Impaired digestion (maldigestion) and absorption (malabsorption)
are the most common syndromes in the practice of general practitioner and
gastroenterologist. Their development can be caused by insufficient production of digestive enzymes
or decrease their activity. Mechanisms for violations
digestion and absorption are varied and are determined primarily by
diseases, underlying (Table 2).
Clinical manifestations of maldigestion and malabsorption syndromes also depend
on the mechanisms of their development (Table 3).
syndrome maldigestion and malabsorption often develop specific
syndromes caused by deficiency in the body of some vitamins and trace elements
. For example, the shortage of retinol (vitamin A), accompanied by the development
night blindness (night blindness), xerophthalmia, keratomalyatsii, hyperkeratosis;
deficiency of nicotinamide (vitamin PP) - dermatitis, diarrhea, dementia and weight loss
body, lack of cyanocobalamin (vitamin B 12 ) - a painful neuropathy,
ataxia parastezii, a violation of temperature sensitivity, macrocytic anemia
, lack of ascorbic acid (vitamin C) - bleeding under the periosteum
and at the bottom hair follicles, iron deficiency - muscle weakness
, glossitis, kolonihy, microcytic anemia, etc. The main focus
in patients with syndromes of impaired digestion and absorption, especially
if you can not eliminate the causes of their development, is a replacement therapy
enzymes, sometimes with vitamins and microelements.
currently available to the doctor there is a large amount of enzyme
preparations, differing in the number of the components, the degree of enzyme
activity, modes of production and registration forms. All enzymes can be roughly
divided into two groups: pure pancreatin and pancreatin + + components
bile gemitsellyulaza. Pancreatin contains three enzymes: lipase, protease and amylase
. The dasg is considered effective if 1 g of pancreatin contains about
40,000 units of lipase (units of the International Pharmaceutical Federation). Lipase
involved in the hydrolysis of emulsified bile neutral fat, mainly
in the duodenum, since the arrival of lipase in the jejunum
its activity is significantly reduced. Proteases in pancreatin consist mainly of
trypsin, under his influence, proteins, mainly of animal origin,
broken down into amino acids, in addition, trypsin of feedback
involved in the regulation of pancreatic secretion. Amylase cleaves extracellular
polysaccharides (starch, glycogen) and virtually absent in the hydrolysis
fiber. Pancreatin preparations do not affect the function
stomach, liver, biliary motility and gut, but decrease the secretion of pancreatic juice
.
The composition of some modern enzymes along with pancreatin include
bile acids (bile) and gemitsellyulaza. Preparations containing bile acids,
increase pancreatic secretion and cholepoiesis stimulate intestinal motility and
gallbladder. Bile acids increase the osmotic pressure
intestinal contents and in terms of microbial contamination is of intestinal
dekonyugatsiya with subsequent development of osmotic and secretory diarrhea. Bile acids
come into enterohepatic circulation and are metabolized in the liver,
which increases its functional load. Dekonyugirovannye
bile acids damage the lining of the gastrointestinal tract.
Enzyme preparations containing bile acids, should not appoint
acute and chronic pancreatitis, hepatitis and cirrhosis, diarrhea ,
ulcer disease and inflammatory bowel disease.
presence in the enzyme preparation gemitsellyulazy provides splitting
polysaccharides of plant origin.
In the appointment of a enzyme must first
consider its composition.
The second factor determining the activity of treatment is a form of release
dasg. Most enzymes are produced in the form of pills or tablets
diameter of 5 (or more) mm in the enteric shell that protects
enzymes from the release in the stomach and the destasction of hydrochloric acid of gastric juice
. From the stomach together with food can evacuate in a duodenal gut
solid particles whose diameter is less than 2 mm. Larger
particles, in particular enzymes in pill or tablet are evacuated in
mezhpischevaritelny period when the food has left the duodenal chyme
intestine. As a result, dasgs do not mix with food and do not participate in
digestion. To ensure rapid and homogeneous "mixing with the food
chyme were created highly polyenzyme preparations in the form of micro
(pantsintrat) and microspheres (Creon), whose diameter is less than 2 mm
. Preparations are enclosed in a gelatin capsule, which is destroyed in the stomach,
content (mikrotabletki and beads) is mixed with the food and chyme with
it gradually enters the duodenum. At a pH of duodenal contents above 5.5
shell microspheres and micro-tablets are dissolved and
enzymes begin to act on a large surface, similar to the physiological processes of digestion
.
