ABSTRACT
ABSTRACT Background: The treatment of chronic pancreatitis does not consistently solve intestinal abnormalities, and despite the implementation of various therapeutic measures, patients often continue to experience persistent diarrhea. Therefore, it is imperative to recognize that diarrhea may stem from factors beyond pancreatic insufficiency, and intestinal inflammation emerges as a potential contributing factor. Objective: The aim of this study was to assess fecal lactoferrin and calprotectin levels as indicators of intestinal inflammation in patients with chronic pancreatitis experiencing persistent diarrhea. Methods: In this study, 23 male patients with chronic pancreatitis primarily attributed to alcohol consumption and presenting with diarrhea (classified as Bristol stool scale type 6 or 7), underwent a comprehensive evaluation of their clinical and nutritional status. Fecal lactoferrin and calprotectin levels were measured utilizing immunoassay techniques. Results: The average age of the participants was 54.8 years, 43.5% had diabetes, and 73.9% were smokers. Despite receiving enzyme replacement therapy and refraining from alcohol for over 4 years, all participants exhibited persistent diarrhea, accompanied by elevated calprotectin and lactoferrin levels indicative of ongoing intestinal inflammation. Conclusion: The findings of this study underscore that intestinal inflammation, as evidenced by elevated fecal biomarkers calprotectin and lactoferrin, may contribute to explaining the persistence of diarrhea in patients with chronic pancreatitis.
RESUMO Contexto: O tratamento da pancreatite crônica não resolve de forma consistente as anomalias intestinais e, apesar da implementação de várias medidas terapêuticas, os pacientes muitas vezes continuam a apresentar diarreia persistente. Portanto, é imperativo reconhecer que a diarreia pode resultar de fatores além da insuficiência pancreática, e a inflamação intestinal surge como um potencial fator contribuinte. Objetivo: O objetivo deste estudo foi avaliar os níveis fecais de lactoferrina e calprotectina como indicadores de inflamação intestinal em pacientes com pancreatite crônica com diarreia persistente. Métodos: Neste estudo, 23 pacientes do sexo masculino com pancreatite crônica atribuída principalmente ao consumo de álcool e apresentando diarreia (classificada na escala de fezes de Bristol tipo 6 ou 7), foram submetidos a uma avaliação abrangente de seu estado clínico e nutricional. Os níveis fecais de lactoferrina e calprotectina foram medidos utilizando técnicas de imunoensaio. Resultados: A idade média dos participantes foi de 54,8 anos, 43,5% tinham diabetes e 73,9% eram fumantes. Apesar de receber terapia de reposição enzimática e abster-se de álcool por mais de 4 anos, todos os participantes apresentaram diarreia persistente, acompanhada por níveis elevados de calprotectina e lactoferrina, indicativos de inflamação intestinal contínua. Conclusão: Os achados deste estudo ressaltam que a inflamação intestinal, evidenciada pelos biomarcadores fecais elevados calprotectina e lactoferrina, pode contribuir para explicar a persistência da diarreia em pacientes com pancreatite crônica.
ABSTRACT
La fibrosis quística (FQ) es un trastorno hereditario, de las glándulas de secreción exocrina, considerada la causa más frecuente de insuficiencia pancreática exocrina (IPE) en la infancia. Esta revisión resume el panorama del tratamiento de reposición enzimática en la IPE asociada a la FQ, las formulaciones disponibles, su dosificación y modo de administración, así como las limitaciones y desafíos actuales y las posibles áreas del desarrollo futuro
Cystic fibrosis (CF) is an inherited disorder of the exocrine secretion glands, considered the most frequent cause of exocrine pancreatic insufficiency (EPI) in childhood. This review summarizes the landscape of enzyme replacement therapy in PEI associated with CF, the available formulations, their dosage and mode of administration, as well as the current limitations and challenges and potential areas for future development.
Subject(s)
Cystic Fibrosis , Exocrine Pancreatic Insufficiency , Enzyme Replacement TherapyABSTRACT
La pancreatitis crónica se asocia a calidad de vida deteriorada, elevada incidencia de comorbilidades, complicaciones graves y mortalidad. Los costes sanitarios son enormes. Algunas sociedades médicas han elaborado guías clínicas basadas en evidencia científica, pero el nivel de evidencia para cada aspecto de la enfermedad suele ser bajo y, consecuentemente, las recomendaciones tienden a ser vagas o débiles. En los presentes documentos de posicionamiento de la Societat Catalana de Digestologia y la Societat Catalana de Pàncrees hemos buscado redactar declaraciones bien definidas orientadas al clínico, basadas en revisiones actualizadas de la literatura y acuerdos de expertos. El objetivo es proponer el uso de terminología común y circuitos diagnóstico/terapéuticos racionales basados en el conocimiento actual. Para este fin se revisaron 51 secciones relacionadas con pancreatitis crónica por 21 expertos de 6 especialidades diferentes para generar finalmente 88 declaraciones que buscan armonizar conceptos y formular recomendaciones precisas. La parte 2 de esta serie de documentos discute temas sobre tratamiento y seguimiento. La aproximación terapéutica debe incluir la evaluación de factores etiológicos, manifestaciones clínicas y complicaciones. La complejidad de estos pacientes requiere un estudio detallado individualizado en comités multidisciplinares donde todas las opciones (conservadoras, endoscópicas, de radiología intervencionista y quirúrgicas) sean sopesadas. Deberían constituirse unidades especializadas de pancreatología. Las indicaciones quirúrgicas son dolor refractario, complicaciones locales y sospecha de neoplasia. El tratamiento enzimático está indicado si existe evidencia de insuficiencia exocrina o tras cirugía pancreática. La respuesta debe evaluarse mediante parámetros nutricionales y síntomas. Se debe planificar un programa de seguimiento para cada paciente.(AU)
