Digestive enzymes

Class Summary

Pancreatic enzyme deficiency may occur because of steatorrhea secondary to malabsorption.

Pancrelipase (Ultrase, Pancrease, Creon)

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Assists in digestion of protein, starch, and fat. Contains lipase, protease, and amylase.

Class Summary

These agents are used in combination with antibiotics for bile acid malabsorption syndromes. Bacteria overgrowth may cause diarrhea by deconjugation and dehydroxylation of bile acids. Primary bile acid malabsorption may also occur.

Cholestyramine (Questran)

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Binds bile acids, thus reducing damage to the intestinal mucosa. Also reduces induction of colonic fluid secretion. Forms a nonabsorbable complex with bile acids in the intestine, which in turn inhibits enterohepatic reuptake of intestinal bile salts.

Class Summary

Metronidazole may be considered and provides anaerobic coverage. Although the use of rifaximin in children for the indication of small intestinal bacterial overgrowth is not US Food and Drug Administration (FDA)-approved, this antibiotic is virtually nonabsorbed (< 0.4%) and has been proven useful in the treatment of small intestinal bacterial overgrowth in adults.

Metronidazole (Flagyl)

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DOC for documented small bowel bacterial overgrowth. Provides good anaerobic coverage.

Rifaximin (Xifaxan)

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Nonabsorbed (< 0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, Gram-positive, Gram-negative, aerobic and anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.

