Altered Bone Metabolism and Bone Density in Patients with Chronic Pancreatitis and Pancreatic Exocrine Insufficiency
Abstract
Context Due to maldigestion, pancreatic exocrine insufficiency (PEI) in chronic pancreatitis may lead to deficiencies in fat-soluble vitamins, including vitamin D. This may, in turn, can cause disturbances in bone metabolism and reduce bone mineral density. Objective To conduct a prospective study of maldigestion, bone metabolism, and bone mineral density in a group of patients with chronic pancreatitis. Methods A total of 50 male patients with proven chronic pancreatitis (36/50 alcohol; 42/50 smokers) were studied. Pancreatic exocrine function was assessed using the fecal elastase-1 test. Blood and urine samples were analyzed for parameters related to pancreatitis, nutrition, endocrine status, and bone metabolism. Bone mineral density was measured with dual-energy X-ray absorption (DXA) and conventional vertebral X-rays. A standardized questionnaire for osteoporosis was given. Results Twenty-eight of the patients had PEI (fecal elastase-1 <200 µg/g), 25 had bone pain, and 21 had a history of bone fractures. Serum 25-OH-cholecalciferol and urine calcium were decreased and deoxypyridinoline concentrations were increased in urine. Serum calcium, bone-specific alkaline phosphatase, and parathyroid hormone were within normal limits. There was no statistical correlation between three classes of fecal elastase-1 (<100 µg/g; 100-200 µg/g; >200 µg/g) and calcium, 25-OH-cholecalciferol, or deoxypyridinoline. Of the 15 patients who underwent DXA, 5 had normal bone mineral density (T score >-1), 9 had osteopenia (T score from -1 to – 2.5), and 1 had osteoporosis (T score <-2.5). There was a trend toward a correlation between low fecal elastase-1 and low T scores (P=0.065). Low fecal elastase-1 correlated with low bone mineral density in conventional X-rays (P<0.05). Patients receiving pancreatic enzyme replacement therapy (PERT) had significantly higher DXA values (P<0.05). Conclusions Patients with chronic pancreatitis have osteoporosis, along with abnormal bone metabolism and reduced bone mineral density as measured by DXA and X-ray. PERT is associated with less osteopathy.
Image: Bone mineral density in correlation with fecal elastase-1.
Downloads
References
DiMagno EP, Malagelada JR, Taylor WF, et al. A prospective comparison of current diagnostic tests for pancreatic cancer. N Engl J Med 1977; 297: 737-42. [PMID: 895803]
Parkins MD, Parkins VM, Rendall JC, et al. Changing epidemiology and clinical issues arising in an ageing cystic fibrosis population. Therapeutic advances in respiratory disease 2011; 5: 105-19. [PMID: 21078692]
Hoffmeister A, Mayerle J, Beglinger C, et al. S3-Leitlinie Chronische Pankreatitis: Definition, Ätiologie, Diagnostik, konservative, interventionell endoskopische und operative Therapie der chronischen Pankreatitis. Leitlinie der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS). Z Gastroenterol 2012; 50: 1176-1224.
