Systematic review and meta-analysis on the prevalence of vitamin D deficiency in patients with chronic pancreatitis

Background/objectivesPatients with chronic pancreatitis (CP) are at risk of malnutrition due to malabsorption, pain and/or alcohol consumption. This can cause vitamin D insufficiency or deficiency, which is associated with osteoporosis and increased risks of fractures. We aimed to perform a meta-analysis to determine the prevalence of vitamin D insufficiency and deficiency in CP patients. Furthermore, we compared these results with healthy controls.MethodsWe performed a systematic review and meta-analysis on the literature by searching PubMed and EMBASE (January 2000–December 2015) on CP and vitamin D. Primary outcome was prevalence of vitamin D insufficiency (<75 nmoL/L) and deficiency (<50 nmoL/L) in CP patients. When available, data of CP patients were compared with healthy controls.ResultsNine studies were included in our meta-analysis, reporting on the prevalence of vitamin D insufficiency/deficiency in 465 patients (mean age 41 years (range 18–60), 81% male) and in 378 controls (mean age 40 years (range 18–67), 76% male). Pooled prevalence of vitamin D insufficiency and deficiency in CP patients was 83% and 65%, respectively. Calculated odds ratio (OR) of vitamin D insufficiency and deficiency between CP patients and controls was 1.34 (0.54–3.29) and 1.14 (0.70–1.85), respectively (p > 0.05).ConclusionThere is a high prevalence of vitamin D insufficiency and deficiency in CP patients. Nevertheless, there is no significant difference in prevalence of vitamin D insufficiency and deficiency compared to healthy controls. Further research should indicate the clinical relevance and consequences of these findings for clinical practice.     

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

IntroductionThe Food and Drug Administration in 2006 required that all pancreatic enzyme products demonstrate bioavailability of lipase, amylase, and protease in the proximal small intestine.MethodsIn this phase I open-label, randomized, crossover trial, 17 adult chronic pancreatitis (CP) patients with severe exocrine pancreatic insufficiency (EPI) underwent two separate gastroduodenal perfusion procedures (Dreiling tube suctioning and [¹⁴C]-PEG instillation by an attached Dobhoff tube in the duodenal bulb). Patients received Ensure Plus® alone and Ensure Plus with Zenpep (75,000 USP lipase units) in random order. The bioavailability of Zenpep was estimated by comparing the recovery of lipase, amylase, chymotrypsin activity in two treatment conditions. ¹⁴C-PEG was used to correct duodenal aspirates volume. The primary efficacy endpoint was lipase delivery in the duodenum after Zenpep administration under fed conditions. Secondary efficacy endpoints included chymotrypsin and amylase delivery, serum CCK levels, and measuring duodenal and gastric pH.ResultsZenpep administration with a test meal was associated with significant increase in duodenal aspiration of lipase (p = 0.046), chymotrypsin (p = 0.008), and amylase (p = 0.001), compared to the test meal alone, indicating release of enzymes to the duodenum. Lipase delivery was higher in the pH subpopulation (the efficacy population with acid hypersecretors excluded) (p = 0.01). Recovery of [¹⁴C]-PEG was 61%. Zenpep was generally well tolerated. All adverse events were mild and transient.ConclusionsIn CP patients with severe EPI, lipase, chymotrypsin and amylase were released rapidly into the duodenum after ingestion of Zenpep plus meal compared to meals alone. Results also reflected the known pH threshold for enzyme release from enteric coated products.     