Follow-up

Siddiqui Z, Osayande AS. Selected disorders of malabsorption. Prim Care. 2011 Sep. 38(3):395-414; vii. [QxMD MEDLINE Link].
Ma K, Hu Y, Smith DE. Peptide transporter 1 is responsible for intestinal uptake of the dipeptide glycylsarcosine: studies in everted jejunal rings from wild-type and Pept1 null mice. J Pharm Sci. 2011 Feb. 100 (2):767-74. [QxMD MEDLINE Link].
Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10. 163(3):286-92. [QxMD MEDLINE Link].
Rubio-Tapia A, Kyle RA, Kaplan EL, et al. Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology. 2009 Jul. 137(1):88-93. [QxMD MEDLINE Link]. [Full Text].
Meyer R, Venter C, Fox AT, Shah N. Practical dietary management of protein energy malnutrition in young children with cow's milk protein allergy. Pediatr Allergy Immunol. 2012 Mar 22. [QxMD MEDLINE Link].
Abenavoli L, Proietti I, Vonghia L, et al. Intestinal malabsorption and skin diseases. Dig Dis. 2008. 26(2):167-74. [QxMD MEDLINE Link].
Scarpellini E, Giorgio V, Gabrielli M, et al. Prevalence of small intestinal bacterial overgrowth in children with irritable bowel syndrome: a case-control study. J Pediatr. 2009 Sep. 155(3):416-20. [QxMD MEDLINE Link].
Bruno MJ, Haverkort EB, Tytgat GN, van Leeuwen DJ. Maldigestion associated with exocrine pancreatic insufficiency: implications of gastrointestinal physiology and properties of enzyme preparations for a cause-related and patient-tailored treatment. Am J Gastroenterol. 1995 Sep. 90(9):1383-93. [QxMD MEDLINE Link].
Ford GA, Preece JD, Davies IH, Wilkinson SP. Use of the SeHCAT test in the investigation of diarrhoea. Postgrad Med J. 1992 Apr. 68(798):272-6. [QxMD MEDLINE Link]. [Full Text].
Wedlake L, A'Hern R, Russell D, Thomas K, Walters JR, Andreyev HJ. Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2009 Oct. 30(7):707-17. [QxMD MEDLINE Link].
Mokrowiecka A, Daniel P, Slomka M, Majak P, Malecka-Panas E. Clinical utility of serological markers in inflammatory bowel disease. Hepatogastroenterology. 2009 Jan-Feb. 56(89):162-6. [QxMD MEDLINE Link].
Ritchie BK, Brewster DR, Davidson GP, Tran CD, McNeil Y, Hawkes JS. 13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health. Pediatrics. 2009 Aug. 124(2):620-6. [QxMD MEDLINE Link].
Yao CK, Tuck CJ. The clinical value of breath hydrogen testing. J Gastroenterol Hepatol. 2017 Mar. 32 Suppl 1:20-22. [QxMD MEDLINE Link].
Gabrielli M, D'angelo G, Di Rienzo T, Scarpellini E, Ojetti V. Diagnosis of small intestinal bacterial overgrowth in the clinical practice. Eur Rev Med Pharmacol Sci. 2013 Dec. 17 Suppl 2:30-5. [QxMD MEDLINE Link].
Rizzello CG, De Angelis M, Di Cagno R, et al. Highly efficient gluten degradation by lactobacilli and fungal proteases during food processing: new perspectives for celiac disease. Appl Environ Microbiol. 2007 Jul. 73(14):4499-507. [QxMD MEDLINE Link].
[Guideline] Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005 Jan. 40(1):1-19. [QxMD MEDLINE Link].
Quigley EM, Quera R. Small intestinal bacterial overgrowth: roles of antibiotics, prebiotics, and probiotics. Gastroenterology. 2006. 130:S78-90. [QxMD MEDLINE Link].
Lauritano EC, Gabrielli M, Scarpellini E, et al. Antibiotic therapy in small intestinal bacterial overgrowth: rifaximin versus metronidazole. Eur Rev Med Pharmacol Sci. 2009 Mar-Apr. 13(2):111-6. [QxMD MEDLINE Link].
Kumpf VJ. Pharmacologic Management of Diarrhea in Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr. 2014 Jan 24. [QxMD MEDLINE Link].
Volta U, Granito A, Fiorini E, et al. Usefulness of antibodies to deamidated gliadin peptides in celiac disease diagnosis and follow-up. Dig Dis Sci. 2008 Jun. 53(6):1582-8. [QxMD MEDLINE Link].
Adachi JA, DuPont HL. Rifaximin: a novel nonabsorbed rifamycin for gastrointestinal disorders. Clin Infect Dis. 2006 Feb 15. 42(4):541-7. [QxMD MEDLINE Link].
Cavataio F, Guandalini S. Cow's milk allergy. Guandalini S, ed. Essential Pediatric Gastroenterology. McGraw-Hill; 2005. 175-92.
Cole CR, Ziegler TR. Small bowel bacterial overgrowth: a negative factor in gut adaptation in pediatric SBS. Curr Gastroenterol Rep. 2007 Dec. 9(6):456-62. [QxMD MEDLINE Link].
Crenn P, Messing B, Cynober L. Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction. Clin Nutr. 2008 Jun. 27(3):328-39. [QxMD MEDLINE Link].
Fonnesu C, Giovinale M, Verrecchia E, et al. Gastrointestinal amyloidosis: a case of chronic diarrhoea. Eur Rev Med Pharmacol Sci. 2009 Mar. 13 Suppl 1:45-50. [QxMD MEDLINE Link].
Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology. 2006. 130 (2 Suppl 1):S16-28. [QxMD MEDLINE Link].
