Pancreatic Insufficiency & Exocrine Pancreas Dysfunction
During a consult when there is a problem with digestion I mentally follow a piece of food from the mouth down the digestive tract to the other end and muscle test each anatomical feature as the food passes. Wherever the energy is blocked, my fingers will release letting me know what part of the digestive tract needs work. Many times “Exocrine Pancreas” will come up. Not an insulin problem, but a challenge with the body digesting certain foods.
These clients, over time, learn to be very patient, are often forgiving, and eventually develop a keen intuition in what will and won’t work for their system. I enjoy being a part of their healing team and like to think I can speed things up a bit for them in finding a balance for themselves or their pets.
Did you know that a human body makes up to a gallon of saliva a day?
So let’s take a look at pancreatic insufficiency shall we?
Pancreatic insufficiency has been associated with cystic fibrosis, Shwachman-Diamond Syndrome or SDS (a rare congenital disease affecting the skeleton), Type 1 diabetes and sometimes pancreatic cancer.
Dog breeds associated with Exocrine Pancreatic Insufficiency include German shepherds (most cases involve this breed actually), Rough Collies, Cavalier King Charles Spaniels, Chow Chows and Picardien Shepherds. The symptoms and treatments are nearly the same as for humans except that often dogs will be coprophagic (meaning they eat their own and other animal’s feces). Affected dogs also have poor hair coats and their feces are often yellow-gray with an oily texture.
Some symptoms of pancreatic insufficiency include malassimilation (mal = bad) which encompasses malabsorption, maldigestion and malnutrition. Vitamin deficiencies, weight loss (or inability to gain weight in children) and steatorrhea (loose, fatty, foul-smelling stools) are common. Chronic pancreatic problems are associated with lowered absorption of fats so fat-soluble vitamins may need to be supplemented.
Symptoms of Carbohydrate Malassimilation include: Flatulence, diarrhea, floating stools, increased borborygmus (sounds of the gut) and abdominal distention. Some of the gas absorbs into the system creating an excess of hydrogen in the lungs and this can be detected with the hydrogen breath test. As the body continues to be chronically deprived of carbohydrates due to improper assimilation, the body will also present with decreased plasma insulin levels, increased glucagon and cortisol levels and decreased conversion of T4 to T3 thyroid hormones (so then you’ll have symptoms of hypothyroidism!) Eventually you’ll lose muscle and fat mass. Patients are weak and easily fatigued both physically and mentally.
Symptoms of Fat Malassimilation include: Weight loss, malnutrition, diarrhea, fat in the feces, oxalate crystals in the urine, calcium oxalate kidney stones and fat-soluble vitamin (A,D,E and K) deficiency symptoms are also present in patients who do not digest fats properly. Symptoms may include bleeding disorders, follicular hyperkeratosis (define), nervous system demyelination, rickets, and osteopenia.
Symptoms of Protein Malassimilation include: Edema, decreased muscle mass, recurrent or severe infections, growth retardation in children, mental apathy and irritability, weakness, hair loss, deformed skeletal bones, anorexia, vomiting and diarrhea.
Exocrine pancreatic insufficiency over time can lead to the formation of:
- Yeast overgrowth
- Food allergies
- Leaky gut
- Immune dysfunction
- Protozoal and other parasitic infections
Of course this is just one tiny component of digestive disorders, and that’s one reason why the medical profession has such a difficult time diagnosing these kinds of problems.
So let’s follow a bolus of food from the stomach into the intestinal tract:
In the stomach food is mixed with stomach secretions to make chyme, a milky, murky semi fluid or paste. The duodenum (first part of the small intestine) determines how much chyme is emptied from the stomach at a pace which shifts and changes depending on the degree of digestion so that it can be absorbed by the small intestine. Food (chyme) in the duodenum stimulates release of hormones (secretin and others) which regulates the nerve reflexes to notify the brain that digestion is happening.
In part, acidity of the food going into the duodenum (less than pH3.5) is responsible for preventing the stomach from releasing more chyme into the intestine until it’s ready for the next little batch. This emptying speeds up though when too much food enters the stomach too quickly. It’s all a very complex, interrelated and a very intriguing system.
Emptying of the stomach also slows when there is excess of fluid in the chyme (like when a person drinks too much fluid with a meal) or if they chyme contains substances that irritate the mucosal membrane of the small intestine.