Zinc deficiency in patients with chronic pancreatitis

BACKGROUND Zinc is a key element in numerous proteins and plays an important role in essential cell functions such as defense against free radicals and DNA damage repair. Chronic pancreatitis(CP) is a chronic inflammation with progressive fibrosis of pancreas ultimately resulting in pancreatic exocrine insufficiency(PEI),which is associated with malnutrition. Studies analyzing zinc levels in patients with CP are sparse and lead to conflicting results.AIM To investigate serum zinc levels in patients with CP of various etiologies.METHODS Between October 2015 and March 2018, patients with a diagnosis of CP were identified and recruited from the Pancreatic Outpatient Clinic at the Karolinska University Hospital in Stockholm, Sweden. Demographic, clinical and laboratory data were analyzed. Etiology of CP was determined according to the MANNHEIM classification system into the following etiological subcategories:alcohol consumption, nicotine consumption, hereditary factors, efferent pancreatic duct factors and immunological factors. Pancreatic exocrine function was defined as normal(fecal elastase 1 > 200 μg/g), mildly reduced(100-200μg/g) and severely reduced(fecal elastase 1 < 100 μg/g).RESULTS A total of 150 patients were included in the analysis. Zinc deficiency(< 11μmol/L) was present in 39(26.0%) of patients: 22 females and 17 males. In the group of patients with zinc deficiency, 76.7% of patients had an exocrine pancreatic insufficiency(FE-1 < 200 μg/g). Older age was significantly associated with low zinc levels. Following a univariate analysis, patients aged 60-69 and patients ≥ 70 years of age had a significantly higher prevalence of zinc deficiencies compared to patients < 40 years of age [OR: 3.8, 95%CI(1.08-13.4); P= 0.04]; [OR 6.26, 95%CI(1.94-20.2), P > 0.002]. Smoking and number of packyears were additionally associated with low zinc levels. The risk of zinc deficiency in current smokers and smokers with ≥ 20 pack-years was approximately three times higher compared to those who had never smoked.Gender, body mass index, etiology of CP, presence of diabetes mellitus, levels of glycated hemoglobin(HbA1 c), bone mineral density, alcohol intake and presence of PEI were not associated with low zinc levels.CONCLUSION Zinc deficiency is common in patients with CP and is significantly associated with age ≥ 60, smoking and the number of pack-years, but not with PEI.     

广西玉林市5岁以下儿童营养不良现状调查分析

目的了解玉林市5岁以下儿童营养不良（体重〈^-x-2s）现状。方法对玉林市5岁以下儿童进行体重检查,并对体重〈〈^-x-2s的资料分7县市区进行统计分析。结果玉林市5岁以下儿童体重检查共414404名,儿童营养不良9549名,营养不良率为2．30％。结论玉林市5岁以下儿童营养状况较好,提倡合理膳食,培养良好的饮食习惯,可进一步降低儿童营养不良的发生率。     

Diagnosis and treatment of exocrine pancreatic insufficiency in chronic pancreatitis: An international expert survey and case vignette study

IntroductionDespite evidence-based guidelines, exocrine pancreatic insufficiency is frequently underdiagnosed and undertreated in patients with chronic pancreatitis. Therefore, the aim of this study is to provide insight into the current opinion and clinical decision-making of international pancreatologists regarding the management of exocrine pancreatic insufficiency.MethodsAn online survey and case vignette study was sent to experts in chronic pancreatitis and members of various pancreatic associations: EPC, E-AHPBA and DPSG. Experts were selected based on publication record from the past 5 years.ResultsOverall, 252 pancreatologists participated of whom 44% had ≥ 15 years of experience and 35% treated ≥ 50 patients with chronic pancreatitis per year. Screening for exocrine pancreatic insufficiency as part of the diagnostic work-up for chronic pancreatitis is performed by 69% and repeated annually by 21%. About 74% considers nutritional assessment to be part of the standard work-up. Patients are most frequently screened for deficiencies of calcium (47%), iron (42%), vitamin D (61%) and albumin (59%). In case of clinically steatorrhea, 71% prescribes enzyme supplementation. Of all pancreatologists, 40% refers more than half of their patients to a dietician. Despite existing guidelines, 97% supports the need for more specific and tailored instructions regarding the management of exocrine pancreatic insufficiency.ConclusionThis survey identified a lack of consensus and substantial practice variation among international pancreatologists regarding guidelines pertaining the management of exocrine pancreatic insufficiency. These results highlight the need for further adaptation of these guidelines according to current expert opinion and the level of available scientific evidence.     

