In
chronic pancreatitis over a course of years to decades, pancreatic parenchyma is gradually lost and
pain is gradually decreasing as signs and symptoms of malabsorption appear. Appearance of calcifications is a late sign and in many cases coincides with appearance of
steatorrhea. Decreasing output of
insulin and
glucagon results in
diabetes mellitus, which is characterized by a high risk of hypoglycemias ('brittle' diabetes). In most instances, measurement of fecal concentration of
elastase may be sufficient to diagnose
exocrine pancreatic insufficiency. Fecal fat analysis is useful to establish malabsorption and to monitor pancreatic
enzyme replacement therapy. Components essential to the optimal management of chronic
pancreatitis are control of
pain, improvement of maldigestion, management of diabetes and of complications like
cysts or
strictures, and alcohol and
nicotine abstinence. Patients with
pain are evaluated for structural abnormalities which can be treated endoscopically or surgically.
Conservative treatment of
pain includes fat-reduced diet,
nonnarcotic analgesics, alcohol and smoking cessation, and, if not successful, an 8-week trial of high-dose pancreatic
enzymes. Pancreatic
enzymes are used for the treatment of maldigestion. Digestion of fat is the determining factor in
pancreatic insufficiency. Treatment success is defined clinically by improved
body weight and consistency of feces. Modern
pancreatin preparations are engineered as
acid-resistant, pH-sensitive
microspheres. Using such preparations, most patients will reduce their
steatorrhea to <15 g fat per day during supplementation of 25,000-40,000 IU of
lipase per meal, but in selected cases larger doses may be needed, depending on size of the meal and severity of the disease. Efficacy of
enzyme replacement therapy is influenced by denaturation of
lipase by gastric acid, improper timing of
enzymes, coexisting small-intestinal mucosal disease, rapid intestinal transit and effects of diabetes. This review focuses on pathophysiology, diagnosis and treatment of pancreatic
steatorrhea.