exocrine pancreatic insufficiency

Question 1

what is it characterised by

Answer 1

reduced secretion of pancreatic enzymes into the duodenum

Question 2

main clinical manifestations

Answer 2

maldigestion and malnutrition, associated with low circulating levels of micronutrients, fat soluble vitamins and lipoproteins

GI symptoms e.g diarrhoea, abdominal cramps, steatorrhea (excessive amounts of fat in poo - they look looser, smellier and paler, like clay)

Question 3

what is steatorrhea

Answer 3

excessive amounts of fat in poo
looser, smellier and paler like clay

Question 4

exocrine pancreatic insufficiency can result from …

Answer 4

○ Chronic pancreatitis
○ Cystic fibrosis
○ Obstructive pancreatic tumours
○ Celiac disease
○ Zollinger-Ellison syndrome
○ GI or pancreatic surgical resection

Question 5

mainstay of treatment

Answer 5

pancreatic enzyme replacement therapy with pancreatin

Question 6

Pancreatin contains three main groups of digestive enzymes

Answer 6

Lipase - digests fats
Amylase - digests carbs
Protease - digests proteins

Question 7

pancreatin needs to be taken with

Answer 7

meals and snacks

Question 8

Fibrosing colonopathy has been reported in pt with CF taking high dose pancreatic enzyme replacement therapy (in excess of 10,000 units/kg/day of lipase). What are some possible risk factors for this?

Answer 8

in children, boys at higher risk than girls
more severe CF
concomitant use of laxatives
peak age for developing fibrosing colonopathy = 2-8 yrs

Question 9

what to do if a patient on pancreatin develops new abdominal symptoms, or change in existing abdominal symptoms

Answer 9

review pt to exclude possibility of colonic damage

Question 10

in patients who continue to experience abdominal symptoms despite high doses of pancreatin, consider a trial of the following drug type, based on limited evidence that acid suppression may improve effectiveness of pancreatin

Answer 10

acid suppressing drugs e.g. PPIs, H2RA

Question 11

what needs to be routinely assessed? - hint vitamins

Answer 11

Levels of fat soluble vitamins and micronutrients (e.g. zinc and selenium) should be routinely assessed and supplementations advised wherever necessary

Question 12

Non drug treatment

Answer 12

• dietary advice
• distribute food intake between 3 main meals a day, and 2-3 snacks
• avoid food difficult to digest
• avoid alcohol completely

Question 13

true or false - pt should stop drinking alcohol completely

Answer 13

true

Question 14

are reduced fat diets recommended?

Answer 14

no

Question 15

avoid food that is difficult to digest e.g.

Answer 15

high fibre food
legumes (peas, beans, lentils)

Question 16

Medium chain triglycerides (MCT) which are directly absorbed by the intestinal mucosa, were thought to be useful in some patients. However, evidence has shown that …

Answer 16

MCT enriched preparations offer no advantage over a normal balanced diet

Question 17

why is pancreatin given

Answer 17

• Supplements of pancreatic are given to compensate for reduced or absent exocrine secretion
• They assist the digestion of starch, fat, protein

Question 18

How should pancreatin be taken

Answer 18

• Dose to be taken with meals or snacks
• Doses should be swallowed whole or contents taken with water, or mixed with acidic fluid or soft food then swallowed immediately without chewing

Question 19

Avoid retaining pancreatin in mouth because..

Answer 19

Can irritate peri oral skin and buccal mucosa if retained in mouth

Question 20

Excessive doses of pancreatin can cause…

Answer 20

perianal irritation

Question 21

Interaction with this uncommonly used anti diabetic drug

Answer 21

Acarbose - Pancreatin predicted to decrease effects of acarbose, avoid

Question 22

Common side effects of pancreatin

Answer 22

Abdominal distension, constipation, nausea, vomiting

Question 23

Why does pancreatin need to be taken with food, or immediately before or after food?

Answer 23

Pancreatin is inactivated by gastric acid therefore manufacturer advises they are best taken with food, or immediately before or after food

Question 24

Can you have pancreatin with a hot meal

Answer 24

Avoid excessive heat if preparations are mixed with liquids or foods - pancreatin is inactivated by heat

Question 25

When pancreatin is mixed with liquid or food, how long can it be kept for

Answer 25

Manufacture advises the resulting mixture should not be kept for more than one hour when it is mixed with liquid or food and any leftover food or liquid that contains pancreatic and should be discarded

Question 26

True or false - EC preps deliver higher enzyme concentration in the duodenum

Answer 26

true as long as the capsule contents is swallowed whole, no chewing

Question 27

How to take gastro-resistant granules

Answer 27

Mixed with slightly acidic soft food or liquid such as apple juice, and then swallow immediately without chewing

Capsules containing EC granules can be opened and the granules administered in the same why

Question 28

Ensure pt taking higher strength pancreatic preparations are always adequately..

Answer 28

hydrated