AGA Institute • Fellows’ Nutrition Course 2007AGA Institute • Fellows’ Nutrition Course 2007Rosemont/Chicago, Illinois Rosemont/Chicago, Illinois • November 10, 2007• November 10, 2007

John A. Martin, M.D.John A. Martin, M.D.

Associate Professor of Medicine and SurgeryAssociate Professor of Medicine and Surgery

Director of EndoscopyDirector of Endoscopy

Northwestern University Feinberg School of Medicine Northwestern University Feinberg School of Medicine •• Chicago, Illinois Chicago, Illinois

Nutrition in Chronic PancreatitisNutrition in Chronic Pancreatitis

Chronic PancreatitisChronic Pancreatitis

Today’s focus onToday’s focus on

The diseaseThe disease The symptomsThe symptoms Nutritional issuesNutritional issues

Chronic Pancreatitis: The DiseaseChronic Pancreatitis: The Disease

Chronic inflammation of pancreasChronic inflammation of pancreas

– Mononuclear cell infiltrateMononuclear cell infiltrate

– Fibrosis/calcification/irreversible anatomic Fibrosis/calcification/irreversible anatomic changeschanges

– Characteristic duct changesCharacteristic duct changes

– With or without calcificationWith or without calcification

– Affects exocrine and/or endocrine organ Affects exocrine and/or endocrine organ (including alpha cells)(including alpha cells)

Chronic Pancreatitis: The DiseaseChronic Pancreatitis: The DiseaseMultiple etiologiesMultiple etiologies

– EtOH (80%)EtOH (80%)

– HereditaryHereditary

• CFCF

• OthersOthers

– TropicalTropical

– Trauma/chronic duct obstructionTrauma/chronic duct obstruction

– Pancreas divisumPancreas divisum

– Recurrent acuteRecurrent acute

– IdiopathicIdiopathic

Chronic Pancreatitis: The DiseaseChronic Pancreatitis: The Disease

Malnutrition results fromMalnutrition results from

PainPain

Decreased nutrient digestion (esp. fat) Decreased nutrient digestion (esp. fat) → → malabsorption malabsorption

(steatorrhea @ >90% loss panc exocr fxn)(steatorrhea @ >90% loss panc exocr fxn)

Chronic Pancreatitis: The SymptomsChronic Pancreatitis: The Symptoms

PainPain– Constant or recurrentConstant or recurrent

– May be exacerbated by meals, alcoholMay be exacerbated by meals, alcohol

– May recur without recurrent acute inflammationMay recur without recurrent acute inflammation

– TreatmentTreatment• AnalgesiaAnalgesia

• HydrationHydration

• NPONPO

• EtOH abstinenceEtOH abstinence

Chronic Pancreatitis: The SymptomsChronic Pancreatitis: The Symptoms

Maldigestion with secondary malabsorptionMaldigestion with secondary malabsorption

– SteatorrheaSteatorrhea

– MalnutritionMalnutrition

• CaloricCaloric

• Vitamin deficienciesVitamin deficiencies

• Mineral deficienciesMineral deficiencies

– Weight lossWeight loss

Chronic Pancreatitis: Nutritional IssuesChronic Pancreatitis: Nutritional Issues

EtiologiesEtiologies

– Maldigestion (a late symptom of CP)Maldigestion (a late symptom of CP)• Pancreatic exocrine insufficiency (PEI): >90% Pancreatic exocrine insufficiency (PEI): >90%

function lossfunction loss

– MalabsorptionMalabsorption• Maldigestion losses (with or without steatorrhea)Maldigestion losses (with or without steatorrhea)

• Fat-soluble vitaminsFat-soluble vitamins

• B12 due to R-factor dysfunctionB12 due to R-factor dysfunction

Chronic Pancreatitis: Nutritional IssuesChronic Pancreatitis: Nutritional Issues

EtiologiesEtiologies

– Decreased oral intakeDecreased oral intake

– Glucose intolerance / diabetes (50-90%)Glucose intolerance / diabetes (50-90%)• Poor glycemic control (can also be assoc with impaired Poor glycemic control (can also be assoc with impaired

glucagon release in up to 30%)glucagon release in up to 30%)

