Published in:
01-07-2019 | Chronic Pancreatitis | Editorial
Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: True Association or EPIphenomenon?
Published in: Digestive Diseases and Sciences | Issue 7/2019
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Exocrine pancreatic insufficiency (EPI) is caused by inadequate delivery of pancreatic digestive enzymes to the intestinal lumen, leading to maldigestion. While longstanding chronic pancreatitis (CP) is the most well-known cause, EPI is also very common in patients with pancreatic malignancy, and in those who have undergone pancreatic resection for benign or malignant disease. Less commonly known are a number of additional conditions, which may also have EPI as a consequence (Table 1). One such condition is acute pancreatitis. While clinicians might recognize that EPI could develop after an episode of severe acute pancreatitis (AP) associated with significant pancreatic necrosis, it is becoming more apparent that EPI may occur even in those with less severe episodes of AP. The systematic review and meta-analysis published in this issue of Digestive Diseases and Sciences [1] provide an estimate of the prevalence and predictors of EPI after AP.
Table 1
Some of the causes of exocrine pancreatic insufficiency
|
Etiology
|
Frequency of EPI
|
Comments
|
|---|---|---|
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Chronic pancreatitis
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Dependent on etiology and duration of disease. Occurs in 30–50%
|
Usually requires loss of 90% of exocrine enzyme secretion. Most common in chronic pancreatitis due to genetic causes, alcohol, autoimmune, or smoking
|
|
Cystic fibrosis
|
Nearly universal, from birth
|
|
|
Pancreatic cancer
|
50–90%, depending on location
|
Most frequent with cancer of head of pancreas, with pancreatic ductal obstruction
|
|
Pancreatic resection
|
Variable depending on operation
|
Most common with larger resections, most common after Whipple resection
|
|
Asynchrony after GI surgery
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Roux-en-Y surgeries most common, including gastric bypass
|
While pancreatic enzyme secretion may be normal, inadequate mixing with food can cause maldigestion
|
|
Shwachman–Diamond and Johanson–Blizzard
|
EPI very common, but diseases are rare
|
Genetic syndromes usually detected in childhood
|
|
Acute pancreatitis
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More common with more extensive necrosis and those with alcohol or smoking as etiologies
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Can occur even in the absence of necrosis, and may persist
|
|
Diabetes
|
Reduced fecal elastase common, but EPI rare
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Longstanding diabetes may produce pancreatic damage similar to chronic pancreatitis, termed “diabetic pancreatopathy”
|
|
Zollinger–Ellison syndrome
|
EPI common, but condition quite rare
|
Acid denaturation of pancreatic enzymes
|