Pancreatic Exocrine Insufficiency

Exocrine  pancreatic  insufficiency  caused  by  pancreatic  resection results from various factors which regulate digestion and absorption of nutrients. However, many aspects of secretion and gastrointestinal adaptation after pancreatic resection are not completely understood. In this paper we will review the current knowledge on these pancreatic pathophysiology aspects and we will also revise the current modalities of  treatment  regarding  pancreatic  exocrine  insufficiency  following pancreatic resection.

The  diagnosis  of  exocrine  pancreatic  insufficiency  is  based  on these  clinical  symptoms  and  the  laboratory  confirmation  by  means of  direct  and  indirect  exocrine  pancreatic  function  tests.  Some  of these  tests  can  be  used  to  determine  the  degree  of  insufficiency.  The most sensitive test is the secretin-CCK or secretin-cerulein test; it has a  double-lumen  tube  capable  of  separately  draining  the  gastric  juice and  the  pancreatic  juice.  The  test  starts  with  pancreatic  stimulation by secretin which produces the hydro-electrolyte pancreatic secretion and  CCK  or  cerulein  which  can  stimulate  enzymatic  secretion. 

This test is highly sensitive and specific  but it is invasive, lengthy and expensive;  moreover,  it  is  possible  only  in  patients  with  a  normal gastrointestinal  tract  and  it  is  not  useful  in  patients  with  an  altered digestive  anatomy  as  in  pancreatic  head  resected  patients.  Fecal chymotrypsin   and   elastase   1   are   more   frequently   used.   In particular, elastase 1 determination is more sensitive and specific than chymotrypsin. The advantage of these tests is that they can be used in patients who have undergone surgery involving the gastro-intestinal tract,  but  they  cannot  reveal  a  mild  degree  of  exocrine  pancreatic insufficiency. 

A  cholesteryl-octanoate  breath  test  is  rarely  used because  of  its  high  cost  and  possible  interference  with  metabolic and  pulmonary  diseases  [20].  Pancreatic  exocrine  evaluation  during magnetic     resonance     cholangiopancreatography     with     secretin administration  is  still  under  study  and  the  results  of  the  published studies seem to be promising [21,22]. Fecal fat determination can be utilized  at  initial  evaluation  and  in  monitoring  lipid  malabsorption therapy.

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Pancreatic Disorder and Therapy