• Endorgan manifestationsEndorgan manifestations– GastroparesisGastroparesis

– NauseaNausea

– Diarrhea/constipationDiarrhea/constipation

– AlcoholismAlcoholism– Increased metabolic activity (30-50%)Increased metabolic activity (30-50%) Hebuterne, et al., 1996Hebuterne, et al., 1996

Chronic Pancreatitis: DiagnosisChronic Pancreatitis: Diagnosis

Diagnosis: imagingDiagnosis: imaging

– AXR: parenchymal AXR: parenchymal ± intraductal calcifications± intraductal calcifications

– CT: calcifications (incl stones), inflammatory CT: calcifications (incl stones), inflammatory enlargement/mass, atrophy (relative), duct changesenlargement/mass, atrophy (relative), duct changes

– MR: similar to CTMR: similar to CT

– EUS: as above; also lobulation, hyperechoic EUS: as above; also lobulation, hyperechoic foci/stranding, hyperechoic duct marginfoci/stranding, hyperechoic duct margin

– ERCP: calcifications/stones, characteristic duct ERCP: calcifications/stones, characteristic duct changeschanges

Chronic Pancreatitis: DiagnosisChronic Pancreatitis: Diagnosis

Diagnosis: function testingDiagnosis: function testing

– Fecal elastaseFecal elastase

– Fecal fatFecal fat

• Quant: 72 hr stool fat: 100g fat diet, >7g fat Quant: 72 hr stool fat: 100g fat diet, >7g fat excr/24 hrsexcr/24 hrs

• Qualitative: spot oil-red OQualitative: spot oil-red O

– Secretin stim testingSecretin stim testing

– Indirect testing (e.g., Bentiromide test in past)Indirect testing (e.g., Bentiromide test in past)

PEI: diagnosisPEI: diagnosisSymptoms, clinical suspicionSymptoms, clinical suspicion

– SteatorrheaSteatorrhea• Lipolytic function decreases more rapid than proteolyticLipolytic function decreases more rapid than proteolytic

– Weight lossWeight loss

– Hypovitaminosis (A, D, E, K, B12): uncommonHypovitaminosis (A, D, E, K, B12): uncommon

– Mineral deficienciesMineral deficiencies• CaCa

• MgMg

• ZnZn

• ThiamineThiamine

• FolateFolate

PEI: diagnosisPEI: diagnosis

Function testingFunction testing

– DirectDirect• Secretin, CCK stim testingSecretin, CCK stim testing

– IndirectIndirect• Fecal fatFecal fat

• Fecal elastase, chymotrypsinFecal elastase, chymotrypsin

• Pancreolauryl testPancreolauryl test

• Breath tests (Breath tests (1313C)C)

Chronic pancreatitis: overall nutritional Chronic pancreatitis: overall nutritional management strategymanagement strategy

Basic (majority of CP patients)Basic (majority of CP patients)– EtOH abstinenceEtOH abstinence

– Dietary modificationDietary modification

– Pancreatic enzyme supplementationPancreatic enzyme supplementation

Advanced (minority of CP patients)Advanced (minority of CP patients)– Oral supplementation (~10%)Oral supplementation (~10%)

– Enteral nutrition (~5%)Enteral nutrition (~5%)

– Parenteral nutrition (<1%)Parenteral nutrition (<1%)

PEI: nutritional managementPEI: nutritional management

Dietary modificationDietary modification

– Increase caloric intake (Increase caloric intake (↑ resting energy ↑ resting energy requirements)requirements)

– Decrease dietary fat (~30%)Decrease dietary fat (~30%)

– Increase dietary protein (1 gm/kg BW/d)Increase dietary protein (1 gm/kg BW/d)

