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Objective Nutrition

Objectif Nutrition N°45 (May 1999)

NUTRITION AND CHRONIC PANCREATITIS


Treatment beyond alcohol abstinence

Dr. Daniel Rigaud

In France, most cases of chronic pancreatitis are linked to alcoholism. Nutritional implications of such an illness become more serious as the disease evolve. Although alcohol abstinence does not bring immediate noticeable benefits, it is necessary, along with a tailored nutritional therapy.
Chronic pancreatitis is an inflammatory disease that evolves through step-like episodes. It causes the destruction of acinous cells and of islets of Langerhan that results in exocrine (malabsorption) and endocrine (diabetes) defects. Formation of calcified proteic plugs in the pancreas secreting ducts induces duct dilatation (causing pain and false cysts) and new cellular destruction.
This pattern of change explains why chronic pancreatitis causes many digestive and metabolic disturbances as well as a progressive degradation of nutritional state. The relationship between nutrition and chronic pancreatitis is bilateral: nutrition is one of the factors involved in the onset of chronic pancreatitis whereas malnutrition is one of its consequences. Alcoholism is the most frequent cause of chronic pancreatitis in France (90% of all cases), other causes include cystic fibrosis, congenital duct defects, hyperthyroidism and protein-energy malnutrition.



I - FROM NUTRITION TO CHRONIC PANCREATITIS

Excessive alcohol consumption induces chronic pancreatitis: risk rises from a consumption level of 15-20 g of pure alcohol per day in women and 20-30 g. per day in men over a ten-year period. Pancreatitis risk has been shown to rise exponentially with increased alcohol consumption. Risk is not related to the type of alcohol consumed.
For an equal amount of alcohol consumption, the risk is twice higher in women.
Before the onset of the first painful episodes of pancreatitis, protein and energy intakes remain at or close to recommended intakes.
In some cases, protein-energy malnutrition may be responsible for chronic pancreatitis. A typical case is nutritional chronic pancreatitis, observed in economically and nutritionally compromised countries such as India. Other factors are also responsible, such as food contaminants.


II - NUTRITIONAL IMPLICATIONS OF CHRONIC PANCREATITIS

The pancreas is an essential organ in micronutrient digestion (proteins, lipids and carbohydrates) and in hormone secretion (insulin, glucagon, somastostatin, and pancreatic polypeptide). It is not surprising that pancreatic insufficiency induces nutritional disturbances.

Undernutrition and chronic pancreatitis
Two thirds of patients with calcifying chronic pancreatitis will develop a state of undernutrition. Onset of undernutrition is late: only after 80-90% loss of exocrine secretion will signs of malabsorption occur (Fig.1). This protein-energy malnutrition will cause adipose and lean mass loss. Nutrient intake is compromised by three factors:
- Pain: present during severe episodes of the disease, pain encourages fear of eating resulting in anorexia. Pain is observed in 60-90% of patients.
- Malabsorption: noted in 25-45% of patients, malabsorption is the result of maldigestion of many nutriments, due itself to chronic pancreatitis exocrine insufficiency. Malabsorbed nutrients include fats and fat-soluble vitamins (A, D, E and K), proteins and carbohydrates, and vitamin B12 (from absence of pancreatic proteolitic enzymes which usually destroy salivary R-binding polypeptide to free vitamin B12 for absorption).
- Insulin-dependent diabetes (see below).



* From Del Prato et Tiengo, 1983.
Figure 1


Metabolism and chronic pancreatitis
- Basal metabolic rate
Basal metabolic rate (BMR) rises 10-15% due to alcohol consumption and tobacco use, as well as to hypermetabolism as a result of necrosis and inflammation occurring during episodes of chronic pancreatitis.
This rise in BMR results in weight loss of about 50 g / day, or 4-5 kg over three months.
- Carbohydrate metabolism
Lack of insulin leads to insulin-dependent diabetes (Table 10). Its frequency rises with the evolution of the disease (Figure 1). The late destruction of the pancreas' tail where most of the endocrine islets are located explains why diabetes is seldom observed during the first 15 years.



Table 1


- Lipid metabolism
Two thirds of patients suffer from steatorrhea during the course of the disease. Steatorrhea beyond 20-25 g / day is seen in 10% of patients suffering from alcoholic chronic pancreatitis and in 60% of children suffering from cystic fibrosis. Parallel to steatorrhea, malabsorption of fat-soluble vitamins A, E and K leads to deficiencies in only 5% of cases.
- Protein metabolism
Protein malabsorption and chronic inflammatory state contribute to loss of lean body mass and muscular mass, as observed by a decrease in nutritional markers including albumin, prealbumin and transferrin.


