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Chronic Pancreatitis and Persistent Steatorrhea: What Is the Correct Dose of Enzymes?

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Exocrine pancreatic insufficiency with steatorrhea is a major consequence of chronic pancreatitis. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality. Nutritional counseling and oral pancreatic enzyme replacement are the basis for the therapy for exocrine pancreatic insufficiency. Aim of enzyme therapy is not only to avoid symptoms but also to normalize digestion. With this aim, oral administration of pancreatic enzymes in the form of enteric-coated minimicrospheres is the therapy of choice. This enzyme preparation avoids acid-mediated lipase inactivation and ensures gastric emptying of enzymes in parallel with nutrients. Despite that, factors like an acidic intestinal pH and bacterial overgrowth may prevent normalization of fat digestion even in compliant patients. The present article reviews the current evidence on therapy of exocrine pancreatic insufficiency in chronic pancreatitis patients, with special attention to different potential endpoints to select the optimal enzyme dose for individual patients.

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Clinical Scenario

A 55-year-old man is referred by the general practitioner to your office because of a history of chronic diarrhea lasting for more than one year. He had no relevant previous medical history, no allergy, and no previous surgical intervention. He referred a daily alcohol intake of about 80 g for more than 30 years, and is smoker of about 20 cigarettes a day. Diarrhea improved initially by modification of dietary habits (reduction of dietary fiber and fat intake), recommendation of alcohol

Management Strategies

Therapy of exocrine pancreatic insufficiency is based on the oral administration of exogenous pancreatic enzymes. Together with that, dietary modifications have classically played an important role that nowadays should probably be reconsidered. The goal of the enzyme therapy is to deliver a sufficient amount of active lipase at the right place, ie, duodenum and proximal jejunum, and at the right time, ie, in parallel with gastric emptying of nutrients.

Classically, the initial approach to

Areas of Uncertainty

The study of the impact of malnutrition on the prognosis of chronic pancreatitis is a difficult task, and clinical consequences of maldigestion in this setting have been poorly investigated. However, because malnutrition of any etiology is associated with a series of well known severe complications leading to a high risk of death, it is generally accepted that this complication plays an important prognostic role in chronic pancreatitis patients too. In the same way, the clinical impact of

Published Guidelines

Unfortunately there are no published guidelines on how to treat exocrine pancreatic insufficiency related to chronic pancreatitis or any other pancreatic disease (pancreatic cancer, after severe necrotizing pancreatitis or after pancreatic surgery) in the adult. Even cystic fibrosis guidelines are mainly focused on pulmonary complications of the disease. Members of the Australian Pediatric Gastroenterological Society published in 1999 the only guidelines on pancreatic enzyme replacement therapy

Recommendations for This Patient

In our institution exocrine pancreatic insufficiency in this patient was confirmed by a CFA of 79.8% (normal >92.5%). 13C-MTG breath test result was also abnormal. A nutritional evaluation revealed a body weight of 60 kg, BMI 18.9, lymphocyte count of 800/mm3 (normal higher than 1000/mm3), serum prealbumin of 17 mg/dL (lower limit of normality 21 mg/dL), retinol binding protein (RBP) of 2.1 mg/dL (lower limit of normality 3.0 mg/dL), vitamin A of 21 μg/dL (normal >30 μg/dL), and vitamin B12 of

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Conflicts of interest The author discloses the following: The author is a consultant and speaker for AbbottPharma.

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