Abstract Refeeding after acute pancreatitis (AP) is traditionally started in a successively increasing manner when abdominal pain is absent and pancreatic enzymes are decreasing. We aimed to evaluate ...length of hospital stay (LOHS) and refeeding tolerance for early refeeding and/or immediately full caloric intake in patients recovering from AP. Methods In this randomized, open-label trial, patients with AP were randomized into four different refeeding protocols. Group 1 and 2 received a stepwise increasing diet during three days while 3 and 4 received an immediately full caloric, low fat diet. Group 2 and 4 started refeeding early (once bowel sounds returned) and 1 and 3 started at standard time (bowel sounds present, no abdominal pain, no fever, leucocytes and pancreatic enzymes decreasing). Main outcomes measurements were LOHS and tolerance (ability to ingest >50% of meals without severe pain, nausea or AP relapse). Results Eighty patients were evaluated and 72 randomized (median age 60 years, range 24–85, 33 male). LOHS was significantly reduced after early refeeding (median 5 versus 7 days ( p = 0.001)) but not in patients receiving immediately full caloric diet, compared to standard management (6 versus 6 days ( p = 0.12)). There was no difference in refeeding tolerance comparing immediately full caloric diet versus stepwise increasing diet (31/35 (89%) versus 33/37 (89%) patients tolerating the treatment, p = 1.00) or early versus standard time for refeeding (33/37 (89%) versus 31/35 (89%), ( p = 1.00)). Conclusions Refeeding after AP when bowel sounds are present with immediately full caloric diet is safe and well tolerated. Early refeeding shortens LOHS.
Hand, foot and mouth disease (HFMD) is a childhood illness frequently caused by genotypes belonging to the enterovirus A species, including coxsackievirus (CV)-A16 and enterovirus (EV)-71. Between ...2010 and 2012, several outbreaks and sporadic cases of HFMD occurred in different regions of Spain. The objective of the present study was to describe the enterovirus epidemiology associated with HFMD in the country. A total of 80 patients with HFMD or atypical rash were included. Detection and typing of the enteroviruses were performed directly in clinical samples using molecular methods. Enteroviruses were detected in 53 of the patients (66%). CV-A6 was the most frequent genotype, followed by CV-A16 and EV-71, but other minority types were also identified. Interestingly, during almost all of 2010, CV-A16 was the only causative agent of HFMD but by the end of the year and during 2011, CV-A6 became predominant, while CV-A16 was not detected. In 2012, however, both CV-A6 and CV-A16 circulated. EV-71 was associated with HFMD symptoms only in three cases during 2012. All Spanish CV-A6 sequences segregated into one major genetic cluster together with other European and Asian strains isolated between 2008 and 2011, most forming a particular clade. Spanish EV-71 strains belonged to subgenogroup C2, as did most of the European sequences circulated. In conclusion, the recent increase of HFMD cases in Spain and other European countries has been due to a larger incidence of circulating species A enteroviruses, mainly CV-A6 and CV-A16, and the emergence of new genetic variants of these viruses.
Summary Background Little is known about risk factors for complications in chronic pancreatitis (CP). High fat diet (HFD) has been demonstrated to aggravate pancreatic injury in animal models. The ...aim of this study was to investigate the role of HFD in age at diagnosis of CP and probability of CP related complications. Methods A cross-sectional case–case study was performed within a prospectively collected cohort of patients with CP. Diagnosis and morphological severity of CP was established by endoscopic ultrasound. Pancreatic exocrine insufficiency (PEI) was diagnosed by13 C mixed triglyceride breath test. Fat intake was assessed by a specific nutritional questionnaire. Odds ratios (OR) for CP related complications were estimated by multivariate logistic regression analysis. Results 168 patients were included (128 (76.2%) men, mean age 44 years (SD 13.5)). Etiology of CP was alcohol abuse in 89 patients (53.0%), other causes in 30 (17.9%) and idiopathic in the remaining 49 subjects (29.2%). 24 patients (14.3%) had a HFD. 68 patients (40.5%) had continuous abdominal pain, 39 (23.2%) PEI and 43 (25.7%) morphologically severe CP. HFD was associated with an increased probability for continuous abdominal pain (OR = 2.84 (95%CI, 1.06–7.61)), and a younger age at diagnosis (37.0 ± 13.9 versus 45.8 ± 13.0 years, p = 0.03) but not with CP related complications after adjusting for sex, years of follow-up, alcohol and tobacco consumption, etiology and body mass index. Conclusions Compared with a normal fat diet, HFD is associated with a younger age at diagnosis of CP and continuous abdominal pain, but not with severity and complications of the disease.
