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Current Treatment Options in Gastroenterology

, Volume 13, Issue 3, pp 347–353 | Cite as

Diagnosis of Exocrine Pancreatic Insufficiency

  • Phil A. Hart
  • Darwin L. Conwell
Pancreas (T Stevens, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Pancreas

Opinion statement

The accurate diagnosis of exocrine pancreatic insufficiency (EPI) helps identify those in need of pancreatic enzyme replacement therapy. Conversely, ruling out EPI identifies those in which additional evaluation should be pursued to explain their symptoms. There are many available tests that can be used to diagnose EPI; however, the tests must be tailored to each clinical scenario. Tests that are convenient but less accurate (e.g., fecal elastase-1, qualitative fecal fat determination) are best suited for patients with a high pretest probability of EPI. In contrast, tests that are highly accurate but more cumbersome (e.g., endoscopic pancreatic function testing, 72-h fecal fat collection) are favored in patients suspected to have mild EPI or an early stage of chronic pancreatitis. Additional research is needed to identify a more convenient means of accurately diagnosing at all stages of EPI.

Keywords

Exocrine insufficiency Steatorrhea Chronic pancreatitis Pancreatic enzymes Lipase 

Abbreviations

CFA

Coefficient of fat absorption

EPI

Exocrine pancreatic insufficiency

FE-1

Fecal elastase-1

MTBT

13C-mixed triglyceride breath test

PERT

Pancreatic enzyme replacement therapy

PPI

Proton pump inhibitor

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Phil A. Hart declares that he has no conflict of interest.

