Recognition and management of insufficient pancreatic exocrine function, one article summarizes the latest progress

Only for medical professionals to read for reference.
The dry goods are full.
On May 23, 2021, 5:30-7: 00 in the morning, Beijing time, the American Digestive Disease Week (DDW) held a theme meeting on the identification and management of pancreatic insufficiency.

In this meeting, Professor Phil Hart from Ohio State University introduced the content of the lecture.
Scholars shared and discussed the basis of the center on the naming, typing, etiology, detection, treatment, and nutritional support of pancreatic insufficiency.
Research and clinical experience.

1.
Pancreatic Diabetes First, Professor Phil Hart shared his team's experience in "pancreatic diabetes".

Professor Phil Hart introduced the etiology and types of pancreatic diabetes and the clinical significance of distinguishing it from type 2 diabetes, which can identify pancreatic tumor-related diabetes at an early stage, identify diabetes-related complications, and guide the treatment of different types of pancreatic diabetes, etc.
This aspect plays an important role.

There are many theories about the naming of pancreatic diabetes, such as type 3c diabetes, exocrine pancreatic diabetes, diabetes secondary to pancreatic disease, and non-pancreatic diabetes.

The classification of pancreatic diabetes has different methods according to its cause, mechanism, and time of onset.

According to the etiology, it can be divided into post-pancreatitis diabetes (PPDM, including acute and chronic pancreatitis), pancreatic cancer-related diabetes (PCRD), and cystic fibrosis-related diabetes (CFRD).

According to the different pathogenic mechanisms, it can be divided into congenital or acquired complete islet loss, acquired partial loss of islet function, paracancerous and other mechanisms.

2.
Diagnosis of Pancreatic Exocrine Insufficiency Next, Dr.
Chris E.
Forsmark from the University of Florida introduced the incidence and diagnosis of pancreatic exocrine insufficiency (EPI).

EPI mainly occurs in chronic pancreatitis, cystic fibrosis, pancreatectomy, pancreatic tumors, etc.

Diagnosis of EPI can be detected by laboratory indicators related to dyspepsia (such as non-specific 72-hour fecal fat, fecal Sudan III staining, and highly specific mixed triglyceride breath test), but currently the United States mainly uses some alternative methods.
Such as observation of changes in clinical symptoms, imaging examination, stool elastase (especially CELA-3) or chymotrypsin, serum trypsin, etc.

Fecal elastase test has a considerable proportion of false positives, and the reliability of this type of test is also affected by stool characteristics and failure to stop pancreatin treatment.

Observing the symptoms of dyspepsia is actually a simple and main way to identify EPI.

However, the current rate of EPI testing in the United States is only about 1.
9%-6.
5%.

3.
EPI-related nutritional assessment and diet management Professor Amanda Lynett from the Gastrointestinal and Liver Disease Center of the University of Michigan introduced us to EPI-related nutritional assessment and diet management.

First of all, for how to screen and monitor EPI patients, Professor A.
Lynett suggested that patients should be asked about symptoms, body mass index, treatment compliance, biochemical methods, etc.
at each visit, and the level of fat-soluble vitamins in patients should be assessed annually.
(Such as vitamin A, D, E, K), diabetes screening (glycated hemoglobin level), and regular blood trace elements (vitamin B12, copper, zinc), bone density every 5 years, and evaluation of pancreatic exocrine function.

Regarding EPI-related serious complications such as severe malnutrition and sarcopenia, Professor Amanda Lynett gave the corresponding causes, existing diagnostic criteria and treatment recommendations.

Regarding the treatment of EPI, calorie intake can be increased in the daily diet, protein and fiber diet can be appropriately increased, and 20%-35% of the patient’s daily calories can come from a lipid diet (exogenous supplementation of medium and long-chain triglycerides can be considered ).

Professor A.
Lynett pointed out that clinicians and patients need to understand the risks of low-fat diets and be cautious in strict control of fat intake.

Effective nutritional intervention measures include: small meals, 5-6 meals a day; balanced protein diet, avoiding strict low-fat diets; avoiding fried foods; a small amount of exercise.

It is best to use water-soluble preparations for supplementing fat-soluble vitamins.
Pay attention to the timing of exogenous pancreatin supplementation, such as taking the first tablet before a meal, taking the remaining dose during or at the end of the meal, or calculating the dose based on body weight (more than 4 For patients who are old, consider the starting dose of 500 units of lipase/Kg·meal, gradually increasing until the symptoms are controlled).

Other nutritional remedies (such as antioxidants, probiotics) currently have no definite evidence of efficacy.

