Yield of testing for micronutrient deficiencies associated with pancreatic exocrine insufficiency in a clinical setting: An observational study

Abstract

BACKGROUND Pancreatic exocrine insufficiency (PEI) can be difficult to diagnose and causes maldigestion symptoms and malabsorption. There has been a number of studiesthat have identified PEI associated micronutrient deficiencies (PEI-MD), howeverthere is variation in both the frequency and type of PEI-MD reported, with themajority of studies including patients with PEI due to chronic pancreatitis (CP) orCP without PEI. There is a paucity of information regarding the prevalence of PEIMDin patients with PEI without CP and the yield of testing for PEI-MD in aclinical setting in patients with suspected benign pancreatic diseases.AIMTo prospectively assess the yield and type of PEI–MD in patients with andwithout PEI secondary to benign pancreatic disease.METHODSPatients investigated for maldigestion symptoms with Faecal Elastase-1 (FEL-1)and suspected or proven benign pancreatic disease were prospectively identified.At the time of FEL-1 testing, serum samples were taken for micronutrientsidentified by previous studies as PEI-MD: prealbumin, retinol binding protein, copper, zinc, selenium, magnesium and later in the study lipid adjusted vitaminE. FEL-1 was recorded, with a result < 200 μg/g considered diagnostic of PEI.Patients underwent computed tomography (CT) imaging when there was aclinical suspicion of CP, a new diagnosis of PEI recurrent, pancreatic type pain(epigastric abdominal pain radiating to back with or without previous acutepancreatitis attacks) or weight loss.RESULTSAfter exclusions, 112 patients were recruited that underwent testing for FEL-1 andPEI-MD. PEI was identified in 41/112 (36.6%) patients and a pancreatic CT wasperformed in 82 patients. Overall a PEI-MD was identified in 21/112 (18.8%)patients. The yield of PEI-MD was 17/41 (41.5%) if PEI was present which wassignificantly higher than those without 4/71 (5.6%) (P = 0.0001). The yield ofPEI–MD was significantly higher when PEI and CP were seen together 13/22(59.1%) compared to CP without PEI and PEI without CP (P < 0.03). Individualmicronutrient assessment showed a more frequent occurrence of prealbumin 8/41(19.5%), selenium 6/41 (14.6%) and magnesium 5/41 (12.2%) deficiency when PEIwas present (< 0.02). The accuracy of using the significant micronutrientsidentified in our cohort as a predictor of PEI showed a positive predictive value of80%-85.7% [95% confidence interval (CI): 38%-100%] and a low sensitivity of 9.8%-19.5% [95% CI: 3.3%-34.9%].CONCLUSIONTesting for PEI-MD in patients with suspected pancreatic disease has a high yield,specifically when PEI and CP are found together. PEI-MD testing should includeselenium, magnesium and prealbumin