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Exocrine pancreatic insufficiency (EPI) contributes to malnutrition, marked by muscle loss during chemotherapy for advanced pancreatic cancer (aPC). Pancreatic enzyme replacement therapy (PERT) is recommended for patients with EPI; however, it's efficacy for attenuating muscle loss has not been demonstrated. We aimed to delineate the impact of PERT dose on muscle loss using a 7-year population-based cohort with aPC who were provided PERT at the discretion of their oncologist or dietitian according to clinical indications of EPI. All patients treated with chemotherapy for aPC from 2013 to 2019 in Alberta, Canada (population ∼4.3 million) were included if they had computed tomography (CT) scans both prior to and 12 ± 4 weeks after chemotherapy initiation. Change in muscle area (cm2) was measured at 3rd lumbar level on repeated CT scans. Muscle loss was defined by measurement error (loss >2.3 cm2). Clinical and pharmaceutical data were retrieved from provincial registries. For patients who were dispensed PERT -8 to +6 weeks from chemo start (PERT users), estimated dose consumed per day was calculated as: (total dose dispensed) / (days, first to last dispensation). PERT users were categorized as high dose or low dose users according to the median estimated dose consumed. Non-users were classified as No PERT. Association between PERT use and muscle loss was analyzed with multivariable logistic regression. Among 210 patients, 81 (39%) were PERT users. Median estimated dose consumed per day of 75 000 USP lipase units defined the cutoff between low dose and high dose uses. There were no significant differences in baseline characteristics between high dose and low dose groups. Muscle loss was more prevalent among low dose compared to both high dose and No PERT groups (88% vs. 58% and 67%, p < 0.05). In the multivariable model predicting muscle loss, low dose PERT was independently associated with greater odds of muscle loss (OR 5.4, p = 0.004) vs. high dose, independent of tumour response, disease stage, and chemotherapy regimen. In patients with clinical indications of EPI during chemotherapy for aPC, low doses of PERT were insufficient to prevent muscle loss. Patients with EPI consuming higher doses of PERT had similar odds of muscle maintenance to patients without clinical indications of EPI. Provider education for optimal PERT dosing in patients with EPI should be prioritized, and resources must be allocated to support dose titration. [ABSTRACT FROM AUTHOR]

Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the life expectancy of PwCF has improved significantly. Various GI aspects of CF care, such as nutrition, are linked to an overall improvement in morbidity, lung function and the quality of life of PwCF. The variable clinical presentations and management of GI diseases in pediatrics and adults with CF should be recognized. Therefore, it is necessary to ensure efficient transfer of information between pediatric and adult providers for proper continuity of management and coordination of care at the time of transition. The transition of care is a challenging process for both patients and providers and currently there are no specific tools for GI providers to help ensure a smooth transition. In this review, we aim to highlight the crucial features of GI care at the time of transition and provide a checklist that can assist in ensuring an effective transition and ease the challenges associated with it. [ABSTRACT FROM AUTHOR]

Exocrine pancreatic insufficiency (EPI) is a clinically defined syndrome based on the physician’s assessment of a patient’s maldigestion. However, current clinical definitions are inadequate in determining (1) the threshold of reduced pancreatic digestive enzyme secretion that determines “pancreatic insufficiency” in an individual patient; (2) the role of pancreatic function tests; (3) effects of differing metabolic needs, nutrition intake, and intestinal function/adaptation (4) when pancreatic enzyme replacement therapy is needed; and (5) how to monitor and titrate multiple therapies. Experts and key opinion leaders were invited to PancreasFest 2021 to discuss and help clarify mechanistic issues critical to defining EPI and to address misconceptions and barriers limiting advancements in patient care. Clinically EPI is defined as inadequate delivery of pancreatic digestive enzymes to meals to meet nutritional needs and is reversed with appropriate treatment. A new mechanistic definition of EPI was proposed that includes the disorders essence and character: (1) EPI is a disorder caused by failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine in concert with ingested nutrients, followed by enzymatic digestion of a series of individual snacks and meals over time to meet nutritional and metabolic needs, given (a) the specific macronutritional and micronutritional needs; (b) nutrient intake; (c) exocrine pancreatic function; and (d) intestinal anatomy, function, diseases, and adaptative capacity. (2) EPI is characterized by variable deficiencies in micronutrients and macronutrients, especially essential fats and fat-soluble vitamins, by gastrointestinal symptoms of nutrient maldigestion and by improvement or correction of nutritional state with lifestyle changes, disease treatment, optimized diet, dietary supplements, and/or administration of adequate pancreatic enzyme replacement therapy. EPI is complex and individualized and multidisciplinary approaches are needed to optimize therapy. Better pancreas function tests and biomarkers are needed to diagnose EPI and guide treatment.

