The document discusses the pancreas and pancreatic exocrine insufficiency (PEI). It notes that the pancreas has both exocrine and endocrine functions, with the exocrine function secreting digestive enzymes through ducts into the small intestine. PEI occurs when there is a decrease or failure of this exocrine secretion, causing symptoms like fatty stools. Causes include chronic pancreatitis, cystic fibrosis, pancreatic cancer, and surgery. Diagnosis involves stool tests and imaging, while treatment is pancreatic enzyme replacement therapy to supplement deficient enzymes.

2. Basics of Pancreas
Pancreatic Exocrine Insufficiency(PEI)
Diagnosis and Treatment (PERT)

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

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

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

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

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)

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

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

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.