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  • • Associated with chronic pancreatitis and extensive pancreatic resections

    • Fat malabsorption and steatorrhea are the principal symptoms

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Epidemiology

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  • • Pancreatic insufficiency may be a sequelae of pancreatectomy or pancreatic disease, particularly chronic pancreatitis

    • The principal problems in otherwise uncomplicated pancreatic insufficiency is fat malabsorption, steatorrhea, and accompanying caloric malnutrition, which do not appear until loss of > 90% of pancreatic exocrine function

    • Total pancreatectomy causes about 70% fat malabsorption; if the pancreatic remnant is normal, subtotal resections may have little effect on absorption

    • Pancreatic insufficiency affects fat absorption more than protein or carbohydrate

    • Malabsorption of vitamins is rarely a significant problem; fat-soluble vitamins do not require pancreatic enzymes for absorption

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Symptoms and Signs

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  • • Fat malabsorption and steatorrhea

    • Diarrhea may or may not be present

    • Weight loss may occur from caloric malnutrition

    • Signs and symptoms of underlying disease process (chronic pancreatitis)

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Laboratory Findings

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  • • Exam of a stool specimen for fat globules is specific and relatively sensitive for fat malabsorption

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  • Secretin or cholecystokinin test: Measures HCO3 concentration in pancreatic juice following administration of either secretin or cholecystokinin

    Pancreolauryl test: Fluorescein, release and absorption of which is dependent on pancreatic esterase, is given and urinary excretion is measured

    PABA excretion (bentiromide) test: Bentiromide, cleaved by chymotrypsin to release PABA, is administered and urinary excretion of PABA is measured

    Fecal fat balance test: After ingesting a diet containing 75-100 g of fat, the amount of dietary fat is measured

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  • • Fecal fat determination

    • Other tests of pancreatic exocrine function if diagnosis remains unclear

    • Appropriate diagnosis of underlying disease process

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When to Admit

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  • • Severe malnutrition

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  • • The diet should aim for 3000-6000 kcal/d, emphasizing carbohydrate (400 g or more) and protein (100-150 g); dietary restriction of fat is important mainly to control diarrhea

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Surgery

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Indications

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  • • No surgical intervention indicated

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Medications

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  • • Pancrelipase replacement

    • H2 receptor blockers to retard gastric acid destruction of lipase

    • Medium-chain triglycerides (MCT)

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Complications

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  • • Fat malnutrition

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Prognosis

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  • • Symptoms often improve with pancreatic enzyme replacement

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References

DiMagno EP. Gastric acid suppression and treatment of severe exocrine pancreatic insufficiency. Best Pract Res Clin Gastroenterol. 2001;15:477.  [PubMed: 11403540]
Layer P, Keller J. Pancreatic enzymes: secretion and luminal nutrient digestion in health and disease. J Clin Gastroenterol. 1999;28:3.  [PubMed: 9916657]

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