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.(AU)
Subject(s)
Humans , Pancreatitis, Chronic , Pancreatitis, Chronic/drug therapy , Pancreatitis, Chronic/prevention & control , Quality of Life , Exocrine Pancreatic Insufficiency , Diabetes Mellitus , Abdominal Pain , Pancreatitis, Chronic/complications , Pancreatitis, Chronic/diagnostic imaging , Spain , Gastroenterology , Follow-Up StudiesABSTRACT
La pancreatitis crónica es una enfermedad fibroinflamatoria del páncreas originada por acción combinada de factores etiológicos. Muestra formas de presentación, tipos de complicaciones y grados evolutivos variables. Las opciones terapéuticas son tan diversas como los múltiples escenarios clínicos. Algunas sociedades médicas han desarrollado guías sobre diagnóstico y tratamiento basadas en evidencia científica. Pero la elevada variabilidad que conforman la conjunción de elementos etiológicos, presentaciones clínicas, complicaciones y progresión de la enfermedad hace que los niveles de evidencia obtenidos sean generalmente bajos y, por tanto, las recomendaciones tienden a ser vagas o débiles, salvo excepciones.En los presentes documentos de posicionamiento de la Societat Catalana de Digestologia y la Societat Catalana de Pàncrees hemos buscado redactar declaraciones bien definidas orientadas al clínico, basadas en revisiones actualizadas de literatura y acuerdos de expertos. El objetivo es proponer el uso de terminología común y circuitos diagnóstico/terapéuticos racionales basados en el conocimiento actual. Para este fin se revisaron 51 secciones relacionadas con pancreatitis crónica por 21 expertos de 6 especialidades diferentes para generar finalmente 88 declaraciones que buscan armonizar conceptos y formular recomendaciones precisas.La parte 1 de esta serie de documentos discute tópicos sobre etiología, diagnóstico y diagnóstico diferencial. Factores etiológicos de mayor relevancia son tóxicos (alcohol y tabaco), genéticos y obstructivos. Dolor abdominal, insuficiencia exocrina y endocrina y síntomas derivados de complicaciones son las presentaciones más frecuentes. Algunos pacientes permanecen asintomáticos. El diagnóstico (seguro, probable o incierto) debe sustentarse en datos objetivos obtenidos en pruebas de imagen, histología y pruebas de función pancreática.(AU)
Chronic pancreatitis is a chronic fibroinflammatory disease of the pancreas with prevalence around 50 cases per 100,000 inhabitants. It appears to originate from diverse and yet mixed etiological factors. It shows highly variable presenting features, complication types and disease progression rates. Treatment options are as wide as the multiple personalized scenarios the disease might exhibit at a given time point. Some medical societies have developed guidelines for diagnosis and treatment based on scientific evidence. Although these efforts are to be acknowledged, the gathered level of evidence for any topic is usually low and, therefore, recommendations tend to be vague or weak.In the present series of position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on interdisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 1 of this paper series discusses topics on aetiology and diagnosis of chronic pancreatitis. Main clinical features are abdominal pain, exocrine and endocrine insufficiency and symptoms derived from complications. Some patients remain symptom-free. Diagnosis (definitive, probable or uncertain) should be based on objective data obtained from imaging, histology, or functional tests.(AU)
Subject(s)
Pancreatitis, Chronic/diagnosis , Pancreatitis, Chronic/etiology , Pancreas , Pancreatic Diseases , Pancreatic Diseases/diagnosis , Pancreatic Diseases/prevention & control , Abdominal Pain , Exocrine Pancreatic Insufficiency/ethnologyABSTRACT
Chronic pancreatitis is a chronic fibroinflammatory disease of the pancreas with prevalence around 50 cases per 100,000 inhabitants. It appears to originate from diverse and yet mixed etiological factors. It shows highly variable presenting features, complication types and disease progression rates. Treatment options are as wide as the multiple personalized scenarios the disease might exhibit at a given time point. Some medical societies have developed guidelines for diagnosis and treatment based on scientific evidence. Although these efforts are to be acknowledged, the gathered level of evidence for any topic is usually low and, therefore, recommendations tend to be vague or weak. In the present series of position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on interdisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 1 of this paper series discusses topics on aetiology and diagnosis of chronic pancreatitis. Main clinical features are abdominal pain, exocrine and endocrine insufficiency and symptoms derived from complications. Some patients remain symptom-free. Diagnosis (definitive, probable or uncertain) should be based on objective data obtained from imaging, histology, or functional tests.
Subject(s)
Pancreatitis, Chronic/diagnosis , Pancreatitis, Chronic/etiology , Diagnosis, Differential , Humans , Liver Cirrhosis/diagnosis , Magnetic Resonance Imaging , Pain Measurement/methods , Pancreatic Function Tests/methods , Pancreatic Neoplasms/diagnosis , Pancreatic Pseudocyst/diagnosis , Pancreatitis, Chronic/pathology , Risk Factors , Societies, Medical , Spain , Tomography, X-Ray Computed , UltrasonographyABSTRACT
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.
