Diagnosis and treatment of pancreatic exocrine insufficiency

Abstract

Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis. Normal digestion requires adequate stimulation of pancreatic secretion, sufficient production of digestive enzymes by pancreatic acinar cells, a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food. Failure in any of these steps may result in pancreatic exocrine insufficiency, which leads to steatorrhea, weight loss and malnutrition-related complications, such as osteoporosis. Methods evaluating digestion, such as fecal fat quantification and the (13)C-mixed triglycerides test, are the most accurate tests for pancreatic exocrine insufficiency, but the probability of the diagnosis can also be estimated based on symptoms, signs of malnutrition in blood tests, fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging. Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption, dietary consultation, enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment. Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicrospheres during meals. The dose should be in proportion to the fat content of the meal, usually 40-50000 lipase units per main meal, and half the dose is required for a snack. In cases that do not respond to initial treatment, the doses can be doubled, and proton inhibitors can be added to the treatment. This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.

Practical considerations in the management of proton-pump inhibitors

“…In exocrine pancreatic insufficiency, the use of these drugs has increased due to the refractoriness of enzyme replacement therapy. Associating a PPI to enzymatic treatment, the pH increases and lipase degradation decreases secondarily (69).…”

Comparison of Fecal Elastase 1 for Exocrine Pancreatic Insufficiency Evaluation Between Ex-Alcoholics and Chronic Pancreatitis Patients

“…Low levels of fecal elastase 1 were reported in patients with celiac disease; thus, exocrine pancreatic insufficiency may be associated with celiac disease and may be the cause of chronic diarrhea in gluten-free diet adherent patients (5) ; conversely, diarrhea may provoke a dilution effect, falsely lowering fecal elastase levels (6) . Cases of inflammation of the duodenal mucosa caused by autoimmune reactions, infections, short gut syndrome, and Crohn's disease with normal secretin-cholecystokinin tests were correlated with lower fecal elastase levels in children (20) by the reduced stimulatory capacity in the intestine of pancreatic exocrine secretion (11,20) . Fecal elastase 1 fails to distinguish primary exocrine pancreatic insufficiency from other causes of diarrhea; thus, the integrity of the intestinal mucosa should be evaluated when primary causes of pancreatic insufficiency were excluded.…”

“…A reliable simple, easy and cheap test for pancreatic insufficiency diagnosis is still lacking; nonetheless, fecal elastase 1 has been used for this purpose (10) . Exocrine pancreatic insufficiency is one of the major complications of chronic pancreatitis (11) that has alcohol as the main etiological cause (13) . The diagnosis of chronic pancreatitis nowadays is mainly based on the morphological changes by image findings with more advanced techniques such as magnetic resonance imaging, magnetic resonance cholangiopancreatography and endoscopic ultrasonography with a limited use of the functional tests for exocrine pancreatic insufficiency diagnosis.…”

“…Nonetheless, functional testing may be important to support the diagnosis, for the indication of enzyme replacement and its effect on fat digestion, in addition exocrine pancreatic secretion impairs progressively along the course of chronic pancreatitis. Thus, fecal elastase test, as a noninvasive test to indicate a reduction in exocrine pancreatic secretion, may be useful for the screening of chronic pancreatitis diagnosis and follow-up (3,11) . Human elastase is synthesized by the acinar cells of the pancreas along with the other proteolytic enzymes, and under normal conditions.…”

“…Human elastase is synthesized by the acinar cells of the pancreas along with the other proteolytic enzymes, and under normal conditions. It has a concentration in the duodenal juice between 170 and 360 μg/mL (6% of the total pancreatic enzymes); human elastase is transported across the gut while bound to bile salts and if not degraded, is enriched in the stool (10,11,15) . An advantage of fecal elastase 1 as a diagnostic marker is its low variability within an individual from day to day, indicating that its measurement in fecal samples is valid diagnostically (8) .…”