APP Perspective: EPI in Acute Pancreatitis

Welcome and thank you for watching this video series on navigating the complexities of acute pancreatitis and its long term implications. I’m Dr. Jennifer Geremia, [bio to come] In this video we’ll discuss the following topics: Overview of acute pancreatitis, Exocrine pancreatic insufficiency (EPI), which is a longer-term complication of acute pancreatitis, New data on EPI following acute pancreatitis. Acute pancreatitis is characterized by inflammation of the organ. Damage to the acinar cells in the pancreas results in inappropriate release and activation of trypsin. This activates other digestive enzymes, resulting in autodigestion of the tissue. There are many causes of acute pancreatitis but the most common causes are gallstones and alcohol abuse. In about 20% of patients, patients with acute pancreatitis may develop pancreatic necrosis. There are other consequences of acute pancreatitis, including pain and discomfort, hospitalization (it is the leading GI cause of hospital visits), recurrent episodes of pancreatitis, chronic pancreatitis, endocrine insufficiency leading to diabetes (also called type 3c diabetes), and exocrine pancreatic insufficiency – or EPI – which is the focus of this webinar. EPI is a disorder that occurs when there is a reduction in the quantity, activity, or delivery of pancreatic enzymes to a level below the threshold needed to maintain normal digestion. In AP, there is a loss of ability of acinar cells to produce pancreatic enzymes due to inflammation or necrosis or obstructions in the pancreatic ducts. Suspecting EPI in high-risk conditions, which includes AP as well as other conditions, Classical symptoms include fatty diarrhea, bloating, and weight loss– all symptoms of maldigestion of nutrients. Fatty diarrhea is a sign of later disease when 90% or more of pancreatic function is lost, so earlier EPI may present as normal diarrhea. In clinical practice, stool fecal elastase test (or FE-1) is the most commonly used test to diagnose EPI. And then after a diagnosis of EPI, management of EPI includes pancreatic enzyme replacement therapy, or PERT, so the patient can properly digest food, as well vitamin supplementation, lifestyle modification, and preventative care to monitor for nutrition, diabetes, and bone health. For assessing response to PERT, it is based on clinical presentation and not a repeat FE-1 since the test is not affected by exogenous PERT. Another thing to note that is you may need to readjust the PERT dose if weight changes. The goal of all this is to improve the symptoms of EPI, which can be quite burdensome, and the reduce the risk of long-term consequences of EPI of vitamin and nutrient deficiencies which can lead to osteoporosis, bone fractions, weight loss, surgical complications, and reduced quality of life. A new study was recently published on the prevalence of EPI after an AP attack. Previous studies were mixed about the risk of EPI after an AP attack, when patients are recovering from acute inflammation. This study aimed to study the prevalence and predictors of EPI at 3 and 12 months after AP. It enrolled 85 adult patients who had an acute pancreatitis attack and used fecal elastase to diagnose EPI, which was categorized as mild or severe based on the test results. The study found that more than a third of patients had EPI 12 months after AP. 22% of patients had severe EPI and 12% had mild EPI. More severe AP was associated with greater odds of developing severe EPI, but severe EPI occurred in 13% of patients who have had just one mild AP episode. The authors stated that long-term EPI surveillance after hospital discharge for AP may aid in the early identification of EPI. In our practice, we check FE-1 and Hga1c in high-risk individuals regardless of clinical presentation at month 1 after event, and also months 3, 6 and 12 months while also discussing and revisiting EPI symptoms with the patient. In summary, exocrine pancreatic insufficiency (EPI) is a common consequence of acute pancreatitis, even up to 1 year afterward. More severe AP is associated with greater odds of developing EPI, but EPI can occur in patients who have had just one mild AP episode. Incorporating routine EPI screening in patients with a history of acute pancreatitis can enhance patient care. To learn more about exocrine pancreatic insufficiency, please visit EssentionsofEPI.com