ISSN:0012-2823    

DOI:10.1159/000201094

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

Several factors related to the patient and the pancreatin formulation influence the efficacy of enzyme supplementation. Up to now, only few tests exist to judge the efficacy of enzyme replacement therapy in pancreatic insufficiency. Tube tests and fecal fat excretion studies are cumbersome, time-consuming and unpleasant. Recently, several breath tests for the detection of pancreatic insufficiency have been developed. The cholesteryl octanoate breath test differentiated between healthy controls and patients with pancreatic insufficiency already after a 30-min collection period. Using this test, it was demonstrated that a pancreatin preparation containing small microspheres (1.0-1.2 mm) induces high duodenal lipolytic activity parallel to gastric emptying of food. In contrast, the gastric emptying of large microspheres (1.8-2.0 mm) is significantly delayed. The cholesteryl octanoate breath test detects pancreatic insufficiency within 30-60 min and offers the possibility of monitoring the in vivo release of pancreatin preparations.

ISSN:0012-2823    

DOI:10.1159/000201095

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

The activities of pancreatic enzymes decrease during their passage from the duodenum to the terminal ileum, but degradation rates of individual enzymes are different. Whereas lipase activity is lost most rapidly, proteases and amylase are more stable. The mechanism by which lipase activity is destroyed is proteolysis, mainly by the action of chymotrypsin. This mechanism is also operative in patients with chronic exocrine pancreatic insufficiency. It explains why fat malabsorption develops earlier compared with protein or starch malabsorption. The substitution of lipase is also more difficult than that of other enzymes, because it is more rapidly destroyed by proteases. Conversely, inactivation of proteases improves intraluminal activity of lipase not only in healthy individuals but also in patients with chronic pancreatitis. Other factors that contribute to problems in lipase substitution therapy include acid-peptic destruction of unprotected enzyme preparations and unphysiological particle sizes of enteric-coated capsules or pellets. Recent data suggest that the adaptation of the diameter of enteric-coated pancreatin micropellets into the range that permits gastric emptying in synchronicity with the meal improves their digestive efficacy.

ISSN:0012-2823    

DOI:10.1159/000201097

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

In clinical practice, exogenous pancreatic enzymes are administered for the treatment of pancreatogenic steatorrhea or with the intention to relieve pain due to chronic pancreatitis. Moreover, a large number of patients take pancreatin (i.e., exogenous pancreatic enzymes) for functional dyspepsia. The effect of exogenous pancreatic enzymes on the enteropancreatic axis is a complex issue. Intraduodenal but not intrajejunal protease activity appears to exert a dose-dependent negative feedback on exocrine pancreatic secretion. Only enzymes with a proteolytic activity but not amylase and lipase exert a control on pancreatic secretion. The mechanism responsible for this feedback regulation is debated, but the cholinergic system seems to play a major role. Intraduodenal pancreatic enzymes (pancreatin) lead to an increased release of pancreatic polypeptide but do not affect the release of insulin and glucagon. In addition, pancreatic enzymes have an influence on the release of some gastrointestinal hormones (i.e., cholecystokinin, motilin, gastric inhibitory polypeptide). Neither exogenous nor endogenous pancreatic enzymes seem to play a major role in the regulation of interdigestive gastrointestinal motility. However, an adequate rate of postprandial pancreatic output is required to control gastric emptying. Current knowledge on the effect of exogenous pancreatic enzymes on the enteropancreatic axis, gut peptide release and gastrointestinal motility are updated in the present article.

