Clinical Edge Journal Scan Commentary: EPI September 2021

Our first study comes out of Sheffield, UK, and Halle, Germany, and looks at the correlation between sarcopenia and EPI (Jalal et al). Notably sarcopenia, or reduction in muscle mass, is a known complication of malnutrition and conditions like EPI. It has traditionally been difficult to diagnose because traditional methods have suffered from low accuracy (i.e., mid-arm circumference). In recent years, commercially available software has been developed to digitally assess skeletal muscle mass on axial CT imaging. Digital imaging allows for granular assessments of metrics such as myosteatosis and sacropenic obesity, both of which remained relatively elusive metrics in prior ways of assessing sarcopenia.

In this study, researchers postulate that, since CT scans are recently performed in the evaluation of those patients with suspected pancreatic pathology, it would be natural to assess for sarcopenia on said CT imaging. Identifying sarcopenia might allow clinicians to identify those patients with or at risk for EPI.

Patients referred to EUS for suspected pancreatic pathology were included in the study (except those found to have pancreatic cancer). This prospective study included 102 patients with suspected or proven benign pancreatic pathology, chronic pancreatitis, or recurrent pancreatic type pain. Fecal elastase testing was used to determine those with EPI, and digital CT analysis was used to recognize patients with sarcopenia.

Overall, EPI was present in 45.1% of patients. The prevalence of sarcopenia (67.4% vs. 37.55%; P < .003), myosteatosis (52.2% vs. 10.7%; P = .046), and sarcopenic obesity (66.7% vs. 24.3%; P = .002) was significantly higher in patients with vs without EPI. Sarcopenia (odds ratio [OR], 4.8; P = .02) was strongly associated with EPI. The authors conclude that digital skeletal mass analysis can be performed on patients already undergoing CT scans for suspected pancreatic pathology for possible further diagnosis, risk assessment and to better inform clinical management.

Another notable study came out of Baylor College of Medicine that looked at the clinical significance of fatty pancreas (FP) (Krill et al). Diffuse echogenicity of the pancreas is a common finding on endoscopic ultrasound (EUS), but of unknown clinical significance. Krill’s group aimed to determine if diffuse fatty infiltration of the pancreas had any clinical implication on pancreatic function. They conducted a retrospective case-control study comparing adult patients with diffuse echogenicity of the pancreas to those without known pancreatic disease with chronic diarrhea. Notably, the incidence of EPI (47% vs. 6%) and chronic pancreatitis (18% vs. 0%) was significantly higher (both P < .001) in the fatty pancreas group vs. the control group. 

The authors conclude “Our findings suggest that FP may not merely be a benign sonographic finding, but rather imply underlying parenchymal dysfunction, such as that seen when fat deposition occurs in the liver (i.e., nonalcoholic fatty liver disease).” Additionally the paper states that recent literature has found an association between fatty pancreas and increasing body mass index (BMI), hyperlipidemia, insulin resistance, and metabolic syndrome. Perhaps we will further appreciate the likely prominent and under-appreciated role of metabolic syndrome in the development of acute and chronic pancreatitis.

References:

Jalal M, Rosendahl J, Campbell JA, Vinayagam R, Al-Mukhtar A, Hopper AD. Identification of “digital sarcopenia” can aid the detection of pancreatic exocrine insufficiency and malnutrition assessment in patients with suspected pancreatic pathology. Dig Dis 2021 (Jun 8), (in press).

Krill JT, Szafron D, Elhanafi S, et al. Endoscopic ultrasound finding of diffuse echogenicity in the pancreas, is it relevant? Dig Dis Sci 2021 (Aug 4), (in press).

Our first study comes out of Sheffield, UK, and Halle, Germany, and looks at the correlation between sarcopenia and EPI (Jalal et al). Notably sarcopenia, or reduction in muscle mass, is a known complication of malnutrition and conditions like EPI. It has traditionally been difficult to diagnose because traditional methods have suffered from low accuracy (i.e., mid-arm circumference). In recent years, commercially available software has been developed to digitally assess skeletal muscle mass on axial CT imaging. Digital imaging allows for granular assessments of metrics such as myosteatosis and sacropenic obesity, both of which remained relatively elusive metrics in prior ways of assessing sarcopenia.

In this study, researchers postulate that, since CT scans are recently performed in the evaluation of those patients with suspected pancreatic pathology, it would be natural to assess for sarcopenia on said CT imaging. Identifying sarcopenia might allow clinicians to identify those patients with or at risk for EPI.

Patients referred to EUS for suspected pancreatic pathology were included in the study (except those found to have pancreatic cancer). This prospective study included 102 patients with suspected or proven benign pancreatic pathology, chronic pancreatitis, or recurrent pancreatic type pain. Fecal elastase testing was used to determine those with EPI, and digital CT analysis was used to recognize patients with sarcopenia.

Overall, EPI was present in 45.1% of patients. The prevalence of sarcopenia (67.4% vs. 37.55%; P < .003), myosteatosis (52.2% vs. 10.7%; P = .046), and sarcopenic obesity (66.7% vs. 24.3%; P = .002) was significantly higher in patients with vs without EPI. Sarcopenia (odds ratio [OR], 4.8; P = .02) was strongly associated with EPI. The authors conclude that digital skeletal mass analysis can be performed on patients already undergoing CT scans for suspected pancreatic pathology for possible further diagnosis, risk assessment and to better inform clinical management.