third factor that determines the activity enzyme preparations, is
intraduodenal pH and the effective motility of the duodenum,
providing prolonged contact of enzymes with food chyme. If the pH
duodenal content is reduced to 3.5 and below, it is irreversible
inactivation of lipase and trypsin, bile acid precipitation, entailing
violation of emulsification and absorption of fats. The main reasons for the fall of pH in the duodenum are
bacterial overgrowth in the gut,
giperatsidoz, decreased secretion of bicarbonate. To increase the pH in the duodenum
use blockers H 2 -histamine receptors (ranitidine, famotidine),
sometimes proton pump blockers (omeprazole and others), antacids (Maalox,
Gustav, etc.) must carry out decontamination and duodenum
antibacterial dasgs (Biseptol, etc.), and sometimes parasitic (metronidazole
, etc.) means.
dose and duration of treatment is determined individually, depending on
leading mechanism of this disturbance. Effectiveness of enzyme preparations
can sometimes depend on the motor disorders of upper digestive tract
. To address these disorders are most commonly used types of prokinetics
motilium (10 mg for 15 minutes before a meal three to four times a day).
most important factor determining the success of therapy is the right choice ~ br> enzyme preparation, its dose and duration of treatment. When choosing
dasg is taken into account the nature of the disease and the mechanisms underlying the
digestive disorders (Table 5).
The main drawback of enzyme therapy is that it sometimes depends on the activity of
from other pathogenic mechanisms. The effect of treatment
enzyme preparations can be increased by removing excess syndrome microbial contamination
duodenum and other parts of the small intestine through
courses of antimicrobial therapy, and when the acidification of duodenum - by restoring the right
pH using blockers H 2 -receptor histamine and antacid
(Maalox, etc.).
| duodenum, jejunum Pancreas trypsin, chymotrypsin peptides, peptones Amino acids, dipeptides Pancreas Alfaamilaza Polysaccharides Maltose, izomaltoza Pancreas Lipase Fats glycerol and fatty acids duodenum, jejunum intestinal wall enterokinase dipeptides , trypsinogen, himotripsinogen amino acids, trypsin, chymotrypsin duodenum, jejunum intestinal wall maltase, izomaltaza, sukraza, lactase Disaccharides Monosaccharides | Note: you must also consider the role of bile and normal intestinal microbial flora in digestion (hydrolysis of the substrate). |
| Intracavitary digestion Reduced production of pancreatic enzymes Chr. pancreatitis, pancreatic cancer, cystic fibrosis inactivation of pancreatic enzymes in the gut gastrinoma, microbial contamination of the small intestine rapid transit of intestinal contents, decrease the concentration of enzymes as a result of breeding Postgastrorezektsionny syndrome, microbial contamination of the small intestine, postcholecystectomical syndrome, a disease Menetries Flag mixing enzymes with food chyme duodeno-and gastrostaz, intestinal psevdoobstasktsiya syndrome Irritable Bowel Impaired production of cholecystokinin Strikturnye damage of small intestinal mucosa deficiency of bile acids in the intestine biliary obstasction and cholestatic liver disease microbial contamination of the small intestine | membrane digestion deficit disaccharidases Lactase deficiency (congenital, acquired), Crohn's disease atrophy of enterocytes Crohn's disease, gluten enteropathy. Sarcoidosis. Lymphoma. Enteritis | Co | Diabetes . Giardiasis. Hyperthyroidism. Amyloidosis. HIV |
article was published in the journal
Attending Physician