ISSN:0012-2823    

DOI:10.1159/000201098

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

Exocrine pancreatic insufficiency combined with pancreatic pain and endocrine pancreatic insufficiency are the leading symptoms of chronic pancreatitis. Due to the large functional reserve capacity of the gland, decompensation, i.e. steatorrhea, does not occur before lipase excretion is reduced to ≤10% of normal. Pancreatic enzyme substitution is indicated when fecal fat excretion exceeds a critical value (normally > 15 g/day) and/or when weight loss is present. A number of studies have dealt with the problems of gastric acid inactivation of pancreatic enzyme preparations as well as their gastric emptying nonsimultaneously with the food. For the present, it is recommended that pancreatic enzyme substitution in patients with proven exocrine pancreatic insufficiency and normal gastric acid secretion be given in multiunit, acid-protected dosages. In patients with gastric hyposecretion and in those who underwent partial or total gastrectomy, enzyme substitution should be administered as granules to enable mixing and simultaneous transport of enzymes with the chyme. The ultimate aim of further scientific and clinical research remains the total abolishment of pancreatic steatorrhe

ISSN:0012-2823    

DOI:10.1159/000201099

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

The non-surgical management of chronic pancreatic pain is reviewed. In accordance with the suggested multifactorial origin of pancreatic pain, different treatment principles are practised. Besides conventional analgesic drugs, oral pancreatic enzymes seem efficient in a subgroup of patients with chronic pancreatitis. Endoscopic treatment aiming at reduction of the pancreatic duct-tissue pressure is promising, but it is still in its infancy. Coeliac nerve blockage is recommended in patients with pancreatic cancer and pain, whereas external radiotherapy plays a role in a diminishing number of these patients. Treatment of chronic pancreatic pain is an example of a complex clinical problem in which a multidisciplinary approach is mandatory.

ISSN:0012-2823    

DOI:10.1159/000201100

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

According to the theory of negative feedback regulation of pancreatic enzyme secretion by proteases, treatment with pancreatic extracts has been proposed to lower pain in chronic pancreatitis by decreasing pancreatic duct pressure. However, we have demonstrated in healthy volunteers that intraduodenal application of porcine pancreatic extracts does not inhibit but rather stimulates pancreatic enzyme secretion. This is probably due to the high protein content of porcine pancreatic extracts which may overwhelm a potential inhibitory effect of proteases. In a prospective placebo-controlled, double-blind, multicenter study to investigate the effect of acid-protected porcine pancreatic extracts on pain in 43 patients with chronic pancreatitis, pain improved in most patients irrespective of whether they started with placebo or verum. There was no significant difference between the two treatment arms. The pancreatic extract that we have used in our study neither inhibits pancreatic enzyme secretion nor is it very efficient in lowering pain in chronic pancreatitis.

ISSN:0012-2823    

DOI:10.1159/000201101

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

Discussion over the role of enzyme therapy in patients with acute pancreatitis is based upon theoretical considerations rather than hard data. In this respect, it differs little from most other treatments used in the management of acutepancreatitis, although, in the case of enzyme treatment, the lack of data results largely from a dearth of experimentation to prove its efficacy rather than from equivocal or negative results.

ISSN:0012-2823    

DOI:10.1159/000201102

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

Several studies have shown that exocrine pancreatic function may be impaired in various non-pancreatic digestive diseases. The impairment, however, is usually mild to moderate and generally does not cause malabsorption. In some patients, however, pancreatic insufficiency is severe enough to cause malabsorption, which can be effectively corrected by oral pancreatic extracts.

ISSN:0012-2823    

DOI:10.1159/000201103

出版商:S. Karger AG    

年代:1993

数据来源: Karger

摘要:

After gastrointestinal surgery, patients often suffer from maldigestion. The extent of this maldigestion syndrome depends on the type of surgical procedure performed. After total pancreatectomy, subtotal left resection, resection for chronic pancreatitis, Whipple operation with ductal occlusion, and total gastrectomy, patients need obligatory enzyme treatment. After partial pancreatectomy without duct occlusion or partial gastrectomy, enzyme treatment should be initiated when exocrine pancreatic insufficiency occurs.

ISSN:0012-2823    

DOI:10.1159/000201104

出版商:S. Karger AG    

年代:1993

数据来源: Karger