Anna Burton, Specialist pancreatic dietitian

The nutritional deficiencies caused by chronic pancreatitis are common and complex, with abdominal pain directly impacting an individual’s ability to eat. Paired with both lifestyle choices and ultimately the consequences of endocrine and exocrine dysfunction, it’s easy to understand why individuals with chronic pancreatitis need close and repeated monitoring of their nutritional status. This blog aims to describe the nutritional consequences and treatment of chronic pancreatitis.

What is chronic pancreatitis?

Chronic pancreatitis is an irreversible progressive disease caused by prolonged inflammation of the pancreas. Symptoms include chronic or recurrent episodes of severe abdominal pain, nausea, vomiting, diarrhoea, steatorrhoea (an excess of fat in stool) and weight loss. Symptoms in the early stages may be vague and non-specific, meaning the time to diagnosis of chronic pancreatitis may be prolonged.

Complications from chronic pancreatitis include pseudocysts (fluid-filled collection arising from the pancreatic duct), pancreatic duct strictures (narrowing) and loss of pancreatic tissue function.

The treatment for chronic pancreatitis includes pain management, pancreatic enzyme replacement therapy (PERT), lifestyle changes regarding alcohol and smoking cessation, surgical, and endoscopic interventions to relieve blocked ducts and pseudocyst drainage. There is no cure for chronic pancreatitis.

What causes chronic pancreatitis?

Table 1: Causes of chronic pancreatitis

Consequences of chronic pancreatitis on nutritional status

The pancreas is a unique gland as it has an endocrine and exocrine function. The exocrine function includes producing pancreatic enzymes required for digestion – particularly fat digestion.

The endocrine role is the production of hormones: – these include insulin and glucagon, both required for the optimum regulation of blood glucose levels.  Hence, all people who have chronic pancreatitis are at risk of malnutrition and diabetes caused by inadequate oral intake, maldigestion and poor glycaemic control in people with diabetes.

Abdominal pain, the main symptom of chronic pancreatitis directly impacts people’s ability to eat, leading to reduced food intake and consequent weight loss. This risk is compounded during a flare of chronic pancreatitis (acute on chronic pancreatitis) as symptoms of vomiting, abdominal pain and diarrhoea can lead to dehydration, electrolyte losses and further weight loss.  Opioids may be required for pain management. Unfortunately, the side effects of opioids on the gut are not insignificant and it’s important to remember this when assessing a patient’s gut motility and bowel habits.

Lifestyle choices namely alcohol and smoking contribute to deteriorating nutritional status including macronutrient and micronutrient deficiencies especially when alcohol replaces a significant part of the person’s diet (Ul Ain, et al, 2021).

Pancreatic Exocrine Insufficiency (PEI) arises due to:-

• Declining pancreatic production of digestive enzymes.
• Blockages within the pancreatic ducts.
• Reduced bicarbonate production impacts the optimal pH for enzyme activity within the duodenum.
• The resulting maldigestion causes significant abdominal symptoms, weight loss and malnutrition.

Diagnosis of PEI is based on clinical assessment, imaging, and diagnostic tests.  Clinical symptoms supporting a diagnosis of PEI include bloating, wind, abdominal pain, cramping, bulky stools which may be paler, floating, offensive to smell and demand urgency to go to the toilet.  Faecal Elastase-1 is a widely available test, however, it may give a false positive result if the stool sample is watery and has limited application to detect mild to moderate PEI.

Osteoporosis, sarcopenia and vitamin and mineral deficiencies are common and untreated PEI is associated with an increased risk of these consequences occurring (Parhiala et al, 2023).

Vitamin D deficiency is present in up to 65% of people with chronic pancreatitis (Hoogenboom et al 2016).

Diabetes caused by chronic pancreatitis is underdiagnosed and misdiagnosed, frequently being classified as type 2 diabetes (Ewald et al, 2012).  Diabetes caused by chronic pancreatitis is primarily a lack of insulin production due to the loss of functioning pancreatic tissue driven by fibrosis (thickening or scarring of the tissue) and calcifications (calcium build up in the body). There is no evidence-based research, and hence guidance, now on the optimal management of type 3c diabetes. Instead, reference is made by the NICE guidance (2018) on the management of type 1 or type 2 diabetes depending on the requirement for insulin or not.  Type 2 diabetes is primarily due to metabolic syndrome and insulin resistance. The health messages for type 2 diabetes are not always appropriate for a person struggling with their nutrition due to chronic pancreatitis.

