Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

Pezzilli, Raffaele; Andriulli, Angelo; Bassi, Claudio; Balzano, Gianpaolo; Cantore, Maurizio; Fave, Gianfranco Delle; Falconi, Massimo; Frulloni, Luca

doi:10.3748/wjg.v19.i44.7930

Cited by 107 publications

(118 citation statements)

References 138 publications

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“…The presence of steatorrhoea as described by a patient and interpreted by a clinician may not represent true steatorrhoea. Ideally the CFA should have been calculated, defined as (mean fat intake -mean stool fat) / mean fat intake [26].…”

Section: Discussionmentioning

confidence: 99%

Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study

Campbell

Sanders

Francis

et al. 2016

JGLD

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Background & Aims: Pancreatic exocrine insufficiency may be under recognised in gastroenterological practice. We aimed to identify the prevalence of pancreatic insufficiency in secondary care gastroenterology clinics and determine if co-morbidity or presenting symptoms could predict diagnosis. A secondary aim was to assess response to treatment. Methods: A dual centre retrospective analysis was conducted in secondary care gastroenterology clinics. Patients tested for pancreatic exocrine insufficiency with faecal elastase-1 (FEL-1) between 2009 and 2013 were identified in two centres. Demographics, indication and co-morbidities were recorded in addition to dose and response to pancreatic enzyme replacement therapy. Binary logistic regression was used to assess if symptoms or co-morbidities could predict pancreatic insufficiency. Results: 1821 patients were tested, 13.1% had low FEL-1 (<200μg/g). This prevalence was sub-analysed with 5.4% having FEL-1 100-200μg/g (mild insufficiency) and 7.6% having faecal elastase readings <100μg/g. Low FEL-1 was most significantly associated with weight loss or steatorrhoea. Co-morbidity analysis showed that low levels were significantly associated with excess alcohol intake, diabetes mellitus or human immunodeficiency virus; 80.0% treated with enzyme supplements reported symptomatic benefit with no difference in response between high and low dose supplementation (p=0.761). Conclusion: Targeting the use of FEL-1 in individuals with specific symptoms and associated conditions can lead to improved recognition of pancreatic exocrine insufficiency in a significant proportion of secondary care patients. Intervening with lifestyle advice such as smoking cessation and minimising alcohol intake could improve outcomes. In addition, up to 80% of patients with low faecal elastase respond to supplementation. Abbreviations: CFA: coefficient of fat absorption; CP: chronic pancreatitis; ELISA: enzyme-linked immune-absorbent assay; PEI: pancreatic exocrine insufficiency; FEL-1: faecal elastase-1; HIV: human immunodeficiency virus; IBD: inflammatory bowel disease; IBS: irritable bowel syndrome; PERT: pancreatic enzyme replacement therapy.

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Section: Discussionmentioning

confidence: 99%

Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study

Campbell

Sanders

Francis

et al. 2016

JGLD

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“…Among indirect testing methods, a 72 stool collection to determine the coefficient of fat absorption (CFA) is considered the gold standard to diagnose fat malabsorption (and EPI) by many experts [18,19]. The test involves consumption of a high-fat diet (100 g/day) for at least 5 days with stool collection during the terminal 72 h. If previously started empirically, PERT should be held during the testing period to most accurately quantitate the amount of fat malabsorption.…”

Section: Indirect Pancreas Function Tests Quantitative Fecal Fat Analmentioning

confidence: 99%

Diagnosis of Exocrine Pancreatic Insufficiency

Hart

Conwell

2015

Curr Treat Options Gastro

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The accurate diagnosis of exocrine pancreatic insufficiency (EPI) helps identify those in need of pancreatic enzyme replacement therapy. Conversely, ruling out EPI identifies those in which additional evaluation should be pursued to explain their symptoms. There are many available tests that can be used to diagnose EPI; however, the tests must be tailored to each clinical scenario. Tests that are convenient but less accurate (e.g., fecal elastase-1, qualitative fecal fat determination) are best suited for patients with a high pretest probability of EPI. In contrast, tests that are highly accurate but more cumbersome (e.g., endoscopic pancreatic function testing, 72-h fecal fat collection) are favored in patients suspected to have mild EPI or an early stage of chronic pancreatitis. Additional research is needed to identify a more convenient means of accurately diagnosing at all stages of EPI.

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“…3,4 When symptoms do not improve with PERT, it has been suggested that there is a need to rule out other possible causes, including small intestinal bacterial overgrowth (SIBO). 5,6 SIBO is a condition in which the increased bacterial load in the small bowel results in excessive fermentation and inflammation, leading to a variety of clinical complaints ranging from mild, non-specific symptoms such as abdominal pain, bloating, and flatulence, to more severe manifestations such as malabsorption and weight loss. 7 In patients with CP, a number of factors such as fat malabsorption, diabetic neuropathy, use of drugs that affect motility or use of proton pump inhibitors, alcohol intake and surgical procedures can favour the occurrence of SIBO.…”

Section: Introductionmentioning

confidence: 99%

Systematic review and meta‐analysis: Small intestinal bacterial overgrowth in chronic pancreatitis

et al. 2016

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Background: Evidence on small intestinal bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP) is conflicting. Aim: The purpose of this study was to perform a systematic review and meta-analysis on the prevalence of SIBO in CP and to examine the relationship of SIBO with symptoms and nutritional status. Methods: Case-control and cross-sectional studies investigating SIBO in CP patients were analysed. The prevalence of positive tests was pooled across studies, and the rate of positivity between CP cases and controls was calculated. Results: In nine studies containing 336 CP patients, the pooled prevalence of SIBO was 36% (95% confidence interval (CI) 17-60%) with considerable heterogeneity (I 2 ¼ 91%). A sensitivity analysis excluding studies employing lactulose breath test gave a pooled prevalence of 21.7% (95% CI 12.7-34.5%) with lower heterogeneity (I 2 ¼ 56%). The odds ratio for a positive test in CP vs controls was 4.1 (95% CI 1.6-10.4) (I 2 ¼ 59.7%). The relationship between symptoms and SIBO in CP patients varied across studies, and the treatment of SIBO was associated with clinical improvement. Conclusions: One-third of CP patients have SIBO, with a significantly increased risk over controls, although results are heterogeneous, and studies carry several limitations. The impact of SIBO and its treatment in CP patients deserve further investigation.

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Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

Cited by 107 publications

References 138 publications

Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study

Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study

Diagnosis of Exocrine Pancreatic Insufficiency

Systematic review and meta‐analysis: Small intestinal bacterial overgrowth in chronic pancreatitis

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