Symptoms of Exocrine Pancreatic Insufficiency
The symptoms of exocrine pancreatic insufficiency typically do not develop until the pancreas has lost 80-90% of its exocrine function. The most common symptoms are weight loss and steatorrhea. If there is a history of chronic pancreatitis, patients will likely have chronic abdominal pain, and when the abdominal pain is accompanied by weight loss and steatorrhea, the diagnosis of exocrine pancreatic insufficiency should be suspected. In severe steatorrhea, patients will pass oily, greasy stools and even droplets of oil. In the absence of severe steatorrhea, most patients will only pass 3 to four stools a day and do not complain of severe abdominal cramps. Some patients may have an overgrowth of intestinal bacteria that can further potentiate the abdominal cramping. In the absence of abdominal pain, weight loss may take a long time to develop, as patients frequently will increase their caloric intake unless the abdominal pain limits the amount of food intake.
The physical examination is typically normal in patients with exocrine pancreatic insufficiency. Patients may still appear well nourished, and may only experience mild abdominal tenderness to palpation. In advanced cases with steatorrhea, severe weight loss may be evident. Rarely, patients with pancreatic exocrine insufficiency can have pancreatic pseudocysts or pancreatic cancer, that may result in a palpable abdominal mass.
Basic laboratory tests in patients with exocrine pancreatic insufficiency are typically normal. White blood cell count, as well as levels of the pancreatic enzymes amylase and lipase will typically be normal. In a patient with a pancreatic pseudocyst or with superimposed acute inflammation, there may be an elevation in white blood cell or amylase but this is typically not the case. Liver enzymes are typically normal, unless there is compression of the bile duct by the pancreas, which will usually result in an elevation of alkaline phosphatase and bilirubin. If there has been significant weight loss and malnutrition, serum albumin and calcium levels may be decrease. Stool will be positive for fat when about 60% of pancreas function is lost, even in the absence of steatorrhea, which as above typically requires loss of 80-90% of pancreas function. The presence of significant steatorrhea can be confirmed by a 72 hour measurement of stool fat excretion, while the patient consumes a diet that contains 100 grams of fat each of the three days. If more than 7 grams of fat are excreted per day, that is diagnostic of steatorrhea.
Finally, as pancreatic exocrine insufficiency is typically associated with chronic pancreatitis, patients will typically complain of abdominal pain.
-Dr. Todd Eisner, MD
