Pancreatic Insufficiency

What is pancreatic insufficiency?

Pancreatic Insufficiency (EPI) is a condition which occurs when the pancreas does not make enough of a specific enzyme the body uses to digest food in the small intestine.

The pancreas is a glandular organ. That means the pancreas secretes juices that maintain the proper function of the body. The pancreas produces both enzymes and hormones.

Enzymes and Hormones

Enzymes are catalysts that perform specific chemical functions in the body, such as breaking down foods, or synthesizing DNA. Enzymes control chemical reactions. The pancreas also secretes digestive enzymes which are released into the small intestine and play an important role in breaking down food products for absorption.

Hormones are signaling chemicals that tell the body how to respond to a specific stimulus. The adrenal gland releases a hormone when you are shocked or frightened. The islet cells of the pancreas secrete the hormones insulin and glucagon into the bloodstream. Insulin causes the body's cells to take up glucose from the blood; glucagon causes the liver to release glucose into the blood.

Symptoms of pancreatic insufficiency

Symptoms may include:

• abdominal pain and tenderness
• loss of appetite
• feelings of fullness
• weight loss and diarrhea

Pancreatic insufficiency may also cause bone pain and muscle cramps.

What causes pancreatic insufficiency?

When the pancreas becomes damaged, pancreatic enzymes are not produced, and malabsorption results. Malabsorption is the result of food that is not properly converted into usable energy by the digestive system.

The pancreas may become damaged by:

• recurring inflammation of the pancreas
• previous pancreatic surgery
• it is rarely caused by cancer

Additionally, there are genetic factors that may cause damage to the pancreas:

• cystic fibrosis, a disease damages glandular organs by creating mucus that impairs their function
• Shwachman-Diamond Syndrome, a rare autosomal recessive disorder

Risk factors of pancreatic insufficiency

Chronic pancreatitis is a serious risk factor resulting from too many instances of pancreatic inflammation. It has many causes, but chronic alcohol abuse is the most common one in western countries. Chronic pancreatitis and subsequent insufficiency can also run in families (hereditary pancreatitis and cystic fibrosis).

Severe malabsorption may cause deficiencies in vitamins and minerals.

Clinical features of pancreatic insufficiency

Patients with chronic pancreatitis may not have any symptoms. However, with ongoing destruction of the gland and loss of its function, symptoms of malabsorption may develop. Chronic pancreatitis can also manifest with abdominal pain, and diabetes.

Diagnosis of pancreatic insufficiency

Pancreatic insufficiency is suspected in a patient who develops diabetes, upper abdominal pain and features of malabsorption. Bowel movements classically are bulky, loose and foul smelling; because of their oily nature, they may float in the toilet bowl, and are difficult to flush.

Simple investigations used to diagnose chronic pancreatitis include:

• an abdominal X-ray (which can show calcifications in the pancreas)
• stools collected and analyzed for high fat content
• CT scan
• MRI scan
• endoscopic ultrasound

Occasionally, the pancreas becomes so chronically inflamed that a scarred mass may develop which can be difficult to distinguish from pancreatic cancer.

Treatment of pancreatic insufficiency

When chronic pancreatitis is discovered, attempts are made to remove causative factors.

• reduce high blood fat (triglyceride) levels
• reduce alcohol use or abuse
• stimulate pancreatic duct drainage using dilation, or stents
• surgery

There are reports of the use of antioxidants (selenium, vitamin A, vitamin C, and vitamin E) to reduce ongoing inflammation.

Conclusion

In terms of maldigestion from chronic pancreatitis, enzyme supplements are usually prescribed. These supplements are in the form of pills which contain pancreatic enzymes. The pills are taken before and during each meal.

Depending on the type of supplements, an antacid may also be prescribed, as some pancreatic supplements are broken down by gastric acid.

Dietary changes are also suggested; a low fat diet (30g fat per day) will reduce the amount of steatorrhea and sometimes abdominal pain associated with chronic pancreatitis. Since fat can be so significantly malabsorbed, supplements of fat soluble vitamins (vitamin D, A, E, and K) may be prescribed.