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Guilabert L, Cárdenas-Jaén K, de-Madaria E. Initial Management of Acute Pancreatitis. Gastroenterol Clin North Am 2025; 54:21-36. [PMID: 39880529 DOI: 10.1016/j.gtc.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
The initial management of acute pancreatitis (AP) is continually evolving. Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies. Antibiotics should be administered only when there is a proven or highly probable infection rather than for prophylactic purposes. Urgent endoscopic retrograde cholangiopancreatography would be beneficial for patients with acute cholangitis. Same-admission cholecystectomy for mild biliary PA is safe, efficiently prevents relapse, and is associated with lower costs compared with interval cholecystectomy. Ongoing research into novel pharmacologic treatments and strategies is essential for further advancements in AP management.
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Affiliation(s)
- Lucía Guilabert
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/Lguilabert1
| | - Karina Cárdenas-Jaén
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/KarinaCardenasJ1
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain; Clinical Medicine Department, Miguel Hernandez University, Campus UMH de Sant Joan, Edificio Francisco Javier Balmis, Carretera Nacional 332 s/n, 03550, San Juan de Alicante, Spain.
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Triantafillidis JK, Papakontantinou J, Antonakis P, Konstadoulakis MM, Papalois AE. Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update. Nutrients 2024; 16:1639. [PMID: 38892572 PMCID: PMC11174039 DOI: 10.3390/nu16111639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.
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Affiliation(s)
- John K. Triantafillidis
- Department of IBD and Endoscopy, “Metropolitan General” Hospital, 15562 Holargos, Greece;
- Hellenic Society of Gastrointestinal Oncology, 15562 Athens, Greece
| | - John Papakontantinou
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Pantelis Antonakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Manousos M. Konstadoulakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
| | - Apostolos E. Papalois
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, University of Athens, 10676 Athens, Greece; (J.P.); (P.A.); (M.M.K.)
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McDonnell D, Afolabi PR, Wilding S, Griffiths GO, Swann JR, Byrne CD, Hamady ZZ. Utilising Pancreatic Exocrine Insufficiency in the Detection of Resectable Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:5756. [PMID: 38136302 PMCID: PMC10741412 DOI: 10.3390/cancers15245756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is usually diagnosed late, leading to a high mortality rate. Early detection facilitates better treatment options. The aim of this UK-based case-control study was to determine whether two validated tests for pancreatic exocrine insufficiency (PEI), namely, the 13C-mixed triglyceride breath test (13C-MTGBT) and a faecal elastase (FE-1) test, can discriminate between patients with resectable PDAC versus healthy volunteers (HVs) along with a comparison group with chronic pancreatitis (CP). Discrimination between disease states and HVs was tested with receiver operator characteristic (ROC) curves. In total, 59 participants (23 PDAC (16 men), 24 HVs (13 men) and 12 CP (10 men)) were recruited, with a similar age in each population, and a combined median (IQR) age of 66 (57-71). The areas under the ROC curve for discriminating between PDAC and HVs were 0.83 (95% CI: 0.70-0.96) for the 13C-MTGBT, and 0.85 (95% CI: 0.75-0.95) for the FE-1 test. These were similar to CP vs. HV. In conclusion, PEI occurs in resectable PDAC to a similar extent as in CP; further large-scale, prospective studies using these tests in the primary care setting on high-risk groups are warranted.
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Affiliation(s)
- Declan McDonnell
- Human Development & Health, University of Southampton, Southampton SO16 6YD, UK; (P.R.A.); (Z.Z.H.)
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Paul R. Afolabi
- Human Development & Health, University of Southampton, Southampton SO16 6YD, UK; (P.R.A.); (Z.Z.H.)
| | - Sam Wilding
- Cancer Research UK Southampton Clinical Trials Unit, University of Southampton, Southampton SO17 1BJ, UK
| | - Gareth O. Griffiths
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Cancer Research UK Southampton Clinical Trials Unit, University of Southampton, Southampton SO17 1BJ, UK
| | - Jonathan R. Swann
- Human Development & Health, University of Southampton, Southampton SO16 6YD, UK; (P.R.A.); (Z.Z.H.)
| | - Christopher D. Byrne
- Human Development & Health, University of Southampton, Southampton SO16 6YD, UK; (P.R.A.); (Z.Z.H.)
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Zaed Z. Hamady
- Human Development & Health, University of Southampton, Southampton SO16 6YD, UK; (P.R.A.); (Z.Z.H.)
- University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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Garay MB, Carbajal-Maldonado ÁL, Rodriguez-Ortiz-DE-Rozas R, Guilabert L, DE-Madaria E. Post-surgical exocrine pancreatic insufficiency. Minerva Surg 2023; 78:671-683. [PMID: 38059441 DOI: 10.23736/s2724-5691.23.10125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.
