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Pancreatic insufficiency
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Cystic fibrosis
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Chronic pancreatitis
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Obstruction of pancreatic duct
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Pancreatic cancer
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Pancreatic resection
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ShwachmanDiamond syndrome
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JohnsonBlizzard syndrome
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Pearson syndromeBiliary stage
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Malabsorption can be described as the bodys inability to absorb certain nutrients from the
gastrointestinal (GI) tract. This problem has become one of the leading health concerns all across
the US today. There are several different types of malabsorption syndromes and the most
common ones include the inability to absorb fat, proteins, vitamins and sugar. The different
factors that could lead to malabsorption exceed 200 in total and so it is not always easy to
pinpoint the main causative factors. Malabsorption of sugar (generally lactose or milk sugar) is
probably one of the most frequent types of malabsorption. Fat malabsorption syndromes, though
less common, can be a lot more serious. Fat malabsorption refers to the impairment of processing
fat, which takes place mainly in the small intestines. In case you are suffering from fat
malabsorption syndromes, it means that your body is not absorbing this nutrient from the foods
that you eat.
Causes: The malabsorption of fat can be caused by organic or functional factors. Under normal
circumstances, less than 5% of the fat you consume is present in your feces. An increase in this
value may be an indication of fat malabsorption. The normal process of fat digestion can be
divided into 3 stages, the pancreatic stage, the biliary stage and the cellular & delivery stage.
Some of the conditions associated with the malabsorption of fats include:
Chronic pancreatitis
Obstruction in the pancreatic duct
Pancreatic cancer
Resection of the pancreas
Shwachmann Diamond syndrome
Johnson Blizzard syndrome
Pearson syndrome
Some of the other possible causes of fat malabsorption syndromes could include:
Most of the causes of fat malabsorption are quite serious and should be treated by a doctor
immediately. Therefore, it is important for you to consult a doctor as soon as you notice any of
the fat malabsorption symptoms.
Symptoms: The signs and symptoms of fat malabsorption may vary, depending upon the causes
and the severity of the condition. Some of the most common fat malabsorption symptoms
include:
If fat malabsorption is left untreated, the symptoms could become more severe, as you body
continues to lose water, electrolytes and other essential nutrients. Some of the fat malabsorption
symptoms that should be checked right away include:
Make sure that you speak to your doctor immediately, if you experience any of the signs and
symptoms mentioned above.
Diagnosis: Your doctor may order a couple of tests to diagnose the condition accurately. Some of
the tests usually conducted include:
Abdominal CT scan
These tests help your doctor determine the root cause of the problem, so that the appropriate
treatment path can be adopted.
Treatment: Fat malabsorption treatment is aimed at addressing the underlying cause of the
problem. Your doctor may recommend various medicines, surgical procedures or even home
remedies to treat fat malabsorption. The diet you follow plays a very important role in the
treatment of fat malabsorption. Your doctor will need to review your current diet and if
necessary, prescribe supplements.
References
1. http://www.nlm.nih.gov/medlineplus/ency/article/000299.htm
The GI tract is responsible for digesting and absorbing food.[5] Lipids provide the richest source
of energy for the body, with 9 calories in every gram of fat; in comparison, carbohydrate and
protein contains 4 calories per gram. Whereas protein and carbohydrate begin to undergo
digestion in the stomach, triglycerides remain mostly unchanged until they reach the small
intestine. Intragastric breakdown accounts for approximately 10% of total lipid digestion.[5]
The pancreatic enzymes responsible for lipid digestion are inactivated when the pH drops below
5; thus, before digestion can continue in the duodenum, the acidic contents of the stomach must
be neutralized. Fortunately, the pancreas also secretes bicarbonate, which increases the pH of the
duodenal contents.
The exocrine pancreas produces 3 main types of enzymes: amylase, protease, and lipase.[1] Under
normal physiologic conditions, pancreatic enzymes (specifically, lipase) break the undigested
triglycerides into fatty acids and monoglycerides. Bile salts then solubilize these breakdown
products to form micelles, which are vehicles for absorbing lipid breakdown products.[5] Normal
fat digestion also depends on postprandial synchrony between delivery of nutrients to the
duodenum and discharge of pancreatic enzymes.[1]
Pancreatic secretion is governed by neural and hormonal mechanisms. The hormones responsible
for regulation are secretin and cholecystokinin (CCK). Secretin is secreted in response to acid in
the duodenum, causing duct cells to release water and bicarbonate; CCK is secreted in response
to protein and fat in the small intestine, stimulating acinar cells to release the pancreatic enzymes
(see the image below).