Subject(s)
Pancreatitis, Chronic , Quality of Life , Follow-Up Studies , Humans , Pancreatitis, Chronic/complications , Pancreatitis, Chronic/diagnosis , Pancreatitis, Chronic/therapy , Societies, MedicalABSTRACT
Eurytrema coelomaticum is a trematode reported in the pancreatic ducts of ruminants. It is conjectured that may cause disorders in the pancreas, as well as digestive and metabolic processes dependent on them. This study, determined if there is an impairment of exocrine pancreatic function, and correlated it with parasite burden. Pancreas, blood, and fecal samples were collected from 119 bovines at a abattoir. Stool samples were subjected to the gelatin and x-ray film digestion tests (to detect the presence of trypsin in feces). Using blood samples, the following biochemical tests were performed: amylase, lipase, glucose, fructosamine, cholesterol, triglycerides, total protein, albumin, and globulins. Analyses were correlated with pancreatic parasite burden. Cattle with a high parasitic load presented higher incidence of negative tests in both gelatin digestion and x-ray film digestion tests (P < 0.001) when compared to non-parasitized animals and those with a low parasitic load. Changes in those tests only occurred if the parasitemia was moderate or severe. The activity of the amylase and lipase enzymes was significantly higher in animals with low parasitemia (P < 0.05), compared to non-parasitized animals and with a high parasitic burden. In this study, in cases of high parasitemia, negative results were observed in both gelatin and x-ray film in the feces digestion tests. However, the low infection of E. coelomaticum, higher levels of serum amylase and lipase that also indicated loss of pancreatic exocrine functions were reported.
Eurytrema coelomaticum, um trematódeo de ductos pancreáticos de ruminantes. Conjectura-se que possa ocasionar transtornos nas funções pancreáticas, mais especificamente nos processos digestivos e metabólicos dependentes destas. Neste estudo, o objetivo foi determinar se há comprometimento da função pancreática exócrina, correlacionado-a a carga parasitária. Foram utilizados pâncreas e respectivas amostras de sangue e fezes de 119 bovinos. As amostras de fezes foram submetidas aos testes de digestão da gelatina em tubo e digestão de filme radiográfico, ambos para detecção de tripsina nas fezes. Foram realizados os seguintes exames bioquímicos em amostras de sangue: amilase, lipase, glicemia, frutosamina, colesterol, triglicerídeos, proteínas totais, albumina e globulinas. Após isto, as análises bioquímicas foram correlacionadas com a quantidade numérica de parasitas encontrados no pâncreas (post-mortem). Houve maior quantidade de testes negativos (digestão do filme radiográfico e prova de digestão da gelatina) nos animais com alta carga parasitária (P < 0.001), quando comparados aos animais não parasitados e com baixa carga parasitária. Portanto, os exames supracitados se alteram somente se a quantidade de parasitas for moderada ou severa. As atividades das enzimas amilase e lipase foram significativamente maiores nos animais que apresentavam baixa parasitemia (P < 0.05), em comparação com os animais com alta carga parasitária e não parasitados. Conclui-se que em quadros de alta parasitemia há alteração significativa nos testes de digestão nas fezes, e que em quadros de baixa parasitemia há alterações significativas nos valores de amilase e lipase séricas, ambos comprovando alterações pancreáticas importantes, de acordo com o quadro de parasitemia.
Subject(s)
Animals , Cattle , Exocrine Pancreatic Insufficiency/parasitology , Pancreatitis/parasitology , Trematode Infections/complications , Trematode Infections/veterinary , Amylases/blood , Lipase/blood , Trematoda , Parasite Load/veterinaryABSTRACT
Introdução: a fibrose cística, também conhecida como mucoviscidose, é uma doença genética cujas manifestações resultam da disfunção do gene cystic fibrosis transmembrane conductorance regulator. Cerca de 85% dos indivíduos com essa doença desenvolvem insuficiência pancreática exógena. Objetivo: comparar os custos da terapia de reposição enzimática empírica com a terapia de reposição enzimática empírica guiada pelo teste da elastase fecal, em indivíduos com fibrose cística, acompanhados em um centro de referência para assistência à doença. Metodologia: realizou-se um estudo descritivo e comparativo, que incluiu indivíduos de 0 a 21 anos, com fibrose cística. Coletaram-se dados referentes ao período de janeiro de 2016 a fevereiro de 2020, com registros clínicos, demográficos e laboratoriais. Inicialmente, com base em critérios clínicos, os participantes foram classificados como suficientes pancreáticos ou insuficientes pancreáticos. Após o resultado da dosagem da elastase fecal, o diagnóstico do status pancreático foi reavaliado. Realizouse a estimativa dos custos do teste da elas tase fecal por participante e da terapia por reposição enzimática empírica da insuficiência pancreática em indivíduos que, posteriormente, foram diagnostica dos como suficientes pancreáticos. Resultados: incluíram-se 50 participantes, com média de idade de 9,4 anos, sendo 52% do sexo masculino. Após o resultado da dosagem da elastase fecal, 7 participantes considerados insuficientes pancreáticos e foram reclassificados como suficientes pancreáticos. No período estudado, a economia média estimada, por participante suficiente pancreático, com a suspensão das enzimas, após resultado da elastase fecal, foi de R$ 6.770,13. Conclusão: a terapia de reposição enzimática empírica no tratamento da insuficiência pancreática pode levar a custos desnecessários. A medida de dosagem da elastase fecal contribui para decisão mais objetiva da avaliação da função pancreática.
