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Exocrine pancreatic insufficiency

An inability to break down and in turn digest food properly is Exocrine Pancreatic insufficiency (EPI). In other words, a deficiency of the exocrine pancreatic enzymes leads to maldigestion or inability to digest food.


Exocrine pancreatic insufficiency or EPI can cause problems in how we digest our food. If our pancreas do not make enough enzymes that the body needs to break down and absorb nutrients, then EPI occurs. Enzymes speed up chemical reactions in our body. The enzymes made by our pancreas move into the small intestine, where they help break down the food we eat.


So much so, that a person who suffers from EPI does not get enough nutrients as the body cannot absorb fats, vitamins or minerals from food. That is the reason why he/she loses weight or has pain in the stomach. Many are prescribed drugs that help substitute a new supply of enzymes, so that they can get back to digesting food the right way. The exocrine pancreas produce three types of enzymes namely amylase, protease and lipase.


Symptoms of EPI

Symptoms of EPI can vary, but the doctor should be contacted if one or more of these signs persist as these symptoms could also possibly arise due to GI condition. A person with EPI may not exhibit all the symptoms first but once the pancreas gets damaged, it starts to hurt due to inability to absorb fat; some symptoms may appear:


Frequent diarrhea: EPI can cause diarrhea as undigested food moves too quickly through the digestive tract.

Weight loss: As those with EPI cannot digest fats, proteins and carbohydrates in the food they consume, this can result in weight loss.


Steatorrhea or foul smelling greasy stools: This is a type of bowel movement that is oily, floats, smells really bad and is difficult to flush. As these patients cannot absorb all the fat they eat, undigested fat is excreted, resulting in stools that look oily or greasy, though not many experience this symptom. It is better to contact the doctor if oil droplets are noticed in the toilet bowl or stools that float or stick to the sides of the bowl and are hard to flush.


Gas and bloating: As these people cannot properly digest the food they eat, it can result in gas and bloating symptoms which can be acutely uncomfortable in public.

Stomach pain: Due to gas and bloating caused by maldigestion, frequent stomach pain is possible. Fatigue, edema or hypoalbuminemia, anemia or deficiency of B-12, Iron, folic acid, bleeding disorders, metabolic bone disease due to Vitamin D deficiency and neurologic manifestations are other related symptoms.


Causes for exocrine insufficiency could be pancreatic or non pancreatic. Chronic Pancreatitis and cystic fibrosis are the result of longstanding inflammation of the pancreas, and they alter the organ's normal structure and function. These arise as a result of malnutrition, heredity or lifestyle behavior such as alcohol use or smoking. In children, this could be caused due to a rare autosomal recessive genetic disorder resulting from mutation of a gene.


Damage to pancreas which is the leading cause of EPI happens when our pancreas get inflamed often when enzymes made by the pancreas start working when they are still inside it, before they get to the small intestine. If a person is alcoholic, then he/she is at risk. Pancreas gets inflamed when the passage way is blocked, if he/she has high levels of triglycerides, due to some immune system disorder.


A surgery on pancreas, stomach or intestine can cause damage. Inherited diseases such as cystic fibrosis or Shwachman-Diamond syndrome can damage pancreas. In case of cystic fibrosis, the body makes unusually thick and sticky mucus which blocks the passage in the pancreas and stops enzymes from getting out. If you have Shwachman-Diamond syndrome, you may be missing cells in your pancreas that make enzymes. Crohn's disease and celiac disease can also lead to EPI in some people.


Diagnosis

The diagnosis of EPI is largely clinical and may go undetected because the signs and symptoms are similar to other Gastro-intestinal diseases. The signs and symptoms are also not always evident. Complete laboratory evaluation is required to diagnose EPI including the pancreatic function testing. The extent of malabsorption and manifestations underlying the disease has to be determined before treatment.


Tests to determine EPI include some blood tests to check if the person is getting enough vitamins and that pancreas are making enough enzymes, to check for celiac disease that can lead to EPI.

A 3-day fecal test is done to check the amount of fat in the bowel movements. Fecal elastase-1 is another test that is usually asked for. These tests can reveal if the pancreas is making enough enzymes. Other tests to check if the pancreas is inflamed include CT scan, MRI and Endoscopic ultrasound.


Treatment

Normally prescription pills that replace the pancreatic enzymes are prescribed. Apart from a healthy diet, the main treatment for EPI is pancreatic enzyme replacement therapy PERT. These enzymes break down your food so you can more easily digest and absorb it. You have to take them during your meals. If you take them before you eat, the replacement enzymes may move through your stomach before your food gets there. If you take the pills after you eat, you have the opposite problem.


An antacid to keep the stomach from breaking down pancreatic enzymes before they can start to work is given. There are six FDA-approved pancreatic enzyme products that are only available by prescription. These include Creon, Pancreaze, Pertzye, Ultresa, Viokace, Zenpep.

Medicines are also prescribed to treat pain such as acetaminophen or ibuprofen. Otherwise, stronger pain drugs such as hydrocodone and oxycodone are given.


