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Background The management of bloating is unclear and its relationship with patients' well-being and treatment satisfaction independent of other abdominal symptoms is uncharacterized. We evaluated the association of bloating with patient-reported outcomes. Methods Thirty-nine centers for functional gastrointestinal disorders joined the laxative inadequate relief survey. We enrolled 2203 consecutive outpatients with functional constipation (FC) or constipation-predominant irritable bowel syndrome (IBS-C) in two cross-sectional waves. Both wave 1 and 2 included the SF-12, the patient assessment of constipation-symptoms (PAC-SYM), and the treatment satisfaction questionnaire for medication (TSQM-2). Wave 2 only included a global rating of change (GRC) scale to assess patients' assessment of efficacy concerning treatment switches occurred in the 3 months prior to the interview. Bloating in the abdomen was defined on the basis of PAC-SYM item 3. Key Results The average age was 50.1 years (SD, 16.7) and 82.1% of patients were women. The prevalence of bloating was 91.6% (n = 1970). Bloating was associated with SF-12 Physical Composite Score (p < 0.01), SF-12 Mental Composite Score (p < 0.01), GRC (p < 0.01), Satisfaction with treatment effectiveness (p < 0.01), convenience of administration (p < 0.01), and side effects (p < 0.01) after adjustment for possible confounders. Conclusions & Inferences Our data suggest that patients regard bloating as a key element in assessing clinical changes and treatments' efficacy as this symptom exerts a strong influence on patient-reported outcomes independent of possible confounders and other symptoms of constipation. Our data provide the rationale to investigate the efficacy and tolerability of new treatments specifically addressing this important, yet disregarded, patients' complain.

Context Paraduodenal pancreatitis (PP) is a special form of chronic pancreatitis, called also groove pancreatitis or cystic dystrophy of the duodenal wall, defined on surgical specimens. Characteristic findings at CT, MR and EUS has been published. Objective to evaluate the clinical and radiological features of PP, and the clinical outcome in a mixed clinical and surgical series. Methods All patients with a final diagnosis of PP in gastroenterology unit and surgical department have been enrolled. Clinical, radiological and pathological data have been collected. The diagnosis was based on surgical specimens in operated patients and on imaging in non operated patients. Results We studied 112 patients (108 males, 4 females; mean age 41.4±10 years), 96.4% of them were drinkers (mean daily alcohol intake: 129.3±65.4 g) and 97.3% smokers (29.2±13.6 cigarettes/day). The clinical onset was acute pancreatitis in 70 patients (63%) and continuous pain in 42 (38%). Other symptoms at onset were vomiting (42 patients, 38%), weight loss (26 patients, 23%) and jaundice (13 patients, 12%). Cystic variant was diagnosed in 79 patients (70%) and solid in 33 (30%). Pure form involving only the groove area was observed in 22 patients (20%) and diffuse form involving all pancreas in 90 (80%). Pancreatic calcifications were diagnosed in 68 patients (61%). Seventy-four patients (70%) underwent surgery, resective in 57 and derivative in 17. The indication for surgery were pain (67 patients, 86%), suspicion of cancer (5 patients, 6%) and duodenal obstruction (6 patients, 8%). Mean follow-up time was 5±7 years. Diabetes was diagnosed in 28% and steatorrhea in 25%. Ten patients (9%) died. Conclusion The clinical profile of PP are middle age males, heavy drinkers and smokers, with painful pancreatitis, associated with vomiting and weight loss. Resective surgery is the treatment of choice in our institution., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Chronic pancreatitis (CP) is not common in elderly people. Idiopathic senile pancreatitis (SP) was described 30 years ago, occurring over 50s, but very little information was reported since that first reported so far. Painless course, steatorrhea or diabetes, and pancreatic calcification were the clinical features. Objective This study was aimed at identifying presence and characteristics of SP in patients with CP aged >65 years. Fifty patients out of a series of 620 CP (8.1%) were identified. In 28 the onset of CP occurred >65 years (Group A), in 22 it occurred before the age of 65 years, but they were referred to our unit after 65 years (Group B). Methods Demographic data, risk factors, clinical features, morphological changes, exocrine function, diabetes were collected. Parametric and non-parametric statistical analysis was carried-out. Results No difference in gender, alcohol consumption (30% of abstainers), smoking (36% of non-smokers), genetic factors was observed between the two groups, though heavy drinkers were 25% in Group A and 40.5% in Group B (P=0.360). Heavy drinkers were also smokers. 25.3% (7 cases) of Group A and 40.5% (9 cases) of Group B were classified as alcoholic CP. Obstructive CP was present in 28.6% of A (8 cases) and 18.8% (4 cases) of Group B (P=0.304). In 22 patients (44.0%) (13 A: 46.4%; 9 B: 40.1%) CP was idiopathic (P=0.46). Painful relapses were observed in 60.7% of Group A and 86.3% of B (P=0.04). No difference in jaundice, body weight loss, diabetes, age of onset and duration of diabetes, and exocrine insufficiency was found. Calcifications were found in 71.4% and 77.3% of A and B respectively. Wirsung duct dilation (>3 mm) was observed in 92.8% and 81.8% of the two groups, and the mean pancreatic duct size was 7.36±0.44 and 7.55±1.01 (P=0.856). Fourteen patients were painless pancreatitis, preceded by painful relapses in a single case. Out of the 13 primary painless CP, 10 (76.9%) belong to Group A, 3 (23.1%) to Group B, being painless CP represented in 35.7% of A and 13.6% of B patients (P=0.044). Alcohol intake was 52.7±16.1 and 24.0±8.2 g/day in non-painless and painless CP of Group A (P=0.01). Five of the 10 CP (A) and 2/3 cases (B) were idiopathic CP (idiopathic senile CP) (17.9% of group A). Conclusions CP with onset or diagnosis over 65 years is not clinically and morphologically different from CP in patient referred over 65 years, but with a preceding onset, except for a higher frequency of primary painless CP. Idiopathic senile CP represents a very small group (10% of patients with CP observed over 65 years), without clinical, morphological and functional distinction from the other CP patients. It does not seems to be a clinical-pathological entity., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context Chronic asymptomatic pancreatic hyperenzymemia (CAPH) has been described since 1996 as a benign disease. Pathological findings at magnetic resonance cholangiopancreatography (MRCP) with secretin stimulation (s-MRCP) have been found in 50% of CAPH subjects, but in 30% their clinical meaning remains undefined. Objective To investigate subjects with CAPH during the follow-up to assess the clinical and radiological outcome. Methods From January 2012 to March 2013, a cohort of 160 subjects previously studied for CAPH were re-evaluate with s-MRCP and biochemical tests. Results Clinical data relative to 108 subjects were collected, whereas 68 (47 males, 21 females; mean age: 49.8 ± 12.2 years) underwent s-MRCP. Clinically, acute pancreatitis was observed in one subject out of 108 (0.9%) after 5 years from the first detection of hyperenzymemia. Among the 68 subjects who underwent s-MRCP, 23 (33.8%) had previous s-RMCP normal and 45 (66.2%) pathological. No radiological alterations in 23 subjects with normal s-MRCP at first evaluation were observed at follow-up, whereas unchanged s-MRCP was documented in 41 out of 45 (91.1%) subjects with pathological s-MRCP at first evaluation after mean follow-up of 3±2 years. One out of 11 subject with IPMN had progression of the size of the cyst, 1 out of 11 with suspected sphincter of Oddi dysfunction showed an increase of Wirsung duct diameter, while a worsening of ductal morphology was observed in 2 out of 20 subjects with suspected chronic pancreatitis. Conclusion CAPH subjects remain asymptomatic during the follow-up. Subjects with previous normal MRCP-s did not show pathological findings at follow-up whereas only a small percentage of those with previous suspected sphincter of Oddi dysfunction or chronic pancreatitis, showed a progression at imaging in a short term follow-up., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