Introduction: Cystic fibrosis, also known as mucoviscidosis, is a genetic disorder whose manifestations result from dysfunction of the cystic fibrosis transmembrane conductance regulator gene. About 85% of individuals with this disease develop exogenous pancreatic insufficiency. Objetivo: to compare the costs of empirical enzyme replacement therapy with fecal elastase test-guided empirical enzyme replacement therapy in individuals with cystic fibrosis followed up at a referral center for disease care. Methodology: a descriptive and comparative study was carried out, which included individuals aged 0 to 21 years, with cystic fibrosis. Data for the period from January 2016 to February 2020 were collected, with clinical, demographic and laboratory records. Initially, based on clinical criteria, participants were classified as pancreatic sufficient or pancreatic insufficient. After the result of the fecal elastase measurement, the diagnosis of pancreatic status was reassessed. Estimates were made of the costs of the fecal elastase test per participant and of the empiric enzyme replacement therapy for pancreatic insufficiency in individuals who were later diagnosed as pancreatic sufficient. Results: fifty participants were included, with a mean age of 9.4 years, 52% male. After the result of the fecal elastase measurement, 7 participants considered as pancreatic insufficient were reclassified as pancreatic sufficient. In the period studied, the estimated mean savings, per sufficient pancreatic participant, with the suspension of enzymes, after the result of fecal elastase, was R$ 6,770.13. Conclusion: empirical enzyme replacement therapy in the treatment of pancreatic insufficiency can lead to unnecessary costs. The measurement of fecal elastase dosage contributes to a more objective decision on the assessment of pancreatic function.
Subject(s)
Humans , Male , Female , Exocrine Pancreatic Insufficiency , Costs and Cost Analysis , Cystic Fibrosis , Comparative Study , Epidemiology, DescriptiveABSTRACT
Resumen Introducción: la pancreatitis crónica (PC) es una inflamación progresiva del páncreas que puede llevar a su destrucción e insuficiencia irreversibles. Es una patología desafiante para el médico, debido a que establecer su diagnóstico puede tomar meses e incluso años, el seguimiento de pacientes suele ser problemático y el conocimiento sobre la clínica y epidemiología en Colombia es incompleto. Este estudio pretende hacer una descripción de pacientes con PC en un centro de referencia en gastroenterología de Cali, Colombia. Metodología: estudio de corte transversal de pacientes adultos con PC confirmada por criterios clínicos y radiológicos entre 2011 y 2017. Resultados: se incluyeron 36 pacientes con PC. La mayoría fueron hombres (72,2%) y la media de edad fue 56 (+ 15,1) años. El dolor abdominal crónico fue la presentación clínica más común (83,3%). Cerca de un cuarto de pacientes presentaba diabetes mellitus (22,2%). Se consideró etiología idiopática en 58,3%, alcohólica en el 11,0% y biliar en el 11,0%. La tomografía axial computarizada (TAC), resonancia magnética (RMN) y colangiopancreatografía por RMN fueron los métodos diagnósticos más usados (60,5%), con los que en su mayoría se visualizó atrofia (53,1%), dilatación de conductos (49,0%) y calcificaciones del páncreas (34,7%). Conclusión: los síntomas inespecíficos de la PC en fases iniciales y su largo curso clínico favorecen al subdiagnóstico de esta patología. Los resultados presentados pueden contribuir a la futura creación de escalas clínicas locales que orienten estudios radiológicos y genéticos tempranos, con el fin de lograr un diagnóstico oportuno y mejorar la calidad de vida de estos pacientes.
Abstract Introduction: Chronic pancreatitis (CP) is a progressive inflammation of the pancreas that can lead to irreversible damage and failure. This condition poses great challenges to physicians since its diagnosis can take months or even years. Patient follow-up is often problematic and knowledge about its clinical presentation and epidemiology in Colombia is scarce. This study aims to describe patients with CP treated at a gastroenterology reference center in Cali, Colombia. Methodology: Cross-sectional study in adult patients with CP confirmed based on clinical and radiological criteria between 2011 and 2017. Results: 36 patients with CP were included. The majority were men (72.2%), and the mean age was 56 (+15.1) years. Chronic abdominal pain was the most common clinical presentation (83.3%). About a quarter of patients had diabetes mellitus (22.2%). Etiology was idiopathic in 58.3%, alcoholic in 11.0%, and biliary in 11.0%. Computed tomography (CT), magnetic resonance imaging (MRI), and MRI cholangiopancreatography were the most commonly used diagnostic methods (60.5%), showing mostly atrophy (53.1%), duct dilation (49.0%), and pancreatic calcifications (34.7%). Conclusion: Nonspecific symptoms of CP in early stages and its long clinical course favor the underdiagnosis of this condition. The results presented may contribute to the future creation of local clinical scales that guide early radiological and genetic studies to achieve a timely diagnosis and improve the quality of life of these patients.
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Abdominal Pain , Epidemiology , Pancreatitis, Chronic , Patients , Magnetic Resonance Spectroscopy , Tomography , Diagnosis , Forecasting , HospitalsABSTRACT
Obesity is a prevalent health problem in our population. Bariatric surgery is the indicated treatment for severe cases. It is very effective (together with an adequate lifestyle modification) but it is also associated with frequent adverse events. One of the most frequent and disturbing adverse event is diarrhea. Diarrhea after bariatric surgery may be secondary to multiple causes and the physiopathogenic mechanisms may depend on the type of surgery performed. The most frequent diarrhea mechanisms are dumping syndrome, vagotomy, short bowel syndrome, carbohydrate malabsorption, protein malabsorption, alterations of the microbiota, Clostridium difficile infection, bacterial overgrowth, bile salt malabsorption, pancreatic insufficiency, endocrinological disorders, addictive disorders, and other digestive disorders not necessarily related to surgery.
