Pancreas

Question 1

What are the main functions of the pancreas?

Answer 1

• small organ located behind the stomach and below the ribcage and has both exocrine and endocrine functions
• exocrine functions: releases digestive enzymes that aid macronutrient breakdown
• endocrine function: produces and secretes insulin + glucagon for glucose homeostasis

Question 2

What causes chronic pancreatitis?

Answer 2

In CP the pancreas is permanently damaged by long term inflammation which over time, makes the pancreas fibrotic.

Question 3

What is the aetiology of CP?

Answer 3

The aetiology of CP includes excessive alcohol intake (60% of cases with western lifestyle) and idiopathic (20% of cases). Other cases include biliary tract disease, duct obstruction, smoking and trauma - CP can arise from repeated episodes of acute pancreatitis

Question 4

What are the main symptoms and consequences of CP?

Answer 4

Symptoms and consequences of CP include malabsorption, diabetes and malnutrition. Malnutrition is frequently reported and arises because of poor intake secondary to pain, hyper-metabolism, and hyperglycaemia and malabsorption.

Question 5

How does chronic inflammation of the pancreas lead to malabsorption? What are the symptoms?

Answer 5

Chronic inflammation causes pancreatic enzyme insufficiency

• Signs and symptoms are similar to other gastrointestinal diseases, and steatorrhea may not become apparent until 90% of pancreatic function is lost and often masked by self imposed fat restriction.

Question 6

How does PEI affect the GI tract and nutrient absorption?

Answer 6

diahorrea and maldigestion associated with PEI cause decreased transit time and increased GI losses of energy, protein, vitamins D, E, K, A, Thiamine, folic acid, and Mg, Ca and Zn.

Question 7

What test is done to test for PEI?

Answer 7

A faecal elastase test can be done which, along with clinical signs of malabsorption, indicates PEI when <200 ug/g. However symptoms and diagnosis can occur at higher levels.

Question 8

What does NICE guideline NG104 recommend?

Answer 8

NICE NG104 states that there should be a trust agreed protocol that is used to identify when specialist dietetic advise is needed, including advice on FOOD (first), ONS and long term PERT.

Question 9

Why is pain management in CP important?

Answer 9

Effective pain management is important to minimise poor intake as a secondary consequence.

Question 10

What did the Yaghoobi et al 2017 paper find?

Answer 10

• PERT failed to show improvement in pain score. however the only study which used non-enteric coated PERT did show pain improvement, highlighting potential scope for further studies in this area

Question 11

What did the zhou et al 2015 paper find?

Answer 11

• 600 patients with CP, found antioxidant therapy was associated with a significant decrease in the need for analgesics

BUT, also found they may be associated with adverse effect, therefore currently, results are inconclusive.

Question 12

Regarding nutrition requirements, what did the Dickinson 2021 paper find?

Answer 12

• 25/kcal/kg
• data from 23 alcohol induced CP, they are only recommended for those of a BMI 18.5-30.

As such should not be particularly generalisable to others of different CP aetiology, e.g. idiopathic, or those who are malnourished

Question 13

What paper does PENG 2018 reference for its nutritional requirements?

Answer 13

Giger et al 2003,

says that limited data suggests that 30-50% of CP patients have a raised energy expenditure, even when expressed per kg fat mass, i.e taking into account malnutrition, Pt with CP should aim for high calorie in take of 35kcal/kg.

Question 14

What are the three main recommendations for well nourished patients? Include the 5 sources

Answer 14

• Diets rich in CHO advised unless CP concurrent with Diabetes
• No need for fat restriction unless symptoms of steatorrhea cannot be controlled (ESPEN 2020) 30% of total calories can be given as fat (Duggan et al, 2010)
• Supplementation with MCT fat source may be useful (Giger et al, 2004, Duggan et al, 2010) with gradual introduction and monitoring
• Very high fibre diets (>25g/day) are not recommended as they may absorb enzymes and delay nutrient absorption (Dutta 1985 - old and n=12)

Question 15

Outline the ESPEN 2020 guidelines for well nourished CP patients

Answer 15

patients who are well nourished (usually early stage) should be encouraged to follow healthy eating advise,

• avoiding alcohol since continuing to drink is associated with increased morbidity and mortality
• smoking cessation should be encouraged since it increases the risk of pancreatic cancer and increases pain.

Question 16

What are the ESPEN 2020 GPP recommendations for malnourished patients?

Answer 16

• small regular means of nutritionally dense high protein foods
• pts might find low far diets help control symptoms but avoid as not nutritionally complete and masks steatorrhoea onset

Question 17

What are the ESPEN 2020 guidelines on ONS for malnourished CP patients?

Answer 17

• ONS should be prescribed to undernourished patients only if oral nutrition is insufficient for reaching the calorie and protein goals.

=There are few studies investigating ONS in CP since 80% of patients are managed with food first advise and PERT. There are no studies investigating the standard ONS vs MCT.

Question 18

Should MCT feeds be used for CP patients?

Answer 18

Theoretically, MCT or predigested ONS would have an advantage in PEI, but up to now there is no evidence. However, it may be good clinical judgement to offer MCT/pre-digested if this would decrease pill burden.

Some patients manage fat free ONS sipped slowly more successfully than standard ons: but the presence of diabetes often precludes these a long term an option (not nutritionally complete).

Question 19

What are the ESPEN 2020 recommendations for EN in CP?

Answer 19

EN is indicated if patients with malnutrition are not responding to oral nutrition support. Semi- elemental formulas with MCT can be used if standard formulas are not tolerated, such as peptamen or Vital 1.5

Question 20

What are 6 things to consider for patients who are finding PERT isn’t working?

Answer 20

• Is dose adequate?minimum dose 50 000 with meals and 25 000 per snack.
• ? Correct timings ? Divided doses - spreading PERT throughout a meal rather than consuming before or after a meal
• Able to swallow - if capsules unable to be swallowed, they should be opened, placed on an acidic puree (eg fruit puree/ fruit yogurt/ juice ONS) and swallowed at intervals.
• ? Compliance with advice – should be swallowed with food and a cold drink.
• Ensure capsules are stored at <25⁰C ?
• Alternative PERT product needed – consider alternative eg Nutrizym, Pancrex V, Pancrease if the dose is >10,000 units lipase/kg/day or 100,000 units lipase per meal or no improvement with increasing doses.
• Exclude other causes if exceeding above doses such as infection / SBBO / BAM / Coeliac Disease / other causes of diarrhoea