relatively high but it does not affect PFS. BMI and pancreatic head resection are independent predictors of DM and PEI, respectively.
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Affiliation(s)
- Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Gabriele Capurso
- Biliopancreatic Endoscopy Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Gianpaolo Balzano
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy.
- Faculty of Medicine and Surgery, "Vita-Salute San Raffaele" University, 20132 Milan, Italy.
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Ribichini E, Stigliano S, Rossi S, Zaccari P, Sacchi MC, Bruno G, Badiali D, Severi C. Role of Fibre in Nutritional Management of Pancreatic Diseases. Nutrients 2019; 11:nu11092219. [PMID: 31540004 PMCID: PMC6770015 DOI: 10.3390/nu11092219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022] Open
Abstract
The role of fibre intake in the management of patients with pancreatic disease is still controversial. In acute pancreatitis, a prebiotic enriched diet is associated with low rates of pancreatic necrosis infection, hospital stay, systemic inflammatory response syndrome and multiorgan failure. This protective effect seems to be connected with the ability of fibre to stabilise the disturbed intestinal barrier homeostasis and to reduce the infection rate. On the other hand, in patients with exocrine pancreatic insufficiency, a high content fibre diet is associated with an increased wet fecal weight and fecal fat excretion because of the fibre inhibition of pancreatic enzymes. The mechanism by which dietary fibre reduces the pancreatic enzyme activity is still not clear. It seems likely that pancreatic enzymes are absorbed on the fibre surface or entrapped in pectin, a gel-like substance, and are likely inactivated by anti-nutrient compounds present in some foods. The aim of the present review is to highlight the current knowledge on the role of fibre in the nutritional management of patients with pancreatic disorders.
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Affiliation(s)
- Emanuela Ribichini
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Serena Stigliano
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Sara Rossi
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Piera Zaccari
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Maria Carlotta Sacchi
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00161 Rome, Italy.
| | - Giovanni Bruno
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Danilo Badiali
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, Gastroenterology Unit, Sapienza University of Rome, 00161 Rome, Italy.
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Barkin JA, Westermann A, Hoos W, Moravek C, Matrisian L, Wang H, Shemanski L, Barkin JS, Rahib L. Frequency of Appropriate Use of Pancreatic Enzyme Replacement Therapy and Symptomatic Response in Pancreatic Cancer Patients. Pancreas 2019; 48:780-786. [PMID: 31210656 PMCID: PMC6749961 DOI: 10.1097/mpa.0000000000001330] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/20/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Pancreatic cancer (PC) and its treatments can result in pancreatic exocrine insufficiency that requires pancreatic enzyme replacement therapy (PERT). Appropriate PERT usage is during meals and snacks. The aim was to determine the frequency of appropriate use of PERT and its impact on symptom alleviation in PC through a patient-reported outcomes online platform. METHODS Users in the Pancreatic Cancer Action Network's Patient Registry were prompted to answer a standalone questionnaire about their experience with PERT. RESULTS Two hundred sixty-two users completed the PERT questionnaire (January 2016-January 2018). Patients who reported taking PERT with meals had higher alleviation of symptoms compared with those taking PERT prior to or after meals. Specifically, "feeling of indigestion," "light-colored or orange stools," and "visible food particles in stool" were significantly decreased. Patients taking PERT with meals reported weight gain and less weight loss. CONCLUSIONS Of the 89% of PC patients prescribed PERT, 65% were prescribed PERT appropriately with all meals and snacks. Overall compliance with PERT administration guidelines was low (50% [105/208]). Improvement in symptoms significantly correlated with appropriate use of PERT. Increase in PC patient and provider education about appropriate PERT usage and administration is warranted.
