Enhance your next patient visit.
Download resources to help elevate your next telemedicine or in-person patient visit
The major hormonal stimulus that causes pancreatic digestive enzyme secretion is the release of cholecystokinin (CCK) from the duodenum.6-8
The pancreatic enzymes are comprised of7:
Bicarbonate alkalinizes intraluminal duodenal pH and prevents inactivation of the enzymes. When nutrients arrive in the proximal small bowel, the pancreatic enzymes begin to break them down.6,7
EPI may result in:
EPI leads to an inability to digest food properly, with fat maldigestion being the most profound.
Malabsorption of fat soluble vitamins A, D, E, and K may accompany EPI.
EPI-related maldigestion and malabsorption can lead to malnutrition and weight loss.
GASTROINTESTINAL (GI) SYMPTOMS7
EPI can lead to GI symptoms due to undigested and unabsorbed food. Steatorrhea, the most common clinical manifestation of EPI, may not occur until the disease is advanced. Yet, there may be significant maldigestion and malabsorption without overt steatorrhea.
References: 1. Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013;19(42):7258-7266. 2. Röder PV, Wu B, Liu Y, Han W. Pancreatic regulation of glucose homeostasis. Exp Mol Med. 2016;48:e219. 3. Gorelick FS, Jamieson JD. Structure-function relations in the pancreatic acinar cell. In: Johnson LR, ed. Physiology of the Gastrointestinal Tract. 4th ed. Burlington, MA: Elsevier Academic Press; 2006:1313-1335. 4. Pandol SJ. The Exocrine Pancreas. San Rafael, CA: Morgan & Claypool; 2011. 5. Molina PE. Endocrine pancreas. In: Molina PE, ed. Endocrine Physiology. 4th ed. New York, NY: McGraw-Hill; 2013:163-186. 6. Fieker A, Philpott J, Armand M. Enzyme replacement therapy for pancreatic insufficiency: present and future. Clin Exp Gastroenterol. 2011;4:55-73. 7. Alkaade S, Vareedayah AA. A primer on exocrine pancreatic insufficiency, fat malabsorption, and fatty acid abnormalities. Am J Manag Care. 2017;23(suppl 12):S203-S209. 8. Chandra R, Liddle RA. Neural and hormonal regulation of pancreatic secretion. Curr Opin Gastroenterol. 2009;25(5):441-446. 9. Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut. 2005;54(suppl 6):vi1-vi28. 10. Ferrone M, Raimondo M, Scolapio JS. Pancreatic enzyme pharmacotherapy. Pharmacotherapy. 2007;27(6):910-920. 11. Domínguez-Muñoz JE. Pancreatic enzyme therapy for pancreatic exocrine insufficiency. Curr Gastroenterol Rep. 2007;9(2):116-122. 12. Lindkvist B, Phillips ME, Domínguez-Muñoz JE. Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: prevalence and diagnostic use. Pancreatology. 2015;15(6):589-597. 13. Durie P, Baillargeon JD, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin. 2018;34(1):25-33. 14. Pezzilli R, Andriulli A, Bassi C, et al; Exocrine Pancreatic Insufficiency collaborative (EPIc) Group. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian Association for the Study of the Pancreas. World J Gastroenterol. 2013;19(44):7930-7946. 15. Borowitz D, Baker SS, Duffy L, et al. Use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis. J Pediatr. 2004;145(3):322-326. 16. Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology. 1994;107(5):1481-1487. 17. Sandhu BS, Hackworth WA, Stevens S, Bouhaidar DS, Zfass AM, Sanyal AJ. Recurrent flares of pancreatitis predict development of exocrine insufficiency in chronic pancreatitis. Clin Gastroenterol Hepatol. 2007;5(9):1085-1091. 18. Kempeneers MA, Ahmed Ali U, Issa Y, et al. Natural course and treatment of pancreatic exocrine insufficiency in a nationwide cohort of chronic pancreatitis. Pancreas. 