Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency

AimBecause of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI).MethodsA working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category.Results and conclusionsRecent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the ‘unlikely’ PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000–40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy.     

The current managements of pancreatic diabetes in Japan

Pancreatic diabetes is secondary diabetes followed by progressions of pancreatic exocrine diseases, such as chronic pancreatitis, pancreatic neoplasm and post-pancreatectomy. Because of destruction and reduction of the pancreatic endocrine and exocrine functional compartments, patients with pancreatic diabetes frequently show malnutrition from maldigestion and malabsorption by insufficiencies in pancreatic digestive enzymes, and show unstable glycemic control and prolonged hypoglycemia by insufficiencies in synthesis and secretion of insulin and glucagon. Epidemiological studies have suggested that the incidence and development of pancreatic diabetes in patients with chronic pancreatitis (CP) depends on several risk factors, such as alcohol intake, the presence of pancreatic calcification and the long-term duration of CP. The clinical management of pancreatic diabetes is divided into two parts: one is the supplementation of pancreatic digestive enzymes and the other is the achievement of appropriate glycemic control. The appropriate and sufficient pancreatic exocrine replacement therapy is important for the maintenance of better nutrient conditions for patients with pancreatic diabetes. Furthermore, the intensive insulin therapy combined with short- or ultra-short-acting insulin and long-acting insulin glargine can be achieved for stable glycemic control and reduction of severe frequent hypoglycemia in patients with pancreatic diabetes. These current advanced management techniques against insufficiencies of pancreatic exocrine endocrine functions are beneficial for improving and maintaining the quality of life in patients with pancreatic diabetes.     

Efficacy of pancreatic exocrine replacement therapy for patients with unresectable pancreatic cancer in a randomized trial

BackgroundWeight loss in pancreatic cancer is associated with maldigestion due to pancreatic duct obstruction. Pancreatic exocrine replacement therapy (PERT) may significantly improve fat and protein absorption.ObjectivesThis prospective, double-blind, randomized, placebo-controlled phase II trial assessed whether PERT could reduce or prevent weight loss in patients with unresectable pancreatic cancer.MethodsSixty seven patients with unresectable pancreatic cancer were randomized to receive enteric coated PERT, consisting of 6–9 capsules of pancreatin (457.7 mg/capsule), or placebo. Patients took two capsules each three times daily during main meals and one capsule each up to three times daily when having between-meal snacks. The primary endpoint was the percentage change in body weight at eight weeks.ResultsThe mean percentage change in body weight (1.49% [1.12 kg] vs. 2.99% [1.63 kg], P = 0.381) and the mean percent change in Patient-Generated Subjective Global Assessment (PG-SGA) score (8.85% vs. 15.69%, p = 0.18) did not differ significantly between the PERT and placebo groups. There was no improvement in quality of life and overall survival did not differ significantly between the PERT and placebo groups (5.84 months vs 8.13 months, p = 0.744).ConclusionsPERT did not reduce weight loss in patients with unresectable pancreatic cancer. Larger randomized trials are needed to identify those patients who may benefit from PERT.Trial registration: ClinicalTrials.gov Number NCT01587534.     

The prevalence of small intestinal bacterial overgrowth in non-surgical patients with chronic pancreatitis and pancreatic exocrine insufficiency (PEI)

Background

Small intestinal bacterial overgrowth (SIBO) is a condition characterised by symptoms similar to pancreatic exocrine insufficiency (PEI) in chronic pancreatitis patients. SIBO is thought to complicate chronic pancreatitis in up to 92% of cases; however, studies are heterogeneous and protocols non-standardised. SIBO may be determined by measuring lung air-expiration of either hydrogen or methane which are by-products of small bowel bacterial fermentation of intraluminal substrates such as carbohydrates. We evaluated the prevalence of SIBO among a defined cohort of non-surgical chronic pancreatitics with mild to severe PEI compared with matched healthy controls.