The pancreas also produces the counter-regulatory hormone glucagon. Glucagon is secreted as blood glucose levels fall to mobilise glycogen stores restoring optimal blood glucose levels. The absence of glucagon in people with chronic pancreatitis increases the risk of severe hypoglycaemic events.

Cardiovascular disease – there is a higher incidence of cardiovascular disease in people with chronic pancreatitis, PEI is independently associated with an increased risk of cardiovascular events (Nikolic et al, 2019).

Dietary recommendations including nutritional guidelines.

National Institute for Health and Care Excellence (NICE) 2018 recommends referral to a specialist dietitian for anyone diagnosed with chronic pancreatitis.

Avoidance of alcohol and smoking is essential, as both play a role in driving forward pancreatic inflammation which increases the speed at which chronic pancreatitis worsens.

Table 2: Nutritional assessment as taken from ESPEN (2020)

Dietary advice required is described by ESPEN (2020) depending on the outcome of a detailed nutritional assessment.  Those with normal nutritional status should focus on achieving a balanced varied diet including nutrient-dense foods.  Undernourished people should be advised to consume high protein, high energy foods in five to six small meals per day which can help meet nutritional needs, especially if struggling with a poor appetite or symptoms caused by maldigestion. Prescribed oral nutritional supplements are indicated for people unable to maintain their nutritional status through dietary adjustments alone.

Pancreatic enzyme replacement therapy (PERT) is a major component of treatment.

The consensus for the management of pancreatic enzyme insufficiency is based on UK practical guidelines (Phillips et al, 2021), which recommend offering people with chronic pancreatitis monitoring by clinical and biochemical assessment for pancreatic enzyme insufficiency (PEI) at least every 6 months.

PERT capsules contain pancreatic enzymes which have been extracted from the pancreas of pigs.  The enzymes are enterically coated.  Informed consent is required for people of Islamic and Judaic faith and people following a vegetarian or vegan diet.  Pancreatic enzymes are temperature, pH and time-sensitive.  Practically this translates into needing to swallow the enzymes with a cold drink, consideration of a proton pump inhibitor (PPI) to reduce the inactivation of enzymes caused by an acidic environment beyond the stomach, and the need to take enzymes with each meal, snack, and nutritious drink.

Practical management of PERT

• Informed consent for porcine-containing medication.
• Starting dose 44-50 000 units of lipase with a meal and 22 – 25 000 units of lipase with a snack/nutritious liquid or supplement (Phillips et al, 2021).
• Patient education regarding the action of PERT.
• Dose adjusting PERT depending on the nutritional composition of the meal, snack or nutritious drink.
• Discuss restaurants, buffets and social situations where food may be eaten over a prolonged time.
• Avoid storing capsules at temperatures above 25 degrees Celsius– such as cars on hot sunny days, sunny windowsills, and trouser pockets.
• Foods not requiring PERT (fruit juice and fizzy drinks, hypo treatments or sugar-only based sweets, a piece of fruit, a plain biscuit, splash of milk in tea and coffee.
• Nutritious fluids including café-style latte, cappuccino, hot chocolate, and oral nutritional supplements, all of which require PERT.
• Monitoring of PEI in response to initiation of PERT.  Failure to resolve maldigestion symptoms warrants dose escalation or the investigation of other causes of bowel and abdominal symptoms such as bile acid malabsorption (BAM), small intestine bacterial overgrowth (SIBO), or coeliac disease.

Figure 1 demonstrates the summary of guidance for the Consensus on the management of pancreatic enzyme insufficiency, taken from UK practical guidelines (Phillips et al, 2021).

Type 3c Diabetes

Did you know, people with chronic pancreatitis have an 80% lifetime risk of developing diabetes (NICE, 2018).  Chronic pancreatitis is a progressive disease, and the risk of diabetes increases over time. Diabetes of the exocrine pancreas is sometimes referred to as type 3c diabetes.  This term originates from the American Diabetes Association (ADA) classification of aetiology.

