Exocrine Pancreatic Insufficiency

Question 1

What are the common products of the exocrine pancreas?

Answer 1

Amylase = breaks down carbs/sugars

Lipases = break down fats

Proteases = trypsin/elastase/etc.
- break down proteins

Bicarbonate = neutralizes stomach acid

Question 2

What are the two stimulation molecules for the exocrine pancreas?

Answer 2

CCK = stimulates protease and lipases from exocrine pancreas
- released by I cells and in the responses to peptides/fatty acids and amino acids

Secretin = stimulates bicarbonate release from exocrine pancreas
- released by S cells and in the presence of acid

Question 3

Classic presentation of exocrine pancreatic insufficiency

Answer 3

Mild = asymptomatic or mild abdominal discomfort and bloating

Moderate-severe

• bloating, steatorrhea, unintended weight loss
• deficiencies of DEAK and vitamin B12

Question 4

What are the common risk factors for exocrine pancreatic insufficiency

Answer 4

Chronic pancreatitis
- most common cause in adults

Cystic fibrosis
- most common cause in children

Gastric/small bowel resection

Pancreatic duct obstruction

Question 5

Acute pancreatitis

Answer 5

1) severe/sharp epigastric abdominal pain w/ tenderness that radiates to the right mid-back/ supraclavicular area
- gets worse with eating
- significant nausea/vomiting can occur with the pain

almost always caused by obstructing gallstones or excessive alcohol use

Confirmation = lipase/amylase is 3x normal and CT imaging shows pancreatic inflammation

Treated by withholding oral intake (liquid diets)

Question 6

Chronic pancreatitis

Answer 6

Similar pain to acute except it is intermittent sometimes

• also can cause N/V
• also radiates to the mid-back

Also shows pancreatic insufficiency symptoms

Usually a history of recurrent acute pancreatitis

lipase/amylase is often normal or may be even lower than normal

CT doesnt correlate with severity of disease, but can show calcifications (acute doesnt show calcifications)

Question 7

Cystic fibrosis

Answer 7

Various symptoms but is caused by mutations in CFTR proteins which causes thickened mucus
- can block pancreas and cause pancreas insufficiency

Testing = sweat chloride and genetic testing can confirm

Question 8

How does resection cause exocrine pancreatic insufficiency?

Answer 8

Can lead to decrease sites of secretin/CCK (if small bowel)

Can lead to less pancreas secretions as well due to less pancreas being present

Question 9

How to diagnosis pancreatic insufficiency

Answer 9

Can use symptoms and patient history (if they have risk factors)

To confirm malabsorption primary
- elevated fecal fat level and vitamin deficiency

To confirm exocrine pancreatic insufficiency primary

• indirect = decreased fecal elastase-1
• direct = secretin test with pancreas biopsy

Question 10

Treatment of exocrine pancreatic insufficiency

Answer 10

1) stop alcoholic drinking.
2) start small low-fat meals and switch from high fat meals if applicable
3) give pancreatic enzymes supplements
4) give vitamin supplements
5) Can add medium chain triglycerides if weight loss persistent with 3/4 done already