Enzyme replacement improves survival among patients with pancreatic cancer: Results of a population based study

Background

Pancreatic exocrine insufficiency (PEI) and malnutrition are prevalent among patients with pancreatic adenocarcinoma. Pancreatic enzyme replacement therapy (PERT) can correct PEI but its use among patients with pancreatic cancer is unclear as are effects upon survival. This population-based study sought to address these issues

Exocrine pancreatic insufficiency following esophagectomy

Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase‐1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase‐1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow‐up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase‐1 measured. PERT was then offered to patients with fecal elastase‐1 less than 200 μg/g (EPI) as well as those in the 200–500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase‐1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1–42) following surgery. Ten patients had fecal elastase‐1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty‐nine patients had a fecal elastase‐1 in the 200–500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase‐1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed.     

Pancreatic cancer after surgery for chronic pancreatitis

BACKGROUND: Chronic pancreatitis is known to be a risk factor for pancreatic cancer. AIMS: To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis. PATIENTS/METHODS: Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed. RESULTS: Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer). CONCLUSION: Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.     

Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study

BackgroundPatients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT).MethodsThis study included 254 patients undergoing pancreatic surgery for oncologic indications. A¹³C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring ¹³CO₂ in breath samples after a test meal with 1.3-distearyl-(¹³C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups.ResultsIn 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11.In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function.ConclusionsThe vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.     

Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis.

GOALS: To evaluate the quality of life (QoL) of patients with chronic pancreatitis before and after pancreatic enzyme replacement therapy in a prospective, multicentre, follow-up study. STUDY: Two groups of patients were evaluated. Group 1 consisted of 31 patients with newly diagnosed chronic pancreatitis who had never been treated with pancreatic enzyme preparations. Group 2 consisted of 39 patients whose disease was diagnosed on average 3.4 years before the start of the study. The latter group of patients had undergone pancreatic enzyme replacement therapy, but during follow-up this treatment proved to be insufficient. The dose of pancreatic enzyme replacement therapy was tailored in accordance with the degree of pancreatic exocrine insufficiency measured by means of exocrine pancreatic function tests. A modified European Organizaton for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) was used to assess QoL. RESULTS: The social functioning and financial strain were significantly better, while the levels of hope and confidence were significantly reduced in group 1 compared with group 2. A significant gain in body weight and a significantly reduced defecation rate were found in both groups one month after the beginning of the pancreatic enzyme replacement therapy when compared with the pretreatment values. The prevalence of general and disease-specific symptoms and the intensity of pain were reduced in both groups after one month of enzyme substitution therapy. The working ability, the financial strain and the overall QoL scores were improved significantly in both groups, while the cognitive functioning score was found to be significantly improved during the follow-up only in group 1. The overall increase in the QoL score correlated significantly with the increase in body weight and the decrease in defecation number in both groups. CONCLUSIONS: Pancreatic enzyme replacement therapy in patients with chronic pancreatitis not only reduced the extent of steatorrhea and pain, but also significantly improved a variety of other symptoms and the patient's QoL. Individually tailored enzyme replacement therapy improved the QoL not only in the untreated chronic pancreatitis patients, but also in the inadequately treated group. This study demonstrated that the EORTC QLQ-C30 questionnaire, with the addition of two further questions about steatorrhea, is a useful tool for the evaluation of QoL in patients with chronic pancreatitis.     

Pancreatic exocrine insufficiency after pancreaticoduodenectomy:Current evidence and management

Pancreaticoduodenectomy(PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency(PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis.A literature search of databases(MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms "pancreatic exocrine insufficiency" and"Pancreaticoduodenectomy". Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher(46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a welltolerated, reliable and reproducible diagnostic test in this setting.     

