Maldigestion

Cystic fibrosis (CF) is a recessive genetic disorder prevalent among whites in North America and certain parts of northern Europe. It is characterized by chronic bacterial infections of the airways and sinuses, fat maldigestion due to pancreatic exocrine insufficiency, infertility in males due to abnormal development of the vas deferens, and elevated levels of chloride in sweat (> 60 mmol/L). 

Maldigestion may be manifested by the presence of numerous large foul-smelling loose stools (steatorrhea) and flatulence. 

Infants and children with maldigestion may have evidence of failure to thrive (below age-based normals in both height and weight), and adults may be near or below their ideal body weight despite apparent adequate caloric intake. 

Maldigestion results in decreased serum levels of the fat-soluble vitamins A, D, E, and K. 

Laboratory testing confirms the diagnosis of CF, and Jessica has been referred to her regional CF center for treatment. Additional stool studies indicate the presence of severe fat maldigestion. The pulmonologist indicates that she would like to start Jessica (weight 8.2 kg) on pancreatic enzyme replacement therapy. 

Another field in which nutritargeting may play an important role is the diseases where either systemic absorption is not possible (e.g., malabsorption/maldigestion) or where local deficits occur, which may not or only inadequately be supplied by systemic application. 

Another interesting feature of nutritargeting is the ability to circumvent absorption or metabolization barriers during malabsorption, maldigestion, or when there is a lack of transport proteins, for example, tocopherol-... 

Most of fhe above-mentioned bioavailability, intervention, and case studies came to the conclusion that water-miscible or water-soluble preparations of faf-soluble vitamins were superior to regular supplements. Based on the evidence from our own bioavailability study as well as from fhe studies mentioned above, it therefore seems justified to assume that fat-soluble vitamin deficit patients with fat maldigestion and/or malabsorption can be corrected more efficiently by using water-soluble as opposed to fat-soluble preparations. Another advantage of water-soluble preparations in general might be that lower daily doses are required when compared to fat-soluble preparations to achieve the same results. 

Exocrine pancreatic insufficiency is most commonly caused by cystic fibrosis, chronic pancreatitis, or pancreatic resection. When secretion of pancreatic enzymes falls below 10% of normal, fat and protein maldigestion occur which can lead to steatorrhea, azotorrhea, vitamin malabsorption, and weight loss. Pancreatic enzyme supplements, which contain a mixture of amylase, lipase, and proteases, are the mainstay of treatment for pancreatic enzyme insufficiency. Two major types of preparations in use are pancreatin and pancrelipase. Pancreatin is an alcohol-derived extract of... 

In patients whose maldigestion is difficult to control, other underlying conditions should be considered, such as noncompliance, infections of the gastro-... 

Relevant quality control should not be restricted to the usual triad of activities of pancreas lipase, a-amylase, and trypsin, but should be extended to the content of colipasc, the activities of the two other lipolytic enzymes present in pancreatine (phospholipase Aj and carboxylester lipase), and the dissolution characteristics of enteric-coated preparations as a function of time and pH (Fig. 16). The availability of such information will certainly contribute to a better tailoring of flic management of maldigestion in the individual patient and to a more appropriate correction of the obligate nonphysio logical route of delivery of these enzyme supplements. 

The gastrointestinal manifestations of primary hereditary delayed-onset hypolactasia, while uncomfortable, are not life threatening and can be completely eliminated by dietary manipulation. Is lactose intolerance a serious health issue or just a nuisance In certain circumstances, specifically at the extremes of life (infancy and old age) lactose maldigestion may have grave health consequences. 

When substantial carbohydrate maldigestion occurs in infants, it can lead to diarrhea. This is most often seen when the infant has experienced some other insult that has damaged the small intestine enterocytes, producing a secondary hypolactasia.This is more so when the infant has a rotavirus infection, and rotavirus is the most important cause of gastroenteritis in infancy. Rotavirus infects only mature enterocytes,... 

