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PANCREAS INSUFFICIENCY
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Fatty acid or monoglyceride
Polar end of bile acid
Hydroxyl groups of bile acids
Bile acid
Bile acids(Conc. >CMC)Micelles
Lipase
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HUMAN PANCREATIC LIPASE
Interfacial enzyme,active in the lipid-water interface
Dependent on clean interface for lipolysis
Colipase binds to lipase in presence of bile salts
Lipase is specific for primary esterbond
Lipase is rapidly and irreversibly inactivated at pH<4
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Chylomicron Formation and Secretion
Nucleus
Granular-endoplasmicreticulum
Mitochondria
Esterification
Surfacestabilization
Addition oflipoprotein
Chylomicronformation
Uptake frommicellar solutionFA and MG
Secretion viaintercellular spacesinto lacteals
Golgi material
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Pancreatic Exocrine Function
Normal post-prandial pancreatic secretion is ±70% of maximal secretory capacity or 4–5 times the basal rate
Post-prandial secretion lasts for about 4 hours
Total intraduodenal lipase output varies from300,000 to 500,000 U/meal
Minimum pancreatic function of 10% of normal is necessary for adequate lipid digestion, correspondingto ± 30,000–50,000 U lipase in the duodenum
Amount of lipase, to be added to meals, varies depending upon degree in insufficiency and degree of gastric/duodenal denaturation
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Pancreatic Exocrine Insufficiency
Steatorrhea (mild:7–10 g/d; moderate: 10–20 g/d; severe: >20 g/d)
Bile salt precipitation due to low duodenal pH (bicarbonate deficiency)→increased fecal bile salt loss
Impaired CCK and GIP release→sluggishgallbladder emptying
Malabsorption of lipid-soluble vitamins,cholesterol
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SYMPTOMATOLOGY OF EXOCRINE PANCREATIC INSUFFICIENCY
Steatorrhea and creatorrhea causes
-Abdominal complaints -bloating,pain,cramps -urgency,diarrhea,foul smelling stools
-Generalised symptoms -weight loss -fatigue,loss of energy -sympoms related to vitamin deficiencies
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Exocrine Pancreatic InsufficiencyDiagnosis
• Suspicion because of associated medical condition and:
clinical history of steatorrhea
weight loss
• Laboratory tests
fat balance test (not specific)
non-invasive pancreatic function test
• fecal elastase, fecal chymotrypsin, PABA test
invasive direct pancreatic function test (gold standard)
• secretin test
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Indications for Pancreatic Enzyme Therapy
Exocrine pancreatic insufficiency causing
– any moderate / severe steatorrhea
– any steatorrhea with weight loss
– chronic / watery diarrhea
–dyspeptic symptoms
Unrelenting pain in chronic pancreatitis(inhibition of pancreatic secretory drive by negative feedback) (non-enteric coated preparations)
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Pancreatic Enzyme PreparationsNon-Enteric Coated Preparations
Pancreatin powder / granulate
blends well with food
unpalatable
denaturation in acid / peptic milieu
hyperuricosuria
Pancreatin tablet / capsule
inadequate dispersion into the meal
neutral taste
denaturation in acid / peptic milieu
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Pancreatic Enzyme PreparationsEnteric Coated Preparations
Enteric-coated tablet / capsule (dissolving at pH >5)
prolonged gastric retention causing de-synchronisation
failed or delayed dissolution when duodenal pH is low (lack of bicarbonate)
Enteric-coated microspheres (dissolving at pH >5)
premature gastric dissolution when pH >5 during early phase of meal
delayed gastric emptying of particles >1.4 mm
failed or delayed dissolution when duodenal pH is low
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Enteric Coated Mini-Doses PreparationGalenic aspects
gelatin capsule
pancreatin
pH dependent enteric coated layer
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Creon 8,000 9,000 450 1.4 (1.2–1.7)
Pancrease 5,000 2,900 330 2.0 (1.7–2.2)
Panzytrat 25,000 22,500 1,250 2.0
Creon forte 25,000 18,000 1,000 1.4 (1.2–1.8)
Lipase Amylase Protease sphere diam.
Microsphere Pancreatic Enzyme Preparations
microspheres larger than 1.4 mm empty more slowly than solid phase of the meal
release of enzymes from microspheres is slow, depending upon pH and ionic strength of medium
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Pancreatic Enzyme PreparationsCourse of dissolution of enteric oat
0
10
20
30
40
50
60
70
80
90
100
5,0 5.2 5.4 5.6 5.8 6.0
Creon
Creon Forte
Pancrease
Pancrease HL
Panzytrat
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• Enzyme supplementation during all meals
• Main meal: 25.000 to 75.000 FIP units lipase of EC preparation
• In-between snacks: 5.000 to 25.000 FIP lipase of EC preparation
• Dosage should be adjusted for individual patient
• Addition of H2-receptor blocker or protonpump inhibitor
Pancreatic Enzyme PreparationsDosage recommendations
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Pancreatic Exocrine InsufficiencyDietary recommendations
Abstinence from alcohol
In principle NO limitation of fat content of food (<60 g/d) (unpalatable; risk of deficit of essential fatty acids e.g. linoleic acid) except therapy failure
Frequent small meals
Reduction in fiber content (fiber inhibitspancreatic enzymes)
Medium chain triglycerides (C6-C12)(80–120 g/d) in case of insufficiently corrected steatorrhea and weight loss
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Therapy of Pancreatic InsufficiencyTreatment failure
• Acid related
– inactivation of lipase
– precipitation of bile salts
– enteric coat dissolves too distally
• Related to the use of medication
– too low dose
– noncompliance
– incorrect timing or mode of ingestion
• False diagnosis or concomitant disease
– celiac disease
– bacterial overgrowth
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