In the stomach the food is mixed with hydrochloric acid, mucous, pepsinogen and intrinsic factors depending on what you just put into your mouth. Stretching and some foods (meat and some fats) stimulate the release of gastrin, a stomach hormone which helps regulate hydrochloric acid.
Because Blood Type A people don’t produce the same amounts of hydrochloric acid as some of the other blood types, they don’t have the ability to digest animal based protein as well.
Alcoholism and people who form stones can also be prone to this disease (5-15% of alcoholics suffer with pancreas problems).
Fats also slow the digestive processes by attaching to specific receptors farther down the small intestine. Fats influence certain cells to release hormones that go to the brain telling the body that it needs to stop eating. This hormone is called cholecystokinin (CCK).
Once in the small intestine the blob of food (called a bolus) passes through the intestine causing the inside of the lumen to stretch. This stretching activates a process called peristalsis. Peristalsis is the movement of food through the digestive tract and it happens in waves. The action acts to move and mix the food. Normally the wave frequency is 12/minute in the first part of the intestine and slows to 8-9/minute in the end of the small intestine.
This whole process of digestion is under parasympathetic nervous control. When it’s time to eat the parasympathetic nervous system takes over and in perfect coordination helps release saliva, mucous, digestive juices and moves the stuff through the intestine. It’s also responsible for getting blood to the center of the body so it can take the nutrition being absorbed by the small intestine to the other body parts.
This is the reason why so many people tell you not to eat when you’re upset or agitated. Upset stimulates the sympathetic nervous system so that the food digestive processes would be postponed which would cause fermentation of what you ate and a sore belly, cramps and bloating.
It takes about 3-5 hours for food to pass from the mouth to the ileocecal valve located on the lower right quadrant of the abdomen (about an inch above and an inch over towards the belly button). Chocolate, iceberg lettuce and hot spicy foods sometimes cause the ileocecal valve to spasm which blocks the passage of your meal to the large intestine. This can cause some bloating and sometimes the valve won’t relax until another meal is eaten which stimulates the process all over again.
Sometimes you can get that valve to relax by just gently putting steady pressure on that spot and holding the pressure for 2-4 minutes.
Each part of the body is highly regulated and interactive with the other organs of the body at all times. Now, when the cecum (the first part of the large intestine that connects to the last part of the small intestine) is irritated it also blocks the ileocecal valve from emptying. There go those stretch receptors and bloating again.
What irritates the cecum? Well, improper foods, some drugs, feces in the large intestine for too long a time, viral and bacterial diseases, parasites, food allergies and yeast are a few things.
Can you see how important it is for your intestines to be healthy? This is just digestion. The gut is also responsible for much of your immune functions.
Enter the pancreas: Now the pancreas makes enzymes for digesting proteins, carbs and fats. Some of these are trypsin, chymotrypsin, carboxypolypeptidase, amylase, lipase, cholesterol esterase and phospholipase. These enzymes split the proteins and carbohydrates into chunks and little pieces and the fats into smaller particles.
The pancreas also makes lots of bicarbonate to neutralize the acid of the stomach which makes up the chyme. How does it know to release which enzymes at the right times? Somehow the pancreas knows which enzymes to release when and the fantastic thing is that these enzymes are often pre-enzymes which are only activated into enzymes depending on the components or other factors they come into contact with in the digestive tracts. If some of these enzymes were activated in the pancreas they would just eat the entire organ up.
If the pancreatic duct becomes blocked or if the enzymes pool in the pancreas and can’t get out we see acute pancreatitis—just mentioning this because during the holidays dogs occasionally get into the trash and eat big portions of turkey fat or other fats which can cause the blocking of the duct. Very serious stuff. It can and has killed many a pet dog and permanently disabled many a pancreas as the self-digestion will destroy the tissue so that it can’t produce the correct amounts of enzymes forever after the event.
Many dogs with pancreatic insufficiency also have Small Intestinal Bacterial Overgrowth (SIBO). The most commonly recommended antibiotics for this condition are tylosin (Tylan), metronidazole (Flagyl) and tetracycline, although there are reports of a number of other antibiotics helping.
Simple Tests to determine the presence of Exocrine Pancreatic Dysfunction:
As a veterinarian by trade in small towns we learn to make do with less. Because of this, we often depend on simple diagnostics and techniques to give us clues for treating cases. Even though we may refer our clients to a teaching facility or specialist eventually, many of our clients can’t afford this type of experience for their animal. A good quality microscope is an essential piece of equipment for these types of cases, especially when the diagnostic process is just beginning-even in human medicine. I’m including these tests because anyone with a microscope and a little knowledge could probably do these tests at home.