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Affiliation(s)
- Maria B Garay
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Ángela L Carbajal-Maldonado
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Rosario Rodriguez-Ortiz-DE-Rozas
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Lucia Guilabert
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain
| | - Enrique DE-Madaria
- Department of Gastroenterology, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), General University Hospital of Alicante, Alicante, Spain -
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Futagami S, Agawa S, Nakamura K, Watanabe Y, Habiro M, Kawawa R, Yamawaki H, Tsushima R, Kirita K, Akimoto T, Ueki N, Tomohide T, Itokawa N, Suzuki N, Naito Y, Takeuchi K, Kashiro A, Ohta R, Mizutani S, Taniai N, Yoshida H, Iwakiri K, Honda K. Apolipoprotein A2 isoforms associated with exocrine pancreatic insufficiency in early chronic pancreatitis. J Gastroenterol Hepatol 2023; 38:1949-1957. [PMID: 37501507 DOI: 10.1111/jgh.16302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/17/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND AIM Apolipoprotein A2 (apoA2) isoforms have been reported to undergo the aberrant processing in pancreatic cancer and pancreatic risk populations compared with that in healthy subjects. This study aimed to clarify whether apoA2 isoforms were as useful as N-benzoyl-p-aminobenzoic acid (BT-PABA) test for exocrine pancreatic dysfunction markers in patients with early chronic pancreatitis (ECP). METHODS Fifty consecutive patients with functional dyspepsia with pancreatic enzyme abnormalities (FD-P) (n = 18), with ECP (n = 20), and asymptomatic patients with pancreatic enzyme abnormalities (AP-P) (n = 12) based on the Rome IV classification and the Japan Pancreatic Association were enrolled in this study. The enrolled patients were evaluated using endoscopic ultrasonography and endoscopic ultrasonography elastography. Five pancreatic enzymes were estimated. Pancreatic exocrine function was analyzed using the BT-PABA test. Lighter and heavier apoA2 isoforms, AT and ATQ levels were measured by enzyme-linked immunosorbent assay methods. RESULTS There were no significant differences in clinical characteristics such as age, gender, body mass index, alcohol consumption and smoking among patients with AP-P, FD-P, and ECP. The BT-PABA test and lighter apoA2 isoform, AT level in the enrolled patients had a significant correlation (P < 0.01). The BT-PABA test in patients with ECP was significantly lower (P = 0.04) than that in AP-P. ApoA2-AT level in patients with ECP was lower than that in AP-P, albeit, insignificantly. Interestingly, apo A2-AT level was significantly (P = 0.041) associated with exocrine pancreatic insufficiency by multiple logistic regression analysis. CONCLUSIONS ApoA2-AT level is a useful tool to evaluate exocrine pancreatic insufficiency in the early stage of chronic pancreatitis.
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Affiliation(s)
- Seiji Futagami
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Shuhei Agawa
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Ken Nakamura
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | | | - Mayu Habiro
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Rie Kawawa
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yamawaki
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Rina Tsushima
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Kumiko Kirita
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Teppei Akimoto
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Nobue Ueki
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Tanabe Tomohide
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Norio Itokawa
- Division of Gastroenterology, Nippon Medical School, Tokyo, Japan
| | - Nami Suzuki
- Department of Bioregulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yutaka Naito
- Department of Bioregulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Keiko Takeuchi
- Department of Bioregulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Ayumi Kashiro
- Department of Bioregulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Ryu Ohta
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Satoshi Mizutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Nobuhiko Taniai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | | | - Kazufumi Honda
- Department of Bioregulation, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Brenner DM, Domínguez-Muñoz JE. Differential Diagnosis of Chronic Diarrhea: An Algorithm to Distinguish Irritable Bowel Syndrome With Diarrhea From Other Organic Gastrointestinal Diseases, With Special Focus on Exocrine Pancreatic Insufficiency. J Clin Gastroenterol 2023:00004836-990000000-00152. [PMID: 37115854 DOI: 10.1097/mcg.0000000000001855] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Chronic diarrhea, defined as diarrhea persisting for more than 4 weeks, affects up to 5% of the population regardless of patient age, sex, race, or socioeconomic status. The impact on patient health and quality of life is substantial, and diagnosis and management of these patients have significant economic consequences for health care services. The differential diagnosis of chronic diarrhea is broad, with etiologies including infections, endocrinopathies, maldigestive/malabsorptive conditions, and disorders of gut-brain interaction. The considerable overlap of symptoms across this spectrum makes accurate diagnosis problematic and may lead to delays in diagnosis or misdiagnosis. In this narrative review, we consider the differential diagnosis of chronic diarrhea, focusing on irritable bowel syndrome with diarrhea and exocrine pancreatic insufficiency, two conditions that may present similarly but have very different underlying causes and require significantly different management strategies. We outline a 4-step diagnostic strategy and propose a straightforward algorithm to assist in efficiently differentiating irritable bowel syndrome from exocrine pancreatic insufficiency and other causes of chronic diarrhea. We anticipate that these aids will improve diagnostic accuracy, which ultimately should lead to improvements in patients' health-related quality of life and reduce the societal burden on health care services.
