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com
1Kettering General Hospital,
Kettering, UK
2Children’s Hospital, Leicester
Royal Infirmary, Leicester, UK
Correspondence to
Dr Nagarajan Nandhakumar,
Kettering General Hospital,
Rothwell Road, Kettering NN16
8UZ, UK;
nagarajan.nandhakumar@kgh.
nhs.uk
Accepted 12 April 2010
Arch Dis Child Educ Pract Ed 2010;95:119–123. doi:10.1136/adc.2009.174359
Interpretations: How to use faecal
elastase testing
N Nandhakumar,1 M R Green2
A number of tests of exocrine pancreatic function
have been devised over the years, but the search
for a simple and yet sensitive and specific test has
been elusive until recently. We will discuss the
evidence that determination of the faecal concen-
tration of pancreatic elastase 1 with an enzyme-
linked immunosorbent assay method fulfi ls these
criteria and thus provides an ideal tool to assess
exocrine pancreatic function.
Approximately 90% of the pancreas is made up
of exocrine tissue comprising acinar cells, which
secrete pancreatic enzymes, and ductal cells,
which secrete bicarbonate rich fluid. About 1%
of the pancreas is endocrine tissue, the remainder
being stromal tissue. The exocrine pancreas has a
large functional capacity. More than 98% of func-
tion is usually lost before symptoms and signs of
fat malabsorption are manifest.
The most common disease causing exocrine
pancreatic insufficiency in children is cystic fibro-
sis (CF). Other conditions are rare but include
chronic and familial pancreatitis, Shwachman–
Diamond syndrome, Johanson–Blizzard syn-
drome, Pearson syndrome and isolated specific
enzyme deficiencies—for example, lipase. A sec-
ondary pancreatic insufficiency may be seen in
small bowel enteropathies, significant protein-en-
ergy malnutrition or short gut syndrome.1 There
is increasing recognition of exocrine pancreatic
dysfunction in children with diabetes. 2
The clinical consequences of inadequate exo-
crine pancreatic output are mainly due to maldiges-
tion of protein and fat rather than carbohydrate.
With protein maldigestion, hypoproteinaemia
and oedema may occur, and in fat maldigestion,
overt malnutrition with steatorrhoea and wasting
is more prominent. In practice, both tend to occur
together and the signs and symptoms associated
with the fat maldigestion are more obvious. Fat-
soluble vitamin deficiencies also develop quickly.
Previously available pancreatic function tests
Direct tests
These tests measure the enzyme activities, the
bicarbonate levels and the pancreatic juice flow
rates in the duodenal juice after exogenous hor-
monal stimulation of the pancreas, usually with
secretin and cholecystokinin or, occasionally,
after a predetermined test meal (the Lundh meal).
Such direct pancreatic function tests were consid-
ered the criterion standard for examining the exo-
crine function of the pancreas. 3–5 However, there
are major practical disadvantages. They require
fluoroscopic duodenal intubation, are time con-
suming, are uncomfortable, are non-standardised
Interpretations
and are expensive. There have been intermittent
supply problems with secretin and cholecystoki-
nin, and in addition, laboratory analysis of the
enzymes has always been limited to a few aca-
demic units; hence, for routine clinical practice,
direct pancreatic function tests are not a practical
option.
Indirect tests
Tubeless tests have included the fluorescein
dilaurate (pancreolauryl) test and the N-benzoyl-
tryrosyl para-aminobenzoic acid test, which rely
on estimation of substrates in urine after inges-
tion and pancreatic digestion and therefore give
indirect estimations of exocrine pancreatic func-
tion.6 7 Breath tests measuring radioactive or
stable carbon isotopes after ingestion of labelled
substrates have also been used. These tests are all
somewhat cumbersome for use in children. Direct
measurement of other pancreatic enzymes has
been undertaken in faeces (chymotrypsin) and in
serum (lipase) but lack specificity. Formal faecal
fat collections for periods between 3 and 5 days
with estimated fat intake for calculation of the
coefficient of fat absorption are unpopular with
children, parents and laboratories alike.