Lactose intolerance can be readily managed by ensuring that the amount of lactose ingested is restricted to the amount the individual can tolerate, which is related to the individual s level of residual intestinal lactase activity. Lactose maldigesters can determine their individual threshold for the occurrence of lactose intoler-... 

If specific treatment is considered necessary, supplemental lactase can be provided as replacement therapy. This is derived from specific species of yeast or fungus and is available as caplets, tablets, and drops. Whole milk pretreated with lactase is marketed in some states as Lactaid and can be used by lactose maldigesters. The availability of the replacement enzyme has made unnecessary the use of the lactose-free diet, which can be nutritionally unsound, as discussed. Also, since lactose is common in many foods and drinks and is used in... 

Carrocio A, Montalto G, Cavera G, et al. Lactose intolerance and self-reported milk intolerance relationship with lactose maldigestion and nutrient intake. /Am CollNutr 17 631-636,1998. 

Hertzler SR, Clancy SM Kefir improves lactose digestion and tolerance in adults with lactose maldigestion. J Am Diet Assoc 103 582-587, 2003. 

Hertzler SR, Savaiano DA Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance. Am J Clin Nutr 64 232-236,1996. 

Johnson AO, Semenya JG, Buchowski MS, et al. Correlation of lactose maldigestion, lactose intolerance, and milk intolerance. Am / Clin Nutr 57 399-401,1993a. 

Pancreatic exocrine insufficiency with nutrient maldigestion as described in the case report is both a classical complication and a defining leading symptom of chronic pancreatitis. Therefore, taking a careful history provides the key for the diagnosis. 

Sufficient absorption of macronutrients to maintain energy supply requires prior hydrolysis by pancreatic enzymes. Thus, complete absence of pancreatic enzymes (e.g., due to pancreatectomy) is, if untreated, incompatible with life. Normally, however, in healthy individuals the cumulative postprandial pancreatic enzyme response exceeds by far (10- to 15-fold) the quantity required to prevent overt maldigestion. In particular, lipid digestion is fast and... 

Nutrient maldigestion due to pancreatic exocrine insufficiency is a classical complication of chronic pancreatitis. In most cases, it occurs... 

Direct tests of secretory function such as fecal chymotrypsin and elastase 1 are the tests of first choice if the main diagnostic goal consists of noninvasive confirmation of chronic pancreatitis. Indirect tests may be preferred, however, if the main goal is to verify maldigestion (which needs not be due to loss of pancreatic secretory capacity) or to optimize enzyme treatment. For patients for whom noninvasive direct or indirect tests are negative or equivocal and diagnosis or exclusion of pancreatic exocrine insufficiency appears relevant, the invasive secretin-cerulein (SC) test should be considered. 

Causes of malnutrition include (7.) reduced quantity and quality of nutrition, (2.) maldigestion and malabsorption, (3.) accelerated protein breakdown and protein loss as well as reduced protein synthesis (PEM), 4.) increased energy requirement, especially in the case of complications, and (5.) metabolic disturbances (e.g. insulin resistance, sympathicotonia, loss of metabolic efficiency), (s. p. 741)... 

T. Nakamura, T. Takeuchi, A. Terada, Y. Tando, and T. Suda, Near-Infrared Spectrometry Analysis of Fat, Neutral Sterols, Bile Acids, and Short-Chain Fatty Acids in the Feces of Patients with Pancreatic Maldigestion and Malabsorption, Int. J. Pancreatol., 23(2), 137-143 (1998). 

Malabsorption of monosaccharides can also cause intestinal symptoms more commonly attributed to maldigestion of disaccharides. Glucose-galactose malabsorption is also inherited as an autosomal recessive trait. Symptoms occur in the affected neonate as soon as milk (lactose) is taken, but also follow ingestion of glucose- or galactose-containing... 

Clinical presentation of the patient suffering from malabsorption or maldigestion classically includes the following features ... 

Carroccio A, Verghi F, Santini B, Lucidi V, lacono G, Cavataio F, et al. Diagnostic accuracy of fecal elastase 1 assay in patients with pancreatic maldigestion or intestinal malabsorption. Dig Dis Sci 2001 46 1335-42. 

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