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EPFT

Secretin Endoscopic Pancreatic Function Test (ePFT)

 

ePFT is safe easy and highly accurate

 

Cost effective 30% lower then traditional testing

 

Can be utilized in almost all facilities that provide endoscopic precedures


(Left - Right) Duodenal fluid before, during, and after Secretin Stimulation
(Pictures Courtesy of the Cleveland Clinic)

 

The two most common indications for pancreatic exocrine function testing are (1) the evaluation of possible early exocrine dysfunction in patients with abdominal pain and (2) the determination of the etiology of steatorrhea. Numerous conditions are associated with pancreatic exocrine insufficiency; the most common cause in adults is chronic pancreatitis (CP). CP is characterized by the gradual and irreversible replacement of normal pancreatic tissue by inflammation and fibrosis. As scarring progresses, there is a concomitant decrease in exocrine function of the duct and acinar cells. Abdominal pain is believed by some investigators to occur in some patients with early or “minimal-change” CP.

Because subtle functional changes occur at an early stage of fibrosis, direct PFTs may be the most sensitive diagnostic tests for early CP. PFTs are usually unnecessary for the diagnosis of advanced CP, because imaging tests often reveal typical structural changes. However, the diagnosis of early CP can be challenging, as these features may not always be apparent. Direct pancreatic function testing is considered the “surrogate” gold standard because obtaining pancreatic tissue from biopsy specimens carries a significant risk of complications.

 

Protocol

 

  1. The patient is placed in left lateral decubitus position with slight head elevation.  The posterior pharynx is sprayed with topical cetacaine spray.  A sedation and analgesia bolus is administered according to our previously published nomogram [Table] (1).  Doses based on this nomogram have not been shown to effect pancreatic secretion (2).  Further sedation doses may be given if necessary for patient comfort; however, the effect of higher doses on pancreatic secretion has not been studied.  After the sedation bolus, a bite-block is placed.
  2. Esophagogastroduodenoscopy (EGD) is performed using a standard (10mm) or thin (6mm) upper endoscope.  We have tended to use the Olympus 160XP (6mm) scope for the ePFT because it optimizes patient comfort during the prolonged endoscopy; however, standard adult scopes also work well.
  3. During luminal examination, an intravenous (IV) test does of synthetic secretin (human or porcine, 0.2 micrograms) is administered.  After the test dose, the pulse-ox and blood pressure are monitored for 5 minutes to insure no rapid change.  An allergic reaction to synthetic secretin has never been reported; however, this measure optimizes safety.
  4. Gastric fluid is aspirated as completely as possible through the scope and discarded.   We recommend retroflexion to optimally aspirate fundic gastric juice.
  5. After gastric fluid aspiration and discard, approximately 3-5 cc of fluid should be suctioned from the post-bulbar duodenum to rinse residual gastric fluid from the suction channel. 
  6. At time “0” a baseline collection of 3-5 cc of duodenal fluid is collected in a trap (bottle A).  Also at time “0”, the full IV dose of synthetic secretin (0.2 micrograms/kg, slow push) is administered.
  7. Intermittent 3-5 cc fluid aspirates are obtained every 15 minutes for an hour (Bottles B at 15 minutes, C at 30 minutes, D at 45 minutes, and E at 60 minutes). 
  8. Some general points about fluid collection:
    • Fluid samples are usually easily aspirated within seconds because of the large volume of pancreatic fluid secretion following secretin.  Occasionally, fluid secretion is less voluminous (particularly in advanced chronic pancreatitis) and may require 3-5 minutes of endoscopic manipulation to obtain an adequate sample.
    • We try to keep the tip of the scope in the post-bulbar duodenum throughout the entire hour-long procedure.  Between collections, the scope may be allowed to rest on the pillow or gurney in a secure position with the guardrail up to minimize movement of the scope and enhance comfort.
    • Occasionally, fluid is very scarce.  In this case, we put the patient in a supine, reverse-trendelenburg position to maximize pooling of fluid in the second duodenum.
    • Low to intermediate suction is best to minimize trauma to the mucosa—blood in the fluid may effect the bicarbonate concentration.  Another practical tip is to remove the suction cap from the scope and hold it lightly on top of the channel hub during aspiration.  This allows close control of the amount of suction and minimizes mucosal trauma.
    • After a collection, tightly cap each specimen and put immediately on ice.
  1. Fluid should be kept on ice and analyzed within 6 hours (3), or may be frozen (subzero freezer is best) and analyzed later. 
  2. A standard, hospital laboratory auto-analyzer (e.g. Beckman-Coulter CX3 Delta model) may be used for bicarbonate concentration analysis. 
  3. The highest bicarbonate concentration from the 5 samples is considered the peak bicarbonate (4).  A peak bicarbonate <= 80 mEq/L is considered abnormal and suggestive of exocrine insufficiency. 

The two-sample ePFT

We recently reported the validity of a shortened, two-sample collection method in which samples are collected at 30 and 45 minutes after secretin administration. This method retains a high sensitivity for detecting pancreatic exocrine insufficiency and is ideal for screening patients in whom there is a low suspicion of pancreatic disease. The two-sample ePFT also serves as a useful adjunct to advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography and EUS. Patients with borderline or equivocal two-sample ePFT results should be considered for the 1-hour five-sample collection method.

 

Summary

 

The ePFT compares well with the traditional PFT, The main advantages of endoscopic collection include patient comfort, universal availability, avoidance of radiation exposure

 

 

 

References:

 

  1. Morrow JB, Zuccaro G, Conwell D, et al.  Sedation for colonoscopy using a single bolus is safe, effective and efficient:a prospective, randomized, double blind trial.  Am J Gastroenterol 2000;95:2242-7.
  2. Stevens T, Conwell DL Zuccaro G, et al. Stability of duodenal fluid bicarbonate concentration as measured by a laboratory auto-analyzer. Pancreas 2004;29:342.
  3. Conwell DL, Zuccaro G, Vargo JJ, et al. An endoscopic pancreatic function test with synthetic porcine secretin test for the evaluation of chronic abdominal pain and suspected chronic pancreatitis. Gastrointest Endosc 2003;57:37-40.
  4. Stevens T, Conwell DL, Purich E, et al. A prospective, randomized, crossover trial in healthy subjects comparing endoscopic and Dreiling tube collection methods for pancreatic function testing. Pancreas 2004;29:341.
  5. Wu B, and Conwell D. The Endospic Pancreatic Function Test. Am J Gastroenterol 2009;104:2381–2383
  6. Pollack BJ, Grendell JH. Where have all the Dreiling tubes gone? Am J Gastroenterol 2006;101:356–9.
  7. Conwell DL, Zuccaro G, Purich E et al. The effect of moderate sedation on exocrine pancreas function in normal healthy subjects:a prospective, randomized, cross-over trial using the synthetic porcine secretin stimulated endoscopic pancreatic function test (ePFT). Am J Gastroenterol 2005;100:1161–6.
  8. Stevens T, Conwell DL, Zuccaro G et al. Electrolyte composition of endoscopically collected duodenal drainage fluid after synthetic porcine secretin stimulation in healthy subjects. Gastrointest Endosc 2004;60:351–5.
  9. Stevens T, Conwell DL, Zuccaro G Jr et al. The efficiency of endoscopic pancreatic function testing is optimized using duodenal aspirates at 30 and 45 minutes after intravenous secretin. Am J Gastroenterol 2007;102:297–301.

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