4.
Pancreatin replacement therapy Next, Professor Dimagno from the University of Michigan shared EPI's experience in pancreatin replacement therapy.

Professor Dimagno suggested that EPI be divided into light, medium and severe, but also mentioned that the clinical symptoms of EPI are not specific for its diagnosis.

In addition, he recommends using the fat absorption coefficient [CFA=(daily fecal fat g/daily dietary fat g) x 100] to evaluate EPI.

The treatment principle for severe EPI is that the minimum normal pancreatic lipolytic activity of each meal needs to be ≥10%, which requires 90,000 USP units of lipase per meal, and attention should be paid to the use of these lipases in the entire process of eating (1/4 in A few mouthfuls before the meal, 1/2 in the middle of the meal, 1/4 in the last few mouthfuls).

EPI caused by chronic pancreatitis can reach 83%±5% after pancreatin replacement therapy (PERT) (normal CFA≥93%).

However, even if patients with severe EPI have undergone PERT, there is still the possibility of persistent steatorrhea, and the appropriate therapeutic dose and the presence of other confounding conditions should be carefully evaluated before enzyme replacement therapy.

Due to the cost, side effects and other issues of enzyme replacement therapy, its compliance during the treatment period also requires close attention.

5.
EPI follow-up management Professor Lewis from the Mayo Clinic shared with you a series of cases about whether diarrhea and weight loss are EPI.

Through the case description, Professor Lewis focused on sharing the possible causes of steatorrhea, as well as screening and treatment methods.

She believes that steatorrhea in EPI is related to chronic intestinal diseases such as the overgrowth of small intestinal bacteria.

Clinicians can use MRI, endoscopy, pathological examinations and other methods to jointly determine the cause, and at the same time also need to pay attention to the role of screening HNF1β gene mutations.

Finally, Professor Michael Ladna from the University of Florida shared his experience in the management of gastrointestinal follow-up in EPI patients.

He mentioned that about 40%-50% of patients with chronic pancreatitis and 70%-80% of patients with pancreatic tumors will eventually develop EPI, but only about one-third of patients have taken exogenous pancreatic enzyme supplementation.
In addition, there are reports of poor efficacy, complications and high mortality in the treatment, which have affected the implementation of PERT treatment.

Professor Michael Ladna’s team retrospectively analyzed the diagnosis of EPI, chronic pancreatitis (CP), pancreatic-related tumor (PDAC) or CPT-10 code based on the ICD-10 code from February 2018 to February 2020 at the University of Florida.
There were 2515 outpatient or inpatient patients undergoing pancreatectomy, and 1464 were finally included in the study.
They analyzed the etiology of these patients and obtained pancreatic elastase, PERT minimum therapeutic dose, vitamin D level and its supplementary treatment, double The correlation between energy X-ray bone scan and gastrointestinal follow-up in EPI management.

This study showed that CP, PDAC, and pancreatectomy patients who received follow-up by gastroenterologists had a higher EPI screening rate, a higher evaluation rate for complications such as diabetes or osteoporosis, and a higher proportion of patients used appropriate The dose of PERT.

In this analysis, most patients did not have follow-up by gastroenterologists.

This shows that the education of parenteral doctors and improved referral to gastrointestinal specialists are necessary.

Through the lectures of this special conference, scholars conducted extensive discussions and shared opinions on the diagnosis and treatment of EPI related to chronic pancreatitis and pancreatic tumors.

Regarding the diagnosis and treatment of EPI, different countries in the world are still unable to achieve a complete uniformity due to the different detection levels and treatment methods.
However, through the sharing of this meeting, clinicians can understand the availability of different detection methods and understand clinical monitoring.
The importance of nutritional support and follow-up management in the treatment of EPI, I believe that the future diagnosis and treatment scholars about EPI will have more and better experience.

 Expert profile Wang Rui, Associate Professor/Associate Chief Physician, Ph.
D.
, Department of Gastroenterology, West China Hospital, Sichuan University.

He graduated from West China Medical College of Sichuan University, and after staying in the hospital, he was responsible for medical treatment, teaching, endoscopy, and scientific research.

Mainly focus on the diagnosis and treatment of biliary and pancreatic diseases.

He is currently a member of the Epidemiology Collaboration Group of the Digestive Branch of the Chinese Medical Association; a young member of the Digestive Endoscopy Branch of the Sichuan Medical Association; a member of the Pancreatic Disease Branch of the Sichuan Medical Association; a research visiting scholar in the Department of Hepatology and Gastroenterology at Johns Hopkins University in the United States.

Participated in and presided over several projects of the National Natural Science Foundation of China and provincial funds, and published more than ten SCI papers as the first author and corresponding author.