Pancreatic exocrine insufficiency in HIV-positive patients

OBJECTIVES: We describe the management of a cohort of eight HIV-positive patients on antiretroviral medication with evidence of pancreatic insufficiency consisting of chronic diarrhoea and a low faecal elastase measurement. PATIENTS AND METHODS: Twenty-two patients with chronic diarrhoea for whom a faecal elastase measurement was available were identified retrospectively. We compared baseline demographic characteristics, antiretroviral treatment and symptoms of steatorrhea between patients with evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement of <200 microg/g (cases), and patients with evidence of normal pancreatic function, i.e. a normal faecal elastase measurement of >200 microg/g (controls). We describe the management of the patients with evidence of pancreatic insufficiency. RESULTS: Of the 22 patients, eight had evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement. Comparing cases with controls, cases were more likely to have symptoms of steatorrhea (P=0.03) or to have lost weight (P=0.02). Cases were also significantly more likely to have taken didanosine (ddI) as part of their antiretroviral treatment when their symptoms started. Seven cases were treated with oral pancreatic supplements and all had symptomatic improvement of their diarrhoea. One patient stopped treatment with oral pancreatic supplements because of side effects without a relapse of symptoms; he had also stopped zalcitabine (ddC). CONCLUSIONS: We believe that measurement of faecal elastase to detect pancreatic insufficiency should be part of the standard investigation of HIV-positive patients with chronic diarrhoea alongside assessment for other causes of diarrhoea. Faecal elastase measurements should be requested, in particular, in all patients with diarrhoea and weight loss, or symptoms of steatorrhea, and in those on treatment with an antiretroviral regime containing ddI. If the faecal elastase level is low, a switch of antiretroviral medication to a nonddI/ddC-containing regime should be considered and treatment with oral pancreatic enzyme therapy should be instituted.