Chronic pancreatitis and persistent steatorrhea: what is the correct dose of enzymes?

Exocrine pancreatic insufficiency with steatorrhea is a major consequence of chronic pancreatitis. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality. Nutritional counseling and oral pancreatic enzyme replacement are the basis for the therapy for exocrine pancreatic insufficiency. Aim of enzyme therapy is not only to avoid symptoms but also to normalize digestion. With this aim, oral administration of pancreatic enzymes in the form of enteric-coated minimicrospheres is the therapy of choice. This enzyme preparation avoids acid-mediated lipase inactivation and ensures gastric emptying of enzymes in parallel with nutrients. Despite that, factors like an acidic intestinal pH and bacterial overgrowth may prevent normalization of fat digestion even in compliant patients. The present article reviews the current evidence on therapy of exocrine pancreatic insufficiency in chronic pancreatitis patients, with special attention to different potential endpoints to select the optimal enzyme dose for individual patients.