Biomedical subjects
Chris E Forsmark
Publications and source records attributed to Chris E Forsmark.
Comparative analysis of direct pancreatic function testing versus morphological assessment by endoscopic ultrasonography for the evaluation of chronic unexplained abdominal pain of presumed pancreatic origin.
OBJECTIVES: The diagnosis of "minimal change" chronic pancreatitis (MCCP) is often considered when conventional imaging studies are unrevealing in a patient population with abdominal pain of presumed pancreatic origin. Direct pancreatic function testing using secretin as a secretagogue (ST) has been considered the most sensitive method to diagnose MCCP but is not widely available to clinicians. Endoscopic ultrasound (EUS) allows detailed imaging of pancreatic architecture, but the sensitivity and specificity for MCCP remain to be determined. We sought to compare the accuracy of EUS and ST in patients with presumed MCCP. METHODS: Seventy-four patients referred to our pancreas clinic with unexplained abdominal pain and previously negative imaging studies underwent an ST for evaluation of possible MCCP. Twenty-one of these also underwent EUS. EUS images were read by 1 of 2 experts blinded to ST results. RESULTS: Using ST as the "gold standard," EUS had a maximum sensitivity of 71% when the cut-off for diagnosis was set at at least 3 EUS features. Conversely, maximum specificity (92%) was seen when the cut-off value was set at at least 6 EUS criteria. Diagnostic certainty was only 50% (positive predictive value = 0.5) when at least 6 criteria were used as the cut-off. MCCP was excluded with greater than 70% certainty when less than 3 criteria were present. At the best cut-off value of at least 4 features, EUS had a sensitivity of 57% and a specificity of 64%. CONCLUSIONS: In this patient population with abdominal pain of presumed pancreatic origin, EUS and standard pancreatic function testing are often discordant. If ST is assumed to be the reference against which other tests are compared, EUS is less accurate than ST in diagnosing MCCP.
Role of osmolality of contrast media in the development of post-ERCP pancreatitis: a metanalysis.
The role of osmolality of contrast media (CM) in the development of post-ERCP pancreatitis (PEP) is debated. We therefore performed a metanalysis to determine whether osmolality affects the incidence of PEP. A literature search of English-language studies was performed using computerized databases and manual searching of abstracts and article bibliographies. Randomized controlled trials comparing the incidence of PEP associated with high- and low-osmolality contrast media (HOCM, LOCM) were considered. The outcome assessed was clinical pancreatitis as evidenced by both elevation of pancreatic enzymes and pain. Data were analyzed using logistic regression with terms for study and osmolality. Fisher's exact test was done to compare PEP rates. Homogeneity between studies was indicated by the nonsignificance of the study effect in the logistic regression model. Logistic regression also indicated no difference in PEP rates between LOCM and HOCM (P = 0.399). Comparison of PEP rates in both groups using Fisher's exact test did not indicate a difference in any individual study (all P values > 0.05). Due to the large variation of study sample sizes, we repeated the analysis by creating three study groups. The effect of osmolality was invariant to how the data were combined. The results of this metanalysis indicate that there is no significant difference between HOCM and LOCM with respect to clinical PEP.
Is a 15-minute collection of duodenal secretions after secretin stimulation sufficient to diagnose chronic pancreatitis?
BACKGROUND: Standard hormonal stimulation tests of pancreatic function use a 60- to 90-minute collection of pancreatic secretions. A shorter 15-minute collection time has been proposed to increase the feasibility of the secretin stimulation test. The accuracy of this brief collection period for the diagnosis of chronic pancreatitis has not been well defined. METHODS: We retrospectively evaluated the accuracy of a 15-minute collection period by comparing the results of 633 complete standard secretin tests (60 minutes) to the result using only the first 15-minute collection of the same test. The gold standard used for the diagnosis of chronic pancreatitis was the final result of the complete 60-minute secretin stimulation test. RESULTS: The specificity of the first 15-minute collection was 34.6% (95% CI, 30.03%-39.21%). The positive predictive value was 44.9% (95% CI, 40.5%-49.3%). The accuracy was 57.3% (95% CI, 53.01% 59.34%). CONCLUSIONS: Using only the first 15-minute collection period in a standard 60-minute secretin test is inaccurate in the diagnosis of chronic pancreatitis.
Chronic pancreatitis and malabsorption.
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Prevalence of gastroparesis in patients with small duct chronic pancreatitis.
