PEI and Chronic Pancreatitis

About

Chronic pancreatitis is the most common cause of PEI.¹ Chronic pancreatitis has several causes and the inflammation results in the persistent loss of pancreatic tissue and impaired function.² Both endocrine and exocrine tissues are irreversibly damaged.² In patients with chronic pancreatitis, destruction of the pancreatic tissue results in PEI due to the loss of the ability to produce pancreatic enzymes.¹

Epidemiology

The reported incidence of chronic pancreatitis in industrialised countries ranges from 3.5 to 10 per 100,000 people² and increases with age.³ The prevalence is estimated to be from 28.5 to 41.8 per 100,000 people, and is most common in adult males.³ The prevalence of PEI within this patient population varies with severity of chronic pancreatitis, from an estimated 30% in mild cases to 85% in severe cases.³

Causes

Chronic pancreatitis may be caused by environmental, autoimmune, and genetic factors^3:2

Of these, environmental factors are the most common, with excessive alcohol intake accounting for 70-80% of cases.³ Smoking is also a dose-dependent contributing factor to chronic pancreatitis development and progression, especially when combined with alcohol abuse.³

In adults, approximately 10% of chronic pancreatitis cases are idiopathic.³

Pathophysiology

The inflammation in chronic pancreatitis has several pathophysiological characteristics including:⁴

Signs and symptoms

The three main clinical features of chronic pancreatitis and associated PEI are abdominal pain, maldigestion and diabetes.²

Maldigestion, caused by PEI, occurs relatively late in chronic pancreatitis because it only becomes evident when production of digestive enzymes falls below 10% of normal secretion.

PEI causes malabsorption and maldigestion, resulting in symptoms of:^2,7

Steatorrhoea, which is characterized by foul-smelling, greasy stools, is the most classical clinical manifestation of PEI, but may not appear until the disease is advanced.^2,8

Steatorrhoea occurs in about 30% of patients with chronic pancreatitis and may be associated with deficiencies of fat soluble vitamins: A, D, E and K, leading to osteoporosis and other complications.²

Diabetes can be a late-stage symptom of chronic pancreatitis because as well as damage to the exocrine pancreas, endocrine function is also affected. This is categorized as Type IIIc diabetes, and includes destruction of insulin-secreting cells and glucagon-secreting cells.²

Complications

Complications from maldigestion and malabsorption may have a progressive and detrimental effect on a patient’s wellbeing and may impact the outcome of the underlying disease, and increase morbidity and mortality.^9,10 For a full discussion on complications of PEI, CLICK HERE.

Diagnosis

PEI is a late-stage development in patients with chronic pancreatitis, and may be easily diagnosed with specific methods, along with imaging techniques to aid the diagnosis of advanced pancreatitis. It is early pancreatitis that presents a diagnostic challenge.²

Chronic pancreatitis patients with abdominal pain, diarrhea, nutritional deficiencies, and unintentional weight loss should be tested for PEI.²

There are several methods available for diagnosing PEI, with the indirect methods being the most frequently used in the clinical setting. For a detailed discussion of these techniques, CLICK HERE.

Treatment

Pancreatic enzyme replacement therapy (PERT) is the standard treatment for PEI.²

In patients with chronic pancreatitis and associated PEI, PERT has demonstrated benefits in fat absorption, stool frequency and fat content, flatulence, abdominal pain, body weight, BMI, and improvements in quality of life.¹¹

Study design¹¹

A 51-week, open-label extension of a 1 week multicentre, double-blind, randomized, placebo-controlled trial conducted in India enrolled 61 adult patients with chronic pancreatitis and confirmed PEI. Patients received pancreatin (pancrelipase) at a dose of 80,000 Ph. Eur. Lipase units with each of three main meals per day, plus an additional 40,000 units with each snack (up to three per day).

After 51 weeks of pancreatin treatment, patients with PEI due to chronic pancreatitis showed significant improvements compared with baseline in a. stool frequency, b. body weight and c. BMI.