Pylorus-preserving pancreatoduodenectomy: preoperative pancreatic function and outcome

BACKGROUND/AIMS: To investigate the effects of preoperative pancreatic function on gastric emptying, body weight, and quality of life after pylorus-preserving pancreatoduodenectomy. METHODOLOGY: Thirty-one patients who underwent pylorus-preserving pancreatoduodenectomy were divided into 2 groups according to preoperative pancreatic exocrine and endocrine function (normal vs. abnormal). Gastric emptying, body weight, and quality of life were evaluated before surgery, 1-2 months after surgery (short-term), and 6-12 months after surgery (long-term). RESULTS: Short-term body weight was significantly decreased in comparison to preoperative body weight regardless of preoperative exocrine and endocrine pancreatic function. Body weight returned to the preoperative level by 12 months after surgery in patients with normal preoperative pancreatic function but not in patients with abnormal pancreatic function. In both groups, gastric emptying was delayed at 1-2 months after surgery and then returned to the preoperative value by 12 months. Short-term quality of life did not differ from preoperative quality of life in either group, but long-term quality of life improved to beyond the preoperative level in both groups. CONCLUSIONS: Preoperative pancreatic function appears to significantly influence long-term body weight after pylorus-preserving pancreatoduodenectomy.     

Less common etiologies of exocrine pancreatic insufficiency

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 3 c(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.     

内窥镜逆行胰胆管造影术对胰腺分裂症的诊断、治疗价值研究

目的:探讨内窥镜逆行胰胆管造影术(ERCP)对胰腺分裂症(PD)的诊断、治疗方法及其效果的价值。方法:回顾性分析本院2008年6月至2012年9月明确诊断的20例PD患者的临床表现、诊断及治疗方法,比较治疗前后患者的体重变化,用直观模拟标度尺(VAS)评分来评估腹痛症状改善的情况。结果:患者症状以腹痛为主,急性胰腺炎或慢性胰腺炎急性发作的发生率为75%。经ERCP确诊的患者中,磁共振胆胰管成像(MRCP)的检出率为24%。内镜下治疗包括行内镜下十二指肠主和(或)副乳头切开引流(95%)、胰管支架置入(65%)及鼻胰管引流(55%)。治疗后患者体重增加(P<0.05),疼痛VAS评分下降(P<0.05)。结论:PD患者主要症状为腹痛,急性胰腺炎或慢性胰腺炎急性发作的发生率较高,内镜下治疗可有效减少PD患者腹痛的程度并增加患者体重。     

Prescription patterns of pancreatic enzyme replacement therapy for patients with pancreatic cancer in the United States

BackgroundExocrine pancreatic insufficiency (EPI) is frequently seen in patients with pancreatic cancer (PDAC) and is thought to contribute to nutritional complications. While EPI can be pharmacologically temporized with pancreatic enzyme replacement therapy (PERT), there is lack of clear evidence informing its use in PDAC. Here we aim to survey pancreatic surgeons regarding their utilization of PERT in the management of EPI for PDAC.MethodsAn online survey was distributed to the members of The Americas Hepato-Pancreato-Biliary Association (AHPBA) and The Pancreas Club.Results86.5% (180/208) of surgeons prescribe PERT for at least some resectable/borderline resectable PDAC cases. Only a minority of surgeons order investigations to confirm EPI before starting PERT (28.1%) or test for adequacy of therapy (28.3%). Few surgeons believe that PERT has an effect on overall survival (19.7%) or disease-free survival (6.25%) in PDAC.ConclusionPERT is widely prescribed in patients with resectable/borderline resectable PDAC, but investigations establishing EPI and assessing PERT adequacy are underutilized. A substantial proportion of surgeons are unclear as to the effect of PERT on survival outcomes in PDAC. These data call for prospective studies to establish guidelines for optimal use of PERT and its effects on survival outcomes in PDAC.     