Fat malabsorption precedes malabsorption of other macronutrients.[6] Bile salt precipitation and
subsequent adsorption to undigested food reduces the bile salt pool, and this reduction further
impairs fat digestion.[7] Undigested fat, rather than being absorbed, is excreted in the feces,
leading to steatorrhea.
PERT is the basis of treatment of EPI[22, 23] ; the endpoints of treatment are normalization of gut
absorption and correction of nutritional deficiencies. The typical indications for initiating PERT
are progressive weight loss and steatorrhea.
Approved agents
The pancreatic enzyme products (PEPs) used for PERT are extracts of porcine pancreas that
contain all 3 pancreatic enzymes (ie, amylase, protease, and lipase) in varying proportions.
However, it is lipase that plays the paramount role in therapy. The following 6 PEPs have been
approved by the US Food and Drug Administration (FDA) for the treatment of maldigestion in
patients whose bodies do not produce sufficient pancreatic enzymes:
These PEPs are not interchangeable. For example, Viokace, unlike the other 5 products, lacks an
enteric coating and must be taken with a proton pump inhibitor.
Because exogenous pancreatic enzymes should exert their action on the ingested meal and
because gastric emptying of nutrients should occur in parallel with pancreatic enzymes reaching
the duodenum, PEPs are administered together with meals and snacks. When a sufficient enzyme
concentration is delivered into the duodenal lumen simultaneously with a meal, fat absorption is
enhanced.
PEP dosing for PERT is based on the content of lipase units (see Table 1 below). The pancreatic
lipase replacement dose should be adjusted on the basis of body weight, clinical symptoms, and
stool fat content. Several days should be allowed between dose adjustments.
Table 1. Lipase Content of Currently Available Pancreatic Enzyme Products (Open Table in a
new window)
The total daily dose is based on the assumption that the patient will have about 3 meals/day and
2-3 snacks/day, with half the mealtime dose given with a snack. Lipase doses larger than 2500
units/kg/meal (or dosages exceeding 10,000 units/kg/day) should be used with caution and only
when supported by documentation of 3-day fecal fat measures. Lipase doses larger than 6000
units/kg/meal are associated with colonic stricture and should be reduced.
Oral lipase dose, 72,000 units/meal with consumption of at least 100 g of fat daily
Alternatively, lower initial lipase doses (500 units/kg/meal) with individualized dose
titration may be considered
In an open-label extension of this study, the investigators determined that pancrelipase was well
tolerated over 6 months and resulted in statistically significant weight gain and reduced stool
frequency in patients with EPI due to chronic pancreatitis or pancreatic surgery who were
previously managed with standard PERT.[25]
Toskes et al carried out a randomized, double-blind, dose-response, crossover study in which the
effect of Zenpep on the coefficient of fat absorption was investigated with a placebo run-in (7-9
days) and 2 treatment periods (9-11 days) consisting of a high dose (7 20,000 lipase units/day)
and a low dose (7 5000 lipase units/day).[26] The results suggested that chronic pancreatitis
patients with EPI benefit from a low dose, whereas a high dose might be needed for patients with
more severe EPI.
In a randomized, placebo-controlled PERT withdrawal study evaluating the efficacy and safety
of Pancreaze in cystic fibrosis patients with EPI, Trapnell et al found that the agent effectively
improved fat absorption and protein absorption in these patients without giving rise to
unexpected adverse events.[27]
A study examining the use of endoscopic therapy in patients with chronic pancreatitis determined
that although this therapy is most useful in patients with pancreatic duct stones and dilation and
should be used as first-line treatment for those patients, it cannot be recommended as the
treatment of choice for all patients with chronic pancreatitis.[28]
Investigational therapy
Liprotamase is a biologically engineered nonporcine PERT agent that has been advocated for the
treatment of EPI associated with cystic fibrosis and pancreatectomy. In January 2011, the FDA
withheld approval of the drug, citing the need for further study.
In a subsequently published phase III 12-month open-label trial designed to assess the safety,
tolerability, and long-term nutritional effects of liprotamase in 215 patients with cystic fibrosis
and EPI aged 7 years and older, Borowitz et al reported that treatment with a mean of 5.5
capsules of liprotamase per day during meals and snacks for up to 12 months was safe and well
tolerated and was associated with age-appropriate growth and weight gain or weight
maintenance.[29]