INTRODUCTION: The most common symptoms of chronic pancreatitis are abdominal pain, diarrhea, and weight loss. The abdominal pain has no consistent pattern, and nausea and vomiting commonly occur simultaneously. Gastroparesis may produce similar symptoms. These similar symptoms may cause diagnostic confusion, particularly with regard to patients with small-duct chronic pancreatitis, for whom diagnosis of chronic pancreatitis is most difficult. We have observed that coexistent gastroparesis may also interfere with the effectiveness of pancreatic enzyme therapy by failing to deliver proteases into the duodenum and therefore not restoring feedback control of pancreatic secretion. AIM: To estimate the prevalence of gastroparesis in patients with minimal-change chronic pancreatitis. METHODOLOGY: Patients with chronic pancreatitis diagnosed on the basis of secretin test results but with otherwise normal pancreatic imaging (ultrasonographic or computed tomographic) findings who had also undergone a gastric emptying study were retrospectively identified. An abnormal secretin test value was defined as a peak bicarbonate concentration in pancreatic secretions of <80 mEq/L after secretin stimulation. Gastroparesis was defined as an emptying half-time greater than 90 minutes. RESULTS: Fifty-six patients were identified. Twenty-five of the 56 patients (44%) had concomitant gastroparesis and small-duct chronic pancreatitis. Twenty-four of these 25 were women, and 22 of the 25 had idiopathic small-duct chronic pancreatitis. CONCLUSION: In our referral population, gastroparesis is frequently seen in patients with small-duct chronic pancreatitis. For patients with small-duct disease whose abdominal pain does not respond to pancreatic enzyme therapy, clinicians should consider an evaluation for gastroparesis.
Controversies in clinical pancreatology: management of acute idiopathic recurrent pancreatitis.
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Maintenance oral pantoprazole therapy is effective for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion.
OBJECTIVE: Maintenance proton pump inhibitor (PPI) therapy is effective for gastric acid hypersecretory states, although data with pantoprazole are limited. The aim of this study was to evaluate the safety and efficacy of long term p.o. pantoprazole in individuals with hypersecretion. METHODS: All subjects had Zollinger-Ellison syndrome or idiopathic hypersecretion. Baseline acid output was measured in the presence of prior maintenance antisecretory therapy before pantoprazole exposure. The starting dose was 40 mg b.i.d. in most cases, and the dose was adjusted to document control within the first 2 wk of therapy. The maximal allowable dose was 240 mg daily. Acid output was measured on day 28 and then quarterly from month 3. The primary efficacy endpoint was documented control of acid secretion at 6 months, i.e., acid output in the last 1 h before the next dose of therapy of <10 mEq/h (<5 mEq/h in subjects with prior acid-reducing surgery). RESULTS: A total of 26 subjects had Zollinger-Ellison syndrome (six with multiple endocrine neoplasia syndrome type 1) and nine had idiopathic hypersecretion. Pre-enrollment therapy included omeprazole in 27 subjects and lansoprazole in eight, and 82.4% of subjects were controlled on their prior regimens. With upward dose titration, acid output was controlled in all subjects by day 10 and in all but two (6%) at the 6-month time point. Median acid secretion on therapy at 6 months was <2 mEq/h (mean 2.2 mEq/h; range 0-10.5 mEq/h) at a dose of 40 mg b.i.d. for 24 subjects, 80 mg b.i.d. for seven subjects, and 120 mg b.i.d. for two subjects. During the course of the study, five subjects required doses of 240 mg daily. Pantoprazole was generally well tolerated. No cases of anterior optic ischemic neuropathy occurred. Five subjects died during follow-up, all because of events unrelated to the study drug. CONCLUSIONS: Maintenance p.o. pantoprazole therapy at a dose of 80-240 mg/day in divided doses was both effective and generally well tolerated for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion.
Chronic pancreatitis and maldigestion.
Patients with chronic pancreatitis may suffer from maldigestion and malnutrition. Longstanding inflammation and fibrosis in the gland can destroy exocrine tissue, leading to inadequate delivery of digestive enzymes to the duodenum in the prandial and postprandial period and subsequent maldigestion. Maldigestion is augmented by inadequate bicarbonate delivery to the duodenum, with secondary inactivation of enzymes and bile acids by gastric acid. Abdominal pain, sitophobia, nausea, vomiting, postprandial satiety, and on-going alcohol abuse may contribute to poor oral intake. Gastric dysmotility and mechanical gastric outlet obstruction from fibrosis in the pancreatic head may contribute to malnutrition and clinical decline. Patients with chronic pancreatitis may at times experience profound steatorrhea and weight loss. In this article, we examine the natural history of exocrine insufficiency in chronic pancreatitis, outline the important nutritional issues in these patients, review the methods of diagnosis of maldigestion, and discuss the approach to therapy.