粪弹性蛋白酶试验在慢性胰腺炎诊断中的意义

粪弹性蛋白酶试验是通过检测粪便中弹性蛋白酶-1的含量来反映胰腺外分泌情况的一项检查,是间接胰腺外分泌试验中较为简便的一种.此文就其临床研究及应用价值作一综述.     

Morphological and functional recovery following acute and acute recurrent pancreatitis in children: A prospective sequential 2-point evaluation

BackgroundThe functional and morphological recovery following an episode of acute pancreatitis (AP) in children still remains ill understood as research exploring this is limited. We aimed to characterize the morphological and functional changes in pancreas following AP and ARP (acute recurrent pancreatitis) in children.MethodsChildren with AP were followed prospectively and assessed at two time points at least 3 months apart, with the first assessment at least 3 months after the AP episode. Exocrine and endocrine functions were measured using fecal elastase and fasting blood sugar/HbA1c levels respectively. Morphological assessment was done using endoscopic ultrasound (EUS) and magnetic resonance imaging and cholangiopancreatography (MRI/MRCP).ResultsSeventy-three children (boys:59%; mean age:8.4 ± 3.2years) were studied and 21 of them (29%) progressed to ARP. Altered glucose homeostasis was seen in 19 (26%) at first and 16 (22%) at second assessment and it was significantly more in ARP group than the AP group at first (42.8%vs19.2%; p = 0.03) as well as second assessment (38.1%vs15.3%; p = 0.03). Twenty-one children (28.7%) at first and 24 (32.8%) at second assessment developed biochemical exocrine pancreatic insufficiency. EUS detected indeterminate and suggestive changes of chronic pancreatitis in 21% at first (n = 38) and 27.6% at second assessment (n = 58). On MRCP, main pancreatic duct and side branch dilatation were seen in 15 (20.5%) and 2 (2.7%) children respectively.ConclusionsMore than one-quarter of children have evidence of altered glucose homeostasis and biochemical exocrine pancreatic insufficiency following an episode of AP. Similarly, morphological features of chronicity seen in some of the children suggest that a fraction of subjects may develop chronic pancreatitis on longer follow-up.     

Morphological and functional evaluation of chronic pancreatitis with magnetic resonance imaging

Magnetic resonance imaging(MRI)techniques for assessment of morphology and function of the pancreas have been improved dramatically the recent years and MRI is very often used in diagnosing and follow-up of chronic pancreatitis(CP)patients.Standard MRI including fat-suppressed T1-weighted and T2-weighted imaging techniques reveal decreased signal and glandular atrophy of the pancreas in CP.In contrast-enhanced MRI of the pancreas in CP the pancreatic signal is usually reduced and delayed due to decreased perfusion as a result of chronic inflammation and fibrosis.Thus,morphological changes of the ductal system can be assessed by magnetic resonance cholangiopancreatography(MRCP).Furthermore,secretin-stimulated MRCP is a valuable technique to evaluate side branch pathology and the exocrine function of the pancreas and diffusion weighted imaging can be used to quantify both parenchymal fibrotic changes and the exocrine function of the pancreas.These standard and advanced MRI techniques are supplementary techniques to reveal morphological and functional changes of the pancreas in CP.Recently,spectroscopy has been used for assessment of metabolite concentrations in-vivo in different tissues and may have the potential to offer better tissue characterization of the pancreas.Hence,the purpose of the present review is to provide an update on standard and advanced MRI techniques of the pancreas in CP.     

