Internal Medicine

Pancreatic insufficiency

Synonyms in a broader sense

definition

In pancreatic insufficiency (Pancreatic insufficiency) is a disease of the pancreas, which, depending on the form, is associated with a reduced, insufficient production of important digestive enzymes or hormones.

Please also read the article: Underactive pancreas

causes

Pancreatic insufficiency can have various causes, but what they all have in common is that they all destroy the pancreatic tissue. A pancreatic insufficiency (pancreatic insufficiency) is therefore a sequela, not an independent disease.
In adults, the cause of insufficiency is usually chronic inflammation of the pancreas (pancreatitis), i.e. pancreatitis.

Here, the inflammation initially results in an increased release of pancreatic enzymes; this excess of digestive enzymes can lead to the pancreas itself being attacked and in the course of this damage then no longer able to form enzymes or hormones, so it happens to a pancreatic insufficiency.
But it can also be a malignant tumor (pancreatic carcinoma), a cyst (that is, a fluid-filled cavity in the pancreas) or fibrosis may be the cause of pancreatic insufficiency.
Fibrosis is a pathological increase in connective tissue in an organ, hardening and scarring occur and the organ can no longer perform its function; this can also occur in the pancreas. Fibrosis usually occurs in the course of cystic fibrosis, a hereditary disease.
Certain diseases of the gastrointestinal tract such as Crohn's disease and gastric ulcers or autoimmune diseases such as systemic lupus erythematosus can also lead to pancreatic insufficiency.

Symptoms of pancreatic insufficiency

With pancreatic insufficiency (-Pancreatic weakness) there is a deterioration in the function of the cells up to the point of death, which leads to failure of the function.

There is insufficient production of pancreatic enzymes. These enzymes play a major role in the digestion of carbohydrates, fats and proteins. If they are missing, the body is no longer able to break down the food into smaller pieces, which are later absorbed by the intestine and thus can get into the blood and other organs.

Read about this: Functions of the pancreas

It comes to one disturbed digestion, also Maldigestion called. It manifests itself in general symptoms such as nausea, Vomit, convulsive or so-called colicky stomach pain throughout the digestive tract. This means that the pain can be in the upper abdomen area, but also in the entire area of the intestine.

Further consequences of inflammation of the pancreas are Flatulence (also Meteorism called) and Diarrhea.

In the Steatorrhea also "Fatty stools"Called, is one of these diarrhea light brownish glossy color characteristic. This typical image of the stool arises from the inability of the body to digest the fats in the food, so that they leave the body again more or less undigested and thus unused.

Due to the bad digestive situation it comes to its consequence Weight loss, or even with a good nutritional intake to a lack of weight gain.

Furthermore, the fat-soluble vitamins A, D, E and K can no longer be absorbed by the intestine, which leads to further deficiency symptoms in the body.

Insulin production is inadequate or even absent, so that the metabolic situation of a diabetic develops.

Supplied carbohydrates and sugar can no longer be absorbed via the blood by muscles and organs, especially the liver, because the hormone insulin is lacking for absorption.

The consequences are, too high "sugar levels" in the blood and an insufficient supply of energy for muscles and organs.

Corresponding sequelae develop over the years as in normal diabetes: poorly healing wounds, impaired vision or Sensory disorder in the legs.

The glucagon as the antagonist of insulin, which Storage substances the carbohydrates, fats and proteins, if necessary, can convert them into quickly effective energy-producing substances, can also only be formed insufficiently, so that on the other hand it is easy to Hypoglycaemia comes that turn to Difficulty concentrating, States of exhaustion up to unconsciousness being able to lead.

frequency

It is estimated that men are about twice as likely as women by one Pancreatic insufficiency (Pancreatic insufficiency) are affected, the frequency peak is in the age group of 45-54 year olds.