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Affiliation(s)
- Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL
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7
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Powell-Brett S, Hall L, Edwards M, Roberts K. A systematic review and meta-analysis of the accuracy and methodology of the 13C mixed triglyceride breath test for the evaluation of pancreatic function. Pancreatology 2023; 23:283-293. [PMID: 36805050 DOI: 10.1016/j.pan.2023.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION The diagnosis of pancreatic exocrine insufficiency (PEI) is challenging. The 13C mixed triglyceride breath test (13C MTGT) has emerged as a promising diagnostic method. However, there is need to assimilate high quality evidence to understand its accuracy and address variation in the conduct of the test. This systematic review aims to appraise the existing literature on the methodology and accuracy of the 13C MTGT. METHODS A systematic literature search of PUBMED, MEDLINE, and EMBASE databases identified articles describing the use of the 13C MTGT in the analysis of pancreatic function in adults. Data extraction addressed each methodological step in detail. These were combined in a narrative synthesis. For quantitative analysis, those studies within this search that assessed the accuracy of the 13C MTGT were selected. RESULTS 37 studies were included for qualitative review, 6 assessed sensitivity and specificity of the 13C MTGT against another measure of PEI and were included in quantitative synthesis. Areas with a majority consensus were pre-test overnight fasting, a test meal with a lipid load of at least 10 g, within-test control of exercise and dietary intake, breath sampling every 30 min and the preference of isotope ratio mass spectrometry (IRMS) for analysis. Good evidence suggests there is no benefit to extend the total timeframe of breath sampling beyond 6 h. Areas of uncertainty are a) Duration of PERT cessation b) the addition of metoclopramide, c) the ideal test meal and d) if the time frame can be shortened. Quantitative analysis among 6 studies demonstrated a pooled sensitivity and specificity of the 13C MTGT for diagnosing PEI of 0.84 (95% CI: 0.73-0.91) and 0.87 (95% CI: 0.79-0.93) respectively. CONCLUSION There is yet to emerge a clear standard of breath test methodology that is validated for all causes of PEI and suitable for routine use. The accuracy of the 13C MTGT for diagnosing PEI is encouraging when compared to other measures. We present a suggested set protocol based on the current literature and identify areas that need further, high quality evidence. With refinement, the 13C MTGT could become a valuable, non-invasive PEI diagnostic tool that could be used outside of specialist centres.
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Affiliation(s)
- Sarah Powell-Brett
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Lewis Hall
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Michael Edwards
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Roberts
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Zeng XP, Zeng JH, Wang R, Wang W. Pathogenesis, diagnosis, and treatment of malnutrition in patients with chronic pancreatitis. Shijie Huaren Xiaohua Zazhi 2023; 31:92-97. [DOI: 10.11569/wcjd.v31.i3.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Chronic pancreatitis (CP) is a persistent and progressive pancreatic inflammatory disease. Malnutrition is a common clinical manifestation in CP patients, which is mainly caused by pancreatic exocrine insufficiency but may also be related to pancreatic endocrine insufficiency and changes of living habit. At present, there is still a lack of gold standard for the diagnosis of malnutrition in patients with CP. Clinicians should comprehensively evaluate such patients through anthropometric parameters, test parameters, imaging diagnosis, pancreatic exocrine function detection, etc., detect malnutrition early, and take timely intervention measures, including improving diet and living habits, enteral/parenteral nutrition, pancreatic enzyme replacement therapy, acid suppressant adjuvant therapy, regulating intestinal flora, and administration of Chinese medicine. And endoscopic and surgical treatment should be used when necessary.
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Affiliation(s)
- Xiang-Peng Zeng
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Jing-Hui Zeng
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Rong Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350001, Fujian Province, China
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Vélez C, Freedman SD, Assis DN. Update in Advancing the Gastrointestinal Frontier in Cystic Fibrosis. Clin Chest Med 2022; 43:743-755. [PMID: 36344078 DOI: 10.1016/j.ccm.2022.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical complications of cystic fibrosis (CF) include a variety of gastrointestinal (GI) and hepatobiliary manifestations. Recent years have witnessed several advances in the understanding and management of these complications, in addition to opportunities for therapeutic innovations. Herein we review the current understanding of these disorders and also discuss the management of the GI and hepatobiliary complications experienced by persons with CF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Department of Medicine, Center for Neurointestinal Health, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street Suite 535, Boston, MA 0211, USA
| | - Steven D Freedman
- Beth Israel Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - David N Assis
- Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06510, USA.
