Associations with Pancreatic Exocrine Insufficiency: An United Kingdom Single-centre Study

Overview

Journal World J Clin Cases

Publisher Baishideng Publishing Group

Specialty General Medicine

Date 2021 Dec 8

PMID 34877281

Authors

Benjamin M Shandro

Joshua Chen

Jennifer Ritehnia

Andrew Poullis

Affiliations

Soon will be listed here.

Abstract

Background: Pancreatic exocrine insufficiency (PEI) is said to be associated with numerous conditions both within and outside the gastrointestinal (GI) system. The majority of research has been concerned with conditions that reduce the volume of functioning pancreatic tissue or prevent adequate drainage to the small bowel, such as chronic pancreatitis, cystic fibrosis, pancreatic cancer and pancreatic resection. However, the evidence base supporting an association with extra-pancreatic conditions, such as coeliac disease, diabetes mellitus and congestive cardiac failure, is heterogeneous.

Aim: To strengthen the evidence base by studying all previously reported associations with PEI in a large cohort of outpatients.

Methods: A single-centre retrospective study was performed. General gastroenterology outpatients tested for PEI with faecal elastase-1 (FE1) were identified and information retrieved from the electronic patient record. PEI was defined as FE1 < 200 μg/g. Patients already taking pancreatic enzyme replacement therapy were excluded. Multiple imputation was used to handle missing data. Univariable logistic regression was used to study which presenting symptoms predicted PEI. Multivariable logistic regression was used to explore the relationship between all previously reported associations and PEI.

Results: Of 1027 patients were included. 182 patients (17.7%) were diagnosed with PEI. Steatorrhoea [odds ratios (OR): 2.51, 95% confidence intervals (CI): 1.58-3.98] and weight loss (OR: 1.49, 95%CI: 1.08-2.06) were the only presenting symptoms that predicted PEI. Chronic pancreatitis (OR: 7.98, 95%CI: 3.95-16.15), pancreatic cancer (OR: 6.58, 95%CI: 1.67-25.98), upper GI surgery (OR: 2.62, 95%CI: 1.32-5.19), type 2 diabetes (OR: 1.84, 95%CI: 1.18-2.87), proton pump inhibitor therapy (OR: 1.87, 95%CI: 1.25-2.80) and Asian ethnicity (OR: 2.11, 95%CI: 1.30-3.42) were significantly associated with PEI in the multivariable analysis. None of the other historically reported associations with PEI were significant after adjustment for the other variables included in our multivariable analysis.

Conclusion: PEI is common in patients with chronic pancreatitis, pancreatic cancer, upper GI surgery and type 2 diabetes. Proton pump inhibitor therapy may also be associated with PEI or a false positive FE1.

References

Pendharkar S, Mathew J, Zhao J, Windsor J, Exeter D, Petrov M . Ethnic and geographic variations in the incidence of pancreatitis and post-pancreatitis diabetes mellitus in New Zealand: a nationwide population-based study. N Z Med J. 2017; 130(1450):55-68. View

Janssen K, Donders A, Harrell Jr F, Vergouwe Y, Chen Q, Grobbee D . Missing covariate data in medical research: to impute is better than to ignore. J Clin Epidemiol. 2010; 63(7):721-7. DOI: 10.1016/j.jclinepi.2009.12.008. View

Pelli H, Lappalainen-Lehto R, Piironen A, Sand J, Nordback I . Risk factors for recurrent acute alcohol-associated pancreatitis: a prospective analysis. Scand J Gastroenterol. 2008; 43(5):614-21. DOI: 10.1080/00365520701843027. View

Bartel M, Asbun H, Stauffer J, Raimondo M . Pancreatic exocrine insufficiency in pancreatic cancer: A review of the literature. Dig Liver Dis. 2015; 47(12):1013-20. DOI: 10.1016/j.dld.2015.06.015. View

Leeds J, Hopper A, Hurlstone D, Edwards S, McAlindon M, Lobo A . Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms?. Aliment Pharmacol Ther. 2007; 25(3):265-71. DOI: 10.1111/j.1365-2036.2006.03206.x. View