Darwin L. Conwell declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Durno C, Corey M, Zielenski J, et al. Genotype and phenotype correlations in patients with cystic fibrosis and pancreatitis. Gastroenterology. 2002;123:1857–64.PubMedCrossRefGoogle Scholar
  2. 2.
    Layer P, Yamamoto H, Kalthoff L, et al. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology. 1994;107:1481–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Tignor AS, Wu BU, Whitlock TL, et al. High prevalence of low-trauma fracture in chronic pancreatitis. Am J Gastroenterol. 2010;105:2680–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Duggan SN, Smyth ND, Murphy A, et al. High prevalence of osteoporosis in patients with chronic pancreatitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2014;12:219–28.PubMedCrossRefGoogle Scholar
  5. 5.
    Czako L, Takacs T, Hegyi P, et al. Quality of life assessment after pancreatic enzyme replacement therapy in chronic pancreatitis. Can J Gastroenterol. 2003;17:597–603.PubMedGoogle Scholar
  6. 6.
    Conwell DL, Wu BU. Chronic pancreatitis: making the diagnosis. Clin Gastroenterol Hepatol. 2012;10:1088–95.PubMedCrossRefGoogle Scholar
  7. 7.
    Hart PA CD. Challenges and updates in management of exocrine pancreatic insufficiency. Pancreas 2015.Google Scholar
  8. 8.
    Dominguez-Munoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol. 2011;26(2):12–6.PubMedCrossRefGoogle Scholar
  9. 9.•
    Conwell DL, Lee LS, Yadav D, et al. American pancreatic association practice guidelines in chronic pancreatitis: evidence-based report on diagnostic guidelines. Pancreas. 2014;43:1143–62. Recently published guidelines regarding the diagnosis of chronic pancreatitis. This article provides further details about encorporating functional and structural assessments of the pancreas to diagnose chronic pancreatitis.PubMedCrossRefGoogle Scholar
  10. 10.
    Conwell DL, Zuccaro G, Morrow JB, et al. Cholecystokinin-stimulated peak lipase concentration in duodenal drainage fluid: a new pancreatic function test. Am J Gastroenterol. 2002;97:1392–7.PubMedCrossRefGoogle Scholar
  11. 11.•
    Law R, Lopez R, Costanzo A, et al. Endoscopic pancreatic function test using combined secretin and cholecystokinin stimulation for the evaluation of chronic pancreatitis. Gastrointest Endosc. 2012;75:764–8. A recent, large study examining endoscopic pancreatic function testing. The authors demonstrated the additon of cholecystokinin stimulation to secretin stimulation did not improve the diagnosis of chronic pancreatitis.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Stevens T, Conwell DL, Zuccaro G, et al. Electrolyte composition of endoscopically collected duodenal drainage fluid after synthetic porcine secretin stimulation in healthy subjects. Gastrointest Endosc. 2004;60:351–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Stevens T, Conwell DL, Zuccaro Jr G, et al. A randomized crossover study of secretin-stimulated endoscopic and dreiling tube pancreatic function test methods in healthy subjects. Am J Gastroenterol. 2006;101:351–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Stevens T, Conwell DL, Zuccaro Jr G, et al. The efficiency of endoscopic pancreatic function testing is optimized using duodenal aspirates at 30 and 45 minutes after intravenous secretin. Am J Gastroenterol. 2007;102:297–301.Google Scholar
  15. 15.
    Stevens T, Conwell DL, Zuccaro Jr G, et al. A prospective crossover study comparing secretin-stimulated endoscopic and dreiling tube pancreatic function testing in patients evaluated for chronic pancreatitis. Gastrointest Endosc. 2008;67:458–66.PubMedCrossRefGoogle Scholar
  16. 16.
    Stevens T, Dumot JA, Zuccaro Jr G, et al. Evaluation of duct-cell and acinar-cell function and endosonographic abnormalities in patients with suspected chronic pancreatitis. Clin Gastroenterol Hepatol. 2009;7:114–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Kadiyala V, Lee LS, Banks PA, et al. Cigarette smoking impairs pancreatic duct cell bicarbonate secretion. J Pancreatol. 2013;14:31–8.Google Scholar
  18. 18.
    Forsmark CE. Management of chronic pancreatitis. Gastroenterology. 2013;144:1282–91.PubMedCrossRefGoogle Scholar
  19. 19.
    Pezzilli R, Andriulli A, Bassi C, et al. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian association for the study of the pancreas. World J Gastroenterol. 2013;19:7930–46.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Vantrappen GR, Rutgeerts PJ, Ghoos YF, Hiele MI. Mixed triglyceride breath test: a noninvasive test of pancreatic lipase activity in the duodenum. Gastroenterology. 1989;96:1126–34.PubMedGoogle Scholar
  21. 21.
    Loser C, Brauer C, Aygen S, et al. Comparative clinical evaluation of the 13C-mixed triglyceride breath test as an indirect pancreatic function test. Scand J Gastroenterol. 1998;33:327–34.PubMedCrossRefGoogle Scholar
  22. 22.
    Dominguez-Munoz JE, Iglesias-Garcia J, Vilarino-Insua M, Iglesias-Rey M. 13C-mixed triglyceride breath test to assess oral enzyme substitution therapy in patients with chronic pancreatitis. Clin Gastroenterol Hepatol. 2007;5:484–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Keller J, Bruckel S, Jahr C, Layer P. A modified (1) (3) C-mixed triglyceride breath test detects moderate pancreatic exocrine insufficiency. Pancreas. 2011;40:1201–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Keller J, Meier V, Wolfram KU, et al. Sensitivity and specificity of an abbreviated (13) C-mixed triglyceride breath test for measurement of pancreatic exocrine function. United Eur Gastroenterol J. 2014;2:288–94.CrossRefGoogle Scholar
  25. 25.
    Dominguez-Munoz JE, Iglesias-Garcia J, Castineira Alvarino M, et al. EUS elastography to predict pancreatic exocrine insufficiency in patients with chronic pancreatitis. Gastrointest Endosc. 2015;81:136–42.PubMedCrossRefGoogle Scholar
  26. 26.
    Jonderko K, Dus Z, Szymszal M, et al. Normative values for the 13C-mixed triglyceride breath test in two age groups. Med Sci Monit. 2009;15:CR255–9.PubMedGoogle Scholar
  27. 27.
    Kalivianakis M, Verkade HJ, Stellaard F, et al. The 13C-mixed triglyceride breath test in healthy adults: determinants of the 13CO2 response. Eur J Clin Investig. 1997;27:434–42.CrossRefGoogle Scholar
  28. 28.
    Sziegoleit A, Krause E, Klor HU, et al. Elastase 1 and chymotrypsin B in pancreatic juice and feces. Clin Biochem. 1989;22:85–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Katschinski M, Schirra J, Bross A, et al. Duodenal secretion and fecal excretion of pancreatic elastase-1 in healthy humans and patients with chronic pancreatitis. Pancreas. 1997;15:191–200.PubMedCrossRefGoogle Scholar
  30. 30.
    Stein J, Jung M, Sziegoleit A, et al. Immunoreactive elastase I: clinical evaluation of a new noninvasive test of pancreatic function. Clin Chem. 1996;42:222–6.PubMedGoogle Scholar
  31. 31.
    Fischer B, Hoh S, Wehler M, et al. Faecal elastase-1: lyophilization of stool samples prevents false low results in diarrhoea. Scand J Gastroenterol. 2001;36:771–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Leeds JS, Oppong K, Sanders DS. The role of fecal elastase-1 in detecting exocrine pancreatic disease. Nat Rev Gastroenterol Hepatol. 2011;8:405–15.PubMedCrossRefGoogle Scholar
  33. 33.•
    Benini L, Amodio A, Campagnola P, et al. Fecal elastase-1 is useful in the detection of steatorrhea in patients with pancreatic diseases but not after pancreatic resection. Pancreatology. 2013;13:38–42. This study compared the diagnostic performance of FE-1 and coefficient of fat absorption in patients with a variety of pancreatic disorders. In those without a history of pancreatic surgery, steatorrhea was only observed in those with an exceedingly low FE-1 level, indicating this test is not accurate as a screening test in those without pancreatic disease.PubMedCrossRefGoogle Scholar
  34. 34.
    Scotta MS, Marzani MD, Maggiore G, et al. Fecal chymotrypsin: a new diagnostic test for exocrine pancreatic insufficiency in children with cystic fibrosis. Clin Biochem. 1985;18:233–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Walkowiak J, Herzig KH, Strzykala K, et al. Fecal elastase-1 is superior to fecal chymotrypsin in the assessment of pancreatic involvement in cystic fibrosis. Pediatrics. 2002;110:e7.PubMedCrossRefGoogle Scholar
  36. 36.
    Dominguez-Munoz JE, Iglesias-Garcia J. Oral pancreatic enzyme substitution therapy in chronic pancreatitis: is clinical response an appropriate marker for evaluation of therapeutic efficacy? JOP. 2010;11:158–62.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2015

Authors and Affiliations

  1. 1.Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology, & NutritionThe Ohio State University Wexner Medical CenterColumbusUSA

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