Abstract
Background and Aims
Irritable bowel syndrome (IBS) is one of the most frequent disorders in clinical practice, with a mean 7.6–10.8% worldwide prevalence. A study showed that 6.1% of patients with diarrhea-predominant IBS (IBS-D) had severe exocrine pancreatic insufficiency (EPI). We aimed to identify the prevalence of EPI based on fecal elastase stool testing (Fel-1) in IBS-D and the clinical characteristics that may predict the diagnosis of EPI.
Methods
Patients aged > 18 years presenting to tertiary hospital outpatient clinics with IBS-D completed validated questionnaires and gave a stool sample where Fel-1 concentration was measured. Patients with Fel-1 < 100 µg/g represented EPI and > 100 to < 200 µg/g underwent testing for pancreatic pathology with laboratory and endoscopic ultrasound (EUS) evaluation.
Results
One hundred forty patients (mean age 60 years, females 75.7%) were studied. EPI was found in 5% (95% CI 2.2–10.4), and pancreatic steatosis was the main EUS finding (71%). Dyspepsia was an independent factor associated with EPI (OR 34.7; 95% CI 4.95–366.37, p = 0.0007). After pancreatic enzyme replacement therapy (PERT), patients showed a significant improvement in the Bristol stool scale (p < 0.0001), bowel movements per day (p < 0.005), distension score (0.0009), pain score (0.0277) and IBS severity (0.0034).
Conclusion
EPI is present in 5% of patients who fulfill Rome IV criteria for D-IBS, and dyspepsia was an independent symptom strongly associated with EPI. Pancreatic steatosis was the main endoscopic ultrasound finding. After PERT therapy, patients had significantly improved stool frequency, stool consistency, abdominal pain, distension and IBS severity score.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Oka P, Parr H, Barberio B, Black CJ, Savarino EV, Ford AC. Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: A systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2020;5:908–917. https://doi.org/10.1016/S2468-1253(20)30217-X.
Drossman DA, Hasler WL. Rome IV—Functional GI disorders: Disorders of gut–brain interaction. Gastroenterology 2016;150:1257–1261. https://doi.org/10.1053/j.gastro.2016.03.035.
Ford AC, Moayyedi P, Lacy BE, Lembo AJ, Saito YA, Schiller LR et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109:S2-26. https://doi.org/10.1038/ajg.2014.187.
Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M et al. Bowel disorders. Gastroenterology 2016;150:1393-1407.e5. https://doi.org/10.1053/j.gastro.2016.02.031.
Mearin F, Lacy BE. Diagnostic criteria in IBS: Useful or not? Neurogastroenterol Motil 2012;24:791–801.
Lacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD et al. ACG clinical guideline: Management of irritable bowel syndrome. Am J Gastroenterol 2021;116:17–44.
Leeds JS, Hopper AD, Sidhu R, Simmonette A, Azadbakht N, Hoggard N et al. Some patients with irritable bowel syndrome may have exocrine pancreatic insufficiency. Clin Gastroenterol Hepatol 2010;8:433–438. https://doi.org/10.1016/j.cgh.2009.09.032.
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32:920–924.
Francis CY, Morris J, Whorwell PJ. The irritable bowel severity scoring system: A simple method of monitoring irritable bowel syndrome and its progress. Aliment Pharmacol Ther. 1997;11:395–402.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–370.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258–266.
Löser C, Möllgaard A, Fölsch UR. Faecal elastase 1: A novel, highly sensitive, and specific tubeless pancreatic function test. Gut 1996;39:580–586.
Stein J, Jung M, Sziegoleit A, Zeuzem S, Caspary WF, Lembcke B. Immunoreactive elastase I: Clinical evaluation of a new noninvasive test of pancreatic function. Clin Chem 1996;42:222–226.
Dominguez-Muñoz JE. Diagnosis and treatment of pancreatic exocrine insufficiency. Curr Opin Gastroenterol 2018;34:349–354.
Catalano MF, Sahai A, Levy M, Romagnuolo J, Wiersema M, Brugge W et al. EUS-based criteria for the diagnosis of chronic pancreatitis: The Rosemont classification. Gastrointest Endosc 2009;69:1251–1261. https://doi.org/10.1016/j.gie.2008.07.043.
Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: Diagnosis and treatment. J Gastroenterol Hepatol 2011;26:12–16.
Talley NJ, Holtmann G, Nguyen QN, Gibson P, Bampton P, Veysey M et al. Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain. J Gastroenterol Hepatol 2017;32:1813–1817.
Lariño-Noia J, de la Iglesia D, Iglesias-García J, Macías F, Nieto L, Bastón I et al. Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study. Pancreatology 2018;18:280–285. https://doi.org/10.1016/j.pan.2018.02.003.
Sahai AV, Mishra G, Penman ID, Williams D, Wallace MB, Hadzijahic N et al. EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia. Gastrointest Endosc 2000;52:153–159.
Tahtaci M, Koseoglu H, Alisik M, Tayfur Yurekli O, Tahtaci G, Erel O et al. Association of low fecal elastase-1 and non-ulcer dyspepsia. J Clin Med 2018;7:155.
Shobassy M, Husainat N, Tabash A, Patel K, El-Serag HB, Othman MO. Endoscopic ultrasound findings in patients diagnosed with exocrine pancreatic insufficiency by low fecal elastase-1. Gastroenterol Res Pract 2019;2019:0–4.
Tahtacı M, Algın O, Karakan T, Yürekli OT, Alışık M, Köseoğlu H et al. Can pancreatic steatosis affect exocrine functions of pancreas? Turk J Gastroenterol 2018;29:588–594.
Dite P, Blaho M, Bojkova M, Jabandziev P, Kunovsky L. Nonalcoholic fatty pancreas disease: Clinical consequences. Dig Dis 2020;38:143–149.
Boga S, Koksal AR, Sen İ, Kurul Yeniay M, Yilmaz Ozguven MB, Serin E et al. Liver and pancreas: ‘Castor and Pollux’ regarding the relationship between hepatic steatosis and pancreas exocrine insufficiency. Pancreatology 2020;20:880–886.
Acknowledgments
The authors thank Hui Jer Hwang for his contribution to this study by performing the endoscopic ultrasound evaluations.
Funding
This study was supported by Abbot Laboratories. However, Abbott had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Jorge A. Olmos received a grant from Abbott Laboratories and is an Abbott speaker. The authors declare that there are no other conflicts of interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
An editorial commenting on this article is available at https://doi.org/10.1007/s10620-022-07574-w.
Rights and permissions
About this article
Cite this article
Olmos, J.I., Piskorz, M.M., Litwin, N. et al. Exocrine Pancreatic Insufficiency is Undiagnosed in Some Patients with Diarrhea-Predominant Irritable Bowel Syndrome Using the Rome IV Criteria. Dig Dis Sci 67, 5666–5675 (2022). https://doi.org/10.1007/s10620-022-07568-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-022-07568-8