7
Enteral Nutrition Options in the Patient with
Fat Malabsorption
Pancreatic enzymes and bile salts are required for optimal absorption of fat in
the diet or enteral feedings.
1. If a patient receiving enteral nutrition has fat malabsorption due to
pancreatic insufficiency:
a. Consider enteral formula selection (Table 6).
b. Consider pancreatic enzyme replacement (Tables 7, 8).
2. If a patient receiving enteral nutrition has fat malabsorption due to bile
salt deficiency:
a. Consider enteral formula selection (defined as ideally <60 g fat/day) (Table 6).
b. There is no bile salt replacer available that has been shown to be clinically
effective.
c. If patient has an external biliary drain and is losing a significant volume of bile
salts, the patient will need a low-fat formula (Table 6).
d. In select patients, reinfusing bile may be an option if patient has an external
biliary drain & jejunal access (NOT if biliary drainage is infected).
e. KEY POINT: Medium chain triglycerides (MCT) can be absorbed across
the brush border. However, in the setting of fat malabsorption, despite
interventions, absorption will still be imperfect. Excessive doses of MCT can
overwhelm mucosal receptors requiring MCT to be absorbed using the same
pathway as long chain fat. Hence, pancreatic enzyme dosing must be based
on total grams of fat intake. Also, MCT will not provide essential fatty acids
(EFA); consider evaluating patient for EFA deficiency if signs and symptoms
develop.
