pancreatic insufficiency

Pancreatic insufficiency: description

The pancreas (pancreas) is located in the upper abdomen, just behind the stomach. It has two basic tasks: First, it produces digestive enzymes (exocrine function). On the other hand, it also produces hormones such as insulin and glucagon (endocrine function). These hormones are involved in blood sugar regulation.

In pancreatic insufficiency, one or both functions may be too weak or may fail altogether. This means that endocrine and exocrine pancreatic insufficiency can occur both independently and simultaneously.

Exocrine pancreatic insufficiency

The pancreas produces about one to two liters of digestive secretions every day. This passes through the pancreatic duct into the duodenum and here supports the digestion of the ingested food: The pancreatic secretion neutralizes the acid gastric acid that has entered the intestine with the food porridge. In addition, the secretion contains enzymes for the digestion of proteins, fats and carbohydrates.

If too little or no digestive enzymes are formed in the pancreas, it is called exocrine pancreatic insufficiency, However, symptoms of this form of illness usually only appear when 90% of the organ function has already failed.

Endocrine pancreatic insufficiency

If the pancreas produces too little or no hormones, it is called endocrine pancreatic insufficiency, Insulin and glucagon are among the best-known pancreatic hormones: both together regulate blood sugar levels:

• Insulin is responsible for the fact that the sugar in the blood (glucose) can be absorbed into the body’s cells – the blood sugar level drops.
• On the other hand, when the body needs more energy (for example, in case of stress or low blood sugar levels), glucagon mobilizes energy reserves in the body – it promotes the release of stored glucose (storage form: glycogen) and the formation of new glucose. This increases the blood sugar level.

Most people with endocrine pancreatic insufficiency have diabetes (diabetes mellitus). With them, the pancreas produces too little or no insulin.

Note: If the sugar level in the blood is too high, this is called hyperglycemia. If it is too low, it is called hypoglycemia.

Pancreatic insufficiency: symptoms

Depending on which region of the pancreas is not working properly, different symptoms appear.

Exocrine pancreatic insufficiency: symptoms

Complaints only occur when about 90 percent of the organ function has already failed.

First and foremost, those with fat digestion experience problems – the dietary fat can no longer be broken down so well Nausea and vomiting can trigger. If the exocrine pancreatic insufficiency is very advanced, the fats contained in the diet no longer reach the intestinal cells sufficiently and are excreted again with the stool. Typical are greasy diarrhea (Fatty stools) with abdominal pain. The droppings then appear greasy shiny and usually smells bad. The stool can also be brightly discolored and liquefied as in diarrhea.

Due to disturbed digestion, people with an exocrine pancreatic insufficiency lose a lot of weightalthough they eat enough.

Another consequence of disturbed fat digestion: The fat-soluble vitamins E, D, K and A can no longer be properly absorbed into the body. That’s how it can be Vitamin deficiencies develop. These in turn cause very own complaints. For example, a strong vitamin K deficiency leads to an increased bleeding tendency.

Due to the insufficient production of the digestive secretion, much undigested food also gets into the colon. There intestinal bacteria decompose the food components with strong gas formation. The result is sometimes very painful flatulence.

An exocrine pancreatic insufficiency often results from repeated inflammation of the pancreas. Therefore, sufferers often notice the symptoms of such pancreatitis: Typical are belt-shaped, radiating to the back pain in the upper abdomen.

Endocrine pancreatic insufficiency: symptoms

In an endocrine pancreatic insufficiency is mainly the normal Sugar metabolism disturbedbecause the pancreas does not produce enough blood sugar regulating hormones.

Becomes Insufficient insulin formed in the pancreas, the circulating in the blood sugar can no longer be absorbed into the cells. This can result in enormously high blood glucose levels (hyperglycemia). The result is complaints, as they are known from diabetes: thirst, frequent urination, fatigue, etc. Insulin deficiency also means that brain cells are not getting enough sugar and therefore energy. As a result, the body produces so-called ketone bodies for energy, which can also be transported into the cells without insulin. The ketone bodies, however, are acidic, that is, they lower the pH in the blood. Thus, a “ketoacidosis” develops with very own complaints (vomiting, thirst, acetone-bad breath, etc.).

When in endocrine pancreatic insufficiency predominantly glucagon is missing, the body can no longer raise a low blood sugar level. This arises, for example, if you have not eaten for several hours. Normally, the glucagon then mobilizes energy reserves in the body to raise blood sugar levels. If this is not possible, severe hypoglycaemia may occur. Typical symptoms are tremor, cold sweat and loss of consciousness. In this situation, glucose must be administered urgently so that there is no shortage of the brain!