Utility of Fecal Elastase-1 to diagnose severe exocrine insufficiency in chronic pancreatitis: Real world experience

IntroductionQuantitative fecal fat estimation is the gold standard test to diagnose steatorrhea (fecal fat >7 g/day) in chronic pancreatitis (CP), but cumbersome and inconvenient. So, fecal elastase-1 (FE) is proposed as a good alternative but the data on the diagnostic utility of FE to diagnose steatorrhea is variable.MethodsThis retrospective study included adult CP patients evaluated with both 24-h fecal-fat and FE tests within a 3-month period. The objective was to evaluate the diagnostic performance of FE to diagnose steatorrhea and to evaluate the FE progression over 9-month period.ResultsAmong the 147 included patients, the frequency of steatorrhea (fecal fat >7 g/day) was 34%. The sensitivity, specificity, and negative likelihood ratio (LR) of FE was 90%, 28.9% and 0.35 at cut-off of <100 μg/g stool to diagnose steatorrhea; and 96%, 11.3% and 0.35 at cut-off of <200 μg/g stool, respectively. The optimal cut-off of FE was <20 on receiver operating characteristic curve (sensitivity 66%; specificity 69%; positive LR 2.14). There was no statistically significant variation in FE levels over 9 months interval among a hundred patients.ConclusionCompared to FE ≥ 200 μg/g stool, FE ≥ 100 can used to exclude steatorrhea (better specificity and negative LR). FE < 20 alone cannot replace fecal fat estimation to confirm steatorrhea but to be interpreted with clinical features. Repeat FE testing for exocrine insufficiency progression can be done at least a year later.     

Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis

Background/objectivesWhile pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP.MethodsMEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI).ResultsAmong the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10–15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73–100%), 51% (95% CI 32–70%), and 47% (95% CI 15–81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively.ConclusionApproximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.     

Occurrence of exocrine pancreatic insufficiency in patients with advanced neuroendocrine tumors treated with somatostatin analogs

BackgroundAlthough exocrine pancreatic insufficiency (EPI) has been described in patients with neuroendocrine neoplasia (NEN) treated with somatostatin analogs (SSAs), its role in the therapeutic management of these patients is not well established.AimTo determine the frequency of EPI in patients with NEN long-term treated with SSAs.MethodsThis is a prospective single-center study evaluating 35 patients treated with SSAs for >12 months due to unresectable/advanced nonpancreatic well-differentiated NEN. Clinical evaluation, biochemical parameters, and fecal elastases 1 (FE-1) were assessed to diagnose EPI.ResultsA total of 7 patients (20%) had EPI, given the presence of abdominal symptoms and a median FE-1 value of 180 mcg/g stool (150–198). No patient had severe EPI, defined as FE-1 < 100 mcg/g stool. Elevated glycated Hb levels were a significant predictor for developing EPI (OR 4.81, p = 0.01). No significant difference in terms of duration of SSA treatment was observed between patients with or without EPI diagnosed (84 months and 72 months, respectively; p = 0.950).ConclusionsMild-moderate EPI is a relatively common condition in patients receiving long-term treatment with SSAs. Specific clinical and biochemical evaluations, including FE-1, should be planned in these patients to diagnose this relevant condition early, which may deteriorate quality of life and cause malnutrition.     

Decreased serum essential and aromatic amino acids in patients with chronic pancreatitis

AIM:To investigate the influence of chronic pancreatitis(CP) on serum concentrations of amino acids.METHODS:Thirty-five male patients with alcoholic CP and 21 healthy male subjects were examined.Serum concentrations of amino acids were assayed by ionpair high-performance liquid chromatography with mass detection.RESULTS:Serum glutamate concentration was increased in CP patients as compared to controls.In contrast,serum concentrations of glutamine,histidine,tyrosine,proline,tryptophan and threonine were sign...     