Green PH, Jabri B. Celiac disease. Annu Rev Med. 2006. 57:207-21. [QxMD MEDLINE Link].
Guandalini S, Dincer AP. Nutritional management in diarrhoeal disease. Baillieres Clin Gastroenterol. 1998. 12:697-717. [QxMD MEDLINE Link].
Gupte GL, Beath SV, Kelly DA, et al. Current issues in the management of intestinal failure. Arch Dis Child. 2006. 91:259-64. [QxMD MEDLINE Link].
Kneepkens CM, Hoekstra JH. Chronic nonspecific diarrhea of childhood: pathophysiology and management. Pediatr Clin North Am. 1996 Apr. 43(2):375-90. [QxMD MEDLINE Link].
Longo N, Elsas LJ. Human glucose transporters. Adv Pediatr. 1998. 45:293-313. [QxMD MEDLINE Link].
Love MW, Dawson PA. New insights into bile acid transport. Curr Opin Lipidol. 1998 Jun. 9(3):225-9. [QxMD MEDLINE Link].
Maldonado J, Gil A, Narbona E, Molina JA. Special formulas in infant nutrition: a review. Early Hum Dev. 1998 Dec. 53 Suppl:S23-32. [QxMD MEDLINE Link].
Montalto M, Curigliano V, Santoro L, et al. Management and treatment of lactose malabsorption. World J Gastroenterol. 2006. 12:187-91. [QxMD MEDLINE Link].
Montalto M, Santoro L, D'Onofrio F, Curigliano V, Visca D, Gallo A, et al. Classification of malabsorption syndromes. Dig Dis. 2008. 26(2):104-11. [QxMD MEDLINE Link].
Nakamura T, Takeuchi T, Tando Y. Pancreatic dysfunction and treatment options. Pancreas. 1998 Apr. 16(3):329-36. [QxMD MEDLINE Link].
Robayo-Torres CC, Quezada-Calvillo R, Nichols BL. Disaccharide digestion: clinical and molecular aspects. Clin Gastroenterol Hepatol. 2006. 4:276-87. [QxMD MEDLINE Link].
Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann''s disease). Orphanet J Rare Dis. 2008 Feb 22. 3:5. [QxMD MEDLINE Link]. [Full Text].
Weiss B, Skourikhin Y, Modan-Moses D, Broide E, Fradkin A, Bujanover Y. Is adult height of patients with celiac disease influenced by delayed diagnosis?. Am J Gastroenterol. 2008 Jul. 103(7):1770-4. [QxMD MEDLINE Link].
Zanchi C, Di Leo G, Ronfani L, Martelossi S, Not T, Ventura A. Bone metabolism in celiac disease. J Pediatr. 2008 Aug. 153(2):262-5. [QxMD MEDLINE Link].
Antunes C, Gossman WG. Whipple Disease. 2017 Jun. [QxMD MEDLINE Link]. [Full Text].
Tack GJ, van de Water JM, Bruins MJ, Kooy-Winkelaar EM, van Bergen J, Bonnet P, et al. Consumption of gluten with gluten-degrading enzyme by celiac patients: a pilot-study. World J Gastroenterol. 2013 Sep 21. 19 (35):5837-47. [QxMD MEDLINE Link].
Syage JA, Murray JA, Green PHR, Khosla C. Latiglutenase Improves Symptoms in Seropositive Celiac Disease Patients While on a Gluten-Free Diet. Dig Dis Sci. 2017 Jul 28. [QxMD MEDLINE Link].
Goel G, King T, Daveson AJ, Andrews JM, Krishnarajah J, Krause R, et al. Epitope-specific immunotherapy targeting CD4-positive T cells in coeliac disease: two randomised, double-blind, placebo-controlled phase 1 studies. Lancet Gastroenterol Hepatol. 2017 Jul. 2 (7):479-493. [QxMD MEDLINE Link].

Media Gallery

The small intestine is a major site of absorption.

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Author

Stefano Guandalini, MD, AGAF Founder and Director Emeritus, Celiac Disease Center, University of Chicago; Former Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medicine; Professor Emeritus, The University of Chicago Pritzker School of Medicine

Stefano Guandalini, MD, AGAF is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology and Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, North American Society for the Study of Celiac Disease

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Imaware.health.

Coauthor(s)

Catherine D Newland, MD Pediatric Gastroenterology Fellow, Comer Children’s Hospital, University of Chicago

Catherine D Newland, MD is a member of the following medical societies: American Academy of Pediatrics, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Richard E Frye, MD, PhD Professor of Child Health, University of Arizona College of Medicine at Phoenix; Chief of Neurodevelopmental Disorders, Director of Autism and Down Syndrome and Fragile X Programs, Division of Neurodevelopmental Disorders, Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society

Disclosure: Nothing to disclose.

M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine

M Akram Tamer, MD is a member of the following medical societies: American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

Eric S Maller, MD

Eric S Maller, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society of Transplant Surgeons, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.