Pancreatic Insufficiency

• • Associated with chronic pancreatitis and extensive pancreatic resections

  • Fat malabsorption and steatorrhea are the principal symptoms

Epidemiology

• • 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

Symptoms and Signs

• • 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)

Laboratory Findings

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

• • 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

• • Fecal fat determination

  • Other tests of pancreatic exocrine function if diagnosis remains unclear

  • Appropriate diagnosis of underlying disease process

When to Admit

• • Severe malnutrition

• • 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

Surgery

Indications

• • No surgical intervention indicated

Medications

• • Pancrelipase replacement

  • H2 receptor blockers to retard gastric acid destruction of lipase

  • Medium-chain triglycerides (MCT)

Complications

• • Fat malnutrition

Prognosis

• • Symptoms often improve with pancreatic enzyme replacement

References