Context International consensus diagnostic criteria (ICDC) for autoimmune pancreatitis (AIP) have been proposed to diagnose type 1 AIP, type 2 AIP and AIP not-otherwise specified (AIP-NOS). Objective The aim of this international multicenter study was to evaluate the possibility of correctly diagnosing AIP itself and its subtype by ICDC in focal AIP patients. Methods Thirty patients (type 1 AIP in 23 and type 2 AIP in 7) diagnosed as AIP based on histology of surgical specimens were classified according to ICDC based on their preoperative data. Results Pancreatic core biopsies and diagnostic steroid trial were not preoperatively performed in any of the patients. Based on preoperative data, ICDC diagnosed 6 patients (20%) as type 1 AIP and 24 (80%) as probable AIP. Assuming all patients had responded to a steroid trial preoperatively, ICDC would have diagnosed 8 patients (27%) as type 1 AIP, 4 (13%) as type 2 AIP, 10 as AIP-not otherwise specified (33%) and 8 (27%) as probable AIP. In the hypothetical situation, 7 of 8 type 1 AIP patients and 3 of 3 type 2 AIP patients would have been classified into the correct subtype of AIP. Conclusion In this retrospective study, the accuracy of ICDC without preoperative histology was quite low. A steroid trial enhances the possibility of correctly diagnosing AIP by ICDC despite of the lack of histology. However, some patients cannot be diagnosed as having AIP or be classified into the correct subtype without histology., JOP. Journal of the Pancreas, Vol 14, N° 5S (2013): September (Suppl.) - p. 528-602

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, PConclusion 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., JOP. Journal of the Pancreas, Vol 13, N° 5S (2012): September (Suppl.) - p. 548-650