The early diagnosis of pancreatic exocrine insufficiency (PEI) is hindered because many of the functional diagnostic techniques used are expensive and require specialized facilities, which prevent ...their widespread availability. We have reviewed current evidence in order to compare the utility of these functional diagnostic techniques with the fecal elastase-1 (FE-1) test in the following three scenarios: screening for PEI in patients presenting with symptoms suggestive of pancreatic disease, such as abdominal pain or diarrhea; determining the presence of PEI in patients with an established diagnosis of pancreatic disease, such as chronic pancreatitis or cystic fibrosis; determining exocrine status in disorders not commonly tested for PEI, but which have a known association with this disorder. Evidence suggests the FE-1 test is reliable for the evaluation of pancreatic function in many pancreatic and non-pancreatic disorders. It is non-invasive, is less time-consuming, and is unaffected by pancreatic enzyme replacement therapy. Although it cannot be considered the gold-standard method for the functional diagnosis of PEI, the advantages of the FE-1 test make it a very appropriate test for screening patients who may be at risk of this disorder.
To develop a ¹³C-labeled substrate breath test by defining the optimal ¹³C-labeled substrate, substrate dose, test meal, and duration of the test and evaluating its accuracy for the diagnosis of ...pancreatic exocrine insufficiency (PEI) in chronic pancreatitis (CP).
Five consecutive prospective comparative studies in patients with known advanced CP and healthy controls were performed to develop the optimal breath test. Coefficient of fat absorption was used as the reference method. The diagnostic accuracy of the optimized breath test was prospectively further evaluated in patients with advanced CP using coefficient of fat absorption as the reference method.
The optimal breath test protocol was that using 250 mg of ¹³C-mixed triglyceride as substrate together with a test meal containing 16 g of fat. Coefficient of fat absorption and breath test results correlated significantly (r = 0.736, P < 0.001). The test has sensitivity, specificity, and overall accuracy of 92.9%, 91.7%, and 92.3%, respectively, for the diagnosis of PEI.
The optimized ¹³C-mixed triglyceride breath test is an accurate and simple breath test for the diagnosis of PEI in patients with CP, easily applicable to the clinical routine.
Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, ...only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.
Pancreatic exocrine insufficiency with steatorrhea is a major consequence of pancreatic diseases (e.g. chronic pancreatitis, cystic fibrosis, severe acute necrotizing pancreatitis, pancreatic ...cancer), extrapancreatic diseases like celiac disease and Crohn's disease, and gastrointestinal and pancreatic surgical resections. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality. Therapy of pancreatic exocrine insufficiency is based on the oral administration of pancreatic enzymes aiming at providing the duodenal lumen with sufficient amount of active lipase at the time of gastric emptying of nutrients. Administration of enzymes in form of enteric-coated minimicrospheres avoids acid-mediated lipase inactivation and ensures gastric emptying of enzymes in parallel with nutrients. Despite that, factors like an acidic intestinal pH and bacterial overgrowth may prevent normalization of fat digestion even in compliant patients. The present article critically reviews current therapeutic approaches to pancreatic exocrine insufficiency.
Summary
Background : Oral pancreatic enzyme supplements should be properly administered in order to ensure an adequate gastric mixing with the food and simultameous gastric emptying with the chyme.
...Aim : To evaluate, in a prospective, randomized, open, comparative, three‐way, crossover study, the effect of the administration schedule on the efficacy of oral pancreatic enzymes for the treatment of exocrine pancreatic insufficiency.
Methods : Twenty‐four consecutive chronic pancreatitis patients with maldigestion secondary to exocrine pancreatic insufficiency were treated with 40 000 U lipase in the form of capsules containing enteric‐coated mini‐microspheres. Capsules were taken just before meals (schedule A), just after meals (schedule B) or distributed along with meals (schedule C) for three consecutive 1‐week crossover periods in a randomized order. Fat digestion before and during the three treatment periods was evaluated by an optimized mixed 13C‐triglyceride breath test.
Results : Before therapy, the 13CO2 recovery in the breath test was 23.8 ± 15.8% (normal >58.0%). During therapy, the 13CO2 recovery tended to be higher when capsules were taken along with meals (13CO2 recovery 61.4 ± 21.4%) or just after meals (13CO2 recovery 60.6 ± 21.8%) than when taken just before meals (13CO2 recovery 53.9 ± 20.3%). The percentage of patients who normalized fat digestion under therapy was 50, 54 and 63% with schedules A, B and C respectively.
Conclusions : The efficacy of pancreatic enzyme supplements for the treatment of exocrine pancreatic insufficiency may be optimized by administration during or after meals.
Background and aims:
Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic ...pancreatitis.
Methods:
Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline.
Summary of selected recommendations
For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 – 8 weeks; if it appears unsatisfactory, the patient’s case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B).
For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).
For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).
For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).
According to previous sample size calculation, 21 consecutive patients (age range 36-76 years, 16 males) newly diagnosed with fat maldigestion secondary to severe alcohol related chronic ...pancreatitis, were included.
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