to form

There are basically two forms of Pancreatic insufficiency (Pancreatic insufficiency): One endocrine and a exocrine form.
This can be explained by the fact that the pancreas has two different functions.
On the one hand, it produces the with part of its cells Hormones insulin and Glucagon, which are important for regulating blood sugar levels. If there is a production disruption in the area of these cells, one speaks of one endocrine pancreatic insufficiency (Pancreatic insufficiency)
On the other hand, the pancreas also provides Digestive enzymes and Bicarbonate here, which has an execution passage in the Intestines be handed in.
The digestive enzymes then break down the nutrients absorbed in the intestine so that they can be optimally utilized.
Bicarbonate is a basic substance that is responsible for the neutralization of the by the Stomach acid sour chyme from the stomach is responsible and also ensures that im Small intestine an ideal one PH value is present where enzymes from the intestines can work.
If there is a fault in this area, one speaks of a exocrine pancreatic insufficiency (Pancreatic insufficiency)
Depending on the form of the disease, there are very different symptoms.

diagnosis

Diagnosing a Pancreatic insufficiency (Pancreatic insufficiency), which is provided by the attending physician, is based on various diagnostic pillars.
In any case, a detailed anamnesis should first take place, i.e. a conversation between the doctor and the patient, in which the history of the disease and the existing complaints are discussed in detail.
If the suspicion of pancreatic insufficiency is hardened, then the following should be done
a physical exam and some laboratory tests will be done.
Usually under this Laboratory tests the concentration of enzymes from the pancreas in one Stool sample of the patient determines it is the enzymes Elastase and Chymotrypsin.

Above all, the enzyme elastase is a reliable marker for the entire enzyme production of the pancreas. If the concentration of this enzyme is lowered (<200µg per 100g stool), the diagnosis of pancreatic insufficiency is likely. The enzyme chymotrypsin also reflects the Pankeas function, but is less precise than the enzyme elastase.
This test is also called the fluorescein dilaurate test and is very common.

Read more about:

Chymotrypsin - What Is It Important For?
What is an elastase?

It is also possible to measure the fat concentration in several stool samples from the patient. If the fat content in the stool is persistently increased, this suggests that there is a deficiency in digestive enzymes, which are responsible for the breakdown and thus absorption of the fat from the intestine.
The most reliable laboratory test, however, is the so-called secretin-pancreozymin test. This test also measures the concentration of digestive enzymes from the pancreas (this is about the enzymes amylase and lipase), but not on the basis of a stool sample, but via a probe that is inserted into the patient's duodenum and thus comes to lie where the pancreatic secretions are released into the intestine via the duct.
Unfortunately, this test is very expensive and time-consuming and is rarely carried out despite its reliability.

Read more on the subject at: Lipase level and lipase in the blood.

therapy

The treatment of pancreatic insufficiency (pancreatic insufficiency) aims to eliminate the cause of the pancreatic damage whenever possible, but this is often difficult.
As long as the pancreatic insufficiency cannot be cured, the aim of therapy should always be to ensure normal digestion and absorption of nutrients, to counteract any further deterioration of the condition and possibly to treat the endocrine form of pancreatic insufficiency with insulin therapy.
Since certain food components, especially fats, can no longer be processed particularly well due to the lack of digestive enzymes, you should make sure that you are as low in fat as possible (not fat-free) to nourish, this already represents a relief for the body. The consumption of stimulants such as alcohol should definitely be stopped, as these also attack the pancreas.
It may also be necessary to compensate for the lack of enzyme production by the pancreas by taking enzyme-containing preparations with meals. Such enzyme replacement therapy is recommended if the patient excretes more than 15g of fat in the stool per day.
The enzymes are divided into three classes:

Amylases for breaking down carbohydrates
Lipases for the breakdown of fats
and
Proteases for the breakdown of proteins.

Basically, around 30,000 units of lipase activity must be taken with meals in order to improve fat absorption, but of course the exact dosage depends on the extent of the pancreatic insufficiency and the composition of the food: the richer a meal is, the more enzymes there are needed.
Since the enzymes in their environment require a basic pH value in order to be able to develop their effect, proton pump inhibitors or H2-receptor blockers have to be taken in addition to reduce gastric acid.
If the pain is severe, analgesics are used, and vitamins may also be useful.
If all these possibilities are combined in the best possible way, a considerable improvement in the quality of life is possible, even if the underlying disease cannot be cured.

