Poor diagnostic values of stool analysis and steatocrit test in detecting exocrine pancreatic insufficiency
BACKGROUND Exocrine pancreatic insufficiency (EPI) is one of the most challenging cases to be diagnosed accurately in Indonesia because of the unavailability of the fecal elastase-1 (FE-1) test, which is the primary indirect diagnostic tool till date. Stool analysis and steatocrit test are feasible alternatives as they can detect nutrient malabsorption, a consistent feature in EPI. Despite the common practice of using both tests, no study has ever been conducted in Indonesia to evaluate their accuracy.
METHODS This cross-sectional diagnostic study was conducted in 182 children aged 6-60 months. Study subjects were divided into children with persistent diarrhea (PD), those with malnutrition, and healthy children. Children with PD and malnutrition were selected on the basis of clinical criteria and the WHO z-score. FE-1 test was used as the gold standard to detect EPI. Primary endpoints of this study were sensitivity and specificity of the stool analysis and the steatocrit test. The accuracy of both tests, represented by area under the curve (AUC) values, was also evaluated individually and in combination.
RESULTS Each component of stool analysis and steatocrit test in each subgroup of patients generally had higher specificity than sensitivity. The specificity of both tests among healthy and malnourished children was good (≥70%), but among children with PD, the specificity of some components was <70%. The individual and combined AUC values of both tests in each subgroup of subjects were poor (<0.7).
CONCLUSIONS Stool analysis and steatocrit test cannot be used as alternative methods for FE-1 to detect EPI.
Rothenbacher D, Low M, Hardt PD, Klor H, Ziegler H, Brenner H. Prevalence and determinants of exocrine pancreatic insufficiency among older adults: results of a population-based study. Scand J Gastroenterol. 2005;40:697-704. https://doi.org/10.1080/00365520510023116
Struyvenberg MR, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency - breaking the myths. BMC Medicine. 2017;15:29. https://doi.org/10.1186/s12916-017-0783-y
Keller J, Layer P. The pathophysiology of malabsorption. Viszeralmedizin.2014;30(3):150-4. https://doi.org/10.1159/000364794
Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013;19:7258-66. https://doi.org/10.3748/wjg.v19.i42.7258
Lüth S, Teyssen S, Forssmann K, Kölbel C, Krummenauer F, Singer MV Fecal elastase-1 determination: 'gold standard' of indirect pancreatic function tests? Scand J Gastroenterol. 2001;36:1029-9. https://doi.org/10.1080/003655201750422729
Löser C, Möllgaard A, Fölsch UR. Faecal elastase 1: a novel, highly sensitive, and specific tubeless pancreatic function test. Gut. 1996;39:580-6. https://doi.org/10.1136/gut.39.4.580
Ministry of Health Republic of Indonesia. Management of community health center laboratory. Ministerial Decree number 37 year 2012.
Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and diseases. Gut. 2005;54:1-28. https://doi.org/10.1136/gut.2005.065946
Widodo AD, Timan IS, Bardosono S, Winarta W, Prasetyo D, Firmansyah A. Variation in faecal elastase-1 reference levels in different regions of the world: an analysis and result from Indonesian children. ESPGHAN 51st annual meeting, Geneva, 2018. https://doi.org/10.1097/MPG.0000000000002005
Widodo AD, Timan IS, Bardosono S, Winarta W, Prasetyo D, Firmansyah A. Panceratic exocrine insufficiency in malnourished children and those with persistent diarrhoea. Asia Pac J Clin Nutr. 2016;25(Suppl 1):S57-61.
The area under an ROC curve [cited 2018 May 21]. Available from http://gim.unmc.edu/dxtests/roc3.htm
Tardelli AC, Camargos PA, Penna FJ, Sarkis PF, GuimarÃ£es EV. Comparison of diagnostic methods for pancreatic insufficiency in infants with cystic fibrosis. J Ped Gastroenterol Nutr. 2013;56:178-81. https://doi.org/10.1097/MPG.0b013e31826f2b71
Bartels RH, Meyer SL, Stehmann TA, Bourdon C, Bandsma RH, Voskuijl WP. Both exocrine pancreatic insufficiency and signs of pancreatic inflammation are prevalent in children with complicated severe acute malnutrition: an observational study. J Pediatr. 2016;174:165-70. https://doi.org/10.1016/j.jpeds.2016.04.013
Simadibrata M, Hardjodisastro D, Rani AA. Pancreatic exocrine insufficiency in chronic diarrhea. The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy. 2005;6:4-8.
Walkowiak J, Nousia-Arvanitakis S, Cade A, Kashirskaya N, Piotrowski R, Strzykala K, et al. Fecal elastase-1 cut-off levels in the assessment of exocrine pancreatic function in cystic fibrosis. J Cyst Fibros. 2002;1(4):260-4. https://doi.org/10.1016/S1569-1993(02)00096-6
Girish BN, Rajesh G, Vaidyanathan K, Balakrishnan V. Fecal elastase1 and acid steatocrit estimation in chronic pancreatitis. Indian J Gastroenterol. 2009;28:201-5. https://doi.org/10.1007/s12664-009-0079-z
Amann ST, Josephson SA, Toskes PP. Acid steatocrit: a simple, rapid gravimetric method to determine steatorrhea. Am J Gastroenterol. 1997;92:2280-4.
Tran M, Forget P, Van den Neucker A, Strik J, van Kreel B, Kuijten R. The acid steatocrit: a much improved method. J Pediatr Gastroenterol Nutr. 1994;19:299-303. https://doi.org/10.1097/00005176-199410000-00007
Hammer HF. Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes. Dig Dis. 2010;28:339-43. https://doi.org/10.1159/000319411
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