SESSION IV The Korean Journal of Pancreas and Biliary Tract 2014;19(Suppl. 1) 소화와췌장 고려대학교의과대학소화기내과학교실 이홍식 Pancreatic Function for the Digestion of Nutrients Hong Sik Lee Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea 서론.,.,,,.,.,,,,. (HCO3 - ),. Corresponding author : Hong Sik Lee Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 136-705, Korea Tel. +82-2-920-5312 Fax. +82-2-953-1943 E-mail; hslee60@korea.ac.kr,. 주요영양소의소화과정 1. 탄수화물의소화 (polysaccharides), (disaccharides), (monosaccharides)., (starch) (dietary fiber). (amylose) (amylopectin). α-1, 4 α-1, 6 (branch). (α-amylase) (dextrin) (maltose).. http://www.kpba.kr 39
이홍식,, maltotriose,. maltase. (sucrose) sucrase (fructose), (lactose) lactase (galactose). 2. 단백질의소화 (polypeptide).,..... (trypsin) (chymotrypsin), (carboxyl peptidase) (dipeptide). (aminopeptidase), (carboxypeptidase), (endopeptidase), (dipeptidase). 3) 췌장단백분해효소의활성. enterokinase (Fig. 1). 3. 지방의소화 (triglycerides). (glycerol) (fatty acid).. 1) 입과위에서의소화 (chief cell).. 1.6-3.2. 2) 장에서의소화 Fig. 1. Mechanism to avoid activation of pancreatic proteases until they are in the duodenal lumen. 40 The Korean Journal of Pancreas and Biliary Tract
Pancreatic Function for the Digestion of Nutrients.. CCK (micelle).. 1-, 3-2- 80% 2-monoglyceride 20%.,. 췌장의소화작용 (acinar cell) (ductal cell) (HCO3 - ),. phase I phase II, III (Fig. 2). 20-30 3-6 3-4 3-4 (Fig. 3).,, 1, 2. 10-20 5-10%. ph 6-7 ph 6 2-3 ph 5-5.5.,,. 20 cal/kg.,... (jejunum) 25%. Fig. 2. Interdigestive amylase output in healthy volunteers during daytime. Enzymeout is cyclical: It is associated with intestinal motility. Fig. 3. Digestive pancreatic enzyme response to a regular meal. Session IV Digestion and Pancreatobiliary System 41
이홍식 Table 1. Duodenal enzyme outputs Interdigestive Early/maximal postprandial Late/mean postprandial Lipase (U/min) 1,000 3,000-6,000 2,000-4,000 Amylase (U/min) 50-250 500-1,000 500 Trypsin (U/min) 50-100 200-1,000 150-500 Data are derived from studies using test meals with 300-600 kcal. References are given in the text. Table 2. Enzyme activities in duodenal juice Interdigestive Early/maximal postprandial Late/mean postprandial Lipase (U/min) 100-400 500-1,500 400-1,000 Amylase (U/min) 100-150 150-300 150-300 Trypsin (U/min) 20-50 80-180 60-100-150 Data are derived from studies using test meals with 300-600 kcal and using no or only low marker perfusion rates (< 3 ml/min). References are given in the text. cephalic phase, gastric phase intestinal phase CCK secretin intestinal phase 80%. 60%, 20-30%.. 만성췌장염에서의소화흡수장애 10-20 90-95%. 5-10 60-90%. 2..,... (oligsaccharidase) 80%.. 42 The Korean Journal of Pancreas and Biliary Tract
Pancreatic Function for the Digestion of Nutrients 췌장수술후소화흡수장애.,.. 6. 췌장외분비기능저하의진단,,. (Table 3).. Table 3. Enzyme activities in duodenal juice Clinical * Steatorrhea Unexplained diarrhea Unexplained weight loss Imaging or endoscopic findings Pancreatic ductal dilatation Main pancreatic duct calculi Eight endosonographic criteria of chronic pancreatitis Laboratory findings Quantitative fecal fat >7 g/day Positive qualitative fecal fat (Sudan III) staining Fecal elastase-1 <100 μg/g of stool 13 C-mixed triglyceride breath test <29% * Usually indicates very severe PEI.. N-benzoyl-l-tyrosyl paraaminobenzoic acid (NBT-PABA). 100 g 5 3. 15 g.. 13 C-MCT (medium chain triglyceride). Acid steatocrit (AS) sudan-iii. elastase chymotrypsin. 췌장소화효소보충치료 (pancreas enzyme replacement therapy) 15 g,,.. 40-60 U/mL 25,000-40,000 U. 1-2 mm. Session IV Digestion and Pancreatobiliary System 43
이홍식 Morphological flndings of advanced chronic pancreatitis (dilated pancreatic duct and/or calcifications), severe necrotizing pancreatitis, following gastrointestinal and pancreatic surgery, unresectable cancer of the head of the pancreas Success: Absence of maldlgestionrelated symptoms Normal nutritional evaluation (BMI, albumin, preolbumin, cholesteral) Enteric-coated pancreatin mini-microspheres (40,000-50,000 Eur. Ph. U Epase/meal) Check for other causes of maldigestion/malabsorption, and treat Increase enzyme dose and/or add a PPI Fig. 4. Management of pancreatic exocrine insufficiency. 1-2 mm microsphere. 50 U/kg/day (cystic fibrosis) fibrosing colonopathy. 75,000 U.. H2, PPI. (Fig. 4)... 결론.,. 3., 44 The Korean Journal of Pancreas and Biliary Tract
Pancreatic Function for the Digestion of Nutrients.,,,,,.,. REFERENCES 1. Kim E. Barrett, Scott Boitano, Susan M. Barman, Heddwen L. Brooks. Ganong s review of medical physiology 24th ed. McGrawhill. 2. Chang YK, Choi YJ, Kim EM, Won SI. Basic Nutrition,2008, Hyungseol publising. 3. Lee YN, Min KJ, Lim HM et al. Fundamental Nutrition, 2006, Kwangmoongak. 4. Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut 2005;54(Suppl VI):vi1-vi28. 5. Layer P, Keller J. Pancreatic enzymes: secretion and luminal nutrient digestion in health and disease. J Clin Gastroenterol 1999;28:3-10. 6. Dominguez-Munoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol 2011;26(Suppl 2):12-16. 7. Pongprasobchai S. Maldigestion from pancreatic exocrine insufficiency. J Gastroenterol Hepatol 2013;28(Suppl 4):99-102. 8. Park JW, Jang JY, Kim EJ, et al. Effects of pancreatectomy on nutritional state, pancreatic function and quality of life. Br J Surg 2013;100:1064-1070.. Session IV Digestion and Pancreatobiliary System 45