Exocrine pancreatic insufficiency

Question 1

What are the causes of pancreatic exocrine insufficiency?

Answer 1

Ultimately, the cause is a lack of pancreatic digestive enzymes being secreted into duodenum.

Specifically lack of amylase, lipase, protease.

Amylase is the digestive enzyme which is responsible for breaking down carbohydrate.

Lipase is the digestive enzyme which is responsible for breaking down fats.

Protease is the digestive enzyme which is responsible for breaking down protein.

Question 2

What are the causes of pancreatic exocrine insufficiency?

Answer 2

Some underlying causes of lack of digestive enzymes include:

• Pancreatic resection (surgical removal of the pancreas)
• Pancreatitis (inflammation of the pancreas)
• Diabetes (lack of insulin atrophies (reduction in size of the pancreas) the pancreas, diabetes is also inflammatory hence can lead to pancreatic inflammation)
• Coeliac disease (pancreatic fibrosis, fewer secretory granules)
• Pancreatic tumours (tumour can potentially lead to a blockage in the pancreatic duct hence reduction in secretion of pancreatic enzymes)
• Cystic fibrosis (pancreatic duct becomes blocked with mucus)

Question 3

What are symptoms of pancreatic exocrine insufficiency?

Answer 3

This is where the overlap with other conditions can be seen.

• Macronutrients (fats, carbs, proteins) are maldigested
• Malnutrition, lack of energy, low blood levels of fat soluble vitamins (A, D, E, K)
• In children this can lead to lack of growth rates (weight loss in adults)
• Low blood levels of Zinc, Selenium- can show up as reduced immune function, poor wound healing, thyroid function.
• General signs of malnutrition can present- lethargy, depression, poor concentration, muscle loss, dry skin, brittle nails etc.

Physical symptoms arise from the inability to digest macronutrients properly:
- Diarrhoea
- Cramping/bloating/flatulence
- Steatorrhoea (fatty, foul smelling stools, usually light in colour)

Question 4

What are the aims of drug treatment for exocrine pancreatic insufficiency?

Answer 4

Supply the patient with pancreatic enzyme replacement (amylase, lipase, protease):

• Pancreas V
• Creon
• Nutrizym 22
• Pancrease HL

Dose will be tailored according to meal due to digestion rate:

• Higher doses for main meals
• Smaller doses for snacks

Physical symptoms should ease.

Clinical manifestations such as lethargy, muscle loss, low blood levels of fat soluble vitamins and nutrients should also improve.