2. Nutrition in Chronic Pancreatitis
AGA Institute • Fellows’ Nutrition Course 2007
Rosemont/Chicago, Illinois • November 10, 2007
John A. Martin, M.D.
Associate Professor of Medicine and Surgery
Director of Endoscopy
Northwestern University Feinberg School of Medicine • Chicago, Illinois

3. Chronic Pancreatitis Today’s focus on The disease The symptoms
Nutritional issues

4. Chronic Pancreatitis: The Disease
Chronic inflammation of pancreas
Mononuclear cell infiltrate
Fibrosis/calcification/irreversible anatomic changes
Characteristic duct changes
With or without calcification
Affects exocrine and/or endocrine organ (including alpha cells)

5. Chronic Pancreatitis: The Disease
Multiple etiologies
EtOH (80%)
Hereditary CF
Others
Tropical
Trauma/chronic duct obstruction
Pancreas divisum
Recurrent acute
Idiopathic

6. Chronic Pancreatitis: The Disease
Malnutrition results from
Pain
Decreased nutrient digestion (esp. fat) → malabsorption
>90% loss panc exocr fxn)

7. Chronic Pancreatitis: The Symptoms
Pain
Constant or recurrent
May be exacerbated by meals, alcohol
May recur without recurrent acute inflammation
Treatment
Analgesia
Hydration
NPO
EtOH abstinence

8. Chronic Pancreatitis: The Symptoms
Maldigestion with secondary malabsorption
Steatorrhea
Malnutrition
Caloric
Vitamin deficiencies
Mineral deficiencies
Weight loss

9. Chronic Pancreatitis: Nutritional Issues
Etiologies
Maldigestion (a late symptom of CP)
Pancreatic exocrine insufficiency (PEI): >90% function loss
Malabsorption
Maldigestion losses (with or without steatorrhea)
Fat-soluble vitamins
B12 due to R-factor dysfunction

10. Chronic Pancreatitis: Nutritional Issues
Etiologies
Decreased oral intake
Glucose intolerance / diabetes (50-90%)
Poor glycemic control (can also be assoc with impaired glucagon release in up to 30%)
Endorgan manifestations
Gastroparesis
Nausea
Diarrhea/constipation
Alcoholism
Increased metabolic activity (30-50%) Hebuterne, et al., 1996

11. Chronic Pancreatitis: Diagnosis
Diagnosis: imaging
AXR: parenchymal ± intraductal calcifications
CT: calcifications (incl stones), inflammatory enlargement/mass, atrophy (relative), duct changes
MR: similar to CT
EUS: as above; also lobulation, hyperechoic foci/stranding, hyperechoic duct margin
ERCP: calcifications/stones, characteristic duct changes

12. Chronic Pancreatitis: Diagnosis
Diagnosis: function testing
Fecal elastase
Fecal fat
Quant: 72 hr stool fat: 100g fat diet, >7g fat excr/24 hrs
Qualitative: spot oil-red O
Secretin stim testing
Indirect testing (e.g., Bentiromide test in past)

13. PEI: diagnosis Symptoms, clinical suspicion Steatorrhea Weight loss
Lipolytic function decreases more rapid than proteolytic
Weight loss
Hypovitaminosis (A, D, E, K, B12): uncommon
Mineral deficiencies Ca Mg Zn
Thiamine
Folate

14. PEI: diagnosis Function testing Direct Indirect
Secretin, CCK stim testing
Indirect
Fecal fat
Fecal elastase, chymotrypsin
Pancreolauryl test
Breath tests (13C)

15. Chronic pancreatitis: overall nutritional management strategy
Basic (majority of CP patients)
EtOH abstinence
Dietary modification
Pancreatic enzyme supplementation
Advanced (minority of CP patients)
Oral supplementation (~10%)
Enteral nutrition (~5%)
Parenteral nutrition (<1%)

16. PEI: nutritional management
Dietary modification
Increase caloric intake (↑ resting energy requirements)
Decrease dietary fat (~30%)
Increase dietary protein (1 gm/kg BW/d)
Increase carbohydrate (except in DM); ± ↓ fiber
Oral MCT supplementation
Vitamin supplementation
Mineral supplementation

17. PEI: nutritional management
Enteral nutrition: indications in CP
Pain
Anatomical etiologies of ↓ intake
Due to CP
Postoperative complications
Recurrent/frequent pancreatitis exacerbations
RAP
Pain exacerbations of CP
Complications of DM

18. PEI: nutritional management
Enteral nutrition: routes of delivery in CP NJ
PEG
PEG-J
D-PEJ
Enteral nutrition: formulas in CP
Not well-studied: semi-elemental diet often recommended by experts

19. PEI: nutritional management
Parenteral nutrition (rarely needed/indicated)
Anatomical reasons
Fistula
Short-term treatment of severe malnutrition
Preop

20. PEI: pharmacological management
Enzyme supplementation
No “set dose”
Generally start with 2 caps AC + titrate
Monitor sx’s (steatorrhea) or (re)check fecal fat
Acid suppression to preserve activity
Clinical value of coating/encapsulation not well-studied

21. PEI: pharmacological management
Antioxidants
Analgesic therapy
Opiates
Tricyclics, etc.
Non-steroidals
Uncoated enzymes
Treatment of diabetes
Insulin, OHGs
Gastroparesis management
Anti-emetics
Anti-diarrheals

22. Summary
Major symptomatic manifestations of CP are all nutrition-related, and all multifactorial
Pain
Maldigestion/malabsorption/malnutrition DM
Nutritional management of CP includes
Dietary modification in almost all
Enteral nutrition in few
Parenteral nutrition in exceedingly few
Pharmacological management of CP includes
Analgesia
Enzyme supplementation
Treatment of DM and its endorgan manifestations
Treatment of nausea and other symptoms
Rigorous studies are lacking in nutritional aspects of CP management

23. INTESTINAL REHABILITATION CENTER NORTHWESTERN UNIVERSITY