Q J Med 2004; 97: 377-378
QJM vol. 97 no. 6 © Association of Physicians 2004; all rights reserved.
Correspondence |
Pancreatic insufficiency and weight loss in older patients
Sir,Weight loss is an important independent predictor of increased mortality in the older population.1 We report three cases of weight loss secondary to pancreatic insufficiency in elderly patients with no previous pancreatic disease.
An 80-year-old widower, presented with a six month history of lethargy, anorexia and weight loss of 6 kg. He was suffering a prolonged bereavement reaction associated with recent alcohol excess following the death of his wife. He weighed 44.5 kg, haemoglobin was 13.5 g/dl. The patient's mood and appetite improved on antidepressant therapy and alcohol withdrawal, but he failed to gain weight, and reported episodes of intermittent diarrhoea. Barium enema and coeliac screen were unremarkable. Pancreatic insufficiency was diagnosed with a positive pancreolauryl test of 14.4% (normal range >30%). The patient's diarrhoea stopped and he gained 14 kg in 10 months following pancreatic enzyme supplementation.
An 80-year-old man presented with vomiting several hours after eating and weight loss of approximately 6 kg in one month. Haemoglobin was 12.4 g/dl. Endoscopy, upper gastrointestinal tract biopsy, barium enema, abdominal ultrasound and coeliac screen were unremarkable. Pancreolauryl test was positive at 12.2% and CT scan showed pancreatic atrophy, but no calcification. His symptoms resolved, and he gained 8 kg in one month following pancreatic enzyme supplementation.
A 78-year-old woman was admitted with a 5-day history of diarrhoea following antibiotics for a chest infection. She also reported weight loss and malaise over a 1 month period. She weighed 39.2 kg, haemoglobin was 10.0 g/dl, and serum ferritin 40 µg/l (15–300 µg/l). Barium enema, upper endoscopy, coeliac screen and abdominal CT scan were normal. Pancreolauryl test was positive at 9.2%, and she gained 6 kg in 3 months following pancreatic enzyme supplementation.
The underlying cause is not identified in approximately one quarter of subjects in studies of weight loss in older people, hence the term geriatric cachexia.1 It is unclear, however, whether pancreatic function has been investigated in these studies. Age-related morphological changes in pancreas including duct cell proliferation, cavity formation and adipose tissue invasion have been described at post mortem in Wistar rats and humans. Structural changes have been confirmed in living subjects using ultrasound and endoscopic retrograde pancreatography.2
The effect of these structural changes on pancreatic exocrine function currently remains unresolved. The majority of physiological studies have consisted of relatively small sample sizes drawn from select populations. There have been no longitudinal studies of pancreatic exocrine function in humans. The ‘gold-standard’ for the diagnosis of pancreatic insufficiency is by direct testing, and requires double lumen gastric and duodenal intubation. Some investigators have reported no significant age-related decline in the volume of pancreatic juice secretion induced by intravenous cholecystokinin/secretin stimulation,3 while others have found reductions of approximately one third.4 The volume of pancreatic juice secreted in response to intravenous cholecystokinin/secretin increased linearly up to the third decade of life, and thereafter declined, in a cross-sectional study of 180 subjects aged 16–83 years.5
Non-invasive investigations of exocrine pancreatic function, including the para-aminobenzoic acid (PABA) and pancreolauryl tests are now available. Between 1996 and 2003, the University Hospital of Wales performed 159 pancreolauryl tests on 155 individuals, mean age 51.16 years (95%CI 49.99–52.33). Given the high prevalence of weight loss with increasing age, this suggests the pancreolauryl test is being under-used in the investigation of older patients.
The prevalence of pancreatic insufficiency in the older population is unknown. It is now easy to investigate and treat with enzyme supplementation, and should be considered in the differential diagnosis of weight loss in older patients.
Department of Medical Biochemistry University Hospital of Wales Cardiff
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University Department of Geriatric Medicine Llandough Hospital Penarth Email: omahonyms{at}cf.ac.uk
Department of Medical Biochemistry University Hospital of Wales Cardiff
References
1. Wallace J, Schwartz R, LaCroix A, Uhlmann R, Pearlman R. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc 1995; 43:329–37.[Web of Science][Medline]
2. Ross S, Forsmark C. Pancreatic and biliary disorders in the elderly. Gastroenterol Clin N Am 2001; 30:531–45.[Medline]
3. Tiscornia O, Cresta M, de Lehmann E, Celener D, Dreiling D. Effects of sex and age on pancreatic secretion. Int J Pancreatol 1986; 1:95–118[Medline]
4. Fikry M. Exocrine pancreatic functions in the aged. J Am Geriatr Soc 1968; 16:463–7.[Medline]
5. Laugier R, Bernard J, Berthezene P, Dupuy P. Changes in pancreatic exocrine secretion with age: pancreatic exocrine secretion does decrease in the elderly. Digestion 1991; 50:202–11.[Medline]
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