III - CHOICE OF A NUTRITIONAL TREATMENT


- Should alcohol consumption be stopped?
It has not been proven that complete alcohol abstinence will result in a regression of histological damage, clinical symptoms (pain) or exocrine and endocrine pancreatic insufficiency, as observed in cases of cirrhosis.
However, since the disease evolves over a long period, alcohol abstinence will probably slow the progression of pancreatitis and certainly raise life expectancy of patients.
- Nutrition and chronic pancreatitis
In most cases, nutrition is not affected before any severe symptoms appear (overt malabsorption, diabetes, portal hypertension, and jaundice). However, some patients have suboptimal protein and energy intakes due to particular risk factors.
In cases of advanced pancreatitis, pancreatic extracts must be prescribed to control energy, lipids and vitamin losses (Figure 2). A fiber-rich diet can not be recommended: soluble and insoluble fiber traps pancreatic enzymes and prevents their action.
Fats should not be restricted, unless the pancreatitis occurs in conjunction with insulin-dependent diabetes. In this case, the dosage of pancreatic extracts has to be adjusted accordingly, as in the case of cystic fibrosis. In cases of major steatorrhea ( > 40 g / day), part of the added fat should be replaced by medium chain triglycerides.



*From Grendell JH, 1983
Figure 2


Calcium and vitamin D chronic deficiency with osteomalacia or osteoporosis may be seen in 20% of patients (Table 2). In spite of pancreatic calcifications, calcium and vitamin D supplements within the "physiological dosage range" (500 mg calcium / day and 800 UI vit. D / day) are recommended.

COMMON DEFICIENCIES OBSERVED IN CASES OF CHRONIC PANCREATITIS, ESPECIALLY IN PRESENCE OF ALCOHOLISM
DEFICIENCIES RESULT MECHANISM
Vitamines
A, D, E and K
- Decrease in antioxidant function
- Osteomalacia
- Exocrine insufficiency and lipid malabsorption
- Due to alcohol
Vitamines B1, B2, B6 and B12 - Neuropathy
- Macrocytic anemia
- Due to alcohol
- R-binder (vitamin B12)
Calcium - Osteoporosis - Steatorrhea (calcium soaps)
- vitamin D deficiency
- Due to alcohol?
Zinc - Immune defects
- Taste and smell alteration
- Due to alcohol?
Magnesium - Muscular cramps - Steatorrhea
- Diabetes

Table 2


- Insulin-dependent diabetes
Onset of insulin-dependent diabetes marks a turning point in the evolution of the disease: it compromises nutritional treatment especially because it is associated with a severe exocrine insufficiency. Insufficient glucagon secretion results in hypoglycemic episodes in 25% of cases, especially in alcoholics. Need for insulin is not greater than in "classical" insulin-dependant diabetes and patients may well follow an intensive insulin therapy.



- Chronic pancreatitis and nutritional support
It is important to regularly evaluate a patient's nutritional state. The extent of anorexia, digestive problems, reduced food intake, fever and rapid weight loss are namely indicating a need for nutritional support. Nutritional support is inevitable following a full pancreatectomy. In cases of severe episodes associated with overt malnutrition, or in cases of pancreatic surgery, mortality is inversely correlated to nitrogen catabolism: it is therefore indicated to pursue nutritional support, more often enteral than parenteral nutrition.


IDENTIFYING SIGNS OF UNDERNUTRITION


Alcohol consumption: may lead to undernutrition and deficiency in B vitamins;
Insufficient food intake: secondary to anorexia, intense pain or economical reasons;
Chronic cholestatis: if there is suppression of bile flow (deficiency in fat-soluble vitamins A, D, E and K);
Related cirrhosis ;
Major surgery removing pancreatic exocrine function (head and body) or endocrine function (tail of pancreas).





CONCLUSION


Nutrition and pancreatitis are closely related.
The impact of alcohol consumption is of major importance to both of these factors. Alcohol weaning is recommended, although a patient should be warned that benefits will not be immediate (on pain, steatorrhea, and insulin-dependent diabetes). Onset of diabetes is a sign of negative prognostic and compromises treatment, especially in the alcoholic patient.
Regular evaluation of a patient's nutritional state is essential. In presence of overt undernutrition and insufficient energy intake, nutritional support is inevitable.

Dr Daniel RIGAUD
Bichat Hospital, Paris



References


DEL PRATO S., TIENGO A. - Pancreatic diabetes. Diabetes Reviews 1993 ; 1 : 260-285.

GRENDELL JH - Nutrition and absorption in disease of the pancreas. Clinics in gastroenterology 1983 ; 12 : 551-563.

LEVY PH., MATHURIN PH., ROQUEPLO A., RUEFF B., BERNADES P. - A multicentric case control study of dietary, alcohol, and tobacco habbits in alcoholic men with chronic pancreatitis. . Pancreas 1995 ; 10 : 231-238.

MAC CLAVE S.A., SNIDER H., OWENS N., SEXTON LK. - Clinical nutrition in pancreatitis. Dig. Dis. Sciences 1997 ; 42 : 2035-2044.

NAKAMURA T., TAKEUCHI T., TANDO Y. - . Pancreatic dysfunction and treatment options. Pancreas 1998 ; 16 : 329-336.