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A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities Samer Alkaade, MD and Ashley A

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A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities Samer Alkaade, MD and Ashley A REPORT A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities Samer Alkaade, MD and Ashley A. Vareedayah, MD Normal Pancreatic Physiology ABSTRACT Positioned next to the duodenum and behind the stomach, the 1 pancreas is an essential part of the gastrointestinal system. The Exocrine pancreatic insufficiency (EPI) is characterized by a deficiency location of the pancreas and its unique cellular organization facilitate of exocrine pancreatic enzymes, resulting in deficits in digestion of all its physiological role in the digestion and absorption of nutrients. macronutrients, with deficiencies in digestion of fats being the most The pancreas is composed of exocrine and endocrine glands; the clinically relevant. The leading cause of EPI is chronic pancreatitis. However, many other causes and conditions may be implicated, including exocrine portion accounts for roughly 85% of the total volume of cystic fibrosis, pancreatic duct obstruction, gastric and pancreatic surgery, the pancreas, whereas the endocrine pancreas represents less than diabetes mellitus and other conditions. Physical and biochemical causes 2%. The remaining pancreatic mass is accounted for by extracellular of EPI include decreased production and secretion of lipase, increased matrix (10%) and ductal cells and blood vessels (4%).2 The exocrine lipase destruction, pancreatic duct obstruction, decreased lipase pancreas is composed of acinar cell clusters and epithelial cells which stimulation and degradation, as well as gastrointestinal motility disorders. EPI is largely diagnosed clinically, and is often identified by symptoms line pancreatic ducts (ductal cells). The pancreatic acini produce such as steatorrhea, weight loss, abdominal discomfort, and abdominal and secrete digestive enzymes which are delivered to the duodenum bloating. Lifestyle modifications (eg, smoking cessation, limiting or and along with bile salts are responsible for the majority of the avoiding alcoholic drinks, and reducing dietary fat intake) and exogenous digestive process within the small intestine. Ductal cells produce pancreatic enzyme supplements are commonly used to help restore large quantities of an alkaline mixture of water and bicarbonate, normal digestion and absorption of dietary nutrients in patients with EPI. which guides enzyme transport through the pancreatic ducts for Am J Manag Care. 2017;23:S203-S209 delivery to the duodenum, as well as providing the optimum pH For author information and disclosures, see end of text. for enzyme activity. Clusters of endocrine cells, or pancreatic islets, make up the endocrine portion of the pancreas.1 The endocrine pancreas is involved in the production of several hormones (ie, insulin, glucagon, somatostatin) that are secreted directly into circulation via the dense network of capillaries associated with pancreatic islets.1 There is no separation of exocrine and endocrine pancreatic components; pancreatic islets are scattered among the pancreatic acini and acinar cells are vascularized through the islet capillaries.1 Thus, disease states which cause malfunction or damage in one of the components of the pancreas may lead to functional defects in the other component.3 Under normal physiological conditions (Figure 11,4,5), the exocrine pancreas post-prandially produces approximately 1.5 L of an aqueous digestive solution that contains 3 main types of enzymes: amylase, protease, and lipase, which aid in digestion of carbohydrates, proteins, and fats, respectively.1,6,7 The relative quantity of these enzymes varies based on multiple factors including diet, age, and gender.6 Pancreatic enzyme synthesis begins during the cephalic phase of digestion, before food reaches the stomach. THE AMERICAN JOURNAL OF MANAGED CARE® Supplement VOL. 23, NO. 12 S203 REPORT brush border.6,8 Lingual and gastric lipases are responsible for fat KEY POINTS digestion in the stomach and hydrolysis continues in the duodenum through the action of pancreatic and gastric lipases. Fat molecules are • The pancreas has an important role in digestion of all 8 macronutrients, but is particularly important in the emulsified by bile salts into micelles and absorbed in the jejunum. digestion of fats. Postprandial fat digestion relies on three critical events facilitated • Exocrine pancreatic insufficiency (EPI) is a condition by the pancreas; disruption in these processes may lead to clinical of deficient exocrine pancreatic enzyme release that manifestations of maldigestion and malabsorption of fat (steatorrhea). may be related to comorbidities such as chronic pancreatitis, cystic fibrosis, pancreatic duct obstruction, Clinical