4. Pancreas - gland which lies behind the stomach
It is about 12-15 cm long and 2.5 cm thick
Divided into three parts: the head, body and tail
Connected to the duodenum usually by two ducts
Storage for digestive enzymes
Dual function gland having both endocrine and exocrine functions
ENDOCRINE
Secretion of a substance (a hormone) from gland into
the blood
EXOCRINE
Refers to the secretion of a substance out through
duct. of a gland
5. ENDOCRINE
• Consists of cells called pancreatic islets
• Islets secrete hormones
eg. insulin, glucagon
EXOCRINE
• Consists of cells called acini
• Acini produce pancreatic juice which
contains digestive enzymes
6. Exocrine pancreas secretes about 2 L pancreatic juice daily
Alkaline pH (7.1-8.2)
It contains water, salts, bicarbonates and digestive enzymes
Functions
Helps to neutralize acidic gastric juice
Pancreatic juice contains enzymes like pancreatic proteases, lipase, and amylase
Pancreatic amylase digests carbohydrates, proteases digest proteins and lipase digest fats
Among these lipase is the most important as fat digestion is primarily done by this
enzyme
Gut 2005;54(Suppl VI):vi1–vi28. doi: 10.1136/gut.2005.065946
7.
8. It is a condition in which there is decrease in or failure of pancreatic exocrine secretion
i.e pancreatic enzymes
Symptoms
Steatorrhea (fatty foul smelling stools) - main symptom
Weight loss
Diarrhea
Abdominal pain
Loss of appetite, nutrient malabsorption
Gut 2005;54(Suppl VI):vi1–vi28. doi: 10.1136/gut.2005.065946
9. CAUSES OF PEI
Genetic disorders
- Cystic fibrosis
Pancreatic disorders
-Chronic pancreatitis
-Duct obstruction due to
stones or cancer
-Surgery of pancreas
Gastrointestinal
surgery
Others
-Diabetes
-HIV
10. Gut 2005;54(Suppl VI):vi1–vi28. doi: 10.1136/gut.2005.065946
Pancreatitis: Inflammation of the pancreas
• Acute Pancreatitis: Acute inflammation of the pancreas, usually accompanied by
abdominal pain and elevations of serum pancreatic enzymes
• Chronic Pancreatitis: Long standing inflammation of the pancreas which leads to slow,
irreversible damage to the pancreas
11. Chronic pancreatitis is a condition affecting nearly 0.04% to 5% of the population
worldwide
In chronic pancreatitis patients, PEI has been seen in 22% to 94% patients
Majority of patients have pancreatitis of unknown origin (60% cases)
Alcohol and smoking is an important risk factor
Other risks include intake of high fat diet, gallstones and repeated attacks of acute
pancreatitis
Cochrane Database of Systematic Reviews 2009, Issue .Journal of Gastroenterology and Hepatology 2004;19 (9) : 998 - 1004
12. Symptoms
Pain, fever ,vomiting
Inability to digest food (weight loss and nutritional deficiencies)
Inability to produce insulin (diabetes)
Diagnosis
Suspected by history of severe abdominal pain, weight loss and steatorrhea, USG and
CT scan
Management
Pancreatic enzymes and pain killers as initial medical therapy for pain relief
Surgical management
Stop alcohol consumption
Journal of Gastroenterology and Hepatology 2004;19 (9) : 998 - 1004 Best Practice & Research Clinical Gastroenterology 2006 ;20(3):507–529
13.
14. Ducts are tubes that carry the pancreatic digestive juices to the main pancreatic duct and
the duodenum
Ductal obstruction can occur due to:
- pancreatic cancer
- gallstones
If the tumour blocks the pancreatic duct the pancreatic enzymes may not be secreted in
the required amount
15. Hereditary disease that mainly affects the exocrine pancreas
Thickened secretions from the pancreas block the pancreatic ducts and movement of the
digestive enzymes into the duodenum
Therapeutics and Clinical Risk Management 2008:4(5) 1079–1084
16. Diabetes :
- PEI may be present in approximately 20% -29%of patients with diabetes mellitus
HIV patients:
-Malabsorption of nutrients and fats which can be improved by pancreatic enzyme
supplements in HIV patients
1.Pancreatology 2003;3:395-402
2.Dtsch Arztebl Int 2009; 106(48): 789–94
3.Aliment Pharmacol Ther. 2001 Oct;15(10):1619-25
17.