150例糖尿病患者胰腺外分泌功能检测及相关因素分析

目的探讨糖尿病患者胰腺外分泌功能不全的发生情况及其相关因素。方法选取2009年3月至2010年6月于第四军医大学西京医院内分泌科就诊的糖尿病患者150例,分为1型糖尿病组（T1DM,23例）、2型糖尿病组（T2DM,127例）,对照组为来我院健康体检者及我科医护人员共48人。记录糖尿病患者的年龄、性别、体质指数（BMI）、病程、糖尿病微血管病变发生情况、糖化血红蛋白（HbAle）等指标。收集受试者24h内排出的粪便,应用酶联免疫吸附实验（ELISA）法测定粪便中粪弹性蛋白酶（FE）的含量,对所有受试者的胰腺外分泌功能进行评估。率的比较采用X2检验或Fisher精确概率法。结果1型糖尿病患者、2型糖尿病患者及对照组粪便FE含量差异有统计学意义[分别为（394±237）比（502±194）比（576±170）μg／g,F=6．93,P〈0．01]。以FE〈200μg／g作为胰腺外分泌功能不全的判断标准,结果显示30．4％（7／23）的T1DM患者及7．9％（10／127）的T2DM患者存在胰腺外分泌功能不全,与对照组（0）相比,差异有统计学意义（Fisher检验P〈0．05）。以是否存在胰腺外分泌功能不全对糖尿病患者进行分组分析,结果显示两组间年龄、性别、BMI、病程、胰岛素治疗与否、糖尿病微血管病变发生情况、稳态模型胰岛素分泌指数（HOMA-B）、空腹胰岛素、餐后2h胰岛素及HbAlc等差异均无统计学意义（均P〉0．05）。结论本研究提示与健康对照相比,T1DM和他DM患者胰腺外分泌功能不全的发生率普遍较高。     

The baseline nutritional status assessed by MUST score has a low accuracy in predicting the risk of hospitalization during follow-up in patients with chronic pancreatitis: A cohort study

BackgroundHospitalization and death in patients with chronic pancreatitis (CP) are often due to extra-pancreatic events. Recent guidelines recommend the use of the MUST score to assess CP patients’ nutritional status, but its association with clinical outcomes has been poorly investigated. The aims of this study are to evaluate the incidence of extra-pancreatic events in patients with CP during follow-up and their association with the nutritional status.MethodsRetrospective analysis of single-centre cohort of CP patients prospectively enrolled and followed-up. Exocrine pancreatic insufficiency (EPI) was assessed by fecal elastase, MUST score calculated at diagnosis. The occurrence of hospitalizations or death were recorded. Differences between subgroups were analysed by Fisher’s and T-test and hospitalization-free survival with Kaplan-Meier curves and Cox regression analysis.ResultsOf 111 enrolled patients (64% male; mean age 57); 52% had alcoholic aetiology, 53% EPI, 10% severe CP and 26% a MUST score≥2 at diagnosis. During a median follow-up of 37 months, 3.6% of patients died and 34.2% needed hospitalization, in 50% of cases for extrapancreatic events (2% cardiovascular events, 8% infections and 3% cancer). There was no significant association between EPI, BMI<20 kg/m², MUST score≥2, alcoholic aetiology and extra pancreatic events or need of hospitalization. A baseline MUST score≥2 had an accuracy of only 64.8% in predicting subsequent hospitalization.ConclusionsA sizeable portion of CP patients are at high risk of malnutrition and are hospitalized during the follow-up, often for extra-pancreatic events. The nutritional status evaluated with the MUST score lacks accuracy in predicting the risk of these events.     

Surgical options in chronic pancreatitis

Summary Chronic pancreatitis is primarily a medical disease but surgery is indicated to treat complications, rule out malignancy, and ameliorate intractable pain. The ideal operation for chronic pancreatitis would relieve this pain while preserving exocrine and endocrine function. No one procedure achieves these goals in all patients so surgeons must tailor their operations to individual patient needs. In patients with a dilated pancreatic duct, complete ductal decompression with a lateral pancreaticojejunostomy is usually indicated. Pancreatic resection is useful in patients with localized disease, nondialated ducts, or in whom cancer cannot be ruled out. More rigorous documentation of the type and outcome of therapeutic interventions for chronic pancreatitis and the patient populations to whom they are applied is needed. Subjective measurements must be replaced by objective findings so that the true benefits of these procedures can be better assessed and compared.     

