Are Proteases needed for EPI compensation?

Energy loss due to nitrogen malabsorption in EPI is mild or null:

  • Energy loss by creatorrhea increase in EPI is nearly null (5 gram of fecal nitrogen in very severe EPI correspond to 20 kcal/day)
  • Compensation of pancreatic protease (i.e. trypsin) by other GI enzymes
  • PPEs have no detectable effects on fecal nitrogen loss and mild effect on transfer dietary nitrogen to metabolic pools (1)

Proteases and/or Eudragit® of PPEs are suspected in the pathophysiology of fibrosing colonopathy:

  • Usually observed in CF children <12 years of age, treated for more than 6 months with high-doses of enteric-coated PPEs,
  • Pancreatic enzymes, together with NSAID, administered via duodenal catheter to rats for 10 days induce ulcers in the cecum and colon (2,3),
  • Eudragit® L30D55 given by oral (rats) or caecal gavage (adolescent pigs) induce fibrosing colonopathy-like changes (4).

1. Airinei G, et al. Postprandial protein metabolism but not a fecal test reveals protein malabsorption in patients with pancreatic exocrine insufficiency. Clin Nutr. 2011 Dec;30(6):831-7
2. Kimura, R.E., et al. Indomethacin and pancreatic enzymes synergistically damage intestine of rats. Dig Dis Sci, 1998. 43: 2322-32.
3. Kimura, R.E., et al. The effects of high-dose ibuprofen and pancreatic enzymes on the intestine of the rat, J Pediatr Gastroenterol Nutr, 1999. 29:178-83.
4. van Velzen D, et al. Comparative and experimental pathology of fibrosing colonopathy. Postgrad Med J. 1996;72 Suppl 2:S39-48

 

Are Amylases needed for EPI compensation?

  • Pancreatic alpha-amylase hydrolyses starch to maltose,
  • Saliva amylase can at least in part compensate EPI, while the rest of starch can be metabolized by the gut microflora (1),
  • Deficiency is poorly documented in patients with EPI,
  • Inherited pancreatic amylase deficiency result in mild symptomatology, i.e. fermentative diarrhea in children , which disappear with a starch free diet (2).

1. Fogel MR, Gray GM. Starch hydrolysis in man: an intraluminal process not requiring membrane digestion. J Appl Physiol 1973; 55: 263-7
2. SjolundK, et al. Selective deficiency of pancreatic amylase, Gut, 1991,32,546-548