Toouli J, Biankin AV, Oliver MR, et al. Management of pancreatic exocrine insufficiency: Australasian Pancreatic Club recommendations. The Medical Journal of Australia 2010; 193: 461-7. [PMID: 20955123]
Frulloni L, Falconi M, Gabbrielli A, et al. Italian consensus guidelines for chronic pancreatitis. Digestive and Liver Disease 2010; 42 Suppl 6: S381-406. [PMID: 21078490]
Martinez J, Abad-Gonzalez A, Aparicio JR, et al. The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis). Pancreatology 2013; 13: 8-17. [PMID: 23395565]
Lankisch PG, Schmidt I, Konig H, et al. Faecal elastase 1: not helpful in diagnosing chronic pancreatitis associated with mild to moderate exocrine pancreatic insufficiency. Gut 1998; 42: 551-4. [PMID: 9616319]
Parker DR, Derby CA, Usner DW, et al. Self-reported alcohol intake using two different question formats in southeastern New England. International Journal of Epidemiology 1996; 25: 770-4. [PMID: 8921455]
Schroder G, Knauerhase A, Kundt G, et al. Effects of physical therapy on quality of life in osteoporosis patients - a randomized clinical trial. Health Qual Life Outcomes 2012; 10: 101. [PMID: 22920839]
Haaber AB, Rosenfalck AM, Hansen B, et al. Bone mineral metabolism, bone mineral density, and body composition in patients with chronic pancreatitis and pancreatic exocrine insufficiency. International Journal of Pancreatology 2000; 27: 21-7. [PMID: 10811020]
Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1994; 843: 1-129. [PMID: 7941614]
Jergas M, Uffmann M, Escher H, et al. Interobserver variation in the detection of osteopenia by radiography and comparison with dual X-ray absorptiometry of the lumbar spine. Skeletal Radiol 1994; 23: 195-9. [PMID: 8016671]
Tignor AS, Wu BU, Whitlock TL, et al. High prevalence of low-trauma fracture in chronic pancreatitis. The American Journal of Gastroenterology 2010; 105: 2680-6. [PMID: 20736937]
Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut 2005; 54 Suppl 6:vi1-28. [PMC: 1867805 ]
Moran CE, Sosa EG, Martinez SM, et al. Bone mineral density in patients with pancreatic insufficiency and steatorrhea. The American Journal of Gastroenterology 1997; 92: 867-71. [PMID: 9149203]
Duggan SN, O'Sullivan M, Hamilton S, et al. Patients with chronic pancreatitis are at increased risk for osteoporosis. Pancreas 2012; 41: 1119-24. [PMID: 22836855]
Sudeep K, Chacko A, Thomas N, et al. Predictors of osteodystrophy in patients with chronic nonalcoholic pancreatitis with or without diabetes. Endocrine Practice 2011; 17: 897-905. [PMID: 21742614]
Mann ST, Stracke H, Lange U, et al. Alterations of bone mineral density and bone metabolism in patients with various grades of chronic pancreatitis. Metabolism: clinical and experimental 2003; 52: 579-85.
Sikkens EC, Cahen DL, Koch AD, et al. The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis. Pancreatology 2013; 13: 238-42. [PMID: 23719594]
Dominguez-Munoz JE, Iglesias-Garcia J, Vilarino-Insua M, et al. 13C-mixed triglyceride breath test to assess oral enzyme substitution therapy in patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2007; 5: 484-8. [PMID: 17445754]
Lindkvist B, Dominguez-Munoz JE, Luaces-Regueira M, et al. Serum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis. Pancreatology 2012; 12: 305-10. [PMID: 22898630]
Benini L, Amodio A, Campagnola P, et al. Fecal elastase-1 is useful in the detection of steatorrhea in patients with pancreatic diseases but not after pancreatic resection. Pancreatology 2013; 13: 38-42. [PMID: 23395568]
Löhr JM, Oliver MR, Frulloni L. Synopsis of recent guidelines on pancreatic exocrine insufficiency. United European Gastroenterology Journal 2013; 1: 79-83. [PMID: 24917944]
Duggan SN, Smyth ND, Murphy A, et al. High prevalence of osteoporosis in patients with chronic pancreatitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014; 12: 219-28. [PMID: 23856359]
Dujsikova H, Dite P, Tomandl J, et al. Occurrence of metabolic osteopathy in patients with chronic pancreatitis. Pancreatology 2008; 8: 583-6. [PMID: 18824882]
Copyright (c) 2015 Stephan Haas, Stefan Krins, Andreas Knauerhase, Matthias Löhr
This work is licensed under a Creative Commons Attribution 4.0 International License.
As a member of Publisher International Linking Association, PILA, iMedPub Group’s JOP follows the Creative Commons Attribution License and Scholars Open Access publishing policies. Journal of the Pancreas is the Council Contributor Member of Council of Science Editors (CSE) and following the CSE slogan Education, Ethics, and Evidence for Editors.