Some of these tests are:
Fecal fat (fat in the stool) is often the first sign of pancreatic insufficiency. The simplest test for fecal fat is to place a suspension of stool onto a glass slide, add a fat stain (Sudan stain), or a couple drops of acetic acid to the slide then boil it with a heat source and count the globules. More than ten globules is considered abnormal. A 24-hour collection and lab evaluation is more accurate to determine the volumes of fecal fat, but the fecal fat smear is a good starter test. If you’re evaluating a dog, then you may want to test another dog eating the same diet as a control.
Starch Test: Stain a fecal smear with Iodine. The starch will show up as blackish blue structures with blue-green fringes. Increased starch may indicate amylase deficiency (which means you are not doing a very good job digesting carbohydrates.)
Protein Test: Prepare a fecal smear. Before staining it with anything to do the other tests look at it under the microscope. If the body is not digesting protein you’ll be able to see undigested muscle fiber (they have blunt ends and prominent cross striations). Seeing protein in the stool suggests a protease deficiency. Protease enzymes include trypsin, chymotrypsin and carboxypeptidase A and B. This means that there is a problem in the duodenum signifying that the mucosal membranes are not producing the enterokinase enzymes needed to convert trypsinogen into trypsin.
X-Ray Film Digestion Test for Protease Enzymes: This test is performed by mixing one part feces with 9 parts of 5% Sodium Bicarbonate solution in a test tube. A strip of x-ray film (you can use developed film if you have some) is inserted into the tube and allowed to sit at room temperature for 2 ½ hours. X-ray film is coated with an emulsion of gelatin. If the gelatin on the x-ray film has been dissolved after that time (it will turn clear) there is fecal protease activity (which is good).
If the film looks the same, then there may be pancreatic exocrine dysfunction. This test has some false positives and negatives and is not the best test, but I just fielded a call from a doctor in China the other day and he told me they don’t always have the ability to do all the testing that Americans do and was asking me how to identify (faster) certain pathogens so that he could help his patients.
Theoretically, a person could actually do this test at home and if it was positive then could get further testing done with their doctor to confirm the results. Another rough and slightly more accurate test for this enzyme is done using a test tube of gelatin. If the gelatin turns to liquid there are enzymes present.
Other tests like the Trypsin test using a stool sample, the Immunoreactive Trypsin serum test to test for trypsinogen and the Elastase test are performed by your doctor’s lab.
Treatment of exocrine pancreatic problems includes healing the underlying condition to prevent further pancreatic damage where possible and managing the symptoms.
Patients may be given nutritional supplements, glandulars, protomorphogens of pancreatic enzymes, fat-soluble vitamins (A, D, E and K) and Vitamin B-12 as supplements to make up for the decreased production and to aid digestion.
Changing how and what you eat and the timing of how you eat is very important.
Not eating when you are on sympathetic overload is important. Sometimes the adrenal glands and liver also need support on the way to healing the pancreas.
By determining what you are or are not digesting your doctor can prescribe further tests to discover exactly what your body is or is not doing in regards to digestion. Of course they will prescribe a bunch of drugs which may or may not work for you. But don’t give up. Often these cases involve integrative therapy which means dietary changes, supplements and a well-placed prescription drug or digestive enzyme to use when things get out of hand.
The person or animal may also benefit from having the 7th thoracic vertebrae adjusted as this spinal nerve innervates the pancreas.
How NOT to eat: One other problem I see causing digestive challenges often is when my clients eat a whole bunch of different foods (like at big meals, buffets or potlucks). With so many types of foods plus drinks and dessert, the body really doesn’t know what to process first. It all gets mixed up in a big ball and just kind of sits there waiting to be digested but the body can’t figure out what to work on first! For these clients I often tell them to Google the words “Food Combining” and to minimize the types of foods they eat. “Eat like a monk” I tell them. Bread for one meal, soup for the next, fruit for the next—very simply, nothing processed, and chew your food thoroughly.
We keep certain homeopathics and protomorphogen/glandulars here to help rebuild the gut flora and help repair damaged pancreas tissues. It’s all very complicated stuff and muscle testing plus the development of the patient’s intuition are often the keys to managing these types of cases.