In summary, in addition to the practical issues
with these tests in children, most of them have
limited sensitivity in mild and moderate exo-
crine pancreatic insufficiency and may be inter-
fered with by some drugs (including exogenous
porcine pancreatic enzymes), diarrhoea, changes
in intraluminal gut pH and gastrointestinal
surgery.8
The ideal pancreatic function test, therefore,
should be non-invasive, quantitative, reproduc-
ible, economic and easy to perform. Exogenous
enzyme supplements should not interfere with
the test performance.
PHYSIOLOGICAL BASIS
Human elastase is synthesised by the acinar
cells of the pancreas with the other proteolytic
enzymes. It is composed of 240 amino acids. The
molecular weight is 26 kd, and it has a special
affi nity for the carboxyl groups of alanine, valine
and leucine.9 10 It was fi rst described in 1950 and
further characterised by Mallory and Travis as
protease E in 1975.11 12 Largman et al13 in 1976
demonstrated its elastolytic properties.
The ontogeny of pancreatic elastase is similar
to other exocrine proteolytic enzymes, and its
decline in developing pancreatic insufficiency
seems to mirror that of the other enzymes.
Faecal elastase 1 (FE1) levels in meconium are low
119
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Interpretations
(<200 μg/g of stool) regardless of gestational age.
Normal adult concentrations >200 μg/g of stool
are reached by day 3 of life in term infants and by
2 weeks of age in premature infants of ≤28 weeks’
gestation. After 2 weeks of life, whatever the ges-
tational age, 96.8% of the infants with normal
pancreatic function have FE1 levels comparable
with those of adults.14
Under normal conditions, elastase 1 concentra-
tion in pancreatic juice is between 170 and 360 μg/
ml, representing about 6% of all secreted pancre-
atic enzymes.15 During intestinal passage, elastase
1 is mainly bound to bile salts and not degraded.
It becomes concentrated approximately fivefold
to sixfold because water is reabsorbed, making
it easier to measure in stool.15 16 It is stable at a
wide range of pH and temperature—even storage
for 5 days at room temperature does not influence
immunological quantification in the stool—and
so samples are easy to transport to laboratories
capable of performing the analysis without spe-
cial handling, provided that post office regulations
for the transport of potentially infectious material
are adhered to (rigid leak-proof container with suf-
ficient absorbent wrapping to absorb leakage if it
did occur and labelled “biohazard” or “pathology
sample”). Unlike faecal chymotrypsin estimation,
there is no cross reaction with porcine-derived
elastase.
TECHNIQUE
FE1 is measured by a sandwich enzyme-linked
immunosorbent assay kit (ScheBo Biotech UK
Limited, Basingstoke, UK) with two monoclonal
antibodies that are highly specific for human pan-
creatic elastase 1, binding to two distinct epitopes.
Results are reported as microgram per gram of
stool. The lower detection limit is 15 μg/g.17 The
cost of analysis is approximately £26, and turn-
around time is approximately 21 days.
Sample material
A single-spot stool sample of cherry size (approxi-
mately 100 mg) is sufficient. Watery stool samples
are not recommended because FE1 levels may be
falsely lowered by dilution. However, a semiliquid
sample usually gives a reliable result. Samples are
stable for convenient mailing and may be stored in
the laboratory for up to 3 days at 4°C–8°C or for
up to 1 year at −20°C.
VALIDATION
Most of the evaluation in children comes from
studies in CF, in other words, children with mod-
erate or more commonly severe pancreatic insuf-
ficiency. However, the sensitivity in mild exocrine
pancreatic insufficiency is much better than other
indirect tests.10 In 204 children with CF, Terbrack
et al18 found a sensitivity of 89.5% and a specific-
ity of 99% for FE1 concentration, with a cutoff of
<200 μg/g of stool.
Beharry et al observed an FE1 level of above
200 μg/g of stool in all their control group of 57
120 Arch Dis Child Educ Pract Ed 2010;95:119–123. doi:10.1136/adc.2009.174359
children with no steatorrhea determined by for-
mal estimation of coefficient of fat absorption.
All 39 patients with steatorrhea caused by CF had
FE1 concentrations <100 μg/g of stool. Sensitivity
and specificity in patients with CF were 100%.
Another 10 patients with steatorrhoea from
a variety of conditions (including the rare
Shwachman–Diamond and Johanson–Blizzard
syndromes, subtotal pancreatectomy and fibros-
ing pancreatitis) had FE1 levels below 100 μg/g.