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Affiliation(s)
- Jodie A. Barkin
- From the Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL
| | - Amy Westermann
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | - William Hoos
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | | | - Lynn Matrisian
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
| | | | | | - Jamie S. Barkin
- From the Department of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL
| | - Lola Rahib
- Pancreatic Cancer Action Network, Manhattan Beach, CA; and
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45
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Malluta ÉF, Maluf-Filho F, Leite AZDA, Ortiz-Agostinho CL, Nishitokukado I, Andrade AR, Lordello MLL, dos Santos FM, Sipahi AM. Pancreatic endosonographic findings and clinical correlation in Crohn's disease. Clinics (Sao Paulo) 2019; 74:e853. [PMID: 31166473 PMCID: PMC6542499 DOI: 10.6061/clinics/2019/e853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.
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Affiliation(s)
- Éverson Fernando Malluta
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fauze Maluf-Filho
- Departamento de Gastroenterologia, Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, SP, BR
| | - André Zonetti de Arruda Leite
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Carmen Lucia Ortiz-Agostinho
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Iêda Nishitokukado
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Adriana Ribas Andrade
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Laura Lacava Lordello
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabiana Maria dos Santos
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aytan Miranda Sipahi
- Laboratorio de Gastroenterologia Clinica e Experimental, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
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46
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Erchinger F, Øvre AKN, Aarseth MM, Engjom T, Brønstad I, Dimcevski G, Gudbrandsen OA, Tjora E. Fecal fat and energy loss in pancreas exocrine insufficiency: the role of pancreas enzyme replacement therapy. Scand J Gastroenterol 2018; 53:1132-1138. [PMID: 30193081 DOI: 10.1080/00365521.2018.1499801] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Chronic pancreatitis (CP) can lead to severe pancreatic exocrine insufficiency (PEI). Pancreatic enzyme replacement therapy (PERT) is well established, but knowledge of the physiological response to increasing doses on fecal fat- and energy loss is scarce. METHODS We included 10 patients with CP and established PEI and 12 healthy controls for a prospective interventional study. Subjects received no PERT in the first week followed by four weeks PERT incrementally increasing doses every week. For each week, three-day stool collection followed three days registration of nutritional intake. We measured the fecal output of fat and energy by van de Kamer titration and decomposition vessel calorimetry, respectively. We calculated fecal fat- and energy loss per day, the coefficient of fat absorption (CFA) and coefficient of energy absorption (CEA). RESULTS Without PERT treatment, CP patients with PEI had significantly higher daily fecal fat and energy loss (p = .022; p = .035) compared to HC. In CP patients, there was a significant reduction of fecal fat and energy loss (p = .045; p = .037) when PERT doses reached maximum intake of 75,000 units per meal. In CP patients, there was a strong positive correlation between fecal loss of energy and fat (r = 0.99), and between fecal loss of energy and daily stool weight (r = 0.97). CFA and CEA correlated negatively with daily fecal fat loss (r = -0.72) and fecal energy loss (r = -0.65). CONCLUSIONS PERT reduces fecal energy and fat loss in patients with CP and PEI. Fecal energy loss in CP patients is strongly dependent on fecal fat loss, and on fecal weight.