symptoms of steatorrhea are prevented when pancreatic lipase gastric surgery, diabetes mellitus and other conditions. output remains greater than 10% of normal physiological output.3,9 • EPI may occur in relation to biochemical and Postprandial synchrony—the appropriate timing and delivery of physiological features such as decreased production gastric contents into the duodenum and discharge of pancreatic and of lipase, decreased lipase stimulation and production, biliary secretions for digestive action following nutrient intake—is increased breakdown of lipase, pancreatic duct 3 obstruction, and gastrointestinal motility disorders. an essential process in fat digestion and absorption. Additionally, • Common symptoms of EPI may include the acidic contents of the stomach must be neutralized to prevent steatorrhea, weight loss, abdominal discomfort, degradation and allow normal function of pancreatic enzymes.3 and abdominal bloating. • A patient with EPI should generally be treated with Exocrine Pancreatic Insufficiency pancreatic enzyme replacement therapy (PERT). Exocrine pancreatic insufficiency (EPI) is a condition characterized • Lifestyle modification (eg, reducing dietary fat intake) by deficiency of exocrine pancreatic enzymes, resulting in the and PERT are commonly used to help restore normal 10,11 digestion and absorption of dietary nutrients in inability to properly digest fats, carbohydrates, and proteins. The patients with EPI. most common cause of EPI is chronic pancreatitis (CP), followed by cystic fibrosis (CF), which is the most common cause of EPI in children.6 EPI is also associated with a variety of conditions, including pancreatic cancer, pancreatic and gastric surgery, diabetes mellitus, However, pancreatic enzymes are not secreted until the initiation Crohn’s disease, Zollinger-Ellison syndrome, and Celiac sprue.6,9 of the intestinal phase—after food has been converted to chyme EPI commonly leads to fat malabsorption and can manifest as and passed into the duodenum. The intestinal phase controls the a wide spectrum of symptoms, including steatorrhea (fatty, frothy, rate of gastric emptying to ensure that digestive and absorptive loose, greasy, foul-smelling stools), weight loss, abdominal discomfort, processes are appropriately carried out in the small intestine.1 and abdominal bloating.6,12 The enzymatic digestion of carbohydrates When chyme reaches the duodenum, pancreatic secretions are and proteins may also be affected by EPI. Deficiency of amylase and triggered by 2 duodenal hormones: secretin and cholecystokinin protease in EPI is typically masked by the multiple other sources of (CCK).1 Entry of acidic chyme stimulates the release of secretin into these enzymes (salivary, gastric, and small intestine).10,12 Therefore, the bloodstream, which in turn stimulates pancreatic production adequate digestion of proteins and carbohydrates is usually maintained, of an aqueous buffer solution (pH 7.5 to 8.8) containing bicarbonate even with complete loss of pancreatic function. As a result, these insuf- and phosphate ions, from pancreatic ductal cells. The secretion of ficiencies are generally not clinically significant in EPI.10,13 Conversely, this pancreatic fluid enables the activity of pH-sensitive pancreatic extrapancreatic sources for fat digestion by gastric lipase and lingual digestive enzymes by neutralizing acidic chyme. CCK stimulates lipase are unable to compensate for pancreatic lipase deficiency in the production and secretion of pancreatic enzymes from acini, EPI.6,8,12 The clinical manifestations of fat malabsorption with EPI are, and movement of bile from the gallbladder.1,6 Pancreatic enzymes therefore, generally noted earlier than clinical manifestations due to are delivered to the duodenum through the pancreatic duct via deficiencies of other pancreatic enzymes.10 The management of EPI pancreatic fluid, which merges with incoming bile from the liver includes dietary and lifestyle modifications (eg, smoking cessation, and gallbladder to initiate intestinal digestion.1 limiting or avoiding alcoholic drinks, and limiting dietary fat intake), Post-prandial secretions of salivary amylase in the mouth aid as well as pancreatic enzyme replacement therapy (PERT); vitamin in the first steps of carbohydrate digestion; pancreatic amylase and supplementation may also be necessary.9 enzymatic activity from the intestinal brush border continue to break EPI is often under-diagnosed because of its wide spectrum of down carbohydrates, and the digested products are absorbed in the symptoms. The exact incidence and prevalence of EPI is difficult to duodenum. Proteins are hydrolyzed in the stomach by gastric acid determine, due to its multiple causes, and because it is not typically and pepsin, and protein digestion continues in the duodenum via recorded as a medical statistic. The prevalence
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