2020;49(2):242-248. 19. Matsumoto J, Traverso LW. Exocrine function following the Whipple operation as assessed by stool elastase. J Gastrointestinal Surg. 2006;10(9):1225-1229. 20. Yuasa Y, Murakami Y, Nakamura H, et al. Histological loss of pancreatic exocrine cells correlates with pancreatic exocrine function after pancreatic surgery. Pancreas. 2012;41(6):928-933. 21. Phillips ME. Pancreatic exocrine insufficiency following pancreatic resection. Pancreatology. 2015;15(5):449-455. 22. Sabater L, Ausania F, Bakker OJ, et al. Evidence-based guidelines for the management of exocrine pancreatic surgery. Ann Surg. 2016;264(6):949-958. 23. Partelli S, Frulloni L, Minniti C, et al. Fecal elastase-1 is an independent predictor of survival in advanced pancreatic cancer. Dig Liver Dis. 2012;44(11):945-951. 24. Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. A prospective assessment of the natural course of the exocrine pancreatic function in patients with a pancreatic head tumor. J Clin Gastroenterol. 2014;(48)5:e43-e46. 25. Subramaniam S, Nobar N, Besherdas K. Pancreatic enzyme replacement therapy in chronic pancreatitis and pancreatic cancer--are we getting it right? Gut. 2016;64(Suppl 1):A1-A584. 26. Belyaev O, Herzog T, Chromik AM, Meurer K, Uhl W. Early and late postoperative changes in the quality of life after pancreatic surgery. Langenbecks Arch Surg. 2013;398(4):547-555. 27. Halloran CM, Cox TF, Chauha S, et al. Partial pancreatic resection for pancreatic malignancy is associated with sustained pancreatic exocrine failure and reduced quality of life: a prospective study. Pancreatology. 2011;11(6):535-545. 28. Roeyen G, Jansen M, Ruyssinck L, et al. Pancreatic exocrine insufficiency after pancreaticoduodenectomy is more prevalent with pancreaticogastrostomy than with pancreaticojejunostomy. A retrospective multicenter observational cohort study. HPB (Oxford). 2016;18(12):1017-1022. 29. Tran TCK, van ‘t Hof G, Kazemier G, et al. Pancreatic fibrosis correlates with exocrine pancreatic insufficiency after pancreatocoduodenectomy. Dig. Surg. 2008;25(4):311-318. 30. Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function. Br J Surg. 2014;101(2):109-113. 31. Hollemans RA, Hallensleben NDL, Mager DL, et al. Pancreatic exocrine insufficiency following acute pancreatitis: systematic review and study level meta-analysis. Pancreatology. 2018;1-10. 32. Huang W, de la Iglesia-Garcia D, I Baston-Rey, et al. Exocrine pancreatic insufficiency following acute pancreatitis: systematic review and meta-analysis. Dig Dis Sci. 2019;64(7):1985-2005. 33. Xu Y, Wu D, Zeng Y, Wang X. Pancreatic Exocrine function and morphology following an episode of acute pancreatitis. Pancreas. 2012;41(6):922-927. 34. Capurso G, Traini M, Picicchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Experimental Gastroenterol. 2019;12:129-139. 35. Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017;23(39):7059-7076. 36. Jasdanwala S, Babyatsky M. Crohn’s disease and acute pancreatitis: a review of literature. J Pancreas (Online). 2015;16(2):136-142. 37. Piciucchi M, Capurso G, Archibugi L, Delle Fave MM, Capasso M, Delle Fave G. Exocrine pancreatic insufficiency in diabetic patients: prevalence, mechanisms, and treatment. Int J Endocrinol. 2015;1-7. 38. Chaudhary A, Domingues-Munoz JE, Payer P, Lerch MM. Pancreatic exocrine insufficiency as a complication of gastrointestinal surgery and the impact of pancreatic enzyme replacement therapy. Dig Dis. 2020;38(1):53-68.