The aim of pancreatic enzyme substitution therapy is not only to relieve maldigestion-related symptoms, but mainly to achieve a normal nutritional status. Therapy of pancreatic exocrine insufficiency is based on the oral administration of exogenous pancreatic enzymes. The

role of complementary dietary modifications, though important in conventional therapy, should probably be reconsidered. Pancreatic exocrine insufficient patients who experience weight loss, those with daily fecal fat excretion of more than 15 g under a diet containing 100 g fat daily, and those with relevant steatorrhea-related symptoms are classically and generally considered as suitable candidates for enzyme substitution therapy.7 Indication for treatment in patients with asymptomatic steatorrhea of less than 15 g/d is debatable. A recent study has, however, demonstrated that patients with asymptomatic steatorrhea of less than 15 g/d and consistently Wnt inhibitor low circulating levels of nutritional parameters like liposoluble vitamins, prealbumin and ferritin, can revert to normal status under enzyme substitution therapy.8 Although the relevance of this subclinical malnutrition status remains unclear, this study supports the prescription of enzyme substitution therapy in every patient with pancreatic exocrine insufficiency and

fat maldigestion, selleck compound independently of the degree of steatorrhea and the presence or absence of associated symptoms, in order to prevent potentially relevant nutritional deficits. Classically, the initial approach to patients with pancreatic exocrine insufficiency is to restrict fat intake in an attempt to reduce steatorrhea. A diet containing less than 20 g fat daily is thus generally recommended in this context. Nevertheless, restriction of fat intake is linked to insufficient intake of fat-soluble vitamins, which are already malabsorbed Etomidate in patients with pancreatic exocrine insufficiency.6 In addition, studies on

the metabolism of both endogenous and exogenous enzymes during small intestinal transit show that the half-life of enzyme activity is enhanced by the presence of their respective substrates.9 That means that maintenance of lipase activity during intestinal transit requires the presence of dietary triglycerides. Actually, it was demonstrated in an experimental model of pancreatic exocrine insufficiency in dogs that fat digestion and absorption was higher when enzyme supplements were taken together with a high-fat diet compared with a low-fat diet.10 As a consequence, fat restriction should no longer be considered as a rule in the management of patients with pancreatic exocrine insufficiency. Frequent meals of low volume and avoidance of food difficult to digest (i.e. legumes) are generally recommended. A fibre-rich diet appears to increase pancreatic lipase secretion, but also inhibit pancreatic lipase activity by more than 50%,11 so its use is under discussion and cannot be considered as adequate.