Duggan S, Ni Chonchubhair H, Lawal O, OConnor D, Conlon K . Chronic pancreatitis: A diagnostic dilemma. World J Gastroenterol. 2016; 22(7):2304-13. PMC: 4735004. DOI: 10.3748/wjg.v22.i7.2304. View

Tseng D, Molenaar I, Besselink M, Van Eijck C, Borel Rinkes I, van Santvoort H . Pancreatic Exocrine Insufficiency in Patients With Pancreatic or Periampullary Cancer: A Systematic Review. Pancreas. 2015; 45(3):325-30. DOI: 10.1097/MPA.0000000000000473. View

Xia T, Chai X, Shen J . Pancreatic exocrine insufficiency in patients with chronic heart failure and its possible association with appetite loss. PLoS One. 2017; 12(11):e0187804. PMC: 5695817. DOI: 10.1371/journal.pone.0187804. View

Keszthelyi D, Masclee A . Effects of proton pump inhibitor therapy in the distal gut: putting the pieces together. Dig Dis Sci. 2012; 57(10):2487-9. DOI: 10.1007/s10620-012-2339-5. View

10.

Machicado J, Chari S, Timmons L, Tang G, Yadav D . A population-based evaluation of the natural history of chronic pancreatitis. Pancreatology. 2017; 18(1):39-45. PMC: 5794616. DOI: 10.1016/j.pan.2017.11.012. View

11.

Hollemans R, Hallensleben N, Mager D, Kelder J, Besselink M, Bruno M . Pancreatic exocrine insufficiency following acute pancreatitis: Systematic review and study level meta-analysis. Pancreatology. 2018; 18(3):253-262. DOI: 10.1016/j.pan.2018.02.009. View

12.

Dominguez-Munoz J . Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol. 2011; 26 Suppl 2:12-6. DOI: 10.1111/j.1440-1746.2010.06600.x. View

13.

Huang W, de la Iglesia-Garcia D, Baston-Rey I, Calvino-Suarez C, Larino-Noia J, Iglesias-Garcia J . Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: Systematic Review and Meta-Analysis. Dig Dis Sci. 2019; 64(7):1985-2005. PMC: 6584228. DOI: 10.1007/s10620-019-05568-9. View

14.

Griesche-Philippi J, Otto J, Schworer H, Maisonneuve P, Lankisch P . Exocrine pancreatic function in patients with end-stage renal disease. Clin Nephrol. 2010; 74(6):457-64. DOI: 10.5414/cnp74457. View

15.

Arasaradnam R, Brown S, Forbes A, Fox M, Hungin P, Kelman L . Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut. 2018; 67(8):1380-1399. PMC: 6204957. DOI: 10.1136/gutjnl-2017-315909. View

16.

Pezzilli R, Morselli Labate A, Ceciliato R, Frulloni L, Cavestro G, Comparato G . Quality of life in patients with chronic pancreatitis. Dig Liver Dis. 2005; 37(3):181-9. DOI: 10.1016/j.dld.2004.10.007. View

17.

Raphael K, Chawla S, Kim S, Keith C, Propp D, Chen Z . Pancreatic Insufficiency Secondary to Tobacco Exposure: A Controlled Cross-Sectional Evaluation. Pancreas. 2016; 46(2):237-243. PMC: 6355146. DOI: 10.1097/MPA.0000000000000721. View

18.

Herzig K, Purhonen A, Rasanen K, Idziak J, Juvonen P, Phillps R . Fecal pancreatic elastase-1 levels in older individuals without known gastrointestinal diseases or diabetes mellitus. BMC Geriatr. 2011; 11:4. PMC: 3039595. DOI: 10.1186/1471-2318-11-4. View

19.

Piciucchi M, Capurso G, Archibugi L, Delle Fave M, Capasso M, Delle Fave G . Exocrine pancreatic insufficiency in diabetic patients: prevalence, mechanisms, and treatment. Int J Endocrinol. 2015; 2015:595649. PMC: 4393909. DOI: 10.1155/2015/595649. View

20.

Grassi M, Lazzari S, Palmisano P, Nocchi S, Fontana M, Raffa S . [Evaluation of exocrine pancreatic insufficiency in cirrhotic patients,using the fecal chymotrypsin test]. Clin Ter. 1994; 144(6):501-9. View