Brief overview
- Course and prognosis: Often progressive in chronic pancreatic disorders, but symptoms often do not appear for many years; not curable, but treatable
- Symptoms: In exocrine form, nausea, vomiting, diarrhea, fatty stools, weight loss, flatulence; in endocrine form, typical symptoms of diabetes
- Causes and risk factors: Usually acute or chronic inflammation of the pancreas, operations and tumors on the pancreas, certain metabolic diseases
- Diagnosis: Physical examination, activity of pancreatic enzymes in stool, blood values, ultrasound and other imaging techniques
- Treatment: Adapted low-fat diet, alcohol abstinence, replacement of missing pancreatic enzymes, supply of missing vitamins, in case of endocrine insufficiency insulin therapy
What is pancreatic insufficiency?
The pancreas is located in the upper abdomen, just behind the stomach. It has two basic jobs: First, it produces digestive enzymes (exocrine function). Second, it also produces hormones such as insulin and glucagon (endocrine function). These hormones are involved in the regulation of blood sugar.
Exocrine pancreatic insufficiency
The pancreas produces about one to two liters of digestive secretions daily. This reaches the duodenum via the pancreatic duct and here supports the digestion of the ingested food: the pancreatic secretion neutralizes the gastric acid that has entered the intestine with the food pulp. The secretion also contains enzymes for the digestion of proteins, fats and carbohydrates.
If the pancreas produces too few or no digestive enzymes, doctors speak of exocrine pancreatic insufficiency. Symptoms of this form of the disease usually only appear when 90 percent of the organ’s function has already failed.
Endocrine pancreatic insufficiency
If the pancreas produces too few hormones or none at all, doctors refer to this as endocrine pancreatic insufficiency. Insulin and glucagon are among the best-known pancreatic hormones. Together, they regulate blood glucose levels:
- Insulin is responsible for ensuring that the sugar (glucose) in the blood is absorbed into the body’s cells – the blood sugar level drops.
Most people with endocrine pancreatic insufficiency suffer from what is known as diabetes mellitus, because the pancreas produces too little insulin or none at all.
If the sugar level in the blood is too high, it is called hyperglycemia. If it is too low, it is called hypoglycemia.
Is pancreatic insufficiency curable?
The course of pancreatic insufficiency depends on the causes. For example, while the pancreas often recovers completely from a mild acute pancreatitis, the risk of pancreatic insufficiency increases with a severe course of the disease. This is especially true for endocrine pancreatic insufficiency.
Chronic pancreatic inflammation (chronic pancreatitis) leads to a progressive loss of exocrine and endocrine functions. In this process, exocrine dysfunction usually precedes endocrine dysfunction. However, this too usually only becomes noticeable when the tissue has already been largely destroyed.
An already existing pancreatic insufficiency cannot be cured. However, it can be positively influenced with the right therapy and the symptoms can usually be reduced to a tolerable level. The prognosis depends mainly on whether only one function (exocrine or endocrine) is impaired and on the underlying cause of the disease. Some diseases that lead to pancreatic insufficiency may affect life expectancy. These include pancreatic cancer (pancreatic cancer), for example. However, there is no general answer to the life expectancy of patients with exocrine or endocrine pancreatic insufficiency and corresponding concomitant diseases.
In any case, affected persons should avoid triggering factors such as alcohol, as they aggravate pancreatic insufficiency.
Symptoms of pancreatic insufficiency
Depending on which region of the pancreas is no longer working properly, pancreatic insufficiency will show different symptoms.
Symptoms of exocrine pancreatic insufficiency
First and foremost, fat digestion causes problems for those affected – the intestine is no longer able to break down dietary fat effectively, which may trigger nausea and vomiting.
If exocrine pancreatic insufficiency is very advanced, the fats contained in the food no longer reach the intestinal cells sufficiently and are excreted again in the stool. Typical symptoms are greasy diarrhea (fatty stools) with abdominal pain. The stool appears greasy and shiny and usually smells foul. Sometimes the stool is also brightly discolored or thin as in diarrhea.
Because of impaired digestion, people with exocrine pancreatic insufficiency often lose a lot of weight even though they eat enough. Another consequence of impaired fat digestion: the body no longer absorbs the fat-soluble vitamins E, D, K and A properly. This is why a vitamin deficiency often develops. A vitamin deficiency, in turn, causes its own set of symptoms. For example, a severe vitamin K deficiency leads to an increased tendency to bleed.
Exocrine pancreatic insufficiency often results from repeated inflammation of the pancreas. That is why those affected often notice the symptoms of such pancreatitis: typical are belt-shaped pains in the upper abdomen radiating to the back.
Symptoms of endocrine pancreatic insufficiency
In endocrine pancreatic insufficiency, sugar metabolism in particular is disturbed because the pancreas produces too few hormones that regulate blood sugar.
If the pancreas does not produce enough insulin, the cells are no longer able to absorb the sugar circulating in the blood. As a result, enormously high blood sugar levels (hyperglycemia) are possible. The result is symptoms that are also familiar from diabetes, such as thirst, frequent urination or fatigue.
If glucagon is predominantly missing in endocrine pancreatic insufficiency, the body is no longer able to compensate for a too low blood glucose level. This occurs, for example, when a person has not eaten for several hours. Normally, glucagon then mobilizes the body’s energy reserves to raise the blood glucose level. If this is not possible, severe hypoglycemia may occur. Typical symptoms include tremors, cold sweats and loss of consciousness. Some people report symptoms such as fatigue or night sweats in connection with pancreatic insufficiency. However, these are not typical of pancreatic insufficiency.
Pancreatic insufficiency: causes and risk factors
In most cases, pancreatic insufficiency develops in the context of acute or chronic inflammation of the pancreas (pancreatitis). Occasionally, the cause is the metabolic disease cystic fibrosis, a malignant tumor, or surgery in which part or all of the pancreas has been removed.