Subject(s)
Bariatric Surgery/adverse effects , Diarrhea/diagnosis , Diarrhea/therapy , Postoperative Complications/diagnosis , Postoperative Complications/therapy , Algorithms , Diarrhea/etiology , Humans , Postoperative Complications/etiology , SyndromeABSTRACT
Introducción.La presente investigación plantea como objetivo principal, describir las características clínicas y epidemiológicas de la fibrosis quística (FQ) en Panamá, que nos permiten hacer el diagnóstico temprano y dar a conocer las características bioquímicas, fenotípicas y morbilidades asociadas para así poder mejorar las necesidades de los pacientes con esta enfermedad. Materiales y métodos. Se realizó un estudio retrospectivo de los pacientes con diagnóstico de fibrosis quística entre el mes de enero 2008 a diciembre 2017, en los hospitales en Ciudad de Panamá: Hospital del Niño Dr. José Renán Esquivel, Hospital de Especialidades Pediátricas y en Chiriquí Hospital José Domingo de Obaldía previa aprobación de las autoridades correspondientes.Se analizaron las características demográficas, fenotípicas, resultados bioquímicos, complicaciones y tratamiento de pacientes con diagnóstico de Fibrosis quística. Mediante un diseño descriptivo, se analizó la información de las mismas.Resultados.El promedio de edad para el diagnóstico de fibrosis quística fue de 2.8 años. El 52% correspondía a sexo masculino y 48% a sexo femenino. El promedio de hospitalización previo al diagnóstico de Fibrosis quística fue de 3.8. En el 72 % de los pacientes los primeros síntomas aparecieron antes del primer año de vida.En la mayoría de los pacientes las manifestaciones clínicas fueron una combinación de síntomas gastrointestinales y/o nutricionales y respiratorios (96 y 92% respectivamente).En el 44% de los pacientes se realizó examen genético molecular. De acuerdo con la clasificación del defecto genético, el 20 % de los pacientes eran del grupo delta F 508. La edad promedio de sobrevida es 8.2, años. Durante el período 2008-2017 se registraron 6 defunciones de pacientes con fibrosis quística, lo que corresponde a una tasa de letalidad del 22%.Conclusiones.Los resultados de nuestro estudio mostraron condiciones tales como falla de medro, infecciones respiratorias recurrentes, esteatorrea como la forma de presentación clínica más frecuente. Encontramos correlación con la literatura con la presencia de manifestaciones respiratorias asociadas a compromiso nutricional. El genotipo no se hace a todos los pacientes, reconociendo la importancia de esta valoración por la disponibilidad y costos de las pruebas genéticas. A pesar del diagnóstico temprano, nuestros pacientes cursan con compromiso nutricional importante. En los últimos años se ha evidenciado una media de edad de diagnóstico más temprana comparada con años anteriores. Es necesaria la estandarización de pruebas diagnósticas y de seguimiento, puesto que no todos los pacientes cumplen en su totalidad con los criterios diagnósticos. En la actualidad, un alto índice de sospecha clínica es obligatorio para su detección e intervención inmediata del tratamiento hasta actualización de las instalaciones de diagnóstico.
Introduction .The main objective of the present investigation is to describe the clinical and epidemiological characteristics of cystic fibrosis (CF) in Panama, which allow us to make a nearly diagnosis and make known the biochemical, phenotypic and associated morbidities in order to improve the needs of the patients with this disease. Materials and methodsA retrospective study of patients diagnosed with cystic fibrosis was conducted between January 2008 and December 2017, in hospitals in Panama City: Hospital del Niño Dr. José Renán Esquivel, Hospital de Especialidades Pediátricas Omar Torrijos Herrera and Hospital José Domingo de Obaldía, upon approval of the corresponding authorities. We analyzed the demographic, phenotypic characteristics, biochemical results, complications and treatment of patients diagnosed with Cystic Fibrosis. Through a descriptive design, the information of them was analyzed. Results. The average age for the diagnosis of cystic fibrosis was of 2.8 years, 52% corresponded tomale and 48% female. The average number of hospitalizations prior tothe diagnosis of cystic fibrosis was 3.8. In 72% of the patients the first symptoms appeared before the first year of life. In the majority of patients, the clinical manifestations were a combination of gastrointestinal and / or nutritional and respiratory symptoms (96 and 92% respectively). Molecular genetics examination was performed in 44% of the patients. According to the classification of the genetic defect, 20% of the patients were from the delta F 508 group. The average age of survival is 8.2 years. During the period 2008-2017 there were 6 deaths of patients with cystic fibrosis, which corresponds to a case-fatality rate of 22%.Conclusions.The results of our study showed conditions such as failure to thrive, recurrent respiratory infections, steatorrhea as the most frequent form of clinical presentation. We found correlation with the literature with the presence of respiratory manifestation associated with nutritional compromise. The genotype is not made to all patients, recognizing the importance of assessing the availability and costs of genetictesting. Despite early diagnosis, our patients have an important nutritional commitment. In recenty ears there is evidence of a lower age of diagnosis earlier compared with previous years.It is necessary to standardize diagnostic tests and follow-up, since not all patients fully meet the diagnostic criteria. At present, a high index of clinical suspicion is mandatory for early detection and immediate intervention of the treatment until updating of the diagnostic facilities.