One patient with chronic pancreatitis had a level
of 150 μg/g. The sensitivity of the test to detect
primary insufficiency overall was 98%, using a
cutoff of 100 μg/g of stool. The specificity of the
test in determining the cause of steatorrhea (pan-
creatic maldigestion vs intestinal malabsorption)
was 80%.19
In 1996, Loser et al compared FE1 determina-
tion with the direct secretin–caerulein test and
faecal estimation of chymotrypsin levels in 79
patients with clinically suspected chronic pan-
creatitis and 50 healthy controls. Using an FE1
cutoff <200 μg/g of stool, he showed sensitivity
of 93% and specificity of 93% for the detection
of pancreatic insufficiency. At the same time,
the sensitivity of faecal chymotrypsin was 64%
with a cutoff <3 U/g of stool. In severe cases
with steatorrhoea, the sensitivity was 100% and
the specificity was 96%. In mild exocrine pan-
creatic insufficiency, the sensitivity overall was
63%. This study also showed very low indi-
vidual day-to-day variations of faecal elastase
concentrations.10
Interpretation of results
Adults and children after the first month of life
Values >200 μg elastase per gram of stool indicate
normal exocrine pancreatic function.10 19
Values <100 μg elastase per gram of stool are
consistent with exocrine pancreatic insufficiency.
In established pancreatic insufficiency, values
>100 μg/g of stool are highly unusual.
Values between 100 and 200 μg elastase per
gram of stool are suggestive of exocrine pancre-
atic insufficiency and should be interpreted in the
light of the clinical circumstance. It is reasonable
to confi rm the result with a second sample and
pursue further with a formal faecal fat collec-
tion in the fi rst instance. Such results may also
be an indication of small bowel enteropathy (see
below).
SUMMARY OF ADVANTAGES OF FE1
MEASUREMENT:
▶ FE1 is pancreas specific.
▶ Because FE1 is stable during intestinal tran-
sit, the stool concentration accurately reflects
the secretory capacity of the pancreas (diag-
nosis or exclusion of pancreatic exocrine
insufficiency).
▶ FE1 determination correlates well with
direct studies. It is more sensitive than faecal
chymotrypsin.10
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▶ Intraindividual variation of FE1 concentra-
tion is low.10
▶ The test is not affected by previous gastroin-
testinal surgery or gastric dysmotility.
▶ The monoclonal antibodies used in the test
do not cross react with elastases of animal
origin, so digestive enzyme substitution
therapy has no influence on the determina-
tion of FE1 (unlike faecal chymotrypsin).
▶ The high stability of FE1 allows time for
convenient mailing of samples.
INDICATIONS
There are a number of reasons to think about
possible pancreatic pathology in clinical prac-
tice. The child who presents with persistent
poor weight gain despite the demonstration of
adequate nutritional intake may be malabsorb-
ing because of a small bowel enteropathy but,
equally, might have pancreatic insufficiency.
The presence of abnormal stools increases the
risk of identifi able pathologic conditions with
or without an accompanying history of respira-
tory symptoms. The stool in exocrine pancreatic
insufficiency tends to be more overtly greasy
than that resulting from small bowel enteropa-
thy. The consistency is soft rather than watery,
and the colour is often pale. Parents may com-
ment on the offensive smell.
Although it is true to say that in most children
with CF, exocrine pancreatic function is abnormal
by the time of diagnosis, in some circumstances,
particularly in those diagnosed by neonatal
screening, pancreatic function will decline over
time. This group may be completely asymptom-
atic initially, but vigilance will allow appropriate
nutritional intervention at an early stage before
malnutrition occurs. Therefore, in children who
are felt to be pancreatic sufficient at diagnosis,
regular elastase monitoring is justified and should
certainly be performed in those with faltering
growth or abnormal stools.
Paediatricians see many children with episodic
abdominal pain. Clearly, most do not have pan-
creatic pathologic conditions, but it can present
with recurrent pain alone. Therefore, if the pat-
tern of symptoms is in anyway unusual (includ-
ing localised pain or periodic vomiting) or more
severe than the norm, it is sensible to exclude a
potential pancreatic pathologic condition.
