Introduction

Malabsorption syndrome may pose the patients at risk of premature atherosclerosis and cardiovascular events. Pancreatic exocrine insufficiency is one of the cause of malabsorption syndrome and often observed in patients with pancreatic diseases, such as chronic pancreatitis, cystic fibrosis, tumors, or after pancreatic resection. Pancreatic exocrine insufficiency can be treated such as pancreatic enzyme replacement therapy and improves the nutrition status as well as clinical symptoms, without serious treatment-emergent adverse events. Therefore it is important to detect pancreatic enxocrine insufficiency as early and properly as possible. Recent studies have shown that the secretory flow of pancreatic juice can be directly and noninvasively visualized as a high-signal-intensity inflow within the tagged area at frequent intervals in normal subjects by means of noncontrast-enhanced cine-dynamic MRCP with a spatially selective inversion recovery (IR) pulse (Fig.1). The purpose of the present study was to elucidate the abdominal symptoms that should suspect decreasing the flow of pancreatic juice for diagnosis of pancreatic exocrine insufficiency with cine-dynamic MRCP.

Methods

Between October 2015 and October 2016, Cine-dynamic MRCP with a spatially selective inversion recovery (IR) pulse and 18 query-items of clinical questionnaire on abdominal symptoms (Fig.2) were performed to 111 patients with various types of abdominal symptoms within three month. Following patients were excluded, the patients whose abdominal symptoms were clearly due to other abdominal disease (n=15), the patients whose abdominal symptoms improved after they were prescribed drugs for symptoms(n=41), Both of them（n=13）. Finally, Forty-two patients were included in this study (18 men, 24 women, mean age 62.1 years; range 23–83 years). Orange-lemon juice (Vitamin lemon citric acid; 1000mg vitamin C and 1000mg citric) was orally ingested 10min before cine-dynamic MRCP scanning to stimulate pancreas exocrine secretion.Examination were performed by 1.5-T or 3-T MR scanner (Toshiba Medical Systems, Tochigi, Japan). The secretion score of pancreatic juice The distance that pancreatic juice flowed within the tagged area, and was divided into 5 scores from score 0-4 (Fig.3). The secretion grade of pancreatic juice The secretion grade in each set consist of 20 images during 5 minutes in cine-dynamic MRCP images was defined as The secretion grade= (Total of secretion score)/20.

Results

The secretion grade were significantly lower in group “yes” than group “no” in univariate analysis in five query-items Q9. Do your gas smell foul? Q13. Is your stool quantity large? (mean±SD; 0.25±0.43 vs 1.31±1.05; p=0.01), (mean±SD; 0.46±0.69 vs 1.30±1.06; p=0.05), Q15. Is your stool color unusual? (mean±SD; 0.00±0.00 vs 1.25±1.04; p=0.00), Q17. Do your stools looks oily? (mean±SD; 0.33±0.34 vs 1.31±1.06; p=0.05), Q18. Is your stools soft? (mean±SD; 0.79±0.77 vs 1.57±1.18; p=0.04). In results of further analysis by multivariate analysis, three query-items Q9. Do your gas smell foul? (β=-0.44, p=0.001), Q13. Is stool quantity large? (β=-0.41, p=0.001), Q18. Is your stools soft? (β=-0.53, p<0.001), were significantly correlated with decreasing the secretion grade (Fig.4).

Discussion

Clinical symptoms of pancreatic exocrine insufficiency mainly appear the symptoms of steatorrhea caused by malabsorption of fats. In steatorrhea, stool is often oily, soft, large, floated and sour smell. In 18 query-items of clinical questionnaire of this study, following five query-items are much as the symptoms of steatorrhea: Q9, Q13, Q14, Q16, Q17 and Q18. In this study, following three query-items were significantly correlated with the secretion grade: Q9, Q13 and Q18. This result was appropriate as the symptoms of steatorrhea. In this study, the symptoms, foul-smelling gas (Q9), large stools (Q13) and soft stools (Q18), might most suspected symptoms of pancreatic exocrine insufficiency in clinical. In the diagnostic process of pancreatic exocrine insufficiency, we recommend that the patients who complains foul smelling gas, large stools and soft stools perform cine-dynamic MRCP for efficient and accurate diagnosis of pancreatic exocrine insufficiency.

Conclusion

The abdominal symptoms for the 3 items indicated in the results are symptoms that are more likely to appear as a result of decreased exocrine pancreatic function. If a patient complains of such symptoms, the possibility of decreased exocrine pancreatic function should be considered, and such function should be aggressively evaluated by cine-dynamic MRCP.

Acknowledgements

This work was supported by JSPS KAKENHI Grant Number 26461841.

References

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