ABSTRACT
Introdução: fibrose cística (FC) é uma doença genética que culmina em alterações na proteína transmembrana CFTR, resultando na produção de muco mais espesso em diversos órgãos, destacando-se os tratos respiratório e digestório. A insuficiência pancreática (IP) acomete até 95% dos pacientes com FC. Objetivos: determinar a frequência de IP através da dosagem de elastase fecal-1 (EF-1) e compará-la com o genótipo de pacientes com FC assistidos em um centro de referência. Metodologia: foi realizado um estudo transversal, incluindo-se pacientes com FC de 0 a 20 anos. Após a inclusão dos sujeitos à pesquisa, foi realizada consulta ao prontuário para a obtenção de dados clinicos e demograficos e amostras de fezes foram obtidas para dosagem da (EF-1). Os pacientes foram submetidos à análise molecular das mutações por métodos convencionais, através da extração do DNA em sangue periférico. Quando duas mutações patológicas não foram identificadas, o sequenciamento de nova geração com utilização da plataforma Illumina HiSeq foi realizado em amostras da mucosa oral. Resultados: foram incluídos 31 pacientes, 17 (54,8%) do sexo feminino, mediana de idade de 10 anos, e apenas um paciente foi classificado como branco. Vinte e dois (70,9%) pacientes apresentaram dosagem de EF-1 inferior a 200 µg/g, compatível com o diagnóstico de IP. Destes, 21 (95,4%) apresentaram dosagem de EF-1 menor ou igual a 15µg/g, caracteristica de IP grave. Todos os pacientes com IP apresentavam duas mutações de classes I a III. Conclusão: a IP foi identificada em 70% dos pacientes, ocorrendo em todos os pacientes com duas mutações de classe I-III.
Introduction: cystic fibrosis (CF) is a genetic disease that culminates in alterations in the CFTR transmembrane protein, resulting in the production of thicker mucus in various organs, especially the respiratory and digestive tract. Pancreatic insufficiency (PI) affects up to 95% of CF patients. Objectives: To determine the frequency of PI by measuring fecal elastase-1 (FE-1) and comparing it with the genotype of CF patients assisted at a referral Center. Methodology: a cross-sectional study was conducted, including patients with CF from 0 to 20 years. After the inclusion of the subjects to the research, medical records were consulted to obtain clinical and demographic data and stool samples were obtained for the measurement of (FE-1). Patients were submitted to molecular analysis of mutations by conventional methods by DNA extraction in peripheral blood. When two pathological mutations were not identified, next-generation sequencing using the Illumina HiSeq platform was performed on oral mucosa samples. Results: thirty one patients were included, 17 (54.8%) female, median age 10 years, and only one patient was classified as white. Twenty-two (70.9%) patients had an FE-1 dosage of less than 200 µg / g, compatible with the diagnosis of pancreatic insufficiency (PI). Of these, 21 (95,4%) had an EF-1 dosage less than or equal to 15µg / g, characteristic of severe PI. All patients with two mutations class I to III were PI. Conclusion: PI was identified in 70% of patients, occurring in all patients with class I-III mutations.
Subject(s)
Humans , Male , Female , Child , Adolescent , Young Adult , Exocrine Pancreatic Insufficiency , Pancreatic Elastase , Cystic Fibrosis , Genotype , Cross-Sectional StudiesABSTRACT
Chronic pancreatitis is a progressive fibroinflammatory process in the pancreas that causes permanent structural damage and leads to a deterioration in exocrine and endocrine function. The appearance of flares of acute pancreatitis, pseudocysts, and inflammatory masses all form part of the natural history of this disease. Vascular and / or digestive complications may occur, and patients with chronic pancreatitis have an increased risk of pancreatic adenocarcinoma. For all these reasons, diagnostic tests that can detect chronic pancreatitis are necessary, especially in the early stages of the disease. We propose a diagnostic algorithm that should progress from noninvasive techniques to invasive procedures. Computed tomography can rule out other causes of abdominal pain and identify complications of pancreatitis. Magnetic resonance cholangiography can be the method of choice because it enables changes in the ducts to be assessed and might obviate the need for endoscopic retrograde cholangiopancreatography. When the findings on imaging tests are normal but clinical suspicion persists, pancreatic function tests or endoscopic ultrasound should be considered.
Subject(s)
Algorithms , Pancreatitis, Chronic/diagnostic imaging , Abdomen , Cholangiography , Cholangiopancreatography, Endoscopic Retrograde , Endosonography , Exocrine Pancreatic Insufficiency/diagnosis , Humans , Magnetic Resonance Imaging , Pancreatic Function Tests , Pancreatitis, Chronic/etiology , Practice Guidelines as Topic , Risk Factors , Sensitivity and Specificity , Tomography, X-Ray ComputedABSTRACT
BACKGROUND/OBJECTIVES: Exocrine pancreatic insufficiency (EPI) is an important complication of chronic pancreatitis (CP). Guidelines recommend to rule out EPI in CP, to detect those patients who would benefit from pancreatic enzyme replacement therapy. The aim of this study was to evaluate the prevalence of EPI in patients with CP without follow-up in the last 2 years and to describe their nutritional status and quality of life (QoL). METHODS: This was a cross-sectional, multicenter Spanish study. CP patients without follow-up by a gastroenterologist or surgeon in at least 2 years were included. EPI was defined as fecal elastase test <200mcg/g. For nutritional assessment, laboratory and anthropometric data were obtained. QoL was investigated using the EORTC QLQ-C30 questionnaire. RESULTS: 64 patients (mean age 58.8±10.3 years, 85.9% men) from 10 centers were included. Median time since diagnosis of CP was 58.7 months [37.7-95.4]. Forty-one patients (64.1%) had EPI. Regarding nutritional status, the following differences were observed (EPI vs. Non-EPI): BMI (23.9±3.5kg/m2 vs. 25.7±2.5, p=0.03); glucose (121 [96-189] mg/dL vs. 98 [90-116], p=0.006); HbA1c 6.6% [6.0-8.4] vs. 5.5 [5.3-6.0], p=0.0005); Vitamin A (0.44mg/L [0.35-0.57] vs. 0.53 [0.47-0.63], p=0.048) and Vitamin E (11.2±5.0µg/ml vs. 14.4±4.3, p=0.03). EPI group showed a worse EORTC QLQ-C30 score on physical (93.3 [66.7-100] vs. 100 [93.3-100], p=0.048) and cognitive function (100 [83.3-100] vs. 100 [100-100], p=0.04). CONCLUSIONS: Prevalence of EPI is high in patients with CP without follow-up. EPI group had higher levels of glucose, lower levels of vitamins A and E and worse QoL.