18. There are few centers where tests for stool fat, stool enzymes are available
Diagnosis is mainly done based on clinical symptoms , stool tests plus imaging
studies
( USG, CT)
Computed Tomography (CT) Scan
Abdominal Ultrasound (USG): Can detect gallstones
Indian J Gastroenterol 2009:28(6):201–205
19. Stool (faecal) fat test
Measures the amount of fat in the stool
> 7 g fat/d in the stool is diagnostic of steatorrhoea ( normal : less than 7 g/day)
Indian J Gastroenterol 2009 :28(6):201–205
Coefficient of fat absorption (CFA)
• Measures amount of fat absorbed by food
• Higher the CFA the better the fat absorption
Coefficient of nitrogen absorption (CNA)
• To evaluate the absorption of proteins
• Higher the CNA the better the protein
absorption
20. Will have some disease of the pancreas OR GI tract
Symptoms of steatorrhea, weight loss, diarrhea, abdominal pain, loss of appetite and
sometimes diabetes
Investigations:
Fat in stools – high
USG/CT scan showing abnormalities of pancreas
Coefficient of fat absorption- low
Coefficient of nitrogen ( protein) absorption- low
21.
22. Symptomatic relief of steatorrhoea, abdominal pain
Decrease in stool fat excretion
Improved quality of life
Best Practice & Research Clinical Gastroenterology 2006 ;20(3):507–529
23. Identify the cause of disorder and treat it
Administration of pancreatic enzymes
Fat soluble vitamins like vitamin A, D, E, and K are needed
Alcoholism and smoking are known risk factors that need to be avoided
A low-fat diet may be useful ( < 20 g/day)
24.
25. Used to replace deficient pancreatic digestive enzymes in the duodenum
Widely accepted therapy of choice for exocrine pancreatic insufficiency of any cause
Useful in the management of PEI in conditions like cystic fibrosis, chronic pancreatitis,
after pancreatic and gastrointestinal surgery
Pancreas 2003; 26: 1–7.
Pancreatic enzyme replacement therapy (PERT) is supplementation therapy containing
pancreatic enzymes like lipase, amylase and protease
26. Helps prevent weight loss and control symptoms such as fullness and diarrhea
Sometimes used for relief of pain
Aliment Pharmacol Ther 2010; 31, 57–72
Pancreatic enzyme replacement therapy should be prescribed with both meals and
snacks
Patient should be instructed to take additional enzymes if a large or fatty meal is eaten
27.
28. PANSTAL capsules are a type of pancreatic enzyme replacement therapy
It contains a mixture of digestive enzymes
Granules are enteric-coated to protect from gastric acid destruction or inactivation
Each capsule contains
Pancreatin (150 mg) which has three types of pancreatic enzymes
Lipase (10,000 PhEur units)
breaks down fats
Amylase (8,000 PhEur units)
breaks down carbohydrates
Protease (600 PhEur units)
breaks down proteins
29.
30. Safe and well-tolerated treatment
Most common side effects were abdominal pain flatulence ,diarrhea & nausea
Other reported complications of pancreatic enzymes include perioral and perianal
irritation in infants, increased uric acid in urine and allergic reactions
N Engl J Med 1997;336:1283-9 http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020725s003lbl.pdf
31. No drug interactions have been identified
Pregnancy and lactation: Should be generally avoided in pregnancy. It is not known if
PANSTAL is excreted in human milk
Pediatric Use: similar to adult patients
32. PANSTAL Capsules are indicated for patients with pancreatic exocrine insufficiency
associated with:
Chronic pancreatitis is the most frequent and relevant indication for pancreatin
supplementation therapy
After pancreatectomy ,gastrointestinal bypass surgery , pancreatic ductal obstruction
Cystic fibrosis
Gut 2005;54(Suppl VI):vi1–vi28. doi: 10.1136/gut.2005.065946
33. When swallowing of capsules is difficult, capsules can be carefully opened and the
contents added to a small amount of low acidic soft food as apple puree, mashed or
pureed bananas or carrots at room temperature
Soft food should be swallowed immediately without chewing and followed with a glass of
water or juice to ensure swallowing
Doses should be taken during meals or snacks, not before or after
Do not take without food
34. Adults and Children Over 6 Years Old
One to two PANSTAL Capsules per meal or snack
Children Under 6 Years Old
Up to one PANSTAL Capsule per meal or snack
35. For smaller meals and snacks 10,000 units of lipase should be used
In case of treatment failure, dosage should be increased two to three times
Because of potential side effects, doses of more than 75,000 units of lipase per meal are
not recommended
Dosage should be adjusted according to the severity of the disease, control of
steatorrhea and maintenance of good nutritional status
Curr Treat Options Gastroenterol. 2003 Oct;6(5):369-374.
Editor's Notes
> 7 g fat/d in the stool is diagnostic of steatorrhea (with treatment generally initiated in patients with symptomatic steatorrhea > 15 g/d), the levels of fat in the stool often exceed 50 g/d in advanced PEI