Symptoms Of Exocrine Pancreatic Insufficiency


What Causes Exocrine Pancreatic Insufficiency In Children

What is exocrine pancreatic insufficiency (EPI) and what are its causes and symptoms?

Cystic fibrosis is the top cause of EPI in infants and children. Children inherit cystic fibrosis from a parent. It causes thick mucus to build up in the lungs, making breathing difficult. Mucus also collects in the pancreas, which keeps digestive enzymes from reaching the small intestine.

Nearly 9 in 10 infants with cystic fibrosis develop EPI within the first year. The rest are at risk for developing EPI during childhood or adulthood.

Another inherited condition, Shwachman-Diamond syndrome , also causes EPI in children. With SDS, the part of the pancreas that makes enzymes doesnt work properly.

Getting Nutrition From Food

The food you eat contains 3 main nutrientsfat, protein, and carbohydrates. Your body uses these nutrients to help give you energy to function.

FAT is found in foods like nuts and cheese.

PROTEIN comes from foods like meat, poultry and fish.

CARBOHYDRATES can be found in bread and pasta. Carbohydrates are broken down into sugars.

If you have EPI, your pancreas cannot properly break down foods, resulting in poor digestion of nutrientsespecially fats. Eating healthy is important for all of us. But its especially important that people with EPI eat a nutrient-rich dietalong with taking pancreatic enzyme replacement therapy with every meal and snacksince EPI interferes with nutrient absorption.

If you have been diagnosed with EPI, you should work with your doctor or nutritionist to make sure that all your dietary needs are being met.

What Can You Expect After An Exocrine Pancreatic Insufficiency Diagnosis

The most common treatment for exocrine pancreatic insufficiency is pancreatic enzyme replacement therapy . This is a prescription oral medication that helps replace your bodys lack of digestive enzymes, according to the Cleveland Clinic.

Heres how it works: Your doctor will recommend a certain amount of PERT based on the results of your lab work. Once you have your prescription, you take PERT with meals to help your body break down the nutrients in the food you eat. I generally recommend that my patients have a full dose of pancreatic enzymes at the beginning of a meal, Dr. Hart says. Its simple that way.

While taking PERT should help you regain any weight you may have lost, your doctor may also recommend that you eat more calories and fat to bridge any other gaps in the meantime, the Cleveland Clinic says. You may also need to take certain supplements to help compensate for possible nutritional deficiencies, which your doctor can help you identify.

Whether youve been diagnosed with EPI or you suspect you might have EPI, Dr. Hart recommends having honest and constant communication with your doctor about your symptoms. Many patients do not feel comfortable discussing GI-related symptoms with their health care providers, but its important, he says. EPI is highly treatable and manageable. Were a team and well work together.

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How Do We Test For Exocrine Pancreatic Insufficiency

Myth: Routinely checking for EPI in patients with chronic diarrhea, using fecal elastase, is a useful and effective diagnostic approach with values 100200 g/g of stool reflecting mild to moderate pancreatic insufficiency and 100 g/g of stool indicating severe EPI

Expert opinion: Routinely checking for EPI in patients with chronic diarrhea, using fecal elastase, is unreliable in the absence of testing a formed stool

A multitude of tests for EPI have been developed over the past several decades and classified as direct versus indirect measures of exocrine pancreatic function. However, many of these have poor sensitivity or specificity and/or are available at only limited centers such as with the 13C mixed triglyceride breath test.

Treatment Of Exocrine Pancreatic Insufficiency

What Is Exocrine Pancreatic Insufficiency?

Myth: PERT should be started at the lowest dose available and taken any time before a meal and at bedtime

Expert opinion: Titrate the dose of PERT to the presumptive degree of PERT and administer PERT with the first bite of a meal, and consider adding extra enzymes during or towards the end of the meal

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Pancreatic Enzyme Replacement Therapy

As evidence for nutritional deficiencies in patients with PEI with and without symptoms has increased in recent years, PERT is now increasingly regarded as a treatment for maldigestion rather than a way to suppress diarrhea in patients with CP. The goal of PERT is stated to be the elimination of maldigestion in the Australasian Pancreatic Club recommendations. Meanwhile, the Spanish Pancreatic Club regards any clinical or nutritional deficiency in a CP patient as an indication for PERT, and the Italian Association for the Study of the Pancreas states in its guidelines that PEI is an indication for PERT.