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10
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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: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [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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11
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Abbreviated 13C-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; 56:390-397. [PMID: 35962951 PMCID: PMC9400450 DOI: 10.2478/raon-2022-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [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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12
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Afolabi PR, McDonnell D, Byrne CD, Wilding S, Goss V, Walters J, Hamady ZZ. DEPEND study protocol: early detection of patients with pancreatic cancer - a pilot study to evaluate the utility of faecal elastase-1 and 13C-mixed triglyceride breath test as screening tools in high-risk individuals. BMJ Open 2022; 12:e057271. [PMID: 35217541 PMCID: PMC8883257 DOI: 10.1136/bmjopen-2021-057271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/07/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Pancreatic cancer (PC) is the fifth leading cause of cancer-related death in the UK. The incidence of PC is increasing, with little or no improvement in overall survival and the best chance for long-term survival in patients with PC relies on early detection and surgical resection. In this study, we propose the use of a diagnostic algorithm that combines tests of pancreatic exocrine function (faecal elastase-1 (FE-1) test and the 13C-mixed triglyceride (13C-MTG) breath test) to identify patients with PC that urgently needs imaging studies. METHODS AND ANALYSIS This prospective pilot (proof of concept) study will be carried out on 25 patients with resectable PC, 10 patients with chronic pancreatitis and 25 healthy volunteers. This study will construct a predictive algorithm for PC, using two tests of pancreatic exocrine function, FE-1 test and the 13C-MTG breath test. Continuous flow isotope ratio mass spectrometry in the 13C-MTG breath test will be used to analyse enriched 13CO2 in exhaled breath samples. The additional predictive benefit of other potential biomarkers of PC will also be considered. Potential biomarkers of PC showing abilities to discriminate between patients with PC from healthy subjects or patients with chronic pancreatitis will be selected by metabolomic analysis. ETHICS AND DISSEMINATION The study was approved by the North of Scotland Research and Ethics Committee on 1 October 2020 (reference: 20/NS/0105, favourable opinion granted). The results will be disseminated in presentations at academic national/international conferences and publication in peer-review journals.
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Affiliation(s)
- Paul Remi Afolabi
- Human Development and Health, University of Southampton Faculty of Medicine, Southampton, UK
- Southampton Centre for Biomedical Research Mass Spectrometry, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Declan McDonnell
- Human Development and Health, University of Southampton Faculty of Medicine, Southampton, UK
- Southampton Centre for Biomedical Research, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Christopher D Byrne
- Human Development and Health, University of Southampton Faculty of Medicine, Southampton, UK
- Southampton Centre for Biomedical Research, NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Sam Wilding
- Southampton Clinical Trials Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Victoria Goss
- Southampton Clinical Trials Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jocelyn Walters
- Southampton Clinical Trials Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zaed Z Hamady
- Southampton Centre for Biomedical Research, NIHR Southampton Biomedical Research Centre, Southampton, UK
- HPB Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Díaz C, Jiménez-Luna C, Diéguez-Castillo C, Martín A, Prados J, Martín-Ruíz JL, Genilloud O, Vicente F, Pérez del Palacio J, Caba O. Untargeted Metabolomics for the Diagnosis of Exocrine Pancreatic Insufficiency in Chronic Pancreatitis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:876. [PMID: 34577799 PMCID: PMC8470962 DOI: 10.3390/medicina57090876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Background and Objectives: The clinical manifestations and course of chronic pancreatitis (CP) are often nonspecific and variable, hampering diagnosis of the risk of exocrine pancreatic insufficiency (EPI). Development of new, reproducible, and non-invasive methods to diagnose EPI is therefore a major priority. The objective of this metabolomic study was to identify novel biomarkers associated with EPI. Materials and Methods: We analyzed 53 samples from patients with CP, 32 with and 21 without EPI, using an untargeted metabolomics workflow based on hydrophilic interaction chromatography coupled to high-resolution mass spectrometry. Principal component and partial least squares-discriminant analyses showed significant between-group differentiation, and univariate and multivariate analyses identified potential candidate metabolites that significantly differed between samples from CP patients with EPI and those without EPI. Results: Excellent results were obtained using a six-metabolic panel to diagnose the presence of EPI in CP patients (area under the ROC curve = 0.785). Conclusions: This study confirms the usefulness of metabolomics in this disease setting, allowing the identification of novel biomarkers to differentiate between the presence and absence of EPI in CP patients.