各型胰腺假性囊肿的治疗策略及预后判断

目的 分析各种急性和慢性胰腺假性囊肿(PPs)的特征和预后,探讨侵入性治疗PPs的预测因子.方法 回顾性分析1995年1月至2004年12月日本医科大学诊治的36例PPs患者的临床资料.将患者分成急性胰腺炎并发的PPs自发缓解组(急性缓解组);急性胰腺炎并发的PPs症状持续或有并发症需要侵入治疗组(急性治疗组);慢性胰腺炎并发的PPs自发缓解组(慢性缓解组)和慢性胰腺炎并发的PPs症状持续或有并发症需要侵入治疗组(慢性治疗组),每组9例.结果 36例患者中,女性13例,男性23例.胰腺炎病因:酒精性18例(50.0%),胆源性8例(22.2%),其他原因10例(27.8%).平均随访时间(24.2±18.5)个月.绝大多数囊肿(32/36,88.9%)与主胰管不相交通;各组囊肿数量、部位均无显著差异;慢性缓解组囊肿直径最小,均<4 cm,显著小于其他3组(P<0.05);两缓解组的囊肿多数无增大,而两治疗组的囊肿绝大多数有增大;急性治疗组中4例(44.4%)囊壁增厚(>2～3cm),慢性治疗组中1例(11.1%)囊壁增厚,余囊壁正常.急性PPs的病因多为胆源性,多数位于胰尾,而且这些患者的体表指数、囊肿大小、确诊时有PPs相关症状的例数均显著高于慢性PPs.结论 随访期间PPs体积增大强烈提示需要侵入治疗.慢性PPs囊肿直径<4 cm是预后良好的指标,急性PPs直径<8 cm是自然消退的指标.     

人胰腺癌胰液蛋白质谱差异表达初步分析

目的 应用蛋白质组学方法 分析胰腺癌胰液与慢性胰腺炎、胆总管结石患者胰液问差异蛋白质的表达,初步探索胰液中可能的胰腺癌标志物,为临床胰腺癌和慢性胰腺炎的鉴别诊断提供依据.方法 内镜下逆行胰胆管造影(ERCP)放置鼻胰引流管收集患者胰液,双向凝胶电泳(2-DE)分离5例胰腺癌、6例慢性胰腺炎和3例胆总管结石患者等量混合胰液的蛋白质,运用图像分析软件进行比较和分析,识别差异表达蛋白质.应用基质辅助激光解析电离飞行时间质谱(matrix-assisted laser desorption/ionization time-of-flight mass spectrometry,MALDI-TOF-MS)鉴定部分差异蛋白质点.结果 收集到胰液总量35～200 ml,Bradford法测定蛋白质浓度为0.8～4.6 μg/μl.胰腺癌、慢性胰腺炎和胆总管结石患者等量混合胰液凝胶的蛋白质点数分别为196±12、209±15和199±10,三组间两两对比后的平均匹配率均在75%以上.部分差异蛋白质点经MALDI-TOF-MS鉴定显示:相比胆总管结石和慢性胰腺炎,转甲状腺素蛋白(TTR)二聚体支链A在胰腺癌患者胰液中表达增高;载脂蛋白A1(ApoA-1)支链A、胰石蛋白支链、Reg1β再生蛋白前体表达降低.结论 人胰腺癌、慢性胰腺炎和胆总管结石患者胰液的蛋白质谱存在一定的差异,TTR、ApoA-1、胰石蛋白和Reglβ再生蛋白可能成为胰腺癌胰液中的肿瘤标志物,为临床胰腺癌和慢性胰腺炎的鉴别诊断提供依据.     

Pancreatoduodenectomy for chronic pancreatitis with an inflammatory mass of pancreatic head: preoperative and postoperative functional assessment