Summary of indications:
▶ possible steatorrhoea
▶ faltering growth patterns
▶ chronic diarrhoea
▶ evaluation of pancreatic function in patients
with CF
▶ diagnosis/exclusion of pancreatic involve-
ment in recurrent abdominal pain—for
example, possible chronic/recurrent
pancreatitis
▶ follow-up of patients with known mild to
moderate pancreatic insufficiency—possible
Arch Dis Child Educ Pract Ed 2010;95:119–123. doi:10.1136/adc.2009.174359
Interpretations
demonstration of longitudinal decline in
exocrine pancreatic function.
LIMITATIONS
Small bowel mucosal integrity is necessary for
normal control of exocrine pancreatic secretion.
In small bowel enteropathies of any cause, faecal
elastase levels may be low despite normal pan-
creatic functional capacity. This probably relates
to alteration of enteric hormonal release, par-
ticularly cholecystokinin, and reverts to normal
once the enteropathy has improved. There is also
a transient fall in acute diarrhoeal illness. This
highlights the need for consideration of mucosal
biopsies in individuals with reduced FE1 concen-
trations in whom causes of primary pancreatic
insufficiency have been excluded. FE1 concentra-
tion, therefore, also acts as a potential marker of
small bowel enteropathy.1
The test is less sensitive in mild exocrine pan-
creatic insufficiency, and values between 100 and
200 μg/g of stool demand further investigation.
Examples of relevant conditions include chronic
or recurrent pancreatitis. Where the test result is
borderline and/or clinical suspicion is high, fur-
ther investigation including formal estimation of
coefficient of fat absorption, estimation of serum
levels of vitamins A, D and E and pancreatic imag-
ing is warranted. Such results may also add impe-
tus to any debate about the need for small bowel
biopsy.
Low FE1 levels in children with Shwachman–
Diamond syndrome should be interpreted with
some caution because in this condition, it is pos-
sible to have low FE1 levels with adequate func-
tional capacity for fat digestion; in other words,
these children remain clinically pancreatic suf-
ficient for longer because changes in specific
enzyme activities occur at differing rates. 20
Exclusion of meat from the diet has been dem-
onstrated to result in significant changes in pan-
creatic secretion with a selective decrease in FE1
output. This may relate to a higher intake of soya
trypsin inhibitors reducing proteolytic activity.
Another possible mechanism is that high-fibre
intake is known to affect pancreatic enzyme
activity in vivo and in vitro, possibly because the
colonic microflora is affected and bigger stools
produce a dilution effect. Selenium deficiency in
the vegetarian diet is also known to reduce exo-
crine pancreatic function. 21 22
CLINICAL QUESTIONS
Is estimation of FE1 levels in children who present
with failure to thrive indicated as a first-line
investigation?
Pancreatic insufficiency is not a common cause for
failure to thrive in children. Often, nutritional and
gastrointestinal history and physical examination
guide us to a reasonable clinical diagnosis.
In children who present with bulky and greasy
stools and weight loss despite adequate nutri-
tional intake or if there is chronic diarrhoea in
121
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Interpretations
the absence of serological evidence of coeliac
disease and without any suggestion of food pro-
tein intolerance, one should consider a pancreatic
pathologic condition. In these selected groups, it is
appropriate to request estimation of FE1 levels.
If pancreatic insufficiency is then suggested, one
should investigate for the cause. CF is by far the
commonest reason for exocrine pancreatic failure
in children.
In children who are diagnosed as having CF and who
do not have any gastrointestinal symptoms, does
routine estimation of FE1 levels identify pancreatic
insufficiency early?
CF is a multiorgan disease. The clinical presen-
tation varies. In some children, exocrine pancre-
atic failure is the predominant problem. Even if
gastrointestinal symptoms are not prominent,
these children may already have pancreatic insuf-
ficiency and, if not, are highly likely to develop it.
The sooner it is diagnosed, the sooner appropriate
management is instituted and the less likely these
children are to become nutritionally compro-
mised. Chronic respiratory illness, recurrent acute
infections, recurrent hospital admissions and poor
nutritional intake all contribute to malnutrition,
and early clinical evidence of pancreatic failure can
be missed, leading to a worsening of prognosis.
