Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
J Gastroenterol Hepatol. 2013 Dec;28 Suppl 4:99-102. doi: 10.1111/jgh.12406.
Pancreatic exocrine insufficiency (PEI) is one of the long-term consequences of chronic pancreatitis (CP). Majority of patients with PEI were undiagnosed or undertreated. Inadequately treated or subclinical severe PEI causes malnutrition and may pose the patients at risk of premature atherosclerosis and cardiovascular events. Indication of pancreatic enzyme replacement therapy (PERT) is patients with severe PEI, as indicated by the presence of steatorrhea, diarrhea, weight loss, fecal fat > 7 g/day, (13) C-mixed triglyceride breath test < 29%, fecal elastase < 100 ug/g stool, imaging or endoscopic findings of pancreatic ductal dilatation or calculi, and eight endosonographic criteria of CP. The mainstay treatment of PEI is PERT. Dietary fat restriction is unnecessary. PERT with lipase > 40,000 U per meal is recommended. Enteric-coating may be preferred to conventional enzymes because of the availability of high-dose preparations and no need of acid suppression co-therapy. Administration of enzymes with meals is proven to be the most effective regimen. Response to PERT should be measured by the improvement of patients' symptoms, nutritional status, and, in selected cases, by fecal fat or (13) C-mixed triglyceride breath test. Patients unresponsive to PERT should be checked for compliance, increase the dose of lipase to 90,000 units/meal or co-therapy with proton pump inhibitor. In patient with previous gastrointestinal surgery that may interfere enzyme-food mixing, opening the capsules and administering the enzyme granules with meals. Finally, search for small intestinal bacterial overgrowth syndrome and other causes of small bowel malabsorption.
胰腺外分泌功能不全（PEI）是慢性胰腺炎（CP）的长期后果之一。大多数 PEI 患者未被诊断或治疗不足。治疗不足或亚临床严重 PEI 会导致营养不良，并使患者面临过早发生动脉粥样硬化和心血管事件的风险。胰腺酶替代治疗（PERT）的指征是严重 PEI，表现为脂肪泻、腹泻、体重减轻、粪便脂肪 >7 g/天、（13）C-混合三酰甘油呼气试验 <29%、粪便弹性蛋白酶 <100 ug/g 粪便、胰腺导管扩张或结石的影像学或内镜检查结果，以及 8 项 CP 的超声内镜标准。PEI 的主要治疗方法是 PERT。不需要限制饮食中的脂肪。建议每餐使用>40,000 U 脂肪酶的 PERT。由于高剂量制剂的可用性和无需酸抑制联合治疗，肠溶性包衣可能优于常规酶。随餐给药是最有效的治疗方案。PERT 的反应应通过患者症状、营养状况的改善来衡量，在某些情况下，还可以通过粪便脂肪或（13）C-混合三酰甘油呼气试验来衡量。对 PERT 无反应的患者应检查其依从性，将脂肪酶剂量增加至 90,000 单位/餐或与质子泵抑制剂联合治疗。对于以前可能干扰酶与食物混合的胃肠道手术的患者，可打开胶囊并随餐给予酶颗粒。最后，寻找小肠细菌过度生长综合征和其他小肠吸收不良的原因。