Subject(s)
Exocrine Pancreatic Insufficiency/etiology , Pancreatitis, Chronic/complications , Aftercare/standards , Aged , Anthropometry , Cross-Sectional Studies , Exocrine Pancreatic Insufficiency/epidemiology , Female , Humans , Male , Middle Aged , Nutritional Status , Prevalence , Quality of Life , Spain/epidemiology , Surveys and QuestionnairesABSTRACT
ABSTRACT Objective: To determine the prevalence of malnutrition in patients attending an adult cystic fibrosis (CF) program and to investigate the associations of malnutrition with the clinical characteristics of those patients. Methods: This was a cross-sectional study involving patients with clinically stable CF patients (16 years of age or older). The patients underwent clinical assessment, nutritional assessments, pulmonary function tests, and pancreatic function assessment. They also completed a questionnaire regarding diet compliance. On the basis of their nutritional status, the patients were classified divided into three groups: adequate nutrition; at nutritional risk; and malnutrition. Results: The study has included 73 patients (mean age, 25.6 ± 7.3 years), 40 of whom (54.8%) were female. The mean body mass index was 21.0 ± 3.0 kg/m2 and the mean FEV1 was 59.7 ± 30.6% of predicted. In this sample of patients, 32 (43.8%), 23 (31.5%), and 18 (24.7%) of the patients were allocated to the adequate nutrition, nutritional risk, and malnutrition groups, respectively. The logistic regression analysis identified three independent factors associated with the risk of malnutrition: Shwachman-Kulczycki score, percent predicted FEV1; and age. Conclusions: Malnutrition remains a common complication in adolescents and adults with CF, despite dietary advice. Malnutrition is associated with age, clinical severity, and lung function impairment.
RESUMO Objetivo: Determinar a prevalência de desnutrição em pacientes de um programa para adultos com fibrose cística (FC) e investigar a relação da desnutrição com as características clínicas desses pacientes. Métodos: Trata-se de um estudo transversal com pacientes com FC clinicamente estáveis (com 16 anos de idade ou mais). Os pacientes foram submetidos a avaliação clínica, avaliação nutricional, testes de função pulmonar e avaliação da função pancreática. Eles também preencheram um questionário sobre sua adesão à dieta proposta. Os pacientes foram divididos em três grupos, de acordo com seu estado nutricional: nutrição adequada, risco nutricional e desnutrição. Resultados: O estudo incluiu 73 pacientes (média de idade: 25,6 ± 7,3 anos), dos quais 40 (54,8%) eram do sexo feminino. A média do índice de massa corporal foi de 21,0 ± 3,0 kg/m2, e a média do VEF1 foi de 59,7 ± 30,6% do previsto. Nessa amostra de pacientes, 32 (43,8%) ficaram no grupo com nutrição adequada, 23 (31,5%) ficaram no grupo com risco nutricional e 18 (24,7%) ficaram no grupo com desnutrição. A análise de regressão logística identificou três fatores independentes relacionados com o risco de desnutrição: escore de Shwachman-Kulczycki, VEF1 em % do previsto e idade. Conclusões: A desnutrição ainda é uma complicação comum em adolescentes e adultos com FC, não obstante o aconselhamento dietético. A desnutrição está relacionada com a idade, a gravidade clínica e o comprometimento da função pulmonar.
Subject(s)
Humans , Male , Female , Adolescent , Adult , Cystic Fibrosis/complications , Malnutrition/epidemiology , Body Mass Index , Cross-Sectional Studies , Malnutrition/diagnosis , Malnutrition/etiology , National Health Programs , Nutritional Status , Predictive Value of Tests , Prevalence , Respiratory Function Tests , Sensitivity and Specificity , SpirometryABSTRACT
This article summarizes some of the recent and clinically relevant advances in chronic pancreatitis. These advances mainly concern the definition of the disease, the etiological diagnosis of idiopathic disease, the correlation between fibrosis degree and pancreatic secretion in the early stages of chronic pancreatitis, the treatment of the disease and of pain, the clinical relevance of pancreatic exocrine insufficiency, and the diagnosis of autoimmune pancreatitis. A new mechanistic definition of chronic pancreatitis has been proposed. Genetic testing is mainly of help in patients with relapsing idiopathic pancreatitis. A significant correlation has been shown between the degree of pancreatic fibrosis as evaluated by elastography and pancreatic secretion of bicarbonate. New data supports the efficacy of antioxidants and simvastatin for the therapy of chronic pancreatitis. The pancreatoscopy-guided intraductal lithotripsy is an effective alternative to extracorporeal shock wave lithotripsy in patients with chronic calcifying pancreatitis. The presence of pancreatic exocrine insufficiency in patients with chronic pancreatitis is associated with a significant risk of cardiovascular events. Fine needle biopsy and contrast enhanced harmonic endoscopic ultrasonography are of help for the diagnosis of autoimmune pancreatitis and its differential diagnosis with pancreatic cancer.
