A 15-Year-Old Girl With Steatorrhea Who Can’t See at Night

Jaime Shalkow, MD; Mayela E. García

Disclosures

November 13, 2019

Patients with exocrine pancreatic dysfunction may benefit from exogenous pancreatic enzymes to assist digestion. However, approximately 10% of patients do not need to take exogenous enzymes because they have preserved exocrine pancreatic function. The benefit of enzymes in the management of pain from chronic pancreatitis is uncertain.

Patients who develop steatorrhea or weight loss may benefit from PFTs to confirm the presence of pancreatic maldigestion. An empiric trial of enzymes may also be appropriate if a high level of clinical suspicion for EPI is present. New-onset steatorrhea or weight loss in adults should prompt CT scan or endoscopic ultrasound to rule out ductal adenocarcinoma. However, most patients with EPI do not show anatomic abnormalities on abdominal CT scan.

Diazoxide is indicated for hypoglycemia due to hyperinsulinism associated with inoperable islet cell carcinoma or extrapancreatic malignancy.

Lifestyle modifications (avoidance of fatty foods, limitation of alcohol intake, cessation of smoking, and consumption of a well-balanced diet) have been shown to positively affect the quality of life for these patients, more so than any other therapeutic measures. Insulin does not improve EPI.

Fat consumption does not need to be entirely eliminated because it is necessary to absorb fat-soluble vitamins (A, D, E, K). Nuts, seeds, and fish (eg, salmon, tuna) that have healthy fat are recommended. Oatmeal, whole-wheat bread, fruits and vegetables, and skinless chicken or turkey breast are low-fat foods that can also provide other types of nutrients (carbohydrates and proteins). Certain vitamins should be added to the diet of these patients in order to overcome their deficiency and eliminate the symptoms.

Vitamin A is found in eggs, milk, butter, and some fruits and vegetables (eg, carrots, broccoli, spinach, pumpkin, melon, mango). Vitamin D can be naturally produced through sun exposure but is also contained in some fish (eg, salmon, sardine, tuna). In many countries, vitamin D can also be found in milk, yogurt, pasta, and some cereals because it has been artificially added.

Sunflower seeds, almonds and nuts, olives, basil, and oregano are rich in vitamin E. The recommended daily amount is 20 mg because exceeded amounts can produce hemorrhage.

Vitamin K is found in small amounts in dry basil, sage, thyme, fresh parsley, coriander, and oregano, as well as cabbage and broccoli.

Vitamin B12 or folic acid and iron can be found in meat (beef, pork, lamb, and chicken), eggs, and dairy products.

Some authors state that pancreatic enzyme replacement therapy is the therapeutic mainstay of chronic pancreatitis. Protease and lipase supplements are effective in restoring normal digestion of dietary nutrients, but they are ineffective if used alone, without diet and lifestyle modifications. Vitamin supplementation (primarily the fat-soluble vitamins A, D, E, and K) is useful to avoid long-term consequences of their deficiency (vision, bone metabolism, wound healing, and coagulation).

Surgery has no role in these patients because they can achieve an adequate quality of life with other measures. Pancreatic transplantation is indicated only for patients with endocrine pancreatic insufficiency and to ameliorate type 1 diabetes and produce complete insulin independence; it has no role in EPI.

This patient was placed on a specific diet, following the recommendations above. At 6 months, most of her symptoms had considerably improved. The steatorrhea and malodorous stools had nearly disappeared. Abdominal distention occurred only with diet changes. Her night vision acuity entirely recovered, and no more bruises appeared. Recent blood tests revealed adequate hemoglobin with normal-size red blood cells, as well as recovered levels of albumin, and acceptable ranges of prothrombin and partial thromboplastin times.

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