Can pancreatic insufficiency be curable?

A pancreatic insufficiency is no longer curable. By treating the symptoms well with appropriate medication, some Digestive enzymes contain an adapted diet with the aim of a Weight gain and one adequate energy supply one can act favorably on the course and the severity of symptoms. However, the symptoms will not go away completely.

Furthermore, it has a positive effect on the further course of the disease complete waiver alcohol (a common cause of pancreatic insufficiency) and nicotine.

Diet for pancreatic insufficiency

If there is pancreatic insufficiency, it is advisable to change diet and use individual medication.

Diet for pancreatic insufficiency should aim to relieve symptoms and ensure a good nutritional situation. An improvement in the absorption of nutrients is achieved through substitution (=Replacement of missing materials) by digestive enzymes in the form of drugs.

In the case of clear symptoms such as steatorrhea (= Fatty stools), Gastrointestinal complaints, meteorism and malabsorption are recommended according to guidelines to prescribe pancreatin. Taken this medication up to 6 times a day may reduce symptoms.

To maintain a robust bone and skeletal system, vitamin D should be given in the form of tablets. Vitamin D is significantly involved in building and maintaining the skeleton and can only be insufficiently absorbed by the body in the case of pancreatic insufficiency.

If the symptoms improve through adequate medication, there is an improved absorption of the individual components of the food. So do the carbohydrates. If there is a diabetic metabolic situation, it is important to carry out a close control of the blood sugar and to initiate an adapted insulin therapy.

In general, it is important to reduce the poor intake of the individual food components and to consume a sufficiently high amount of food orally. However, this does not mean avoiding fats or consuming only limited carbohydrates. A better option is to adjust the medication accordingly.

Only in difficult exceptional casesIn the case of non-treatable fatty stools, for example, the intake of fats should be reduced, in return one must pay attention to an increase in proteins and carbohydrates in the diet.
At very pronounced pancreatic insufficiency it may be necessary to get through the diet parenteral ( = „artificial nutrition“) To increase the added additives. There is therefore the possibility of eating so-called high-calorie food. These are drinks that contain many kilocalories in a relatively small volume.
There is also the option of intravenous, gastric tubes or PEG's (percutaneous endoscopic gastrostomy) add more calories in liquid form.

Pancreatic insufficiency and alcohol

Alcohol abuse is one of the leading in Germany Causes of Pancreatic Insufficiency. Excessive alcohol consumption leads to short-term or permanent inflammation of the pancreas in some people and can cause damage. The progression of a pancreatic insufficiency that has developed in this way can usually only be managed by completely abstaining from alcohol. All other forms of therapy are only used to improve symptoms.

Continued consumption of alcohol in the presence of pancreatic insufficiency can have serious consequences. Large amounts of alcohol can die Severely affect digestion. This is dangerous in the long run in people with an insufficient pancreas, as existing digestive problems are exacerbated.
Is it already for sick people diabetes can come, alcohol consumption life threatening become. This is because alcohol lowers the blood sugar level and, if not eaten at the same time, can cause hypoglycaemia with symptoms such as sweating, tremors, difficulty concentrating, loss of consciousness and even death. Since many people with pancreatic insufficiency are addicted to alcohol, a complete abstinence from alcohol must be observed - even one beer can lead to relapse!

Life expectancy

People with a chronic pancreatitis have due to their illness decreased life expectancy.

Mostly because pancreatic insufficiency is associated with other serious illnesses, or because this illness is also the result of other serious underlying illnesses.

An increase in the disease is also found with excessive alcohol consumption, whereby alcohol on its own, after years of drinking, can lead to a reduction in life expectancy due to its possible consequences.

The 10 year survival rate the pancreatic insufficiency is present 50%.

This means that half of the people who suffer from pancreatic insufficiency today will die of their disease in the next 10 years.

Treating the condition through the above measures such as medication, lifestyle adjustments with a healthy diet, and abstinence from nicotine and alcohol can lead to a Forecast improvement contribute to pancreatic weakness. However, a cure can no longer be achieved through these measures.