Endoscopy in Benign Ampullary Neoplasms: Not Just for Diagnosis Anymore

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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

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Chronic Pancreatitis

• Todays focus on
• The disease
• The symptoms
• Nutritional issues

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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)

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Chronic Pancreatitis The Disease

• Multiple etiologies
• EtOH (80)
• Hereditary
• CF
• Others
• Tropical
• Trauma/chronic duct obstruction
• Pancreas divisum
• Recurrent acute
• Idiopathic

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Chronic Pancreatitis The Disease

• Malnutrition results from
• Pain
• Decreased nutrient digestion (esp. fat) ?
  malabsorption
• (steatorrhea _at_ gt90 loss panc exocr fxn)

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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

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Chronic Pancreatitis The Symptoms

• Maldigestion with secondary malabsorption
• Steatorrhea
• Malnutrition
• Caloric
• Vitamin deficiencies
• Mineral deficiencies
• Weight loss

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Chronic Pancreatitis Nutritional Issues

• Etiologies
• Maldigestion (a late symptom of CP)
• Pancreatic exocrine insufficiency (PEI) gt90
  function loss
• Malabsorption
• Maldigestion losses (with or without steatorrhea)
• Fat-soluble vitamins
• B12 due to R-factor dysfunction

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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

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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

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Chronic Pancreatitis Diagnosis

• Diagnosis function testing
• Fecal elastase
• Fecal fat
• Quant 72 hr stool fat 100g fat diet, gt7g fat
  excr/24 hrs
• Qualitative spot oil-red O
• Secretin stim testing
• Indirect testing (e.g., Bentiromide test in past)

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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

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PEI diagnosis

• Function testing
• Direct
• Secretin, CCK stim testing
• Indirect
• Fecal fat
• Fecal elastase, chymotrypsin
• Pancreolauryl test
• Breath tests (13C)

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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 (lt1)

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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

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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

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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

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PEI nutritional management

• Parenteral nutrition (rarely needed/indicated)
• Anatomical reasons
• Fistula
• Short-term treatment of severe malnutrition
• Preop

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PEI pharmacological management

• Enzyme supplementation
• No set dose
• Generally start with 2 caps AC titrate
• Monitor sxs (steatorrhea) or (re)check fecal fat
• Acid suppression to preserve activity
• Clinical value of coating/encapsulation not
  well-studied

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PEI pharmacological management

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

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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

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INTESTINAL REHABILITATION CENTER NORTHWESTERN
UNIVERSITY
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