Nutrition in Chronic Pancreatitis

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 (steatorrhea @ >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 • 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 • 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