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Affiliation(s)
- Caridad Díaz
- Fundación MEDINA, Centro de Excelencia en Investigación de Medicamentos Innovadores, 18012 Granada, Spain; (C.D.); (A.M.); (O.G.); (F.V.); (J.P.d.P.)
| | - Cristina Jiménez-Luna
- Center of Biomedical Research (CIBM), Institute of Biopathology and Regenerative Medicine (IBIMER), University of Granada, 18012 Granada, Spain; (C.J.-L.); (O.C.)
| | - Carmelo Diéguez-Castillo
- Department of Gastroenterology, San Cecilio University Hospital, 18012 Granada, Spain; (C.D.-C.); (J.L.M.-R.)
| | - Ariadna Martín
- Fundación MEDINA, Centro de Excelencia en Investigación de Medicamentos Innovadores, 18012 Granada, Spain; (C.D.); (A.M.); (O.G.); (F.V.); (J.P.d.P.)
| | - José Prados
- Center of Biomedical Research (CIBM), Institute of Biopathology and Regenerative Medicine (IBIMER), University of Granada, 18012 Granada, Spain; (C.J.-L.); (O.C.)
| | - José Luis Martín-Ruíz
- Department of Gastroenterology, San Cecilio University Hospital, 18012 Granada, Spain; (C.D.-C.); (J.L.M.-R.)
| | - Olga Genilloud
- Fundación MEDINA, Centro de Excelencia en Investigación de Medicamentos Innovadores, 18012 Granada, Spain; (C.D.); (A.M.); (O.G.); (F.V.); (J.P.d.P.)
| | - Francisca Vicente
- Fundación MEDINA, Centro de Excelencia en Investigación de Medicamentos Innovadores, 18012 Granada, Spain; (C.D.); (A.M.); (O.G.); (F.V.); (J.P.d.P.)
| | - José Pérez del Palacio
- Fundación MEDINA, Centro de Excelencia en Investigación de Medicamentos Innovadores, 18012 Granada, Spain; (C.D.); (A.M.); (O.G.); (F.V.); (J.P.d.P.)
| | - Octavio Caba
- Center of Biomedical Research (CIBM), Institute of Biopathology and Regenerative Medicine (IBIMER), University of Granada, 18012 Granada, Spain; (C.J.-L.); (O.C.)
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Carrillo Lozano E, Osés Zárate V, Campos Del Portillo R. Nutritional management of gastric cancer. ENDOCRINOL DIAB NUTR 2021; 68:428-438. [PMID: 34742476 DOI: 10.1016/j.endien.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/17/2020] [Indexed: 06/13/2023]
Abstract
Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of "post-gastrectomy syndromes", the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.
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Affiliation(s)
- Elena Carrillo Lozano
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Madrid, Spain.
| | | | - Rocío Campos Del Portillo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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15
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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 13C‐breath test group. 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: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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 13 C-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 13 C-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 13 C-breath testing and provides recommendations for the use of 13 C-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 13 C-breath testing are summarized briefly. The recommendations specifically detail when and how individual 13 C-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 13 C-breath tests.
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Affiliation(s)
- Jutta Keller
- Department of Internal MedicineIsraelitic HospitalAcademic Hospital University of HamburgHamburgGermany
| | - Heinz F. Hammer
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
| | - Paul R. Afolabi
- NIHR Southampton Biomedical Research CentreUniversity Hospital Southampton NHS Foundation Trust and University of SouthamptonSouthamptonUK
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
| | - Enrique Dominguez‐Munoz
- Department of Gastroenterology and HepatologyUniversity Hospital of Santiago de CompostelaSantiagoSpain
| | | | - Oliver Goetze
- Department of Medicine IIDivision of HepatologyUniversity Hospital WürzburgWürzburgGermany
| | - Stephan L. Haas
- Department of Upper GI DiseasesKarolinska University HospitalStockholmSweden
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and NutritionKidZ Health Castle UZ BrusselsBrusselsBelgium
| | - Daniel Pohl
- Division of Gastroenterology and HepatologyUniversity Hospital ZürichZürichSwitzerland
| | - Silvia Salvatore
- Pediatric DepartmentHospital "F. Del Ponte"University of InsubriaVareseItaly
| | - Marc Sonyi
- Department of Internal MedicineDivision of Gastroenterology and HepatologyMedical University of GrazGrazAustria
- Clinic for General Medicine, Gastroenterology, and Infectious DiseasesAugustinerinnen HospitalCologneGermany
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of GastroenterologyNeurogastroenterology and MotilityGreat Ormond Street HospitalLondonUK
- Department of Gastroenterology, Hepatology and Liver TransplantationQueensland Children's HospitalBrisbaneAustralia
