Chronic_Pancreatitis by wanghonghx

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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
Chronic Pancreatitis

  Today’s focus on

   The disease
   The symptoms
   Nutritional issues
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)
Chronic Pancreatitis: The Disease
Multiple etiologies

  – EtOH (80%)
  – Hereditary
     • CF
     • Others
  – Tropical
  – Trauma/chronic duct obstruction
  – Pancreas divisum
  – Recurrent acute
  – Idiopathic
Chronic Pancreatitis: The Disease

Malnutrition results from

   Pain

   Decreased nutrient digestion (esp. fat) →
    malabsorption
    (steatorrhea @ >90% loss panc exocr fxn)
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
Chronic Pancreatitis: The Symptoms

 Maldigestion with secondary malabsorption

   – Steatorrhea
   – Malnutrition
      • Caloric
      • Vitamin deficiencies
      • Mineral deficiencies
   – Weight loss
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
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
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
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)
               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
                PEI: diagnosis

Function testing

  – Direct
    • Secretin, CCK stim testing
  – Indirect
    •   Fecal fat
    •   Fecal elastase, chymotrypsin
    •   Pancreolauryl test
    •   Breath tests (13C)
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%)
  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
   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
 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
  PEI: nutritional management

Parenteral nutrition (rarely needed/indicated)

– Anatomical reasons
– Fistula
– Short-term treatment of severe malnutrition
– Preop
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
PEI: pharmacological management

    Antioxidants
    Analgesic therapy
     –   Opiates
     –   Tricyclics, etc.
     –   Non-steroidals
     –   Uncoated enzymes
    Treatment of diabetes
     –   Insulin, OHGs
     –   Gastroparesis management
     –   Anti-emetics
     –   Anti-diarrheals
                              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
INTESTINAL REHABILITATION CENTER
   NORTHWESTERN UNIVERSITY

								
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