Editors

MarkkuPeräaho

Pancreatic Insufficiency

Consider pancreatic exocrine dysfunction as a cause of chronic diarrhoea.
Abstinence and diet are the treatments of choice. In advanced cases pancreatic enzyme substitution is required.
Determine fasting blood glucose regularly to detect diabetes caused by endocrine insufficiency.

Chronic pancreatitis Chronic Pancreatitis is the most common cause.
Carcinoma of the pancreas Carcinoma of the Pancreas
Extensive resection of the pancreas
Pancreatic trauma
Hereditary diseases
- Hereditary pancreatitis
- Cystic fibrosis Cystic Fibrosis (CF)
Undernutrition

Fat malabsorption
- Diarrhoea
- Weight loss
- Postprandial abdominal pain
- Voluminous foul-smelling stools
Diabetes
- Chronic pancreatitis is associated with impaired glucose tolerance but actual diabetes is a late complication.

Serum cholesterol concentration is typically remarkably low.
Serum albumin is decreased.
Hypocalcaemia (real)
Blood glucose concentration is increased in 50% of the patients.
Serum alkaline phosphatase concentration is increased if the patient has biliary obstruction or deficiency of vitamin D.
Pancreatic function tests show abnormal results (serum trypsin and pancreatic amylase concentrations are normal or slightly increased, secretin-stimulated pancreatic bicarbonate secretion is low).
Faecal elastase I determination is useful in the diagnosis of moderate or severe pancreatic dysfunction.
Investigations for pancreatic dysfunction should be performed if the cause of diarrhoea and malabsorption is not evident on the basis of the patient's history (alcoholic pancreatitis, pancreatic carcinoma).

Total abstinence from alcohol
Treatment of undernutrition prevents complications.
Meals are divided into several servings, and sufficient energy content of the meals is ensured.
Only 30-40% of total energy should come from dietary fats.
- In patients with cystic fibrosis Cystic Fibrosis (CF), the prevention of malnutrition is a primary goal, and fat consumption should not be restricted (diet with 35 to 40% of calories from fat is recommended) 2.
High intake of carbohydrates
Proteins 1-1.5 g/kg body weight/day

Pancreatic enzymes should be given if the patient has
- abdominal pain
- low body weight
- steatorrhoea.
Treatment
- Sufficient amount of lipase (25 000-40 000 units) in association with the main meal, with snacks 10 000 units
- The dose can be increased up to 2-3-fold, but not over 75 000 units.
- The enzymes are taken together with the food.

Should be considered if adequate nutritional state cannot be maintained with diet and pancreatic enzyme preparations.

Deficiency of vitamin D may develop. Deficiencies of vitamins A, E, and K are rare.

Insulin and glucagon deficiencies are typical.
Ketosis is rare.
Periods of hypoglycaemia Hypoglycaemia in a Patient with Diabetes are common.
Vascular complications are rare.
The daily requirement of insulin is usually 20-30 units. Even a small dose should be divided in two because of the risk of hypoglycaemia.

Yankaskas JR, Marshall BC, Sufian B, Simon RH, Rodman D. Cystic fibrosis adult care: consensus conference report. Chest 2004 Jan;125(1 Suppl):1S-39S. [PubMed]