What Actually Helps When You Have Pancreatic Exocrine Insufficiency?

The pancreas has two main functions: endocrine and exocrine. The endocrine function regulates blood glucose by releasing glucagon and insulin from the pancreas. The exocrine function releases digestive enzymes (trypsin, chymotrypsin, lipase, amylase) and bicarbonate into the duodenum. The exocrine activity of the pancreas is controlled by both hormonal and neural mechanisms. The presence of acidic chyme in the duodenum stimulates secretin so that pancreas would produce bicarbonate into the duodenum. The presence of fatty acids and amino acids in the duodenum stimulates cholecystokinin to produce pancreatic enzymes and bile into the small intestine. An alkaline chyme in the duodenum is unlikely to stimulate hormones and may reduce production of pancreatic enzymes.

The main contributing factor for this problem is decreased stomach acid or hypochlorhydria. Aside from long-term use of antacids, common eating habits that can reduce stomach acid are drinking liquids with meal, overeating, eating more cooked food than raw foods, stress, and constant snacking. The causes of pancreatic insufficiency are hypochlorhydria, SIBO, and consumption of toxic substances such as tobacco and alcohol. Contributing diseases or health problems are diabetes mellitus, pancreatic adenocarcinoma, biliary stasis, gluten intolerance, adrenal maladaption, hepatitis B or C, and cystic fibrosis. Approximately 20% of patients with celiac disease have pancreatic insufficiency. Steroid hormones and bone mineral density are associated with pancreatic function. A steroid hormone called glucocorticoids upregulate the pancreatic enzyme secretion but chronic exogenous administration of cortisol may lead to pancreatic exocrine dysfunction. Malabsorption of fat-soluble vitamins resulting from pancreatic insufficiency decreases bone mineral density and is considered a contributing mechanism in osteopenia.

There are 2 best screening tests for pancreatic insufficiency: fecal chymotrypsin and pancreatic elastase. These are markers for total pancreatic exocrine output. A result of fecal elastase <200 ug/g signifies pancreatic insufficiency. A patient should discontinue pancreatic enzyme supplements prior to the stool chymotrypsin test.

Treatment options in pancreatic insufficiency include treating gastroparesis, hypochlorhydria, insulin resistance, stimulating the Chapman’s pancreatic reflex, and using pancreatic enzyme supplements. Pancreatic enzyme replacements include pancreatin from porcine pancreas, black mold (Aspergillus niger), papain from papaya, and bromelain from pineapple. Patients with moderate to severe chronic pancreatitis would benefit from selenium supplements.

Hypochlorhydria is the main contributing factor for pancreatic exocrine insufficiency. The acidic chyme that enters into the duodenum stimulates hormones so that pancreatic enzymes will be released for further digestion of macronutrients such as carbohydrates, proteins, and fats. An alkaline chyme cannot stimulate these hormones leading to poor absorption. In contrast, bacterial or toxicant damage to the pancreas can cause hyperchlorhydria because they decrease the release of bicarbonate from the pancreas. As a result, the chyme remains acidic instead of being neutralized to a more alkaline pH, which is necessary for the further digestion of macronutrients.

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