In these cases, it is very useful to judge the
functional capacity of the pancreas even if there
is no history of chronic diarrhoea or bulky and
greasy stools. Properly adjusted enzyme replace-
ment therapy often helps to restore the nutritional
status of these children even before they become
symptomatic.
Is treatment with enzyme replacement indicated in
children with borderline FE1?
Borderline results for FE1 level should be inter-
preted with caution. The test should be repeated
to make sure there is no sample error. If the repeat
test result is also between 100 and 200 μg/g, it sug-
gests that there is some element of exocrine pan-
creatic dysfunction.
If the child is symptomatic with failure to thrive
and chronic diarrhoea, it is prudent to do further
investigations to establish the cause for the abnor-
mal result before considering enzyme therapy. This
includes investigation for CF, and the other potential
causes of exocrine pancreatic failure as indicated.
Any small bowel enteropathy including coeliac
disease may give rise to a minor degree of exo-
crine pancreatic insufficiency caused by interfer-
ence in the enteric hormonal axis due to small
bowel mucosal damage. In this group of children,
once the small bowel disease is treated, pancreatic
function improves.
In a small group of these patients, when there is
no obvious pathologic feature in the small bowel,
the pancreas is structurally normal and fi ndings
of other investigations have been negative, it is
reasonable to start (and monitor) enzyme replace-
ment therapy to improve the nutrition of the
child. This will also improve the symptoms of
malabsorption.
122 Arch Dis Child Educ Pract Ed 2010;95:119–123. doi:10.1136/adc.2009.174359
In children with a proven pancreatic insufficiency
syndrome—for example, Shwachman–Diamond
syndrome, is testing of FE1 levels useful? Do these
children need enzyme replacement?
In these circumstances, with a proven diagnosis,
FE1 levels give very useful information in planning
enzyme replacement therapy in conjunction with
nutritional markers including fat-soluble vitamins.
However, we also know that these children can
maintain pancreatic function despite low FE1 lev-
els because of parallel development of other pro-
teolytic enzymes, so treatment strategy should be
based on the investigation results and the clinical
symptoms and signs.
In children with recurrent abdominal pain, does a
normal FE1 level rule out a pancreatic pathologic
condition?
In the common pattern of non-specific recurrent
abdominal pain in otherwise healthy young chil-
dren, there is probably no reason to do anything
else. Normal levels of FE1 mean that there is no
exocrine pancreatic insufficiency.
However, in children with chronic pancreatitis
who present with recurrent pain, the FE1 level
may be normal if there is still adequate functional
reserve. The diagnosis and the subsequent investi-
gation here depends on clinical suspicion.
If FE1 levels are low in children who present with
recurrent pain, it suggests a pancreatic pathologic
condition. The possibility of chronic pancreati-
tis should be investigated with further imaging/
endoscopic retrograde cholangiopancreatography.
One should also not forget the possibility of
small bowel enteropathy, which may present with
recurring abdominal pain.
CLINICAL BOTTOM LINE: SUMMARY
▶ FE1 is a simple, non-invasive tool and is useful
in the clinical assessment of children suspected
of having pancreatic insufficiency, provided
that the limitations of the test are recognised.
▶ A result >200 μg/g of stool reliably excludes
exocrine pancreatic insufficiency.
▶ A result <100 μg/g of stool provides enough
information to warrant a clinical trial of
pancreatic enzyme therapy, especially if
supported by other evidence of fat malab-
sorption—for example, estimation of serum
levels of fat-soluble vitamins.
▶ In mild exocrine pancreatic insufficiency,
faecal elastase is less sensitive but remains
better than the other non-invasive tests.
Test sample
One random semisolid to solid stool specimen
weighing at least 100 g (cherry sized) should be
sent to the laboratory in an ordinary container at
room temperature. This specimen can be stored at
4–8°C in the fridge while waiting for transport.
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Interpretations

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Arch Dis Child Educ Pract Ed 2010;95:119–123. doi:10.1136/adc.2009.174359 123

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Interpretations: How to use faecal elastase

testing
N Nandhakumar and M R Green

Arch Dis Child Educ Pract Ed 2010 95: 119-123

doi: 10.1136/adc.2009.174359

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