[Sense and nonsense in the treatment of exocrine pancreatic insufficiency].

Application of pancreatic digestive enzymes is indicated in cases of a quantitatively decreased exogenous secretion or an asynchronous secretion of enzymes with regard to the duodenal passage of chyme. A clear indication for therapy is a proven steatorrhea, a relative indication loss weight of and/or uncharacteristic abdominal discomfort in patients with proven pancreatic disease, i.e. chronic pancreatitis. Uncharacteristic abdominal discomfort alone, which is regarded as a consequence of 'maldigestion' without proven pancreatic disease, is not an indication for therapy. To prevent a destruction of exogenously applied lipase by gastric acid and to enable a synchronous gastroduodenal passage of the enzymes together with food, acid-protected micropellets or -tablets with an ideal diameter around 1.4 mm containing high amounts of lipase are requested. In cases of anacidity i.e. gastrectomy or type-A gastritis, lipase rich 'conventional' enzymes applied as granulate are sufficient. Combinations (pancreatic enzymes with bile acids) or fungal lipases have either more side effects (diarrhea) or are less efficient when compared to porcine enzymes. Acid-resistant microbial lipases may be useful in the near future. Application of pure proteases or pancreatic enzymes with high concentrations of proteases as treatment of pain in chronic pancreatitis ('negative feedback regulation') are a rather expensive form of treatment when compared to analgetics and are probably ineffective.