Fecal Elastase-1 Is Useful in the Detection of Steatorrhea in Patients with Pancreatic Diseases But Not After Pancreatic Resection

Context The measurement of steatorrhea in pancreatic disorders is complex and has limited diagnostic role. Fecal elastase-1 (FE-1) has been suggested as a simpler alternative to evaluate pancreatic insufficiency, but its diagnostic performance has never been compared with steatorrhea in patients with chronic pancreatitis or after pancreatic resection. Methods. The relationship between steatorrhea and FE-1 was studied in patients with suspected of malabsorption due to chronic pancreatic disorders or pancreatic resection. Analysis of variance (ANOVA) was used for statistical analysis, accepting a P value of 0.05 as limit for significance. Results Eighty-two patients were studied (42 non operated; 40 previously submitted to pancreatic resection). Fat output was pathological in 50, and more severe in operated than non-operated patients (29.2±3.1 vs. 9.9±2.2 g/day, P<0.001). FE-1 was consistent with exocrine impairment in 58 (severe 50, moderate 8), which was significantly more severe in operated patients. The relationship between FE-1 and steatorrhea was described by a power regression model (Figure 1), with a regression line significantly different in operated and non operated patients (P<0.001). A steatorrhea of 7 g (upper limit of reference range) was calculated by this regression when FE-1 was 15 μg/g in non-operated, but as high as 225 μg/g in operated patients. Conclusion FE-1 is useful to identify pancreatic insufficiency. Steatorrhea is anticipated in non operated patients only when FE-1 is below the limit for a confident measurement of our assay. In operated patients, steatorrhea may be present even if FE-1 is only slightly reduced, to confirm a role for non pancreatic factors

Azathioprine Maintenance Therapy to Prevent Relapses in Autoimmune Pancreatitis

Steroids are used to induce remission in autoimmune pancreatitis (AIP). Low-dosage steroid therapy or immunosuppressant (IMs) has been proposed as maintenance therapy to prevent AIP relapse. Few and conflicting data have been published on the efficacy of azathioprine (AZA) in preventing AIP relapse. The aim of this study was to evaluate the indication and efficacy of AZA as maintenance therapy to prevent disease relapse in AIP

Chronic pancreatitis and nutritional support

: Malnutrition in patients with chronic pancreatitis is common, but its evaluation is often missed in clinical practice. Pancreatic exocrine insufficiency is the single most important cause of malnutrition; therefore, it needs to be screened for and treated appropriately. Specific diet regimens in patients suffering from chronic pancreatitis are rarely reported in the literature. Patients suffering from chronic pancreatitis have a higher demand for energy but a lower caloric intake secondary to pancreatic exocrine insufficiency, combined with the malabsorption of liposoluble vitamin and micronutrients, which needs be corrected by appropriate dietary counselling. Diabetes is frequently observed in chronic pancreatitis and classified as type 3c, which is characterized by low levels of both serum insulin and glucagon; therefore, there is a tendency towards hypoglycaemia in patients treated with insulin. Diabetes contributes to malnutrition in chronic pancreatitis. Strategies to treat exocrine and endocrine insufficiency are important to achieve better control of the disease

Circulating IgG4+ Plasmablast Count as a Diagnostic Tool in Autoimmune Pancreatitis

BACKGROUND & AIMS: Type 1 autoimmune pancreatitis (AIP) is an IgG4-related disease whose diagnosis is challenging. The aim of this study was to investigate the diagnostic value of circulating total and IgG4þ plasmablasts in differentiating this condition from the other main pancreatic diseases. METHODS: Patients with type 1 AIP (n ¼ 19) were prospectively enrolled in a tertiary center together with patients suffering from type 2 or not otherwise specified (NOS) AIP (n ¼ 10), pancreatic adenocarcinoma (n ¼ 17), chronic pancreatitis (n ¼ 20), and intraductal papillary mucinous neoplasia or chronic asymptomatic pancreatic hyperenzymemia (n ¼ 21) as control groups. Flow cytometry was used to measure the total plasmablast and IgG4þ plasmablast number by gating peripheral blood CD45þCD19þCD38hiCD20-CD24-CD27þ and CD45þCD19þCD38hiCD20-CD24-CD27þIgG4þ cells, respectively. In patients with AIP, these cell populations were also evaluated after 1 month of therapy, after 2–4 months from the end of treatment, and after 1 year from the enrollment. The study was approved by the local ethics committee (protocol number: 59133, 30/11/2017). RESULTS: Total plasmablast quantification was capable of discriminating type 1 AIP from all the other pancreatic disorders with a sensitivity of 47% and a specificity of 81%, according to a cutoff of 4500 cells/mL (AUC ¼ 0.738), whereas IgG4þ plasmablast count distinguished type 1 AIP from all the other pancreatic disorders with a sensitivity of 80% and a specificity of 97% when applying a cutoff of 210 IgG4þ cells/mL (AUC ¼ 0.879). The basal IgG4þ plasmablast number was significantly higher (P ¼ .0001) in type 1 AIP than in type 2/NOS AIP, decreased after steroid therapy, and increased at disease relapse. CONCLUSION: IgG4þ plasmablast count represents a potentially useful biomarker to differentiate type 1 from type 2/NOS AIP and from other pancreatic diseases