| | - Kristin Verbeke
- Translational Research Center for Gastrointestinal DisordersKU LeuvenLeuvenBelgium
| | - Mark R. Fox
- Division of Gastroenterology and HepatologyUniversity Hospital ZürichZürichSwitzerland
- Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal DiseasesCentre for Integrative GastroenterologyKlinik ArlesheimArlesheimSwitzerland
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Cárdenas-Jaén K, Vaillo-Rocamora A, Gracia Á, Garg PK, Zapater P, Papachristou GI, Singh VK, Wu BU, de-Madaria E. Simvastatin in the Prevention of Recurrent Pancreatitis: Design and Rationale of a Multicenter Triple-Blind Randomized Controlled Trial, the SIMBA Trial. Front Med (Lausanne) 2021; 7:494. [PMID: 33644082 PMCID: PMC7902790 DOI: 10.3389/fmed.2020.00494] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
Background: One in every four patients with a first episode of non-gallstone-related acute pancreatitis (AP) develops recurrent disease. Recurrent episodes of AP or acute flares of chronic pancreatitis (CP) are associated with decreased quality of life and progression of the disease. Besides removing the etiology of pancreatitis (which sometimes is not possible), there are no effective measures to prevent recurrence. Meta-analyses of randomized controlled trials, as well as epidemiological and cohort studies, suggest that statins may be protective against the development of index AP. Methods: The SIMBA study is a triple-blind randomized placebo-controlled, parallel-group multicenter trial. Patients with recurrent AP or with acute flares of CP (at least two episodes in the last 12 months) will be randomized to receive simvastatin 40 mg daily or placebo. During a 3-year study period, 144 patients (72 per arm of treatment) from 26 centers will be enrolled. The patients will receive the study treatment for 1 year. The primary aim is to compare the recurrence of AP or acute flares in CP. Secondary endpoints include the incidence of new-onset diabetes mellitus, new-onset exocrine pancreatic insufficiency (EPI), new-onset imaging signs of CP, frequency of all-cause hospital admissions, severity of AP, adherence to treatment, and frequency of adverse events. Discussion: The SIMBA trial will ascertain whether simvastatin, a safe, widely used and inexpensive drug, can change the natural course of recurrent pancreatitis. Trial Registration: ClinicalTrials.gov Identifier: NCT04021498.
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Affiliation(s)
- Karina Cárdenas-Jaén
- Pancreatic Unit, Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Alicia Vaillo-Rocamora
- Pancreatic Unit, Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Ángel Gracia
- Pharmacy Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Pramoud K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pedro Zapater
- Department of Clinical Pharmacology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Bechien U Wu
- Center for Pancreatic Care, Division of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Enrique de-Madaria
- Pancreatic Unit, Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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17
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Carrillo Lozano E, Osés Zárate V, Campos Del Portillo R. Nutritional management of gastric cancer. ACTA ACUST UNITED AC 2020. [PMID: 33388299 DOI: 10.1016/j.endinu.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the third leading cause of cancer mortality and is frequently associated with nutritional disorders, the detection and proper management of which can contribute to improving quality of life and survival. Being aware of the consequences and of the different treatments for this neoplasm allows us to offer an adequate nutritional approach. In surgical candidates, integration into ERAS-type programs (Enhanced Recovery after Surgery) is increasingly frequent, and includes a pre-surgical nutritional approach and the initiation of early oral tolerance. After gastrectomy, the new anatomical and functional state of the digestive tract may lead to the appearance of «post-gastrectomy syndromes», the management of which may require diet modification and medical treatment. Those who receive neoadjuvant or adjuvant antineoplastic therapy benefit from specific dietary recommendations based on intercurrent symptoms and/or artificial nutrition. In palliative patients, the nutritional approach should be carried out while respecting the principle of autonomy and weighing the risks and benefits of the intervention. The objective of this review is to highlight the importance and role of nutrition in patients with gastric cancer and to provide guidelines for nutritional management based on the current evidence.
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Affiliation(s)
- Elena Carrillo Lozano
- Servicio de Endocrinología y Nutrición, Hospital Universitario de La Princesa, Madrid, España.
