Poor diagnostic values of stool analysis and steatocrit test in detecting exocrine pancreatic insufficiency

  • Ariani Dewi Widodo Pediatric Gastrohepatology Division, Harapan Kita Women and Children Hospital, Jakarta, Indonesia
  • Ina Susianti Timan Department of Clinical Pathology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
  • Saptawati Bardosono Department of Clinical Nutrition, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
  • Minarma Siagian Department of Physiology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
  • Widdy Winarta Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
  • Dwi Prasetyo Department of Child Health, Faculty of Medicine, Universitas Padjajaran, Hasan Sadikin Hospital, Bandung, Indonesia
  • Agus Firmansyah Department of Child Health, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Keywords: children, exocrine pancreatic insufficiency, body fat, malabsorption syndromes, pancreatic elastase, pancreatic function tests
Abstract viewed: 199 times
PDF downloaded: 171 times
HTML downloaded: 12 times
EPUB downloaded: 108 times

Abstract

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.

References

  1. 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

  2. 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

  3. Keller J, Layer P. The pathophysiology of malabsorption. Viszeralmedizin.2014;30(3):150-4. https://doi.org/10.1159/000364794

  4. 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

  5. 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

  6. 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

  7. Ministry of Health Republic of Indonesia. Management of community health center laboratory. Ministerial Decree number 37 year 2012.

  8. 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

  9. 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

  10. 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.

  11. The area under an ROC curve [cited 2018 May 21]. Available from http://gim.unmc.edu/dxtests/roc3.htm

  12. Tardelli AC, Camargos PA, Penna FJ, Sarkis PF, Guimarães 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

  13. 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

  14. 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.

  15. 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

  16. 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

  17. Amann ST, Josephson SA, Toskes PP. Acid steatocrit: a simple, rapid gravimetric method to determine steatorrhea. Am J Gastroenterol. 1997;92:2280-4.

  18. 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

  19. 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

Published
2019-08-09
How to Cite
1.
Widodo AD, Timan IS, Bardosono S, Siagian M, Winarta W, Prasetyo D, Firmansyah A. Poor diagnostic values of stool analysis and steatocrit test in detecting exocrine pancreatic insufficiency. Med J Indones [Internet]. 2019Aug.9 [cited 2019Nov.22];28(2):154-61. Available from: https://mji.ui.ac.id/journal/index.php/mji/article/view/1690
Section
Clinical Research