Some tips to manage EPI

The right diet is essential for EPI. A dietician can be consulted to help choose the food that keep energy level up and nutrition that the body needs. Instead of traditional three, eat six small meals per day. A big meal may not appeal if he/she has EPI troubles of digestion.

Do not drink as alcohol makes it even harder for body to absorb fat and can damage pancreas over time.

Take vitamins A, D, E and K to replace ones that are not getting absorbed from the diet.


It is essential that you do not lose much weight and a nutritionist can be consulted to help choose foods that have enough protein and nutrients in them. Support from friends and family is by far more important than the treatment itself. A doctor can help to put you in support groups.


Preventing EPI

Many diseases such as pancreatic cancer, cystic fibrosis, diabetes, and pancreatic cancer that are related to EPI cannot be controlled. But some factors can such as intake of heavy continual alcohol, combining alcohol with high-fat diet and smoking - all these that increase the chances of Pancreatitis can be controlled. Those with Pancreatitis caused by heavy alcohol use tend to have severe stomach pain and can develop EPI more rapidly. In case there is a family history of cystic fibrosis or Pancreatitis, this can increase your chances of developing EPI.

Pancreatitis

The pancreas help in synthesizing food with the help of digestive enzymes. Vital hormones such as insulin and glucagon are released by the pancreas into the bloodstream. When the pancreas are inflamed, a condition of Pancreatitis sets in. In a case of Pancreatitis, the digestive enzymes end up attacking the pancreas itself. Milder cases of Pancreatitis can be treated with dietary and lifestyle changes. Patients with Pancreatitis notice dropping body weight inspite of normal appetite and eating habits. This is due to malabsorption as there are insufficient pancreatic enzymes to break down food. At this stage, it can also lead to diabetes since the insulin-producing cells are also damaged.


Acute Pancreatitis is a severe form of the disease that can lead to many a complication. This condition is usually the result of gallstones or too much alcohol. The pancreas help in synthesizing food with the help of digestive enzymes. The symptoms of acute Pancreatitis are nausea and vomiting, accompanied by a swollen abdomen that it tender to touch. The pain may also be noticed in the back and other areas. Sometimes it may lead to dehydration. Acute Pancreatitis is a life-threatening condition if ignored and untreated. It can trigger off breathing complications. It may lead to a kidney failure. Chronic Pancreatitis also manifests in symptoms such as bloating and oily malodorous stools. Cases of chronic Pancreatitis are usually attributed to excessive alcohol consumption. Other factors that can trigger acute Pancreatitis are elevated levels of triglycerides, bacterial or viral infections such as hepatitis or mumps and pancreatic cancer. Any structural abnormality of the pancreas or common bile duct can lead to Pancreatitis.


A case of acute Pancreatitis may need to be monitored and treated in a hospital. Surgical removal of pancreatic pseudo cysts may be necessary. Blood tests will reveal unusually high levels of amylase and lipase in patients suffering from acute Pancreatitis. Abdominal ultrasound can reveal presence of gallstones and inflammation of the pancreas. Other diagnostic procedures to detect chronic Pancreatitis are ERCP - endoscopic retrograde cholangiopancreatography and CAT scan.


Pancreatic Cancer

Pancreas lies deep within the abdomen and secrete enzymes that are vital to digestion. Hormones secreted by the pancreas aid in maintaining sugar levels in the body. Pancreatic cancer is a condition where there is a malignant tumor, mostly found in the exocrine portion of the pancreas. Pancreatic cancer is not easily detectable in the early stages. Besides, it spreads rapidly and can metastasize to other organs such as bile duct, duodenum (small intestine), spleen, colon, adrenal gland, kidney, or vertebra.


Typical symptoms associated with pancreatic cancer are loss of appetite, nausea, vomiting, abdominal pain and weight loss. The patient is likely to suffer from back pain and complain of tiredness and fatigue. Pancreatic cancer may result in blood clots and liver dysfunction. The abdominal pain associated with pancreatic cancer is likely to radiate to the upper and middle back. There may be yellowing of the skin since most persons suffering from cancer of the pancreas tend to develop jaundice. In advanced stages of pancreatic cancer, there is considerable accumulation of bile acids in the skin leading to severe itching.


Some people have a hereditary genetic predisposition to cancer while there are certain factors that increase the likelihood of developing pancreatic cancer.

  • High fat diet consisting largely of animal fat and lesser vegetables and fruits
  • Smoking
  • Obesity
  • Sedentary lifestyle

Blood test for serum bilirubin will show high bile pigment. Abdominal ultrasound and abdominal MRI aids in diagnosing the extent of tumor in the pancreas. ERCP (Endoscopic retrograde cholangiopancreatography) is a procedure that allows a physician to observe the common bile duct and pancreatic ducts. A pancreatic biopsy can help understand the kind of tumor in the pancreas. Pancreaticoduodenectomy (Whipple procedure) involves surgical removal of the pancreatic tumor. This surgical procedure is conducted on patients whose tumors are located in the head of the pancreas or regions adjacent to it. Surgery may involve removal of a section or the entire pancreas. A combination of radiation therapy and chemotherapy is given to those patients whose tumor is not removed.

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Collection of Pages - Last revised Date: June 24, 2019