Subject(s)
Exocrine Pancreatic Insufficiency/therapy , Pancreatitis, Chronic/therapy , Chronic Disease , Humans , Lithotripsy , Pancreatic Diseases , PancreatitisABSTRACT
Desde hace más de 70 años se conoce la asociación de diarrea con diabetes mellitus. En pacientes diabéticos su prevalencia es de alrededor del 20%. Sus manifestaciones clínicas son diversas, y representa un reto diagnóstico y terapéutico. Existen ciertos diagnósticos de mayor prevalencia en pacientes diabéticos que en la población general. Las distintas etiologías relacionadas pueden ser diagnosticadas adecuadamente a través de la historia clínica y pruebas diagnósticas complementarias. Los medicamentos utilizados por el paciente diabético para el manejo de su enfermedad, frecuentemente causan diarrea crónica, por lo que se debe profundizar en los antecedentes farmacológicos al momento de estudiar la diarrea. Los pacientes diabéticos pueden presentar otras condiciones patológicas asociadas, como enfermedad celíaca o colitis microscópica, cuya molestia única es la diarrea. La función del páncreas exocrino puede estar disminuida en el paciente diabético, frecuentemente llevando a insuficiencia pancreática exocrina. Factores dietarios, como los edulcorantes libres de azúcar y otros agentes, pueden causar diarrea en el paciente diabético. La presencia de condiciones como la neuropatía autonómica y neuropatía periférica secundarias a la diabetes mellitus, pueden explicar desordenes como la disfunción anorrectal y la incontinencia fecal. Finalmente, la enteropatía diabética per se o con sobrecrecimiento bacteriano asociado, puede causar diarrea. Lograr un control glicémico adecuado constituye el pilar del tratamiento de la diarrea en el diabético, después de esto existen medidas adicionales que se aplican según el contexto especifico del paciente. En el presente artículo se revisan las causas de mayor incidencia diarrea en el paciente diabético y los mecanismos fisiopatológicos implicados
The association of diarrhea with diabetes mellitus has been known for more than 70 years. In diabetic patients its prevalence is around 20%.Its clinical manifestations are diverse, and represents a diagnostic and therapeutic challenge.There are certain diagnoses of higher prevalence in diabetic patients than in the general population.The different related etiologies can be adequately diagnosed through the clinical history and complementary diagnostic tests.The medications used by the diabetic patient to manage their disease often cause chronic diarrhea, so the pharmacological background should be studied at the time of the study of diarrhea.Diabetic patients can present other associated pathological conditions, such as celiac disease or microscopic colitis, which only discomfort is diarrhea.Exocrine pancreatic function may be decreased in the diabetic patient, frequently leading to exocrine pancreatic insufficiency. Dietary factors, such as sugar-free sweeteners and other agents, can cause diarrhea in the diabetic patient.The presence of conditions such as autonomic neuropathy and peripheral neuropathy secondary to diabetes mellitus may explain disorders such as anorectal dysfunction and faecal incontinence. Finally, diabetic enteropathy alone or with associated bacterial overgrowth can cause diarrhea.Achieving adequate glycemic control is the pillar of the treatment of diarrhea in the diabetic, after which there are additional measures that are applied according to the specific context of the patient.This article reviews the causes of higher diarrhea incidence in the diabetic patient and the pathophysiological mechanisms involved
Subject(s)
Humans , Diabetes Complications/etiology , Diarrhea/etiology , Chronic Disease , Risk Factors , Diabetes Complications/diagnosis , Diabetes Complications/physiopathology , Diabetes Complications/therapy , Diarrhea/diagnosis , Diarrhea/physiopathology , Diarrhea/therapyABSTRACT
Autoimmune pancreatitis (AIP) is an uncommon disease that represents a diagnostic challenge unless it is considered as a cause of acute pancreatitis, pancreatic exocrine insufficiency and a pancreatic mass. This entity is under diagnosed and successful medical therapy is available. In this paper, we will describe a case of a 59 year-old, Hispanic woman diagnosed with autoimmune pancreatitis, a disease previously believed to affect typically older men. We will review the definition, types, clinical manifestations, radiological features, serology, histopathological findings, treatment strategies and diagnostic criteria of autoimmune pancreatitis
La pancreatitis autoinmune (PAI) es una enfermedad rara que se presenta como un reto diagnóstico a menos que sea considerada como causa de pancreatitis aguda, insuficiencia pancreática exocrina y masa pancreática. Es una enfermedad sub diagnosticada y existe una terapia médica satisfactoria. En este trabajo, describiremos un caso de una mujer hispana de 59 años diagnosticada de pancreatitis autoinmune, una enfermedad que se creía previamente que afectaba típicamente a hombres de avanzada edad. Revisaremos la definición, los tipos, las manifestaciones clínicas, hallazgos radiológicos, serología, hallazgos histopatológicos, estrategias de tratamiento y criterios diagnósticos de la pancreatitis autoinmune
ABSTRACT
This article summarizes some of the recent and clinically relevant advances in chronic pancreatitis. These advances mainly concern the early diagnosis of the disease, the treatment of symptoms and complications, mainly pain and pancreatic exocrine insufficiency, and the diagnosis and therapy of autoimmune pancreatitis. The multimodal dynamic endoscopic ultrasound-guided secretin-stimulated evaluation of the pancreas provides relevant morphological and functional information for the diagnosis of chronic pancreatitis at early stages. Extracorporeal shock wave lithotripsy in patients with calcifying pancreatitis and endoscopic pancreatic stent placement are effective alternatives for pain therapy in patients with chronic pancreatitis. Presence of pancreatic exocrine insufficiency in patients with chronic pancreatitis is associated with a significantly increase of mortality rate. Despite that, pancreatic enzyme replacement therapy is not prescribed in the majority of patients with pancreatic exocrine insufficiency, or it is prescribed at a low dose. The newly developed and commercialized needles for endoscopic ultrasound-guided pancreatic biopsy are effective in retrieving appropriate tissue samples for the histological diagnosis of autoimmune pancreatitis. Maintenance therapy with azathioprine is effective and safe to prevent relapses in patients with autoimmune pancreatitis.
