LIPASES AND LIPID ABSORPTION IN THE NEWBORN

Intragastric lipolysis resulting from the action of lingual lipase occurs in preterm infants and may be important quantitatively in the digestion of fat.     

Fat-soluble vitamin concentration in chronic alcohol-induced pancreatitis

In order to study the fat-soluble vitamin concentration of patients with chronic alcohol-induced pancreatitis (CAIP) we measured vitamins A and E, total lipids, and retinol-binding protein (RBP) in the plasma of 44 patients with CAIP and 83 controls (44 healthy controls; 39 Crohn's disease patients). Mean plasma vitamin E and vitamin E/total lipid ratio were significantly lower in CAIP when compared with either control or Crohn's disease groups. A low vitamin E/total lipid ratio was found in 75% of CAIP patients (91% with steatorrhea) and a ratio less than 1.0 was virtually 100% predictive of steatorrhea. The mean plasma vitamin A level for the CAIP group was significantly lower (overall 16%, 38% with steatorrhea) than in controls. Patients with CAIP show subnormal plasma levels vitamin E more often as compared to vitamin A. Further, the plasma vitamin E/total lipids ratio may be a sensitive and practical means in the detection and follow-up of steatorrhea in these patients.This work was accepted for oral presentation at the XXII Meeting of the European Pancreatic Club, September 16–18, 1991, Lund, Sweden.     

High Prevalence of Steatorrhea in 101 Diabetic Patients Likely to Suffer from Exocrine Pancreatic Insufficiency According to Low Fecal Elastase 1 Concentrations: A Prospective Multicenter Study

Impaired exocrine pancreatic secretion has been frequently observed in diabetic patients by different methods, including direct function tests. However, the clinical importance remained unclear. In the present study, the fecal fat excretion in patients with type 1 or type 2 diabetes mellitus and exocrine dysfunction according to fecal elastase 1 concentrations <100 g/g was investigated. Subjects with a history of gastrointestinal cancer, gastrointestinal surgery, alcohol abuse, or inflammatory diseases were excluded. In 101 patients the mean (±SD) fat excretion was 9.19 ± 5.39 g. Only 41 patients (40.6%) had normal fat excretion <7 g/day. In 40 patients (39.6%), it was higher than 10 g/day, indicating relevant steatorrhea. The fat excretion did not correlate with diabetes type, duration, or clinical symptoms. This finding is of some clinical importance and might influence pathophysiological concepts and the management of diabetic patients.     

A new oral margarine loading test in children

Margarine (2g/kg) was orally administered to 39 children with normal fat digestion and absorption (control group) and 17 children with abnormal fat digestion and absorption (malabsorbed group). The serum triglyceride (TG) level was serially determined by capillary blood sampling. In the control group, the TG level was significantly elevated after 2, 3 and 4 h as compared with the level before margarine ingestion (basal TG). The maximum TG elevation rate [MTER - (maximum TG-basal TG)/basal TG x 100] was > 50% in all but three children. In contrast, a significant increase in TG was not observed in the malabsorbed group after margarine ingestion, and the MTER was < 50% in all but two children. The MTER was significantly lower in children with a high microscopic score of fecal fat than that in children with a low score. This oral margarine loading test is a simple and semi-quantitative evaluation of fat digestion and absorption, and is considered to be useful for the assessment of the presence or severity of fat maldigestion and malabsorption in children.     

Can pancreatic steatorrhea be diagnosed without chemical analysis?