Pancreatic insufficiency: causes and risk factors

In most cases, pancreatic insufficiency develops as part of an acute or chronic inflammation of the pancreas (pancreatitis). Occasionally, the cause is the metabolic disease cystic fibrosis, a malignant tumor, or an operation that removes some or all of the pancreas.

In rare cases you can not find a trigger for the disease. Then experts speak of idiopathic pancreatic insufficiency.

Pancreatic insufficiency in inflammation of the pancreas

The pancreas may inflame for various reasons (pancreatitis). One differentiates the acute and chronic inflammation. Acute inflammation is caused in over half of the cases by biliary tract diseases such as constrictions or gallstones. Often, too, excessive alcohol consumption is responsible for the disease. In rare cases, medications (such as estrogens, cyclosporine, HIV medications), abdominal injuries, infections, or genetic disorders trigger acute pancreatitis.

For chronic inflammation of the pancreas is responsible in 80 percent of regular and excessive consumption of alcohol. It is less likely to be caused by drugs, genetic alterations or metabolic diseases that affect lipid metabolism or affect the parathyroid glands. Repeated inflammation of the pancreas (recurrent pancreatitis) gradually damages more and more cells of the pancreas. The result is chronic pancreatic insufficiency.

Pancreatic insufficiency in cystic fibrosis

Cystic fibrosis is a hereditary disease that affects the pancreas as well as the respiratory tract, intestine, liver and biliary tract. A faulty information in the genome leads to a channel in cell membranes (chloride channel) is not formed correctly. This influences important transport and metabolic processes of the cells. In particular, glands in the body in which this channel performs an important function may be impaired – for example, those pancreatic glands that produce the digestive secretions. In those affected the secretion is much more viscous than in a healthy person. It blocks the pancreatic duct. As a result, the digestive enzymes are still activated in the pancreas, causing the organ to become inflamed. First, an exocrine pancreatic insufficiency develops. In the course of the disease, an endocrine pancreatic insufficiency may be added.

Pancreatic insufficiency in tumors or after surgery

For malignant tumors located near the pancreas, some of the pancreas sometimes has to be surgically removed because of its anatomical proximity. This is the case, for example, with certain stomach tumors. Tumors of the pancreas (pancreatic carcinoma) are also partially removed surgically. They can clog the pancreatic duct, through which the digestive secretions enter the duodenum. The juice then builds up and causes inflammation of the pancreas. As a result, pancreatic tissue is destroyed. Surgical removal of tumors further reduces pancreatic tissue. Overall, then the secretion production can no longer be sufficient. If the proportion of functioning tissue shrinks below ten percent, symptoms of exocrine pancreatic insufficiency usually appear.

Pancreatic insufficiency: examinations and diagnosis

The right contact person for suspected pancreatic insufficiency is your family doctor or a specialist in internal medicine. Already by the description of your complaints (anamnesis) the physician receives important information. Possible questions from the doctor could be:

• Do you have oily bowel movements?
• Do you have diarrhea? If so, how many times a day?
• Have you ever had inflammation of the pancreas?
• Do you tolerate fatty foods bad?
• Do you take any medicine?

Physical examination

After the medical history, the doctor will examine you physically if necessary. For this he will listen in particular to the stomach with the stethoscope and gently scan with his fingers. Please tell the doctor if you have abdominal pain or pain in palpation.

The inspection of the skin and the eyes also belongs to the clarification of a possible dysfunction of the pancreas. In fact, in pnakreas diseases yellowing of the skin and eyes may occur (jaundice = jaundice). However, jaundice is not specific to a pancreatic dysfunction! It can also occur, for example, in diseases of the liver (hepatitis) or biliary tract.

Laboratory examination for pancreatic insufficiency

The determination of the enzymes elastase-1, lipase and amylase in the blood can provide evidence of inflammation of the pancreas as the cause of pancreatic insufficiency. Specifically to demonstrate involvement of the pancreas, especially the Activity of pancreatic enzymes (elastase and chymotrypsin) in stool analyzed. This examination of the stool is the most important part of diagnosis in cases of suspected exocrine pancreatic insufficiency.

Very rarely, in addition, a complex test is used in which the secretion production of the pancreas can be measured directly (secretin-pancreozymin test). Since the pancreas does not work continuously, a substance is injected before this examination, which artificially stimulates secretion production. With a probe, which is advanced over the mouth to the duodenum, can then be measured directly, how good the secretion performance of the pancreas is still.

