Pancreatic Insufficiency

Question 1

what is exocrine pancreatic insufficiency (EPI)?

Answer 1

reducing pancreatic enzyme activity (i.e. pancreatic lipase) in the intestinal lumen below the threshold required for digestive functions

Question 2

what are the two principal causes of exocrine pancreatic insufficiency?

Answer 2

• chronic pancreatitis
• cystic fibrosis (CF)

Question 3

what are the other causes of exocrine pancreatic insufficiency?

Answer 3

• acute pancreatitis
• pancreatic cancer
• diabetes
• coeliac disease
• IBD
• HIV

Question 4

what is the TIGAR-O classification system for chronic pancreatitis and pancreatic exocrine insufficiency?

Answer 4

• toxic-metabolic (e.g. alcohol, smoking, hypercalcemia, hyperlipidaemia, chronic renal failure)
• idiopathic
• genetic (e.g. CFTR mutations, SPINK1 mutations, hereditary pancreatitis)
• autoimmune (e.g. sjögren syndrome, PBC, IBD)
• recurrent and severe acute pancreatitis (e.g. recurrent acute pancreatitis, vascular diseases, post-necrotic, post-radiation)
• obstructive (e.g. congenital duct anomalies, sphincter of oddi dysfunction, tumours, post-traumatic fibrosis)

Question 5

how does the pancreas normally secrete pancreatic juice, and how is this affected in chronic pancreatitis?

Answer 5

• secretin + cholecystokinin are released when chyme reaches the duodenum, stimulating the pancreas to secrete *1.5 L/day of pancreatic juice containing enzymes (e.g. amylase, lipase, protease), water, and ions (e.g. bicarbonate, phosphate)
• in chronic pancreatitis, recurrent inflammation leads to fibrosis, which can impair both endocrine + exocrine pancreatic functions

Question 6

what are the symptoms of exocrine pancreatic insufficiency?

Answer 6

• steatorrhea
• flatulence
• weight loss
• abdominal pain
• bloating
• signs of vitamin/mineral deficiency (e.g. bone pain, bleeding disorders, etc.)

Question 7

what are the direct investigations for exocrine pancreatic insufficiency?

Answer 7

• secretin-cholecystokinin stimulation test
• endoscopic pancreatic function test

Question 8

what is the gold-standard test for diagnosing exocrine pancreatic insufficiency?

Answer 8

72-hour faecal fat quantification + determination of the coefficient for fat absorption

Question 9

what is the faecal elastase-1 test?

Answer 9

• a non-invasive test used to detect exocrine pancreatic insufficiency
• it measures the concentration of elastase-1 enzyme in stool, with low levels (<200 μg/g) indicating reduced pancreatic enzyme production

Question 10

how is exocrine pancreatic insufficiency treated?

Answer 10

• pancreatic enzyme replacement therapy (PERT)
• a combination of pancreatic enzymes (e.g. lipase, amylase, and protease), which prevents malabsorption and restores the normal physiological digestive process

Question 11

what are the long-term complications of exocrine pancreatic insufficiency?

Answer 11

• malnutrition
• fat-soluble vitamin deficiency
• osteoporosis
• increased motility