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Affiliation(s)
- Friedemann Erchinger
- a Department of Medicine , Voss Hospital, Haukeland University Hospital , Voss , Norway.,b Department of Clinical Medicine , University of Bergen , Bergen , Norway
| | | | | | - Trond Engjom
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Ingeborg Brønstad
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,d National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway
| | - Georg Dimcevski
- b Department of Clinical Medicine , University of Bergen , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d National Centre for Ultrasound in Gastroenterology , Haukeland University Hospital , Bergen , Norway
| | | | - Erling Tjora
- e Department of Pediatrics , Haukeland University Hospital , Bergen , Norway.,f KG Jebsen center for Diabetes Research, Department of Clinical Science , University of Bergen , Bergen , Norway
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47
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Ikuse T, Kudo T, Arai K, Fujii Y, Ida S, Ishii T, Mushiake S, Nagata K, Tamai H, Toki A, Tomomasa T, Ushijima K, Yanagi T, Yonekura T, Taguchi T, Shimizu T. Shwachman-Diamond syndrome: Nationwide survey and systematic review in Japan. Pediatr Int 2018; 60:719-726. [PMID: 29804317 DOI: 10.1111/ped.13601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 12/11/2017] [Accepted: 05/24/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Shwachman-Diamond syndrome (SDS) is a rare multisystem disorder associated with exocrine pancreatic insufficiency. The present study reports the results of a nationwide survey and a systematic review on SDS to develop consensus guidelines for intractable diarrhea including SDS. METHODS Questionnaires were sent to 616 departments of pediatrics or of pediatric surgery in Japan in a nationwide survey. A second questionnaire was sent to doctors who had treated SDS patients and included questions on clinical information. Additionally, a systematic review was performed using digital literature databases to assess the influence of medical (i.e. non-surgical) treatment on SDS prognosis. RESULTS Answers were received from 529 institutions (85.9%), which included information on 24 patients with SDS (median age, 10.4 years; male, n = 15) treated from January 2005 to December 2014. Although 75% of patients received pancreatic enzyme replacement therapy, there was no significant association between treatment and prognosis. Systematic review identified one clinical practice guideline, two case series, eight case reports and 26 reviews. Patient information from those studies was insufficient for meta-analysis. CONCLUSIONS The rarity of SDS makes it difficult to establish evidence-based treatment for SDS. According to the limited information from patients and published reports, medical treatment for malabsorption due to SDS should be performed to improve fat absorption and stool condition, but it is not clear whether this treatment improves the prognosis of malabsorption.
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Affiliation(s)
- Tamaki Ikuse
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Takahiro Kudo
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Katsuhiro Arai
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshimitsu Fujii
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Division of Pediatrics, Department of Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Shinobu Ida
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Osaka Women's and Children's Hospital, Osaka, Japan
| | - Tomohiro Ishii
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatric Surgery, Kindai University Nara Hospital, Nara, Japan
| | - Sotaro Mushiake
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics, Kindai University Nara Hospital, Nara, Japan
| | - Kouji Nagata
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroshi Tamai
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - Akira Toki
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Division of Pediatric Surgery, Department of Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Takeshi Tomomasa
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,PAL Children's Clinic, Gunma, Japan
| | - Kosuke Ushijima
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
| | - Tadahiro Yanagi
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
| | - Takeo Yonekura
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatric Surgery, Kindai University Nara Hospital, Nara, Japan
| | - Tomoaki Taguchi
- Study Group for Rare and Intractable Chronic Gastrointestinal Diseases supported by Health Labour Sciences Research Grant, Ministry of Health Labour and Welfare, Tokyo, Japan.,Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Children's Medical Center, Kyushu University Hospital, Fukuoka, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University, Faculty of Medicine, Tokyo, Japan
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48
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Lamarca A, McCallum L, Nuttall C, Barriuso J, Backen A, Frizziero M, Leon R, Mansoor W, McNamara MG, Hubner RA, Valle JW. Somatostatin analogue-induced pancreatic exocrine insufficiency in patients with neuroendocrine tumors: results of a prospective observational study. Expert Rev Gastroenterol Hepatol 2018; 12:723-731. [PMID: 29923433 DOI: 10.1080/17474124.2018.1489232] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with advanced well-differentiated neuroendocrine tumours (Wd-NETs) are commonly treated with somatostatin analogues (SSAs). Some patients may develop SSA-related side effects such as pancreatic exocrine insufficiency (PEI). METHODS In this prospective, observational study, the frequency of SSA-induced PEI in 50 sequential patients with advanced Wd-NETs treated with SSAs was investigated. Toxicity was assessed monthly and faecal elastase-1 (FE1) and quality of life (QoL) were assessed 3-monthly. RESULTS The median age was 65.8 years, 58% were male and the majority (92%) of patients had metastatic disease; patients received 4-weekly long acting octreotide (60%) or lanreotide (40%). Twelve patients (24%) developed SSA-related PEI after a median of 2.9 months from SSA initiation; FE1 was a reliable screening tool for PEI, especially in symptomatic (abdominal bloating, flatulence and/or diarrhea) patients (risk ratio 8.25 (95% confidence interval 1.15-59.01)). Most of these patients (11/12; 92%) required PERT. Other SSA-related adverse events (any grade) included flatulence (50%), abdominal pain (32%), diarrhoea (30%) and fatigue (20%). Development of PEI did not significantly worsen overall QoL, however gastrointestinal symptoms and diarrhoea were increased. CONCLUSION This study demonstrated that PEI occurs at a higher rate than previously reported; clinicians need to diagnose and treat this SSA-related adverse-event which occurs in 1 in 4 patients with Wd-NETs treated with SSAs. Screening with FE1 in symtomatic patients is recommend.
