# Situation: A 44-year-old man has chronic pancreatitis from long-term alcohol use and stopped drinking 3 months ago. He has diabetes caused by the pancreatitis and uses insulin glargine and insulin lispro. He also takes pancrelipase capsules. At a clinic visit he reports bulky, greasy, foul-smelling stools that float, and he has lost 3 kg in a month. He has no jaundice. His diary for a typical day: Meals and snacks: breakfast 06:30, snack 10:00, lunch 12:30, snack 15:30, dinner 19:00 Pancrelipase: 2 capsules each at 08:00, 13:30 and 21:00, swallowed whole Which problem BEST explains his symptoms?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630499  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 44-year-old man has chronic pancreatitis from long-term alcohol use and stopped drinking 3 months ago. He has diabetes caused by the pancreatitis and uses insulin glargine and insulin lispro. He also takes pancrelipase capsules.

At a clinic visit he reports bulky, greasy, foul-smelling stools that float, and he has lost 3 kg in a month. He has no jaundice. His diary for a typical day:
Meals and snacks: breakfast 06:30, snack 10:00, lunch 12:30, snack 15:30, dinner 19:00
Pancrelipase: 2 capsules each at 08:00, 13:30 and 21:00, swallowed whole
Which problem BEST explains his symptoms?

## 보기

1. No enzymes in the gut when he eats his food **✔ 정답**
2. Poorly controlled diabetes causing weight loss
3. Lactose intolerance from damage to the bowel
4. A tumor blocking the flow of bile into the gut

**정답: 1**

## 해설

Pancrelipase replaces the digestive enzymes the damaged pancreas no longer makes, so it works only when taken with the first bite of every meal and snack. His diary shows each dose taken 1–2 hours after a meal and none with his snacks, so the enzymes are not in the gut when fat is eaten, and steatorrhea and weight loss continue. The absence of jaundice argues against a tumor blocking bile flow, and poor glucose control does not produce greasy stools.

## 심화 해설

The timing problem in his diary
Pancrelipase contains lipase, protease, and amylase that replace the digestive enzymes his damaged pancreas no longer secretes. The enzymes act only on food that is in the gut at the same time, so they must be taken with the first bite of every meal and snack. His diary shows meals at 06:30, 12:30, and 19:00, but doses at 08:00, 13:30, and 21:00, each 1–2 hours after eating, and no doses with his snacks. When the enzymes are not in the gut while fat is eaten, fat is not digested, and steatorrhea and weight loss continue.

Linking symptoms to the cause
Bulky, greasy, foul-smelling stools that float are steatorrhea, the hallmark of fat malabsorption from exocrine pancreatic insufficiency. Undigested fat carries calories out of the body, explaining his 3-kg weight loss in a month, and also reduces absorption of fat-soluble vitamins. He is taking the medicine, and swallowing the capsules whole is correct, so the problem is not the drug or the dose as much as the timing. Correcting the timing is the first step before the provider considers increasing the dose.

| Explanation | Fits his findings? | Reason |
| --- | --- | --- |
| Enzymes not in the gut with food | Yes | Doses taken 1–2 hours after meals; none with snacks |
| Poorly controlled diabetes | No | Can cause weight loss but not greasy stools |
| Lactose intolerance | No | Causes watery stools and bloating after milk |
| Tumor blocking bile flow | No | Would cause jaundice, dark urine, pale stools |

Why the other explanations are wrong
His diabetes caused by pancreatitis can cause weight loss if glucose is poorly controlled, but hyperglycemia does not produce fatty, floating stools. Lactose intolerance causes watery diarrhea, gas, and bloating after dairy, not steatorrhea. A tumor at the head of the pancreas blocking bile flow would cause jaundice, dark urine, and pale stools; he has no jaundice. Watch out! Diary-based questions reward comparing times carefully; here the meal and dose times never line up.

Teaching for pancrelipase
The nurse teaches him to take pancrelipase with the first bite of every meal and snack, to swallow capsules whole without crushing or chewing, and, if a meal is long, to split the dose between the start and middle as directed. Capsules may be opened and the beads sprinkled on soft acidic food if swallowing is difficult, but the beads are not chewed. Key point! Pancreatic enzymes work only if they meet the food: take them with every meal and snack, not afterward.

## 임상 시나리오

Pancrelipase TimingWhy steatorrhea persists
Pancrelipase replaces pancreatic enzymes and works only on food in the gut at the same time. Take it with the first bite of every meal and snack.

His doses come 1–2 hours after meals, and none with snacks, so fat is not digested: bulky, greasy, floating stools (steatorrhea) and 3-kg weight loss.

Swallow capsules whole; do not crush or chew the beads.

CautionNo jaundice argues against a tumor blocking bile flow; poor glucose control does not cause greasy stools.

## 핵심 개념

- **Pancrelipase** — A pancreatic enzyme replacement containing lipase, protease, and amylase, taken with meals and snacks.
- **Steatorrhea** — Bulky, greasy, foul-smelling stools that float, caused by fat malabsorption.
- **Exocrine pancreatic insufficiency** — Inadequate secretion of digestive enzymes by the pancreas, leading to maldigestion.
- **Chronic pancreatitis** — Progressive inflammation and fibrosis of the pancreas that destroys exocrine and endocrine tissue.

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