Another notable study came out of Baylor College of Medicine that looked at the clinical significance of fatty pancreas (FP) (Krill et al). Diffuse echogenicity of the pancreas is a common finding on endoscopic ultrasound (EUS), but of unknown clinical significance. Krill’s group aimed to determine if diffuse fatty infiltration of the pancreas had any clinical implication on pancreatic function. They conducted a retrospective case-control study comparing adult patients with diffuse echogenicity of the pancreas to those without known pancreatic disease with chronic diarrhea. Notably, the incidence of EPI (47% vs. 6%) and chronic pancreatitis (18% vs. 0%) was significantly higher (both P < .001) in the fatty pancreas group vs. the control group. 

The authors conclude “Our findings suggest that FP may not merely be a benign sonographic finding, but rather imply underlying parenchymal dysfunction, such as that seen when fat deposition occurs in the liver (i.e., nonalcoholic fatty liver disease).” Additionally the paper states that recent literature has found an association between fatty pancreas and increasing body mass index (BMI), hyperlipidemia, insulin resistance, and metabolic syndrome. Perhaps we will further appreciate the likely prominent and under-appreciated role of metabolic syndrome in the development of acute and chronic pancreatitis.

References:

Jalal M, Rosendahl J, Campbell JA, Vinayagam R, Al-Mukhtar A, Hopper AD. Identification of “digital sarcopenia” can aid the detection of pancreatic exocrine insufficiency and malnutrition assessment in patients with suspected pancreatic pathology. Dig Dis 2021 (Jun 8), (in press).

Krill JT, Szafron D, Elhanafi S, et al. Endoscopic ultrasound finding of diffuse echogenicity in the pancreas, is it relevant? Dig Dis Sci 2021 (Aug 4), (in press).

Our first study comes out of Sheffield, UK, and Halle, Germany, and looks at the correlation between sarcopenia and EPI (Jalal et al). Notably sarcopenia, or reduction in muscle mass, is a known complication of malnutrition and conditions like EPI. It has traditionally been difficult to diagnose because traditional methods have suffered from low accuracy (i.e., mid-arm circumference). In recent years, commercially available software has been developed to digitally assess skeletal muscle mass on axial CT imaging. Digital imaging allows for granular assessments of metrics such as myosteatosis and sacropenic obesity, both of which remained relatively elusive metrics in prior ways of assessing sarcopenia.

In this study, researchers postulate that, since CT scans are recently performed in the evaluation of those patients with suspected pancreatic pathology, it would be natural to assess for sarcopenia on said CT imaging. Identifying sarcopenia might allow clinicians to identify those patients with or at risk for EPI.

Patients referred to EUS for suspected pancreatic pathology were included in the study (except those found to have pancreatic cancer). This prospective study included 102 patients with suspected or proven benign pancreatic pathology, chronic pancreatitis, or recurrent pancreatic type pain. Fecal elastase testing was used to determine those with EPI, and digital CT analysis was used to recognize patients with sarcopenia.

Overall, EPI was present in 45.1% of patients. The prevalence of sarcopenia (67.4% vs. 37.55%; P < .003), myosteatosis (52.2% vs. 10.7%; P = .046), and sarcopenic obesity (66.7% vs. 24.3%; P = .002) was significantly higher in patients with vs without EPI. Sarcopenia (odds ratio [OR], 4.8; P = .02) was strongly associated with EPI. The authors conclude that digital skeletal mass analysis can be performed on patients already undergoing CT scans for suspected pancreatic pathology for possible further diagnosis, risk assessment and to better inform clinical management.

Another notable study came out of Baylor College of Medicine that looked at the clinical significance of fatty pancreas (FP) (Krill et al). Diffuse echogenicity of the pancreas is a common finding on endoscopic ultrasound (EUS), but of unknown clinical significance. Krill’s group aimed to determine if diffuse fatty infiltration of the pancreas had any clinical implication on pancreatic function. They conducted a retrospective case-control study comparing adult patients with diffuse echogenicity of the pancreas to those without known pancreatic disease with chronic diarrhea. Notably, the incidence of EPI (47% vs. 6%) and chronic pancreatitis (18% vs. 0%) was significantly higher (both P < .001) in the fatty pancreas group vs. the control group. 

The authors conclude “Our findings suggest that FP may not merely be a benign sonographic finding, but rather imply underlying parenchymal dysfunction, such as that seen when fat deposition occurs in the liver (i.e., nonalcoholic fatty liver disease).” Additionally the paper states that recent literature has found an association between fatty pancreas and increasing body mass index (BMI), hyperlipidemia, insulin resistance, and metabolic syndrome. Perhaps we will further appreciate the likely prominent and under-appreciated role of metabolic syndrome in the development of acute and chronic pancreatitis.

References:

Jalal M, Rosendahl J, Campbell JA, Vinayagam R, Al-Mukhtar A, Hopper AD. Identification of “digital sarcopenia” can aid the detection of pancreatic exocrine insufficiency and malnutrition assessment in patients with suspected pancreatic pathology. Dig Dis 2021 (Jun 8), (in press).

Krill JT, Szafron D, Elhanafi S, et al. Endoscopic ultrasound finding of diffuse echogenicity in the pancreas, is it relevant? Dig Dis Sci 2021 (Aug 4), (in press).