Pancreatic insufficiency (also called exocrine pancreatic insufficiency, or EPI) is a condition in which people are unable to properly digest food due to a deficiency of the exocrine pancreatic enzyme.
If there is an underlying condition that is causing pancreatic insufficiency, and that condition is able to be successfully treated or managed, that may cure the resulting pancreatic insufficiency. Otherwise, pancreatic insufficiency can often be managed by correcting nutritional deficiencies and use of pancreatic enzyme replacement therapy.
Treatment for pancreatic insufficiency includes:
- Lifestyle modifications
- Vitamin supplementation
- Primarily with fat-soluble vitamins A, D, E, and K
- Pancreatic enzyme replacement therapy (PERT)
- This is the mainstay of treatment
- They should be taken with meals and snacks because they are intended to act on ingested foods so gastric emptying of nutrients occurs at the same time as the pancreatic enzymes reach the duodenum
- Pancreatic enzyme products (PEPs): pancrelipase (Creon, Pancreaze, Pertzye, Ultresa, Viokace, Zenpep)
- PEPs are not interchangeable
What Are Symptoms of Pancreatic Insufficiency?
Symptoms of pancreatic insufficiency include:
- Fat in stools
- Bulky stools that float in the water and are difficult to flush
- Stools may appear pale and oily
- Stools may be foul-smelling
- Weight loss
- Diarrhea (may be watery)
- Fatigue
- Gas (flatulence), which may cause abdominal cramping
- Abdominal distention
- Fluid retention/swelling (edema)
- Swelling of extremities
- Buildup of fluid in the lower abdomen (ascites)
- Anemia due to malabsorption of iron or vitamin B-12
- Bleeding disorders due to vitamin K malabsorption
- Metabolic bone disease due to vitamin D deficiency, which can result in osteopenia or osteomalacia, and in severe cases, bone pain and fractures
- Neurologic manifestations due to electrolyte disturbances (e.g., low calcium and low magnesium)
- Generalized motor weakness due to malabsorption of pantothenic acid and vitamin D
- Numbness and tingling of extremities due to malabsorption of thiamine
- Loss of a sense of vibration and position due to malabsorption of cobalamin
- Night blindness due to malabsorption of vitamin A
- Seizures due to malabsorption of biotin
What Causes Pancreatic Insufficiency?
Pancreatic insufficiency has both pancreatic and non-pancreatic causes.
Pancreatic causes of pancreatic insufficiency include:
- Chronic pancreatitis (the most common cause)
- Cystic fibrosis
- Obstructions of the pancreatic duct (e.g., from pancreatic cancer or ampullary tumors)
- Diabetes
- Shwachman-Diamond syndrome (SDS), a rare genetic disorder
Non-pancreatic causes of exocrine pancreatic insufficiency include:
- Autoimmune pancreatitis
- Celiac disease
- Crohn’s disease
- Gastrointestinal and pancreatic surgical procedures
- Zollinger-Ellison syndrome
How Is Pancreatic Insufficiency Diagnosed?
In addition to a patient history and physical examination, tests used to diagnose pancreatic insufficiency include:
- Blood tests
- Complete blood count (CBC)
- Electrolytes
- Erythrocyte sedimentation rate (ESR)
- Iron, vitamin B-12, and folate concentrations
- Nutritional markers (e.g., magnesium, albumin, prealbumin)
- Antigliadin and antiendomysial antibody levels
- Immunoglobulin A (IgA) levels
- Stool tests
- Fecal elastase and chymotrypsin (2 proteases produced by the pancreas)
- Tests of malabsorption
- Bile salt absorption test
- C-D-xylose breath test
- Carbohydrate absorption test
- D-xylose test
- Fat absorption tests
- Schilling test (for vitamin B-12)
- Pancreatic function tests
- Direct testing
- Endoscopy
- Dreiling tube method after stimulation with secretin or cholecystokinin (CCK)
- Secretin test
- CCK test
- Secretin-CCK test
- Direct testing
- Indirect testing
- Fecal fat analysis
- Measurement of fecal elastase and fecal chymotrypsin levels
- Abdominal imaging tests