There are no studies investigating the long-term effects of PERT on morbidity and mortality from PEI, which should be kept in mind if patients with no or minimal symptoms of PEI are considered for PERT.

Is It Possible To Treat Epi

Highly digestible, low fat diets together with pancreatic enzyme replacement will usually stabilize the condition. Cobalamin supplementation may be considered by your veterinarian when hypocobalaminemia is documented. Treatment is usually for the rest of the dog’s life. If elevated folate levels are detected indicating an overgrowth of bacteria in the small intestine, then an antibiotic called tylosin may be prescribed.

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What Are Pancreatic Enzyme Pills What Do They Do

Pancreatic Enzymes are extracts from pig pancreas. They are given as a pill that you take with your meal. They can be enteric-coated or non-enteric-coated. These enzymes can improve protein and fat absorption. This can reduce digestive symptoms in children and adults with EPI. The enzymes work in the digestive system. Their goal is to mimic the function of the pancreas during the process of digestion.

Diagnosing Pancreatic Exocrine Insufficiency

Exocrine Pancreatic Insufficiency

The symptoms of PEI are often similar to other gastrointestinal illnesses, which can make diagnosis difficult. However, since PEI is caused by other ailments, your physician can establish if it is likely that you have PEI based on your medical history. They will ask you questions about your current symptoms and history, then perform diagnostic tests if they suspect PEI, or if they wish to rule out other diseases or disorders.

Stool tests: your physician will provide you with a container and ask you to collect a stool sample when you are able to, which you will then return to their office or directly to the lab. Then, lab technicians analyze the sample. There are two types of stool tests your physician might order. The first one is the fecal elastase test, which looks for the quantity of an enzyme called elastase in the stool. Those with PEI often have lower levels of elastase in their stool than individuals without PEI. The second type is a fecal fat test, which lets your physician learn how much fat is in your stool. This can show them how well youre absorbing fats.

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What Causes This Pancreatic Insufficiency

The causes can be congenital , inherited , or acquired as the result of pancreatic infection, inflammation, or injury. The condition is seen more commonly in Chow Chows, Cavalier King Charles Spaniels, Rough-Coated Collies, and German Shepherd Dogs.

The main cause appears to be a progressive loss of pancreatic cells but chronic pancreatitis can also result in EPI.

Pancreatic Exocrine Insufficiency Causes

PEI does not occur on its own, but rather is a consequence of pancreatic damage. Causes of this damage include chronic pancreatitis, alcohol abuse, pancreatic cancer, type 1 diabetes, genetic disorders such as cystic fibrosis or Shwachman-Diamond syndrome, inflammation from digestive diseases such as Crohns disease or celiac disease, or as a complication from surgery on the pancreas or nearby parts of the digestive tract. To learn more about chronic pancreatitis, contact us and ask for our free Pancreatitis pamphlet.

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Clinical Findings Of Exocrine Pancreatic Insufficiency In Dogs And Cats

Exocrine pancreatic insufficiency due to pancreatic acinar atrophy is most frequent in young adult German Shepherds but has also been described in Rough Collies and Eurasians. Dogs and cats with EPI due to other causes are usually middle-aged to older and can be of any breed. Clinical signs most commonly reported are polyphagia, weight loss, and loose stools. Vomiting and anorexia are observed in some patients and may be a sign of concurrent conditions rather than EPI itself. The feces are most commonly pale, loose, and voluminous and may be malodorous. In rare cases, watery diarrhea may be seen. In a small portion of cats with EPI, the high fat content of the feces can lead to a greasy appearance of the hair coat, especially in the perianal and tail region.

Use Of Perts For Chronic Pancreatitis Pain

What is Exocrine Pancreatic Insufficiency?

Only Viokace, which exists only in quick release form, may help reduce chronic pancreatitis pain. Other PERTs have shown NOT to be effective for pain, although they are effective for enzyme insufficiency.

Viokace has worked best in young women without a dilated pancreatic duct on CT or MRI scans. A normal dose is three tablets with each meal with an acid blocker.