Summary Conclusion Visual observation of feces, considering fecal output, is considered to be an excellent method of detection of steatorrhea when judged by experienced doctors. Methods Feces from 192 patients with untreated chronic pancreatitis or under pancreatic enzyme therapy were investigated. Feces were collected for three consecutive days and homogenized with water. Fecal samples were freeze-dried and analyzed for fatty acids by gas chromatography (GLC). The quantity of fat was calculated from the amount of fatty acid to obtain daily fecal fat excretion. Comparison of GLC method with van de Kamer method gave a significant (p<0.01) positive correlation with correlation coefficient of 0.916 (n=38). Steatorrhea was defined as fecal fat excretion exceeding 5 g/d. Mild steatorrhea was defined as 5–10 g/d, and severe steatorrhea as more than 10 g/d. Results Three visual identification items were used to consider fecal output exceeding 200 g/d: fecal fat concentration exceeding 4%, appearance, and odor. The results were compared with the results from GLC method. Detection of steatorrhea by means of visual properties was the most accurate, and correlation coefficient was 0.843 (p<0.01) by Spearman’s rank correlation test. This detection method was also significantly effective for differentiation of normal stool from mild and severe steatorrhea. The sensitivity and specificity were 89.3 and 91.1%, respectively, indicating a favorable result.     

Postcibal gastric emptying of pancreatin pellets: effects of dose and meal oil

To treat pancreatic exocrine insufficiency, physicians often prescribe enterically coated pellets of pancreatin to be taken with meals. The pellets are only partially effective in correcting the digestion and absorption of fat. We sought to determine in normal subjects whether emptying of pellets from the postcibal stomach was dose-related and whether the gastric emptying of lipophilic Creon-20 or Pancrease was altered by the presence or the absence of oil in a meal. Gastric emptying of pellets surface-labeled with ^113mIn or ^99mTc was followed with a gamma camera for 300 min after isocaloric meals. From our observations, we concluded that gastric emptying of 0.28–1.12 g of 1-mm or 2-mm pellets was dose-related (P < 0.01) and emptying of neither Creon-20 nor Pancrease was much affected by oil in the meal.     

CLINICAL EVALUATION OF THE "GTRIOLEIN BREATH TEST: A CRITICAL ANALYSIS

Twenty-two hospital patients without gastrointestinal symptoms and fourteen patients with clinically suspected fat malabsorption were studied using the ¹⁴C-Triolein Breath Test and three day fecal fat estimation. The ¹⁴C-Triolein Breath Test was 100% sensitive and 86% specific for fat malabsorption. Three day fecal fat estimations were 86% sensitive and 91% specific. These data confirm the high sensitivity and specificity obtained using the ¹⁴C-Triolein Breath Test. The speed and convenience of the ¹⁴C-Triolein Breath Test plus acceptable sensitivity and specificity make this a practical screening test to detect fat malabsorption.     

Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel

Background: Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release.

Purpose: To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI.

Methods: For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? consensus.

Findings: The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist.

Conclusions: In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.     

Shwachman–Diamond syndrome: Nationwide survey and systematic review in Japan

Background

Shwachman–Diamond syndrome (SDS) is a rare multisystem disorder associated with exocrine pancreatic insufficiency. The present study reports the results of a nationwide survey and a systematic review on SDS to develop consensus guidelines for intractable diarrhea including SDS.

Methods

Questionnaires were sent to 616 departments of pediatrics or of pediatric surgery in Japan in a nationwide survey. A second questionnaire was sent to doctors who had treated SDS patients and included questions on clinical information. Additionally, a systematic review was performed using digital literature databases to assess the influence of medical (i.e. non‐surgical) treatment on SDS prognosis.

Results

Answers were received from 529 institutions (85.9%), which included information on 24 patients with SDS (median age, 10.4 years; male, n = 15) treated from January 2005 to December 2014. Although 75% of patients received pancreatic enzyme replacement therapy, there was no significant association between treatment and prognosis. Systematic review identified one clinical practice guideline, two case series, eight case reports and 26 reviews. Patient information from those studies was insufficient for meta‐analysis.

Conclusions

The rarity of SDS makes it difficult to establish evidence‐based treatment for SDS. According to the limited information from patients and published reports, medical treatment for malabsorption due to SDS should be performed to improve fat absorption and stool condition, but it is not clear whether this treatment improves the prognosis of malabsorption.