Original articleSerum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis
Introduction
Pancreatic exocrine insufficiency (PEI) leading to maldigestion, steatorrhea and malnutrition is an important complication in chronic pancreatitis. Most patients with chronic pancreatitis will eventually develop PEI after a median time of 12 years after the diagnosis of chronic pancreatitis [1]. It is generally accepted that the degree of malnutrition in PEI correlates with risk for complications and mortality even though specific studies on this issue are lacking [2]. Early detection of PEI in subjects with chronic pancreatitis can be assumed to be of great clinical importance considering the potential deleterious effects of PEI-related malnutrition and the fact that PEI can be treated with oral administration of pancreatic enzyme preparations. Gold standard for demonstration of PEI is 3 days fecal fat quantification with calculation of the coefficient of fat absorption [3]. The method requires the patient to keep a strict diet of 100 g fat per day during five days and to collect and store the complete volume of feces during the last three days. Dietary restrictions and the handling of large volumes of feces make the method cumbersome and unpleasant for both patients and laboratory personnel. As a consequence, the use of fecal fat quantification is nowadays limited to a few specialized centers. Other methods for evaluation of pancreatic exocrine function include direct function tests where pancreatic juice is collected by a tube or an endoscope placed in the duodenum after the intravenous administration of secretin, and fecal measurement of pancreatic enzymes, mainly elastase. These tests, however, are in fact measurements of pancreatic secretion and not digestion. Furthermore, direct function tests have the drawback of being time consuming, invasive, expensive and cumbersome for the patient. Fecal elastase test, on the other hand, is easy to perform and widely available, but notoriously insensitive and never properly tested against coefficient of fat absorption in patients with chronic pancreatitis [4].
An alternative to fecal fat quantification for evaluation of fat malabsoption in chronic pancreatitis is the 13C-mixed triglyceride (13C-MTG) breath test [5]. This has been recommended for PEI diagnosis and treatment follow up in subjects with chronic pancreatitis since it is easy to perform and the results correlate well with those from fecal fat quantification [6]. However, the 13C-MTG breath test is not commercially available for the moment in most countries and requires advanced equipment for measurement of 13C in exhaled air. Hence, there is a need in clinical practice for a simple and widely available screening tool for detection of PEI in chronic pancreatitis and indication of pancreatic enzyme substitution therapy.
Deficiencies of micro- and macronutrients are objective consequences of malnutrition. Several nutritional deficiencies have been demonstrated in subjects with chronic pancreatitis, including lipid soluble vitamins A, D, E and K, zinc, magnesium, calcium, thiamine and folic acid [7], [8], [9], [10]. However studies investigating the correlation between nutritional parameters and PEI are sparse.
The aim of the present study was to investigate the probability of PEI in relation to levels of nutritional markers in blood in a consecutive series of enzyme replacement naïve patients with chronic pancreatitis, using the 13C-MTG breath test as reference.
Section snippets
Patients
Consecutive patients evaluated for a suspicion of chronic pancreatitis at the Pancreas Unit of the Department of Gastroenterology, University Hospital of Santiago de Compostela, Spain, have been registered in a prospective manner from 2005 and forth. For the diagnosis of chronic pancreatitis, all patients underwent an endoscopic ultrasonography (EUS) of the pancreas with evaluation of the number of chronic pancreatitis criteria [11], [12]. The diagnosis was considered as confirmed if five or
Results
A total of 114 subjects with chronic pancreatitis were included in the study, 38 with PEI and 76 without, according the 13C-MTG breath test. Forty-two cases from the original database were previously excluded due to lack of nutritional laboratory evaluation in the time frame stipulated for the study (three months before, until 1 month after the breath test). Mean age was 48.1 years (SD 13.9). General demographics and clinical characteristics are given in Table 1.
The prevalence of diabetes and
Discussion
The usefulness of serum nutritional markers as surrogate markers for PEI in subjects with chronic pancreatitis is investigated in the present retrospective analysis of 114 subjects within a prospectively collected chronic pancreatitis cohort. Among investigated nutritional markers, serum magnesium was the one that correlated best with PEI. The sensitivity and specificity for detection of PEI were 0.88 and 0.66 respectively using a magnesium of 2.05 mg/dL as cut-off. The probability of PEI was
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