National Institute for Health and Care Excellence (NICE) 2018 recommendations:

• Offer people with chronic pancreatitis an HbA1c (haemoglobin A1C) test for diabetes at least every 6 months.
• Assess people with type 3c diabetes every 6 months for the potential benefit of insulin therapy.
• Dietary advice includes following a regular meal pattern, which if indicated may mirror the 5 – 6 small meals and snacks per day for people struggling with a poor appetite.  These meals should include lower glycaemic index starchy carbohydrates.  Minimise sugary foods and drinks unless for the treatment of a hypoglycaemic event.  Further recommendations are detailed by Duggan et al, (2017).
• Regular monitoring of blood glucose levels is important to enable the tailoring and adjustment of oral hypoglycaemic agents and/or insulin.  A continuous glucose monitor (CGM) is available under the NICE guidelines NG28, 2022 for people with other types of diabetes requiring insulin. Due to the severity of hypoglycaemia and hyperglycaemia that people with chronic pancreatitis can experience, a discussion with the patient’s diabetes team or GP regarding funding of a CGM is advisable.

Follow-up recommendations

Table 3: Long-term follow up recommendations for those on pancreatic enzyme insufficiency, as taken from UK practical guidelines (Phillips et al, 2021)

It is recommended to monitor and treat any vitamin and mineral deficiencies according to individual assessment and local guidelines. Adults with chronic pancreatitis should be offered a bone density assessment every 2 years (NICE, 2018).

Myths surrounding chronic pancreatitis impact people’s experience of healthcare and nutritional choices

Myth 1.  Chronic pancreatitis is always caused by alcohol.

For 20% of people, their chronic pancreatitis is not caused by alcohol but by genetic, anatomical, or autoimmune pancreatitis for example. It is important to consider patients’ experiences when accessing health care support due to a painful exacerbation of chronic pancreatitis, assuming alcohol is the cause may be very frustrating for the patient.

Myth 2. A low-fat diet is the standard dietary treatment for chronic pancreatitis.

NICE, ESPEN 2020 and the UK consensus guidelines (2021) state restrictive and low-fat diets are no longer recommended for the management of chronic pancreatitis.  Due to our clinical understanding of the importance of PERT, it is now recommended that people follow a moderate-fat diet ensuring adequate PERT is taken to optimise digestion and minimise symptoms of maldigestion.   Due to an increased cardiovascular risk for people with chronic pancreatitis healthier fat food choices including omega-3 food sources, whilst restricting saturated fat should be encouraged.

Myth 3. Steatorrhoea only occurs when at least 90% of pancreatic function has been lost.

PEI occurs when there are insufficient pancreatic enzymes to enable normal digestion.  Duggan et al (2017) challenged and reviewed the original research by DiMagno et al, (1973) and Lankisch et al, (1986) which initiated the widely held concept that “90% of the gland must be functionally destroyed or obstructed before steatorrhoea or creatorrhoea occurs”.   16 of the 17 patients with chronic pancreatitis within the DiMagno et al, (1973) study had severe PEI causing fat malabsorption of >7g/d, therefore, there is insufficient data that patients with >10% pancreatic exocrine function have normal fat losses.  The Lankisch et al (1986) study showed that patients with mild/moderate lipase secretion did have excess fat loss.  A progressive increase over time of fat maldigestion should be considered rather than waiting for severe symptoms of PEI to initiate PERT.

Summary

Patients need regular nutritional reviews and assessments due to the complex and progressive nature of the disease.  Referral to a specialist pancreatic dietitian is ideal, advice can be complex in the setting of PEI, type 3c diabetes, and malnutrition, with a background of significant symptoms impacting the ability to eat normally.  Dietitians are expertly trained to assess how aggressive nutritional support needs to be when considering the initiation of oral nutritional supplements, enteral tube feeding or parenteral nutrition. Earlier interventions ideally need to limit the nutritional decline that people experience regarding body weight and sarcopenia, osteopenia, osteoporosis, and vitamin and mineral deficiencies all impacting quality of life. There is a dearth of research focusing on diabetes relating to pancreatic diseases, hopefully in the future clearer understanding of the pathophysiology and management strategies will be available.

Resources and references

Guts UK is a charity for the digestive system, including the pancreas!  Includes patient information and support for people with chronic pancreatitis.

The Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland (NIGPS) offer training courses and an annual membership option to join the group.  Written information available for patients with chronic pancreatitis and diet including information on poor appetite and physical activity.

References