Chapter 7. Digestive System

decreased work capacity. Hypoproteinaemic oedema can develop in pa­tients with cachexia.

Pancreatic secretion is studied for the diagnosis of the syndrome of pancreatic exocrine insufficiency. Activity of trypsin, antitrypsin, lipase, and amylase in the blood serum, and also amylase in the urine is studied simultaneously. Upset intestinal digestion, which is characteristic of pan­creatic insufficiency, is determined in grave cases by the typical disorders in stools (pancreatogenic diarrhoea) and coprogram. Since in most diseases of the pancreas its endocrine apparatus is also involved (pancreatic islands) determination of blood sugar (with a fasting stomach), the level of glycaemia and glucose tolerance (single and double loads) is diagnostically important (see " Diabetes Mellitus").

It should be remembered that the exocrine pancreatic insufficiency oc­curs in many diseases. The diagnosis of the main disease (by direct ex­amination and laboratory studies) is therefore of primary importance for further treatment of the patient.

Three stages of exocrine pancreatic insufficiency are differentiated: the first stage (initial, latent) becomes only manifest when the requirement for the digestive enzymes increases (overeating, especially intake of much fats); the second stage is a pronounced pancreatic insufficiency (frequent or per­manent diarrhoea, steatorrhoea, creatorrhoea, amylorrhoea); and the third stage, dystrophy; it is characterized by considerable wasting (to cachexia) due to severe disturbances in the intestinal digestion and absorption, polyhypovitaminosis, and dystrophic changes in various organs and tissues.

Treatment. The following three principles are observed: (1) treatment of the main disease; (2) mechanically and chemically sparing diet: food must be easily hydrolysed by the enzymes and contain much protein, vitamins, and limited quantity of carbohydrates (depending on the pan­creatic incretory function); (3) substitution enzyme therapy including preparations containing pancreatic enzymes: pancreatin, pansinorm, and others.