重组生长激素治疗慢性阻塞性肺疾病营养不良的现状

慢性阻塞性肺疾病（COPD）是全世界范围内威胁人类健康的主要疾病,营养缺乏是COPD患者一个常见的问题,也是关系到其预后的一个独立危险因素。重组人类生长激素能增强细胞对氨基酸吸收,促进蛋白质合成和增强免疫功能。应用GH治疗COPD合并营养不良患者甚至需机械通气的COPD患者取得了提高营养状态和改善免疫功能效果。     

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience

Background

Surgical treatment of chronic pancreatitis is indicated for intractable pain. Frey''s procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Frey''s procedure.

Methods

A retrospective analysis of 73 patients who underwent a Frey''s procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed.

Results

The median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1 kg/m². All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n = 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278 g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4 kg/m² (P < 0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late.

Conclusions

Frey''s procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.     

Improving nutritional status assessment in patients with chronic pancreatitis

Introduction

Chronic pancreatitis (CP) is a progressive inflammatory disorder causing irreversible destruction of pancreatic tissue, leading to malnutrition. A previous study has found that currently used screening methods (periodic recording of body weight and faecal and serological markers) fall short in identifying and curbing malnutrition. Moreover, data is lacking regarding change in nutritional status over time. The aim of our study is to investigate changes in nutritional status in CP patients over time and to determine whether a more extensive set of measurements would be beneficial for nutritional screening of these patients.

内镜下诊治伴发胰管结石慢性胰腺炎的价值

目的探讨ERCP在胰管结石诊断和治疗中的临床价值及其安全性评估。方法分析2008年2月～2008年10月期间共20例接受ERCP诊断和治疗的伴发胰腺结石慢性胰腺炎患者的临床资料。结果20例病例中,16例（80％）胰管结石位于胰头处,3例（15％）位于胰头及胰体处,1例（5％）累及全程胰管。14例（70％）患者一次性取石完全,5例患者术后接受体外震波碎石（ESWL）,1例患者未能完成取石,建议其外科手术治疗．18例表现为腹痛的病例,在接受内镜下治疗结石后,腹痛症状均消失,在接受治疗后2～10d内出院,平均（5．3±2．43）d。术后2例（10％）出现一过性的血淀粉酶升高。结论对于伴有胰管结石的慢性胰腺炎病例而青,内镜下取石是安全有效的方法,同时应川支架及鼻胰管引流,不仅对胰管结石的治疗有效,而且充分的胰液引流对于缓解腹痛症状、减少术后的胰腺炎、高淀粉酶m症的发乍有着重要的作用。     

Function tests in the diagnosis of chronic pancreatitis

Summary Direct pancreatic function tests, such as the secretin-pancreozymin test and the Lundh test, are—by direct measurement of the contents of duodenal secretion following exogenous (hormonal) or endogenous (test meal) stimulation—the best way to assess exocrine pancreatic function. However, these tests are time-consuming, invasive, and expensive, and therefore their use is limited to specialized centers only. Several studies have shown that indirect pancreatic function tests are a practicable alternative to direct pancreatic function tests for diagnosing exocrine pancreatic insufficiency. They allow staging of the disease and thereby facilitate comparison of different studies. They are also useful in some cases for determining whether pancreatic enzyme replacement therapy is necessary or not. In contrast to morphological procedures, they involve neither side effects, risks for the patient, nor complications for patients, investigators, and laboratory staff alike. The procedures being standardized, the test results depend to a lesser extent on the experience of the investigator, and more on the selection of and the instructions to the patient, and to some extent, on the severity of the exocrine pancreatic insufficiency. Like all pancreatic function tests, the indirect tests do not give a clue to etiology nor help investigators to differentiate between pancreatic insufficiency owing to chronic pancreatitis and that owing to pancreatic cancer. The role of pancreatic function tests in diagnosing early chronic pancreatitis in comparison to morphological examinations remains to be established.