Imaging in pancreatic insufficiency

In the case of exocrine pancreatic insufficiency, imaging is primarily used to discover obvious causes of the disease (tumor, inflammation). A calcification of the pancreas, the doctor can see, especially in computed tomography (CT) well. If such calcifications are visible, chronic pancreatitis probably led to pancreatic insufficiency. The pancreas can also be examined in detail using MRI (magnetic resonance imaging, MRI).

During an endoscopic examination, pancreas stones and changes in the ducts can be assessed well. For this purpose, as with a gastroscopy, a thin tube is advanced through the mouth to the mouth of the pancreatic duct in the duodenum. With a small probe, the physician injects a contrast agent into the pancreatic ducts and makes them so well visible for the X-ray image.

Another method for assessing the pancreas is ultrasound examination (sonography). However, since the pancreas is located quite deep in the abdomen and is usually superimposed by intestinal gases, it can be seen relatively poorly with the sonography. Therefore, ultrasound is more likely to be used in lean patients.

Pancreatic insufficiency: treatment

If an exocrine pancreatic insufficiency is triggered by a specific cause, it should be eliminated first. Thus, stones or bottlenecks in the duct of the pancreas can be treated endoscopically. The examination is similar to a gastroscopy. Stones are removed with a pair of pliers and a small catching basket or crushed and rinsed out. Narrow areas are dilated with a small balloon and then held open with a small tube piece (“stent”).

If the exocrine pancreatic insufficiency persists despite such an intervention, attempts are made to relieve the symptoms and to replace the function of the pancreas. The following therapeutic measures help:

1) Exocrine pancreatic insufficiency: diet

People with exocrine pancreatic insufficiency should divide their food into five to seven small meals a day and avoid as much as possible of fatty foods. In addition, sufferers should completely abstain from alcohol. These dietary measures serve to relieve the digestion and thereby reduce the symptoms. If fatty stools continue to occur despite this diet, the fat content of the diet must be further reduced.

2) Exocrine pancreatic insufficiency: enzyme replacement

If a diet change alone does not improve the symptoms, the enzymes of the pancreas secretion can be replaced. For this purpose, special capsules are taken several times a day. These have an enteric envelope, so that the digestive enzymes contained therein are activated only in the small intestine. The digestive enzymes contained in the drug are mostly derived from the pancreas of slaughtered pigs. But there are also preparations with mushroom enzymes.

Some digestive enzymes can also be produced in the body by other organs such as the salivary gland. So they do not necessarily have to be replaced. Only the fat-splitting enzyme (lipase) must be added to the larger meals. The amount depends on the size and composition of the meal.

3) Exocrine pancreatic insufficiency: vitamin replacement

Vitamins E, D, K, A are liposoluble. This means that they can only be absorbed in the intestine if they are dissolved in fat (“emulsified”). This is only possible if the fats are digested by certain enzymes (lipases). Split fats, together with the fat-soluble vitamins, form a complex (“micelle”) that is not shed to the outside by the polar intestinal wall.

The exocrine pancreatic insufficiency may interfere with sufficient vitamin intake, as insufficient fat-splitting proteins are formed and the fat-soluble vitamins therefore can not be absorbed from the intestine into the blood. For example, serious bleeding can occur due to vitamin K deficiency. A vitamin D deficiency can promote the development of osteoporosis. In severe pancreatic insufficiency (with many fatty stools), the fat-soluble vitamins are therefore artificially supplied with a syringe into the muscle.

Endocrine pancreatic insufficiency: insulin therapy

In endocrine pancreatic insufficiency, the blood sugar level must be checked regularly and, if necessary, artificially supported. If there is an absolute insulin deficiency, this is also called diabetes mellitus type 1. Those affected must inject insulin regularly.

Even if the antagonist of the insulin, the glucagon, is affected by the endocrine pancreatic insufficiency, this increases the risk of life-threatening hypoglycaemia due to insulin administration. This must be taken into account in pancreatic insufficiency treatment.

Pancreatic insufficiency: disease course and prognosis

An existing pancreatic insufficiency is not curable. But you can influence them positively with the right therapy and usually reduce the symptoms to a bearable level. The prognosis depends essentially on whether only one function (exocrine or endocrine) of the pancreas is impaired and what the cause of the disease is. In any case, triggering factors such as alcohol should be avoided as they have a pancreatic insufficiency can worsen.