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Background: A previous retrospective study documented restored patency to 48.2% of occluded enteral feeding tubes using alkalinized Creon pancreatic enzyme capsules. In light of the low efficacy rate, the institutional enteral feeding tube clearance protocol was subsequently revised to incorporate a newly marketed non–enteric-coated Viokace pancreatic enzyme tablet, despite the lack of published data for this indication. Objective: This study aims to evaluate the effectiveness of a Viokace-based alkalinized pancreatic enzyme protocol to clear occluded enteral feeding tubes in a university health system. Methods: This retrospective, cohort quality assurance study included adult and pediatric patients receiving a Viokace-based pancreatic enzyme protocol for enteral feeding tube occlusions in a university health system during a 12-month period. The primary outcome was effectiveness in enteral tube clearance as documented in the electronic medical record. Efficacy of the new protocol was also compared with a Creon-based alkalinized solution using historical data. Results: The Viokace protocol successfully cleared 176 of the 277 (63.5%) occluded enteral feeding tubes occurring in 205 patients included in the analysis. The revised protocol was significantly more effective at clearing occluded enteral feeding tubes (P = 0.0056) than a protocol using Creon pancreatic enzyme capsules. Conclusion: According to this retrospective evaluation, an alkalinized Viokace pancreatic enzyme protocol was effective in clearing 63.5% of occluded enteral feeding tubes. This significantly higher success rate than previously documented with a Creon-based protocol supports the change in pancreatic enzyme formulations in the institutional protocol. [ABSTRACT FROM AUTHOR]

Shailesh V Shrikhande,1 VG Mohan Prasad,2 J Enrique Domínguez-Muñoz,3 Kevin E Weigl,4 Kushal D Sarda5 1Division of Cancer Surgery and Gastrointestinal and Hepato-Pancreato-Biliary Service, Tata Memorial Hospital, Mumbai, Maharashtra, India; 2Department of Gastroenterology, Dr. M.G.R. Medical University and VGM Hospital, Coimbatore, Tamil Nadu, India; 3Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain; 4Department of Gastroenterology, Abbott Laboratories GmbH, Hannover, Germany; 5Established Pharmaceuticals Division – Medical Affairs, Abbott India Ltd, Mumbai, Maharashtra, IndiaCorrespondence: Kushal D SardaAbbott India Ltd, Floor 16, Godrej BKC, Plot No. C – 68, Bandra-Kurla Complex, Near MCA Club, Bandra (E), Mumbai, 400051, Maharashtra, IndiaTel +91-22-38160938Fax +91 22 38162400Email kushal.sarda@abbott.comPurpose: Pancreatic enzyme replacement therapy (PERT) involves exogenous enzyme supplementation and is used in the treatment of pancreatic exocrine insufficiency. Clinical efficacy of PERT preparations is a function of physical properties and release kinetics that vary between commercially available products. In this study, we evaluated the physical properties, in vitro dissolution, and release kinetics of commercially available pancreatic enzyme preparations available in the Indian market.Methods: Physical properties such as particle size distribution and water content of the capsules were measured by dynamic light scattering and Karl–Fischer titration method, respectively. An analytical procedure based on the European pharmacopoeia (EP) method was used to determine lipase activity, and a modified United States pharmacopoeia (USP)–based method was used for dissolution studies. Enzyme release was ascertained under gastroduodenal conditions in buffered media.Results: Considerable variations in physical properties such as particle size and water content were observed between pancreatic enzyme preparations. Some preparations failed to meet the labeled lipase content as per USP standards (> 90% label claim) and showed inconsistent release behavior (> 5% relative standard deviation).Conclusion: Differences exist between pancreatic enzyme preparations in terms of physical properties, dissolution, and release behavior that can affect their clinical efficacy. The present study suggests, therefore, that these preparations should not be used interchangeably.Keywords: pancreatic enzyme, physical properties, in vitro dissolution, lipase activity, release kinetics

Zymosan is a fungi-derived pathogen-associated molecular pattern. It activates the immune system and induces the reduction of feed passage rate in the gastrointestinal tract of vertebrates including birds. However, the mechanism mediating the zymosan-induced inhibition of feed passage in the gastrointestinal tract remains unknown. Since the medulla oblongata regulates the digestive function, it is plausible that the medulla oblongata is involved in the zymosan-induced inhibition of feed passage. The present study was performed to identify the genes that were affected by zymosan within the medulla oblongata of chicks (Gallus gallus) using an RNA sequencing approach. We found that mRNAs of several bioactive molecules including neuropeptide Y (NPY) were increased with an intraperitoneal (IP) injection of zymosan. The increase of mRNA expression of NPY in the medulla oblongata was also observed after the IP injection of lipopolysaccharide, derived from gram-negative bacteria. These results suggest that medullary NPY is associated with physiological changes during fungal and bacterial infection. Furthermore, we found that intracerebroventricular injection of NPY and its receptor agonists reduced the feed passage from the crop. Additionally, the injection of NPY reduced the feed passage from the proventriculus to lower digestive tract. NPY also suppressed the activity of duodenal activities of amylase and trypsin. The present study suggests that fungi- and bacteria-induced activation of the immune system may activate the NPY neurons in the medulla oblongata and thereby reduce the digestive function in chicks. [Display omitted] • IP injection of zymosan affected gene expression in the medulla oblongata in chicks. • IP injections of zymosan and NPY increased NPY mRNA expression in the medulla. • ICV injection of NPY inhibited feed passage from the digestive tract. • ICV injection of NPY inhibited the activity of pancreatic enzymes in the duodenum. • Central NPY may be associated with infection-induced inhibition of digestive function. [ABSTRACT FROM AUTHOR]

