Effects of Deficiency of Exocrine Pancreatic

Secretion

Sajaratul Syifaa’ Binti IbrahimBatch 6

0313887Physiology Seminar ( 16th April 2015)

Products Exocrine Part by of Pancreas

Provide Digestive Enzymes

1. Proteolytic enzymes- Trypsin- Chymotrypsin- Carboxypeptidase

2. Lipid digesting enzymes- Pancreatic lipase- Phospholipase- Cholesterol esterase

3. Pancreatic Amylase

4. Ribonucleases & deoxyribonucleases

Provide Electrolytes

1. Cl- secreted by acinar cells—with small volume of water

2. HCO3- is secreted by ductular

cells–with larger volume of water

Functions of Pancreatic Enzymes• Pancreatic Amylase- The chyme empties from the stomach

- Chyme mixes with the pancreatic amylase

- Carbohydrates → maltose or glucose before passing beyond the duodenum

• Pancreatic Protease‐ The pancreas secretes several proteases (trypsinogen,

chymotrypsinogen and procarboxypeptidase)

‐ Trypsin and chymotrypsin will break down protein → peptides

‐ Carboxypeptidase will split off individual amino acids of peptides

• Lipid Digesting Enzyme‐ Most of triglycerides → monoglycerides & fatty acids by pancreatic

lipase

‐ Cholesterol esterase & phospholipase hydrolyse phospholipids & cholesterol esters → free fatty acids

What is Pancreatic Insufficiency ?

Exocrine Pancreatic Insufficiency (EPI)

Characterized by deficiency of the exocrine pancreatic

enzymes, resulting in the inability to digest and absorb

nutrients from the diet

•MaldigestionImpaired breakdown of nutrients (carbohydrates, protein, fat) to absorbable split-products

•MalabsorptionDefective mucosal uptake and transport of adequately digested nutrients including vitamins and trace elements.

Etiology of Pancreatic Insufficiency

Pancreatitis

- Alcohol drinking- Cystic fibrosis- Gallstones

Pancreatectomy

- Due to pancreatic cancer

- Severe pancreatitis

Overview of Exocrine Pancreatic Insufficiency Symptoms

Exocrine Pancreatic Insufficiency

Steatorrhea

Abdominal Distension

Weight loss

Oedema

Exacerbate motility disorders

Deficiency of vitamin B12

Malabsorption of lipid-soluble vitamins

Diarrhea

Clinical Features of Exocrine Pancreatic Insufficiency

1. Diarrhea - Results from undigested contents settling inside the intestines.- Excessive amounts of solutes tend to retain water inside the intestines

causing diarrhea ( Osmotic Diarrhea )

2. Steatorrhea- Hallmark of malabsorption- Due to excess presence of fat in stools - As a results of deficient amount of pancreatic lipase

3. Malabsorption of lipid-soluble vitaminVitamin Functions DeficiencyA • Components of the visual pigments -

Rhodopsin• Acts as antioxidant to prevent injury to

cellular membrane

• Visions problems• Xeropthalmia - a pathologic

dryness of conjunctiva and cornea

• Skin problems ( scaling skin’ psoriasis and acne)

D • Aids in absorption of calcium and phosphate for bone growth

• Rickets and osteomalacia• Malabsorption lead to secondary

hyperthyroidism

E • Acts as antioxidant which prevents the injury to cellular membrane

• Rarely occur as large amount stored in the adipose tissues

• Neurological disorder may occur

K • Required in the formation of hepatic synthesized blood clotting factors ( II, VII, IX and X) and prothrombin

• Bleeding disorders

4. Abdominal distension‐ Deficiency in pancreatic enzyme secretions lead to poor digestion and

absorption of foods in the duodenum ‐ More undigested food reach the bacteria in the colon‐ The bacteria will react with the undigested contents inside the colons and

cause production of gas

5. Weight loss - Malabsorption cause deficiencies of sugar, fats, proteins and selective

vitamins and minerals. - Lack of nutrients provided to meet the requirements

6. Oedema

Chronic protein malabsorption due

to pancreatic enzyme insufficiency

Decrease the serum albumin

level- Hypoalbuminemia

Loss of protein into the intestinal

lumen

Reduced plasma protein (albumin) in the blood

thus reducing the osmotic pressure- reduces pulling

of fluid into vessels

Enhances retention of fluid in the tissue

space OEDEMA

7. Exacerbate motility disorders

- Exocrine pancreatic insufficiency itself can cause motility disorders. -Maldigestion and malabsorption of lipid and protein may

lead to inability to stimulate the secretion cholecystokinin (CCK) by the I cells of duodenum and jejunum- CCK act as inhibitor of gastric emptying -With the absence of CCK, gastric emptying will be rapid

8 . Deficiency of vitamin B12

‐ When vitamin B12 enters stomach, it binds to Haptocorrin ‐ Haptocorrin and vitamin B12 complex can’t be broken down by

pancreatic enzyme in exocrine pancreatic insufficiency ‐ Vitamin B12 will be unable to bind with intrinsic factors

Megaloblastic Anaemia

- Most pronounced in rapidly dividing cells such as erythropoietic tissue of bone marrow

- Leads to insufficient DNA synthesis in the red blood cell synthesis—vitamin B12

Neurological Manifestations

- Abnormal fatty acids will accumulate and become incorporated into cell membrane including those of the nervous system

Test Confirming Exocrine Pancreatic Insufficiency

1. 72 Hour Fecal Fat Test - Consume diet containing 100 g of fat- For 3-5 days and collect all stool for 72 hours during this period. - Presence of an amount of fat in the stool greater than 7% of the total

amount of fat consumed in the diet during this period is indicative of fat malabsorption

2. 13C-Labelled Mixed Triglyceride Breath Test ( 13C MTG-BT)

• A labelled substrate is given orally together with test meal• After intraduodenal hydrolysis of the substrate by specific pancreatic enzymes, 13C-

marked metabolites are released, absorbed from the gut and metabolized within the liver.

• As a consequence of the hepatic metabolism, 13CO2 is released and thereafter eliminated with the expired air

The amount of 13CO2 expired, which indirectlyreflects the exocrine pancreatic function, can be measured by means of mass spectrometry or infrared analysis

References• Textbook of Medical Physiology, Guyton and Hall ( 11th Edition) Page : 799-802• Textbook of gastroenterology, Tadataka Yamada ( 5th Edition) Page : • Journal of Gastroenterology and Hepatology : Pancreatic exocrine

insufficiency: Diagnosis and Treatment by Enrique Domínguez-Muñoz• http://www.merckmanuals.com/professional/gastrointestinal-disorders/mala

bsorption-syndromes/overview-of-malabsorption• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132852/pdf/ceg-4-055.pdf• http://www.everydayhealth.com/health-report/exocrine-pancreatic-insufficie

ncy/know-the-symptoms-of-epi.aspx• http://emedicine.medscape.com/article/2121028-clinical

Questions • What kind of diet that should be taken for pancreatic insufficient patient

1. Low fat diet as fat is more complex to be digested and it can’t be compensated if there is insufficiency. With taking low fat diet, steatorrhea incidence can be reduced.

2. Include whole grains in your diet as it can bulk up the fatty stool which is the results of malabsorption of fat

3. Milk or any sources of calcium as in exocrine pancreatic insufficiency, patients are not able to absorb calcium due to deficient vitamin D absorption.