Role of Amylase-\u3b12A Autoantibodies in the Diagnosis of Autoimmune Pancreatitis

Several serological markers have been reported in autoimmune pancreatitis (AIP) patients. However, only serum IgG4 (sIgG4) is available in clinical practice for AIP diagnosis. Antiamylase \u3b1 antibodies (AMY-\u3b1 Abs) have been proposed to diagnose AIP. This study evaluates the utility of AMY-\u3b1 Abs and sIgG4 for AIP diagnosis

Clinical and Morphological Features of Paraduodenal Pancreatitis: An Italian Experience With 120 Patients

This study aimed to evaluate the clinical and radiological features and clinical outcomes of paraduodenal pancreatitis (PP)

NMR and MRCP After Secretin Infusion in a Long-Term Comparison Study of Pancreogastro- vs. Pancreojejuno-Duodenopancreatectomy

Context After pylorus-preserving pancreaticoduodenectomy the anastomosis of pancreatic remnant may be done with the stomach (pancreogastric, PGA) or the jejunum (pancreojejunum, PJA). Recently, we have found that, in the long-term, PGA is associated with a more severe impairment of the residual pancreatic function. No data are available on the RNM ability to demonstrate an impairment of the residual pancreatic secretion or morphological changes after surgery. Methods Patients who 6 years ago entered a controlled short term comparison of PGA and PJA were studied by RNM and MRCP after secretin infusion (quantification of residual pancreatic volume, pancreatic duct diameter immediately proximal to the anastomosis, qualitative impairment of secretion), and tests of exocrine (fecal elastase-1, fecal fat balance) function. Two radiologists, blinded to the results of functional parameters, independently scored the residual pancreatic volume, duct diameter and secretin-stimulated secretion. Mean±SEM are shown. The Student’s t test was used. Results We studied 34 patients (16 PGA, 18 PJA; age 56.6±2.7 vs. 57.5±2.5 years; time from surgery 81±5 vs. 80±3 months). PGA was associated with a more severe impairment of steatorrhea than PJA (26.6±4.1 vs. 18.2±3.6 g/day; reference range: 0-7; P<0.01) and of fecal elastase-1 (70.2±25.5 vs. 121.4±6.7 µg/g; P<0.001). RNM showed in PGA a more marked dilatation of the pancreatic duct (diameter 4.63±0.91 vs. 2.50±0.18 mm, P<0.05) and non significant tendency to a smaller residual pancreas (26.3±3.0 vs. 35.9±4.1 mL; P=0.069). There is a power correlation between residual pancreas and steatorrhea. After secretin infusion, the secretion was consistently considered by two different radiologists to be more frequently impaired in PGA (42%) than in PJA (18%; P=0.05, Fisher test). Conclusion The pancreo-gastric anastomosis is associated, in the long run, with more severe morphological and functional impairment of exocrine function than the pancreo-jejunal one

Ablation Difficulty Score: Proposal of a new tool to predict success rate of percutaneous ablation for hepatocarcinoma

Purpose: Identify the factors related to failure ablation after percutaneous ultrasound guided single electrode radiofrequency ablation (RFA) for hepatocarcinoma (HCC) and propose a score for improving patient selection and treatment allocation. Methods: From 2010 to 2020 585 HCC nodules treated with RFA were prospectively collected. Ablation Difficulty Score (ADS) was built-up according to clinical and radiological factors related to failure ablation identified by Cox-logistic regression analysis. The study population was stratified in low risk (ADS 0), intermediate risk (ADS 1), and high risk (ADS ≥ 2) of failure ablation. Results: Overall ablation success rate was 85.5%. Morbidity and mortality rates were 3.5% and 0.0%. According to per nodule analysis the following factors resulted related to failure ablation: size > 20 mm (p = 0.002), sub-capsular location (p = 0.008), perivascular location (p = 0.024), isoechoic appearance (p = 0.008), and non-cirrhotic liver (p = 0.009). The ablation success rate was 93.5% in ADS 0, 85.8% in ADS 1 and 71.3% in ADS ≥ 2 (p < 0.001). The 1-year local tumor progression (LTP) free survival was 90.2% in ADS 0, 80.6% in ADS 1, and 72.3% in ADS ≥ 2 (p = 0.009). Nodule's size > 20 mm (p = 0.014), isoechoic appearance (p = 0.012), perivascular location (p = 0.012) resulted related to lower LTP free survival. Conclusion: Ablation Difficulty Score could be a simple and useful tool for guiding the treatment decision making of HCC. RFA in high risk nodules (ADS ≥ 2) should be carefully evaluated and reserved for patients not suitable for surgery or liver transplantation