Pancreatic insufficiency in inflammation of the pancreas.
The pancreas becomes inflamed for various reasons. Doctors distinguish between acute and chronic pancreatitis. Acute inflammation is caused in more than half of the cases by diseases of the bile ducts such as stenosis or gallstones. Often, excessive alcohol consumption is also to blame for the disease. In rare cases, medications (for example, estrogens, cyclosporine, HIV medications), abdominal injuries, infections, or genetic disorders trigger acute pancreatitis.
Regular and excessive consumption of alcohol is responsible for chronic inflammation of the pancreas in 80 percent. Less frequently, it is caused by medications, genetic changes or metabolic diseases that affect fat metabolism or the parathyroid glands. In cases of repeated inflammation of the pancreas (recurrent pancreatitis), more and more cells of the pancreas are gradually damaged. The result is chronic pancreatic insufficiency.
Pancreatic insufficiency in cystic fibrosis
In affected individuals, the secretion is much more viscous than in a healthy person. As a result, it clogs the pancreatic duct. As a result, the digestive enzymes are not first activated in the intestine, but still in the pancreas, so that the organ digests and inflames itself to a certain extent. The first thing that develops is exocrine pancreatic insufficiency. As the disease progresses, endocrine pancreatic insufficiency may also develop.
Pancreatic insufficiency in tumors or after surgery
In the case of malignant tumors located near the pancreas, it is sometimes necessary to surgically remove part of the pancreas because of the anatomical proximity. This is the case, for example, with certain stomach tumors or tumors of the pancreas itself.
Pancreatic insufficiency: examinations and diagnosis
The right person to contact if pancreatic insufficiency is suspected is the family doctor or a specialist in internal medicine. The description of the symptoms (anamnesis) already provides the physician with important information. During the conversation, the doctor may inquire whether the person affected:
- has greasy, shiny stools
- Has diarrhea, and if so, how often a day
- @ Has ever had inflammation of the pancreas
- Does not tolerate fatty foods well
- Takes medication
Physical examination
After taking a medical history, a physical examination is performed if needed. During this, the doctor listens to the abdomen with a stethoscope and palpates it carefully.
Clarification of a possible pancreatic dysfunction also includes inspection of the skin and eyes. Pancreatic disorders may cause yellowing of the skin and eyes (jaundice). However, jaundice is not specific to a functional disorder of the pancreas! It also occurs, for example, in diseases of the liver (hepatitis) or the bile ducts.
Laboratory testing for pancreatic insufficiency
Another test for diagnosing pancreatic insufficiency is to determine the activity of pancreatic enzymes (elastase and chymotrypsin) in the stool. This stool examination is the most important part of the diagnosis of suspected exocrine pancreatic insufficiency.
Blood glucose levels (fasting glucose and HbA1c) provide information on whether endocrine pancreatic insufficiency may be present.
Imaging for pancreatic insufficiency
Another method of assessing the pancreas is ultrasound examination (sonography). However, since the pancreas lies quite deep in the abdomen and is usually covered by intestinal gases, it is relatively difficult to see with sonography. Endo-sonography is therefore often used as a supplement. Here, the physician inserts a small ultrasound head via the esophagus into the stomach in order to assess the neighboring organs from there.
During an endoscopic examination, the physician may assess whether pancreatic stones and changes in the excretory ducts are present. To do this, he pushes a thin tube through the mouth to the mouth of the pancreatic duct in the duodenum, as in a gastroscopy. Using a small probe, the physician injects a contrast medium into the pancreatic ducts, making them easily visible for x-ray imaging.
Is pancreatic insufficiency treatable?
If exocrine pancreatic insufficiency has a specific cause, it is important to eliminate this cause if possible. For example, stones or narrowing in the pancreatic duct can be treated endoscopically. The procedure is similar to a gastroscopy. The doctor removes the stones with forceps and a small basket, or he crushes them and flushes out the debris. He dilates constrictions with a small balloon and then inserts a small tube (“stent”) to keep them open.
Diet
People with exocrine pancreatic insufficiency should divide their diet into five to seven small meals per day and avoid fatty foods as much as possible. In addition, affected individuals should completely avoid alcohol. These dietary measures serve to relieve the digestive system and thus reduce the symptoms. If fatty stools continue to occur despite this diet, it is advisable to further reduce the fat content of the diet.
Enzyme replacement
If a change in diet alone does not lead to an improvement in symptoms, the enzymes of the pancreatic secretion can be replaced. To do this, patients take special capsules several times a day. These have an enteric coating so that the digestive enzymes they contain are not activated until they reach the small intestine. The digestive enzymes contained in the drug usually come from the pancreases of slaughtered pigs. Religions that reject the consumption of pork also usually permit the use of such drugs.
Vitamin substitute
Vitamins E, D, K, A are fat-soluble. This means that the body only absorbs them in the intestine if they are dissolved (“emulsified”) in fat. However, this is only the case if the fats are also broken down by certain enzymes (lipases). The broken down fats, together with the fat-soluble vitamins, form a complex (“micelle”) that easily enters the intestinal cells.
Exocrine pancreatic insufficiency may interfere with adequate vitamin absorption because of insufficient fat-cleaving enzymes. In severe pancreatic insufficiency (with many fatty stools), it is therefore important to supply the fat-soluble vitamins artificially by injection into the muscle to prevent deficiency manifestations.
Insulin therapy
In the case of endocrine pancreatic insufficiency, the affected person should check his blood glucose level regularly. If the insulin deficiency leads to diabetes mellitus type 1, it is necessary to support the sugar metabolism with medication. Affected persons then have to inject insulin regularly.