| | | | - Rocío Campos Del Portillo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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18
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Sleeve gastrectomy relieves exocrine pancreatic insufficiency in morbidly obese patients: a prospective case-control study. GASTROENTEROLOGY REVIEW 2020; 14:268-273. [PMID: 31988673 PMCID: PMC6983761 DOI: 10.5114/pg.2019.84223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/11/2019] [Indexed: 12/15/2022]
Abstract
Introduction Bariatric surgery is the most effective treatment modality in morbidly obese patients. Compared to Roux-en Y gastric bypass (RYGB), sleeve gastrectomy (SG) has better metabolic and nutritional outcomes after surgery. Exocrine pancreatic insufficiency (EPI) can be seen after RYGB but there is not any knowledge about EPI-SG association. Aim To assess exocrine pancreatic functions before and after the SG procedure. Material and methods This is a single-center, prospective and case-control study. Forty morbidly obese patients were included in the study. Their pre-operative and post-operative, third month fecal samples were collected. Exocrine pancreatic insufficiency was determined by using fecal elastase-1 and diagnosed when fecal elastase-1 levels were < 200 μg/g. Results The mean fecal elastase-1 level was 256.25 ±137.16 μg/g and the mean post-surgical fecal elastase-1 level was 437.7 ±212.43 μg/g (p = 0.001). In the pre-operative period, half of patients had FE levels under 200 μg/g. In the third month after surgery, only 4 patients had fecal elastase-1 levels under 200 μg/g. Comparison of fecal elastase-1 between pre-surgery and post-surgery revealed a significant difference (p = 0.001). Conclusions This is the first study to investigate EPI-SG association. Surgery-associated morbidity and mortality are the leading limitations of bariatric surgery procedures. Exocrine pancreatic insufficiency is one of them; prior studies demonstrate its increased frequency after RYGB. Our study revealed that SG relieves exocrine pancreatic insufficiency.
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19
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Exocrine Pancreatic Insufficiency and Nutritional Complications. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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20
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Abstract
Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine Exocrine pancreatic insufficiency (EPI) is characterized by inadequate pancreatic enzyme delivery to the small intestine, resulting in malabsorption. Clinical manifestations of EPI are often nonspecific and can lead to lack of timely recognition and diagnosis. Central to this clinical dilemma is the lack of highly accurate or specific testing which leads to misdiagnosis and suboptimal treatment. Identification of high-risk patients is key in the diagnosis of EPI and this includes patients with pancreatic parenchyma disorders such as chronic pancreatitis, pancreatic malignancy, cystic fibrosis, and those undergoing pancreatic resection for benign and malignant disease. Less recognized are the number of additional conditions which may also have EPI as a consequence. Owing to an increase in morbidity and impaired quality of life associated with this condition, goals of treatment have been aimed at repleting exocrine enzyme deficiency by oral pancreatic enzyme replacement therapy (PERT). The basis of PERT is to provide activated digestive enzymes to the small bowel during the prandial period, mainly, leading to sufficient absorption of fat and fat-soluble vitamins. The benefits of PERT have been shown to go beyond the improvement in signs and symptoms associated with EPI and include decreasing prevalence of osteopathy and improving survival outcomes in subsets of patients with this condition. However, despite the overall benefits in treatment, the diagnosis and management of EPI are suboptimal. Current literature suggests patients at high risk of developing EPI are not tested and those who are diagnosed are not treated with adequate dosages. In this review, we highlight patients who are at high risk for the development of EPI, analyze consequences and treatment of this disorder, review rationale for enzyme replacement therapy, and examine current evidence for treatment optimization.
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Affiliation(s)
- Yaseen Perbtani
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL, USA
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21
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Zsóri G, Illés D, Terzin V, Ivány E, Czakó L. Exocrine pancreatic insufficiency in type 1 and type 2 diabetes mellitus: do we need to treat it? A systematic review. Pancreatology 2018; 18:559-565. [PMID: 29779830 DOI: 10.1016/j.pan.2018.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 05/11/2018] [Accepted: 05/12/2018] [Indexed: 12/11/2022]
Abstract
The exocrine and endocrine pancreata are very closely linked both anatomically and physiologically. Abdominal symptoms such as nausea, bloating, diarrhea, steatorrhea, and weight loss can often occur in diabetic patients. Impairments of the exocrine pancreatic function seem to be a frequent complication of diabetes mellitus; however, they are largely overlooked. The aim of this paper is to provide an overview of the current concepts of exocrine pancreatic insufficiency (PEI) in diabetes mellitus. The prevalence and symptoms of PEI in diabetes mellitus, the pathomechanism, and difficulties of diagnosis and therapy of PEI are summarized in this systematic review.
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Affiliation(s)
- Gábor Zsóri
- University of Szeged, Faculty of Medicine, Albert Szent-Györgyi Medical and Pharmaceutical Center, First Department of Medicine, Szeged, Korányi Fasor 8-10, H-6720, Hungary.
