Exocrine Pancreatic Insufficiency: Seen but Not Recognized?

David A. Johnson, MD


May 21, 2014

In This Article

Pancreatic Insufficiency: Possible Causes

What causes this?

The differential when you approach a patient with chronic pancreatic insufficiency includes chronic pancreatitis, clearly the most common cause.

We see pancreatic insufficiency in patients who are alcoholic and particularly in smokers, but a variety of things can aggravate this risk as well, such as surgical changes or anything that obstructs the pancreatic duct. In younger people, cystic fibrosis is a common cause of chronic pancreatitis and pancreatic insufficiency.

A variety of autoimmune-related causes are increasingly recognized, including autoimmune pancreatitis and IgG4-related consequences. Even Crohn's disease can have an autoimmune component with pancreatitis. Chronic pancreatic insufficiency should not be forgotten in a patient with Crohn's disease.

We have also seen this in celiac disease. It is estimated that up to one third of patients with celiac disease may have some degree of pancreatic insufficiency. It's something to think about when a patient does not respond to a gluten-free diet. It may not be "refractory sprue" that is causing diarrhea; in fact, it may be a sign of pancreatic insufficiency.

Clinical Presentations

What are the clinical presentations of pancreatic insufficiency?

There are several possible presentations.

The classic presentation is patients who come in with malnourishment and steatorrhea, the foamy, fatty stools that float in the toilet bowl water.

Anything that aggravates malabsorption can cause the patient to have symptoms.

Malabsorption of the fat-soluble vitamins (A, D, E, and K) can lead to night blindness, metabolic bone disease, abnormal coagulation profiles, and neurologic dysfunction. We have seen impaired biotin absorption in a patient with seizures that was related to chronic pancreatic insufficiency.

A variety of things must be considered when you expand the net and think about pancreatic insufficiency.


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