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Diagnosis Based On Symptoms Blood Tests And Imaging

Symptoms in patients with PEI vary, depending on the degree and etiology of PEI. The classical clinical picture is a patient presenting with foul-smelling, loose stools, weight loss, muscle wasting and flatulence. Advanced tests of pancreatic exocrine function can usually be avoided in patients with a well-established CP diagnosis based on morphological findings and a clear clinical picture of PEI. A trial of pancreatic enzyme replacement therapy based only on the clinical picture is recommended by several national societies when the clinical presentation is strongly suggestive of PEI. However, only relying on symptoms may lead to both the over- and under-diagnosis of PEI. Diarrhea and weight loss may be due to conditions other than PEI, and PEI can also be present in the absence of overt steatorrhea.

How Is Exocrine Pancreatic Insufficiency Managed Or Treated

EPI is a lifelong condition. Treatments focus on getting your body the nutrients it needs to maintain good health. Treatments include:

  • Pancreatic enzyme replacement therapy: This prescription medication is a substitute for the missing digestive enzymes. You take PERT with meals to help your body break down nutrients in food.
  • High-calorie, high-fat diet: Its important to get enough calories and fat with your meals. Fat helps your body absorb nutrients. You may benefit from working with a dietitian.
  • Vitamins: You may need to take prescription vitamins to help your body maintain healthy nutrient levels. Your provider may prescribe vitamins A, D, E and K. People with EPI have a harder time absorbing these fat-soluble nutrients from food.

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Digestive Symptoms Of Epi

Since EPI affects digestion and absorption, its no surprise that it can lead to a number of uncomfortable gastrointestinal symptoms. These can range in severity from mild to extremely painful.

According to the AGA, digestive symptoms of EPI include:

  • Thinning hair or hair that falls out easily
  • Swollen or cracked tongue

When food isnt properly absorbed, a number of vitamin deficiencies can develop. Deficiencies in important vitamins and minerals can lead to a number of health problems.

World Journal of Gastroenterology

Signs & Symptoms Of Pancreatic Exocrine Insufficiency

Exocrine Pancreatic Insufficiency

You may not have any symptoms at first. But once your pancreas gets so damaged that it starts to negatively affect your ability to absorb fats, you may experience the following:

  • Pain or tenderness in your belly
  • Foul-smelling bowel movements
  • Gas and bloating
  • You might also lose weight among other things, because your body doesnt absorb enough vitamins. For instance, you could develop a bleeding disorder if youre not getting enough vitamin K. Or you could get bone pain if you dont get enough vitamin D.

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    Definition And Diagnosis Of Pei

    Statement 1.1: PEI is defined as a reduction of pancreatic exocrine activity in the intestine at a level that prevents normal digestion

    There is now agreement across pancreatic societies, globally, for this definition. The most common cause of PEI is CP due to loss of functioning pancreatic parenchyma and reduced secretion. Although PEI due to loss of functioning pancreatic parenchyma is also the result of pancreatic cancer, pancreatic resections and CF, other mechanisms exist. Decreased secretion can result from duct obstruction , or secondary causes, such as reduced endogenous stimulation and postprandial asynchrony .

    Statement 1.2: Although the coefficient of fat absorption is regarded as the gold-standard diagnostic test for PEI, we recommend that the faecal pancreatic elastase test is a suitable first-line test for PEI

    Diagnosis Of Pancreatic Exocrine Insufficiency

    The gold standard for the diagnosis of PEI is three-day fecal fat quantification and determination of the coefficient of fat absorption. A major drawback of fecal fat quantification is that the test is cumbersome and unpleasant for both the patient and laboratory personnel. The patient is required to keep a strict diet, with 100 g of fat per day for five days, and to collect the complete volume of feces for three days. Laboratory personnel need to handle large volumes of feces. Therefore, this test is very rarely performed in daily clinical practice and is only available at few specialized centers. Several alternative methods for the diagnosis of PEI have been proposed.

