Pancreas

Question

Why is there a maximum amount of pancreatic enzymes that can be taken? My stools remain very fat despite taking the maximum dose. I do take gastric acid inhibitors, but is there something else I can do to have less fatty stool, less flatulation and less belly aches? My fat absorption remains about 70 percent.

Answer

Thank you for this practical and relevant question. We can only answer this question in general. For specific advise you should consult your doctor.
Pancreatic enzymes are dosed according to the size of the meal and the fat content of the meal. The more one eats and the more fatty the food, the higher the dose of pancreatic enzymes needed. But still, this relation is not straight forward and one patient will need a higher enzyme dose than the other. At times this is explained because some patients have residual pancreatic function. But part of the explanation is also how well the pancreatic enzymes can function. Pancreatic enzymes have a special coating to protect them from being dissolved in the acid stomach and to only release the enzymes in the small intestine where the milieu is no longer acid but alkaline thanks to the secretions of bicarbonate by the pancreas. In people with CF, the acid content of the first part of the small intestine can however be relatively high because of an increased acid production in the stomach and because of the absence of bicarbonate secretion by the pancreas. Taking ‘acid inhibitors’ will improve this balance a bit.
Also other things can play a roll, such as the timing of the emptying of the stomach and the intake and timing of the pancreatic enzymes: for optimal digestion the food and the pancreatic enzymes should reach the small intestine simultaneously. When the digestion remains poor with a lot of fat loss in the stools, the dose of enzymes can be increased. But an unlimited increase in dose will bring no further benefit. The usual guideline states that 10000U lipase per kg body weight is the maximum. Increasing above this maximum can be of use in the individual patient but it should then be evaluated whether this is really giving extra benefit and no harm.
Some years ago a rare complication (fibrosing colonoscopy) was described and thought to be related to the intake of very high enzyme doses. It was also suggested that it was not the enzyme dose itself, but the coating of the enzymes that cause this problem.

I also want to mention that ongoing digestive problems can find their cause of the intestine itself. If the enzymes are taken with every meal and divided over the meal and there is still severe malabsorption other causes than CF such as celiac disease (=gluten enteropathy) or inflammatory bowel disease should be considered.

Best regards,

Prof. dr. M. Proesmans

30.08.2011