| | - Dóra Illés
- University of Szeged, Faculty of Medicine, Albert Szent-Györgyi Medical and Pharmaceutical Center, First Department of Medicine, Szeged, Korányi Fasor 8-10, H-6720, Hungary
| | - Viktória Terzin
- University of Szeged, Faculty of Medicine, Albert Szent-Györgyi Medical and Pharmaceutical Center, First Department of Medicine, Szeged, Korányi Fasor 8-10, H-6720, Hungary
| | - Emese Ivány
- University of Szeged, Faculty of Medicine, Albert Szent-Györgyi Medical and Pharmaceutical Center, First Department of Medicine, Szeged, Korányi Fasor 8-10, H-6720, Hungary
| | - László Czakó
- University of Szeged, Faculty of Medicine, Albert Szent-Györgyi Medical and Pharmaceutical Center, First Department of Medicine, Szeged, Korányi Fasor 8-10, H-6720, Hungary
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22
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Singh VK, Schwarzenberg SJ. Pancreatic insufficiency in Cystic Fibrosis. J Cyst Fibros 2017; 16 Suppl 2:S70-S78. [DOI: 10.1016/j.jcf.2017.06.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022]
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23
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Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 2017; 23:7059-7076. [PMID: 29093615 PMCID: PMC5656454 DOI: 10.3748/wjg.v23.i39.7059] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 05/27/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malabsorption, results from primary pancreatic diseases or secondarily impaired exocrine pancreatic function. Besides cystic fibrosis and chronic pancreatitis, the most common etiologies of EPI, other causes of EPI include unresectable pancreatic cancer, metabolic diseases (diabetes); impaired hormonal stimulation of exocrine pancreatic secretion by cholecystokinin (CCK); celiac or inflammatory bowel disease (IBD) due to loss of intestinal brush border proteins; and gastrointestinal surgery (asynchrony between motor and secretory functions, impaired enteropancreatic feedback, and inadequate mixing of pancreatic secretions with food). This paper reviews such conditions that have less straightforward associations with EPI and examines the role of pancreatic enzyme replacement therapy (PERT). Relevant literature was identified by database searches. Most patients with inoperable pancreatic cancer develop EPI (66%-92%). EPI occurs in patients with type 1 (26%-57%) or type 2 diabetes (20%-36%) and is typically mild to moderate; by definition, all patients with type 3c (pancreatogenic) diabetes have EPI. EPI occurs in untreated celiac disease (4%-80%), but typically resolves on a gluten-free diet. EPI manifests in patients with IBD (14%-74%) and up to 100% of gastrointestinal surgery patients (47%-100%; dependent on surgical site). With the paucity of published studies on PERT use for these conditions, recommendations for or against PERT use remain ambiguous. The authors conclude that there is an urgent need to conduct robust clinical studies to understand the validity and nature of associations between EPI and medical conditions beyond those with proven mechanisms, and examine the potential role for PERT.
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Affiliation(s)
- Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Mark E Haupt
- Medical Affairs, AbbVie Inc., North Chicago, IL 60064, United States
| | - David E Geller
- Cystic Fibrosis Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
| | - Jerry A Hall
- CREON® Clinical Development, AbbVie Inc., North Chicago, IL 60064, United States
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Sperti C, Moletta L. Staging chronic pancreatitis with exocrine function tests: Are we better? World J Gastroenterol 2017; 23:6927-6930. [PMID: 29097865 PMCID: PMC5658310 DOI: 10.3748/wjg.v23.i38.6927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/07/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis (CP) is an inflammatory disease of the pancreas evolving in progressive fibrotic disruption of the gland with exocrine and endocrine pancreatic insufficiency. Although imaging features of CP are well known, their correlation with exocrine pancreatic function tests are not obvious, particularly in the early stage of the disease. There are many clinical classification of CP, all suggested for better distinguish and manage different forms based on etiological and clinical factors, and severity of the disease. Recently, a new classification of CP has been suggested: the M-ANNHEIM multiple risk factor classification that includes etiology, stage classification and degree of clinical severity. However, more accurate determination of clinical severity of CP requires a correct determination of exocrine function of the pancreas and fecal fat excretion. Recently, Kamath et al demonstrated that the evaluation of exocrine pancreatic function by acid steatocrit and fecal elastase-1 (EF-1) was helpful, but EF-1 was able to detect exocrine pancreatic insufficiency in more patients, upgrading some patients in higher stage of disease according to M-ANNHEIM classification. So, EF-1 is a more accurate test to determine exocrine pancreatic insufficiency and to stage chronic pancreatitis in the M-ANNHEIM classification. On the contrary, EF-1 determination shows low sensitivity in detecting exocrine pancreatic insufficiency in early stage of the disease.
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Affiliation(s)
- Cosimo Sperti
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, 35128 Padua, Italy
| | - Lucia Moletta
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, 35128 Padua, Italy
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Safiri S, Ayubi E. Diagnosis of exocrine pancreatic insufficiency in chronic pancreatitis: 13C-Mixed Triglyceride Breath Test versus Fecal Elastase: Methodological issues. Pancreatology 2017; 17:647. [PMID: 28462863 DOI: 10.1016/j.pan.2017.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/16/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Saeid Safiri
- Managerial Epidemiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Erfan Ayubi
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Epidemiology & Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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