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    Dietary Management And Lifestyle Changes

    Fat malabsorption is the predominant cause of the symptoms of pancreatic steatorrhea resulting in weight loss as well as deficiencies of fat-soluble vitamins A, D, E, and K. In patients with chronic pancreatitis, a low fat diet has been the recommendation in order to minimize the pain of this disease and, in conjunction with PERT, to effectively treat steatorrhea. However, in patients with CF, a high fat diet in conjunction with increased amounts of PERTs has been shown to improve the associated CF lung disease and thus low fat diets are no longer advocated in this disease. Fat soluble vitamins A, D, E, and K should be supplemented if indicated, and taken with PERT . Consulting a dietitian is helpful to assess nutritional adequacy . In addition, smoking has been proven to be a risk factor in acute pancreatitis, chronic pancreatitis, pancreatic cancer , and to be associated with reduced exocrine pancreatic function . Therefore, smoking and alcohol cessation is recommended in EPI due to chronic pancreatitis.

    Research And Statistics: How Many People Have Exocrine Pancreatic Insufficiency

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    Clinical and Experimental Gastroenterology

    For example, about 60 to 90 percent of people with cystic fibrosis will develop EPI within the first 10 to 12 years of diagnosis, the study authors report. People with chronic pancreatitis have a 30 to 90 percent chance of developing EPI, while unresectable pancreatic cancer causes EPI in 20 to 60 percent of patients, according to the report.

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    When To See A Doctor/go To The Hospital

    Early detection of EPI yields a good prognosis for better management of the disease. If you have any of the common symptoms of EPIbloating and flatulence, abdominal pain, diarrhea, or foul-smelling stool that can be difficult to flushdo not hesitate to seek medical attention.

    While other warning signs can be too subtle for you to notice, it is especially important to discuss EPI with your healthcare provider if you have a family history of the disease or if you have underlying gastrointestinal issues that contribute to EPI. EPI can occur in both adults and children.

    Treatment Of Exocrine Pancreatic Insufficiency In Dogs And Cats

    • Supplementation with digestive enzymes and cobalamin

    Most dogs and cats with exocrine pancreatic insufficiency can be successfully treated by supplementation with pancreatic enzymes. Powder is more effective than tablets, capsules, and especially enteric-coated products. Initially, 1 teaspoon/10 kg should be given with each meal for dogs and 1 teaspoon/cat with each meal for cats. Once the clinical signs have completely resolved, the dose can be slowly decreased until the lowest effective dose has been reached. However, it should be noted that the lowest effective dose can vary between enzyme batches. Oral bleeding has been reported in 3 of 25 dogs with EPI treated with pancreatic enzyme supplements the bleeding stopped in all three dogs after a dose reduction. Moistening the food and pancreatic powder mix may also decrease the frequency of this adverse effect.

    Fresh pancreas may be a viable alternative to the use of powder 1â3 oz of raw chopped pancreas can replace 1 teaspoon of pancreatic extract. Raw pancreas can be kept frozen for several months without loss of enzymatic activity. Preincubation of the food with pancreatic enzymes or supplementation with bile salts is not necessary.

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    Diagnosis Of Pancreatic Insufficiency

    Pancreatic insufficiency is suspected in a patient who develops diabetes, upper abdominal pain and features of malabsorption. Bowel movements classically are bulky, loose and foul smelling because of their oily nature, they may float in the toilet bowl, and are difficult to flush.

    Simple investigations used to diagnose chronic pancreatitis include:

    • an abdominal X-ray
    • stools collected and analyzed for high fat content
    • endoscopic ultrasound

    Occasionally, the pancreas becomes so chronically inflamed that a scarred mass may develop which can be difficult to distinguish from pancreatic cancer.

    Can Pancreatic Insufficiency Be Cured

    How is exocrine pancreatic insufficiency (EPI) diagnosed?

    Theres no cure for exocrine pancreatic insufficiency , a chronic condition characterized by an inability to digest certain nutrients, especially fat. But EPI can be managed with a type of medication called pancreatic enzyme replacement therapy , which consists of enzymes that aid digestion.

    How can I get more enzymes in my pancreas?

    Eat more fruits and vegetables Eating fresh and seasonal fruits and vegetables can be helpful for the health of your pancreas. Including fruits and veggies in your diet automatically provides pancreas with digestive enzymes.

    Which disease is related to a malfunctioning pancreas?

    With repeated bouts of acute pancreatitis, damage to the pancreas can occur and lead to chronic pancreatitis. Scar tissue may form in the pancreas, causing loss of function. A poorly functioning pancreas can cause digestion problems and diabetes.

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