– Increase carbohydrate (except in DM)Increase carbohydrate (except in DM); ; ± ↓ fiber± ↓ fiber

– Oral MCT supplementation Oral MCT supplementation

– Vitamin supplementationVitamin supplementation

– Mineral supplementationMineral supplementation

PEI: nutritional managementPEI: nutritional management

Enteral nutrition: indications in CPEnteral nutrition: indications in CP

– PainPain

– Anatomical etiologies of Anatomical etiologies of ↓ intake↓ intake• Due to CPDue to CP

• Postoperative complicationsPostoperative complications

– Recurrent/frequent pancreatitis exacerbationsRecurrent/frequent pancreatitis exacerbations• RAPRAP

• Pain exacerbations of CPPain exacerbations of CP

– Complications of DMComplications of DM

PEI: nutritional managementPEI: nutritional management

Enteral nutrition: routes of delivery in CPEnteral nutrition: routes of delivery in CP

– NJNJ

– PEGPEG

– PEG-JPEG-J

– D-PEJD-PEJ

Enteral nutrition: formulas in CPEnteral nutrition: formulas in CP– Not well-studied: semi-elemental diet often Not well-studied: semi-elemental diet often

recommended by expertsrecommended by experts

PEI: nutritional managementPEI: nutritional management

Parenteral nutrition (rarely Parenteral nutrition (rarely needed/indicated)needed/indicated)

– Anatomical reasonsAnatomical reasons

– FistulaFistula

– Short-term treatment of severe malnutritionShort-term treatment of severe malnutrition

– Preop Preop

PEI: pharmacological managementPEI: pharmacological management

Enzyme supplementationEnzyme supplementation

– No “set dose”No “set dose”

– Generally start with 2 caps Generally start with 2 caps AAC + titrateC + titrate

– Monitor sx’s (steatorrhea) or (re)check fecal fatMonitor sx’s (steatorrhea) or (re)check fecal fat

– Acid suppression to preserve activityAcid suppression to preserve activity

– Clinical value of coating/encapsulation not Clinical value of coating/encapsulation not well-studiedwell-studied

PEI: pharmacological managementPEI: pharmacological management

AntioxidantsAntioxidants Analgesic therapyAnalgesic therapy

– OpiatesOpiates

– Tricyclics, etc.Tricyclics, etc.

– Non-steroidalsNon-steroidals

– Uncoated enzymesUncoated enzymes

Treatment of diabetesTreatment of diabetes– Insulin, OHGsInsulin, OHGs

– Gastroparesis managementGastroparesis management

– Anti-emeticsAnti-emetics

– Anti-diarrhealsAnti-diarrheals

SummarySummary

Major symptomatic manifestations of CP are all nutrition-related, and Major symptomatic manifestations of CP are all nutrition-related, and all multifactorialall multifactorial– PainPain– Maldigestion/malabsorption/malnutritionMaldigestion/malabsorption/malnutrition– DMDM

Nutritional management of CP includesNutritional management of CP includes– Dietary modification in almost allDietary modification in almost all– Enteral nutrition in fewEnteral nutrition in few– Parenteral nutrition in exceedingly fewParenteral nutrition in exceedingly few

Pharmacological management of CP includesPharmacological management of CP includes– AnalgesiaAnalgesia– Enzyme supplementationEnzyme supplementation– Treatment of DM and its endorgan manifestationsTreatment of DM and its endorgan manifestations– Treatment of nausea and other symptomsTreatment of nausea and other symptoms

Rigorous studies are lacking in nutritional aspects of CP managementRigorous studies are lacking in nutritional aspects of CP management

INTESTINAL REHABILITATION CENTERINTESTINAL REHABILITATION CENTER

NORTHWESTERN UNIVERSITYNORTHWESTERN UNIVERSITY

INTESTINAL REHABILITATION CENTERINTESTINAL REHABILITATION CENTER

NORTHWESTERN UNIVERSITYNORTHWESTERN UNIVERSITY