This study investigated the effects of the inclusion of solid propolis residue (PR) from alcoholic propolis extraction in the diets of broiler chickens from 1 to 21-d of age on their performance, intestinal morphology, and digestive enzyme activity. 405 male chicks were distributed in a completely randomized design with five treatments (inclusion of 0, 1, 2, 3 and 4% PR in the diets), and three replications with 27 birds each. The birds were fed experimental diets from 1 to 21-d of age and basal diet from 22 to 42-d of age. Feed intake (from 1 to 21-d and 1 to 42-d of age) decreased linearly with increasing levels of PR inclusion (P < 0.05). Dietary inclusion of PR did not affect intestinal morphology at 7 and 21-d of age (P > 0.05). Pancreatic amylase activity presented a quadratic response at 7 and 21-d of age, with its lowest activity estimated at 2.45 and 1.91% PR inclusion, respectively. At 7-d of age, trypsin activity decreased linearly, whereas chymotrypsin activity varied quadratically, with its activity estimated at 2.06% PR inclusion. Intestinal maltase activity varied quadratically with lowest activity predicted at 1.57% PR inclusion at 21-d of age. The dietary inclusion of solid propolis residue of propolis decreases feed intake in broilers and modulates their intestinal and pancreatic enzyme activity.

Benign Pancreatic Hyperenzymemia (BPH) is characterized by a long-term increase of serum pancreatic enzymes (PE) in otherwise healthy subjects. The study investigates the prevalence and correlates of the condition using data from Electronic Health Records (EHR) in a large sample of general population, to identify subjects potentially affected by BPH. Cross-sectional retrospective observational study integrated by a follow-up visit. The database of a reference laboratory identified, out of 577.251 admittances from 2011 to 2015, 4964 patients tested at least for one PE assay and 1688 subjects who had at least 3 PE tests (normal or increased) over two years. Forty-two individuals showed an increase of PE at least three times throughout 2 years without any evidence of pancreatic disease, even after matching with the ICD 9-CM code in the GPs database. Data retrieved at follow-up visit showed that for 34 the diagnosis of BPH could be made. Our data indicate that BPH prevalence among subjects underwent blood testing for multiple PE testing is 2%. This condition, even if not a disease, is perceived by nearly all the BPH patients as a serious threat to their life. Further studies are needed to manage its heavy psychological impact. [ABSTRACT FROM AUTHOR]

Inflammatory bowel disease (IBD) is a chronic condition that includes two clinical entities: Crohn’s disease and ulcerative colitis. Although both entities mainly affect the gastrointestinal tract are considered multisystemic diseases and may present extraintestinal manifestations involving other organs and systems. Pancreatic involvement in Pediatric IBD includes a heterogeneous group of clinical entities like acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, asymptomatic exocrine pancreatic insufficiency, increased pancreatic enzyme levels, structural abnormalities, and granulomatous inflammation. Although the mechanism for pancreatic involvement in IBD is not clearly elucidated, is important to keep in mind the association of these two entities in order to perform a prompt diagnosis and establish an appropriate treatment. The objective of this review is to update the available evidence on pancreatic involvement in children with IBD.

Exocrine pancreatic insufficiency (EPI) is one of the possible mechanisms of fat maldigestion following gastric surgery, together with reduced food intake, loss of gastric reservoir, small bowel bacterial overgrowth and rapid small bowel transit. Oral pancreatic enzyme replacement therapy (PERT) is the mainstay of treatment for EPI. The efficacy and safety of pancreatic enzyme substitution in patients following gastric resection remains unclear. This review article summarizes relevant studies addressing PERT after gastric resection. [ABSTRACT FROM AUTHOR]

Purpose:Total pancreatectomy (TP) for pancreatic neoplasms is associated with high morbidity and mortality rates. However, with recent advances in surgical techniques and improved postoperative management, the number of cases with clinical indications for TP is increasing. Here, we evaluated the clinical outcomes post-TP. Materials and methods:Patients (n = 41) who underwent TP between 2004 and 2011 at Tokyo Women’s Medical University were retrospectively examined. Pre- and postoperative clinicophysiological data were collected up to 12 months post-TP and then analyzed. Results:Only glycated hemoglobin (HbA1c), percentage of lymphocytes and hepatic Hounsfield unit level on computed tomography (CT) were significantly different between the preoperative state and at 12 months post-TP, while other clinicophysiological parameters remained unchanged. The quantity of the pancreatic enzyme administered significantly influenced glycemic control at 12 months post-TP (p < 0.05). Conclusions:All clinicophysiological parameters except for HbA1c were temporarily decreased after TP but normalized by 12 months. Thus, TP is a feasible surgical approach to treating pancreatic neoplasms with the potential to spread across the entire pancreas when adequately supplemented by synthetic insulin and pancreatic enzymes. [ABSTRACT FROM AUTHOR]