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Affiliation(s)
- Angela Lamarca
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Lynne McCallum
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Christina Nuttall
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Jorge Barriuso
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK.,b Division of Cancer Sciences , University of Manchester , Manchester , UK
| | - Alison Backen
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Melissa Frizziero
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Rebecca Leon
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Was Mansoor
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Mairéad G McNamara
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK.,c Division of Cancer Sciences , University of Manchester, Manchester Academic Health Science Centre (MAHSC) , Manchester , UK
| | - Richard A Hubner
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK
| | - Juan W Valle
- a Department of Medical Oncology , European Neuroendocrine Tumour Society (ENETS) Centre of Excellence, The Christie NHS Foundation Trust , Manchester , UK.,c Division of Cancer Sciences , University of Manchester, Manchester Academic Health Science Centre (MAHSC) , Manchester , UK
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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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50
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Kostopoulou E, Shah P, Ahmad N, Semple R, Hussain K. Gastrointestinal dysmotility and pancreatic insufficiency in 2 siblings with Donohue syndrome. Pediatr Diabetes 2017; 18:839-843. [PMID: 28004474 DOI: 10.1111/pedi.12483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/23/2016] [Accepted: 11/13/2016] [Indexed: 01/02/2023] Open
Abstract
Donohue syndrome is a rare congenital syndrome of insulin-resistance and abnormal glucose homeostasis, caused by mutations in the insulin receptor (INSR) gene. It is characterized by specific phenotypic and clinical features and the diagnosis is based on clinical, biochemical and genetic criteria. We report 2 siblings with Donohue syndrome (cases 1, 2) with multiple clinical and biochemical characteristics. Both patients shared the same mutation and presented with intra-uterine growth restriction, failure to thrive, fasting hyperinsulinaemic hypoglycaemia and episodic post-prandial hyperglycaemia. Less common clinical features were also present, such as atrial septal defect and biventricular hypertrophy, clotting disorders, abnormal liver function tests and nephrocalcinosis. Interestingly, 2 previously unrecognized manifestations of the syndrome were also identified: severe gastrointestinal dysmotility (case 1) and exocrine pancreatic insufficiency (case 2). The co-existence of all the above clinical features makes these cases extremely rare. Gastrointestinal dysmotility should always be considered as a potentially fatal feature in patients with the syndrome, due to the complexity of the possible co-morbidities. In addition, our clinical experience for the first time suggests that pancreatic exocrine insufficiency may offer a possible explanation for the growth retardation observed in some patients with this syndrome. Our finding that replacement treatment with pancreatic enzymes improved weight gain (case 2) implies that all patients with Donohue syndrome should be investigated for exocrine pancreatic insufficiency.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Pratik Shah
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK.,Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, University College London Institute of Child Health, London, UK
| | - Noman Ahmad
- Department of Paediatric Endocrinology, King Faisal Specialist Hospital and Research Centre, Al Rawdhah Jeddah, Saudi Arabia
| | - Robert Semple
- Metabolic Research Laboratories, Institute of Metabolic Science, Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Khalid Hussain
- Department of Paediatric Medicine, Sidra Medical & Research Center, Doha, Qatar
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