BACKGROUND/AIMS: In chronic pancreatitis patients with an inflammatory mass of the pancreatic head receiving pancreatoduodenectomy, postoperative quality of life, including nutritional status, has become important. Pre- and postoperative evaluation of pancreatic function is essential as an effective means of proper nutritional management of patients following pancreatoduodenectomy. METHODOLOGY: Fifteen patients with chronic pancreatitis and inflammatory mass of the pancreatic head who had received standard pancreatoduodenectomy were enrolled in this investigation. All patients had their biliary and pancreatic ducts reconstructed according to Child's arrangement. Furthermore, all patients had smooth postoperative courses and were assessed for the pancreatojejunostomy by magnetic resonance cholangiopancreatography at least a month after the initial operation. Exocrine pancreas functions were clinically assessed with various clinical items and two indirect pancreatic function tests: the fecal elastase test and the Bentiromide test. Endocrine pancreas functions were assessed using serum C-peptide level, HbA1 level and the need for hypoglycemic therapy. RESULTS: The results indicated that the pancreatojejunostomies of all patients are patent magnetic resonance cholangiopancreatography. All patients benefited from the selected symptom relief and various clinical parameters, including medications, dietary restrictions, body mass index and plasma albumin levels, experiencing pain relief and improved exocrine and endocrine functions. CONCLUSIONS: Pancreatic function did not deteriorate after pancreatoduodenectomy for chronic pancreatitis with an inflammatory mass of pancreatic head, while quality of life was significantly improved.     

Malnutrition after pancreatic enzyme replacement therapy in chronic pancreatitis: Risk factors in real world practice

BackgroundRCTs that have shown improvement in coefficient of fat absorption with pancreatic enzyme replacement therapy (PERT) have seldom evaluated the impact on overall nutritional status.ObjectiveIn this study we evaluated factors responsible for persistence of malnutrition after PERT.MethodsIn this cross-sectional observational study, patients were enrolled based on predefined enrolment criteria. Patients were divided into those taking PERT regularly (Group A), irregularly (Group B) and not taking (Group C) for at least 3 months. Comprehensive evaluation of anthropometric measurements, nutritional assessment and dietary intake was performed. Malnutrition was measured using the Subjective Global Assessment (SGA) tool. Relationship between PERT status, dietary intake and nutritional status were evaluated using standard statistical methods. Logistic regression was performed to identify factors associated with persistence of malnutrition after PERT.Results377 patients with CP and 50 controls were included. 95 (25.2%) patients with CP were in Group A, 106 (28.1%) in Group B and 176 (46.7%) in Group C. 130 (34.5%) patients were malnourished, of which 76 (58.5%) were continuing PERT. There were no differences in clinical and biochemical nutritional markers between Groups A, B, and C. Calorie deficit and daily intake of calorie, protein, carbohydrates and fats were not different between those with and without PERT, but was significantly less in those with malnutrition. Logistic regression demonstrated inadequate dietary intake as independent risk factor for persistence of malnutrition.ConclusionEven though PERT is effective in PEI, comprehensive nutritional assessment, personalized nutritional counselling and therapy along with PERT is mandatory.     

Clinical significance of main pancreatic duct dilation on computed tomography： Single and double duct dilation

AIM: To study the patients with main pancreatic duct dilation on computed tomography (CT) and thereby to provide the predictive criteria to identify patients at high risk of significant diseases, such as pancreatic cancer, and to avoid unnecessary work up for patients at low risk of such diseases. METHODS: Patients with dilation of the main pancreatic duct on CT at Emory University Hospital in 2002 were identified by computer search. Clinical course and ultimate diagnosis were obtained in all the identified patients by abstraction of their computer database records. RESULTS: Seventy-seven patients were identified in this study. Chronic pancreatitis and pancreatic cancer were the most common causes of the main pancreatic duct dilation on CT. Although the majority of patients with isolated dilation of the main pancreatic duct (single duct dilation) had chronic pancreatitis, one-third of patients with single duct dilation but without chronic pancreatitis had pancreatic malignancies, whereas most of patients with concomitant biliary duct dilation (double duct dilation) had pancreatic cancer. CONCLUSION: Patients with pancreatic double duct dilation need extensive work up and careful followup since a majority of these patients are ultimately diagnosed with pancreatic cancer. Patients with single duct dilation, especially such patients without any evidence of chronic pancreatitis, also need careful follow-up since the possibility of pancreatic malignancy, including adenocarcinoma and intraductal papillary mucinous tumors, is still high.