Management of maldigestion associated with pancreatic insufficiency

The etiology, pathophysiology, clinical presentation, dietary management, and drug therapy of maldigestion associated with pancreatic insufficiency are reviewed. Maldigestion can occur in a number of conditions that lead to pancreatic insufficiency but is seen most frequently in patients with alcohol-related chronic pancreatitis or cystic fibrosis. Destruction of pancreatic tissue and obstruction of the ducts that lead into the small intestine prevent pancreatic secretions from reaching the small intestine and result in weight loss, anorexia, abdominal distention, and changes in the appearance and frequency of stools. The goal of dietary intervention in patients with maldigestion is to provide sufficient calories and protein to maintain weight while limiting fat intake to an amount tht the patient can tolerate. Medium-chain triglycerides can be substituted for dietary fat in patients whose symptoms continue despite dietary fat restriction. Drug therapy involves supplementing deficient pancreatic enzymes with pancreatin or pancrelipase. Regimens must be individualized for each patient because of problems with gastric inactivation of orally administered enzymes, lack of standardization of commercially available preparations, and large interpatient variation in response. In selecting an enzyme supplement preparation, the amount of available enzyme activity, dosage form, number of dosage units needed per dose, dosage schedule, and product cost must be considered. When enzyme supplementation alone does not adequately control the symptoms of maldigestion, a histamine H2-receptor antagonist or antacids may be added to the therapeutic regimen. Although complete resolution of the symptoms of maldigestion is difficult to achieve, a regimen of dietary modification and pancreatic-enzyme replacement can improve patients' quality of life.