Treating Exocrine Pancreatic Insufficiency
The treatment of exocrine pancreatic insufficiency depends on the underlying cause and symptoms present. In patients with chronic pancreatitis, the cardinal symptom is abdominal pain. Pain control can be difficult. Basic strategies include cessation of alcohol, small meals that are low in fat, hydration and smoking cessation. In some patients, using pancreatic enzyme replacement to suppress pancreatic exocrine secretion can relieve pain. It is unclear which patients benefit most from the use of pancreatic enzyme supplementation for pain control, but it is felt that those with less advanced disease, manifested as without involvement of large ducts and without steatorrhea, as well as women, appear to benefit most. When using pancreatic enzyme supplementation, it is important that patients be on acid-suppressing agents such as proton pump inhibitors or H2-blockers , as enzymes can be inactivated by gastric acid secretion. If treatment with pancreatic enzymes fails, other treatment options for abdominal pain in patients with chronic pancreatitis include analgesics. Opiates in combination with low dose amitriptyline have been shown to be effective.
The use of anti-oxidants also has been shown to increase the number of pain free days per month. In patients with chronic pancreatitis who are refractory to treatment with pancreas enzyme supplementation and pain medication, there are other options. One is a celiac nerve block. This is accomplished by injecting alcohol or steroids into the celiac nerve either with a needle through the skin (percutaneously) or endoscopically. Alternatively, as some of the pain in patients with chronic pancreatitis is felt to be related to duct hypertension due to strictures, endoscopic therapy to decompress obstructed pancreatic ducts with pancreatic stents has been shown to improve pain in some patients. Lastly, surgery is an option. Surgical decompression of the pancreatic duct has been shown to be more effective and last longer than endoscopic decompression. Surgical resection usually involves removal of some of the pancreas, rarely the entire pancreas. Resection is usually accompanied by better results when disease is limited to the body and tail of the pancreas. Patients who undergo resection frequently develop exocrine and endocrine dysfunction.
The treatment of pancreatic exocrine insufficiency involves treating the symptoms of severe maldigestion and steatorrhea. Treatment is generally a low fat diet and pancreatic enzyme replacement. Generally restricting fat intake to 20 grams a day or less is sufficient. There are many different types of pancreatic enzymes available.
Studies have shown that in order to correct for malabsorption due to exocrine pancreatic insufficiency, 10% of pancreatic enzyme output must be replaced. This typically will require 30,000 IU of lipase per meal. Typically this will requires 1-3 capsules with each meal, and 1-2 capsules with each snack.
Malnutrition is the main contributing factor to weight loss. Patients with significant steatorrhea will require fat-soluble vitamins. The 25-hydroxylated form of vitamin D is more easily absorbed. Medium chain triglycerides can be used to provide extra calories with weight loss and a poor response to pancreatic enzyme replacement.
While pancreatic supplements are generally safe, prolonged contact with oral mucosa may cause ulcers. This is particularly important in infants with cystic fibrosis, in whom it is essential that the powdered supplements be administered with food, and that the mouth be rinsed after administration.
While patients can never be cured of pancreatic insufficiency, symptoms can be controlled in a majority of patients.
-Dr. Todd Eisner, MD
