Definition

Chronic pancreatitis is characterized by chronic inflammation of the pancreas. Alcohol abuse is the most common risk factor, accounting for 60-70% of cases. Over the course of the disease, fibrosis develops, with connective tissue replacing pancreatic parenchyma. As a result, the exocrine and endocrine pancreatic tissue loses functionality, potentially leading to exocrine and endocrine insufficiency. This process is progressive and irreversible. Long-term complications include exocrine pancreatic insufficiency with malnutrition, diabetes mellitus, and pancreatic carcinoma. ^[1,2]

Impact on Nutritional Status

Approximately 30% of affected individuals are at risk of malnutrition, primarily due to abdominal pain, reduced oral intake, exocrine and endocrine dysfunction, and increased basal metabolic rate. The severity and duration of pancreatitis, alcohol abuse, diabetes mellitus, and smoking influence the extent of malnutrition. Exocrine pancreatic insufficiency leads to maldigestion with steatorrhea and azotorrhea, promoting numerous deficiencies and complications (e.g., protein and vitamin deficiencies, severe osteoporosis, bone loss). Early screening and subsequent prevention/treatment of malnutrition are critical to prevent the loss of lean body mass and/or sarcopenia, which frequently impair physical function and quality of life. ^[1,2]

Nutritional requirements of patients with chronic pancreatitis. Adjustments necessary for malnourished patients, physical activity and age of the patient. Weight is the adjusted body weight (ADJ) from BMI 28, otherwise body weight before hospital admission.

BW = body weight; d = day

Goals of Nutritional Therapy

• Maintain/improve nutritional status and body function
• Prevent malnutrition and nutrient deficiencies
• Treat maldigestion with appropriate substitution

Patients should undergo annual screening for micro- and macronutrient deficiencies and receive treatment as needed. For severe disease or uncontrolled malabsorption, more frequent screening is recommended ^[1].

Protein and energy requirements should be met through oral nutrition whenever possible, regardless of serum lipase concentrations in patients with chronic pancreatitis. If less than 75% of requirements are met despite enrichment, snacks, or oral nutrition supplements, complementary enteral nutrition should be initiated by day five. Parenteral nutrition is indicated if less than 75% of requirements can be met via oral and/or enteral nutrition.

Oral Nutrition

Nutritional restrictions are generally unnecessary. Fat restriction is only recommended if enzyme substitution is insufficient and uncontrolled steatorrhea persists. Malnourished patients should increase protein and energy intake; otherwise, a balanced diet is usually sufficient. If protein and energy needs cannot be met through oral intake alone, oral nutrition supplements should be prescribed.

If malabsorption persists despite enzyme supplementation and the exclusion of small intestinal bacterial overgrowth, supplements containing medium-chain triglycerides (MCTs) are indicated. MCTs are absorbed directly into the portal vein from the small intestine without the need for lipase, colipase, or bile acids (Caution: MCTs may cause cramps, nausea, and diarrhea) ^[1].

Practical Tips, if Indicated:
For nutrient deficiencies:

• Increase the number of meals to 5-6 per day ^[1]
• Protein enrichment
• Energy enrichment (Caution: monitor carbohydrate intake in diabetes mellitus)
• Oral nutrition supplements (Caution: diabetes mellitus)

Enteral Nutrition

Enteral nutrition is used to maintain nutritional status when patients cannot consume adequate food orally. Causes include anatomical factors (e.g., duodenal stenosis), inflammatory complications (e.g., acute pancreatitis), and prolonged fasting due to repeated medical interventions. Nasal feeding tubes are generally recommended for short-term use ([1]. Perioperative enteral nutrition may improve outcomes, such as reducing postoperative infections and shortening hospital stays ^[3].

Parenteral Nutrition

Parenteral nutrition is rarely needed in chronic pancreatitis and is typically required only for short periods. Indications include gastric outlet obstruction, complex fistulas, or intolerance to enteral nutrition. Generally, central venous access is necessary ^[1].

Monitoring

• Micro- and Macronutrient Deficiencies: Assessment should be performed at least every 12 months, and more frequently in cases of severe disease or ongoing malabsorption ^[1].
• Increased Risk of Osteoporosis and Fractures: Early detection (e.g., Dual-energy X-ray absorptiometry, DXA) and evaluation of preventive measures (e.g., adequate intake of calcium and vitamin D).
• Effectiveness of Pancreatic Enzyme Replacement Therapy: Evaluate effectiveness based on gastrointestinal symptoms, anthropometric, and biochemical nutritional parameters. If patients do not respond, pancreatic function tests (e.g., fecal fat excretion or 13C-MTG-breath test) should be conducted ^[1].

Nutritional Status Assessment, adapted from ^[1].

Special Considerations

• Alcohol Consumption and Smoking: Both should be avoided ^[1,2].
• Dietary Fiber: Fiber can interfere with pancreatic enzyme replacement therapy and may contribute to malabsorption. A high-fiber diet is not recommended ^[1].

Medications/Supplements

• Pancreatic Enzyme Replacement: To counteract maldigestion. Depending on the severity of the disease and meal size/composition, a minimum of 20,000–50,000 PhU should be administered, with half the dose for snacks. Enzymes should be taken immediately before or during meals. Note: Dietary fibers can interfere with enzyme effectiveness ^[1].
• Acid Inhibitors (Proton Pump Inhibitors): Recommended for insufficient efficacy of pancreatic enzyme replacement. Lowering the pH in the duodenum can prevent lipase inactivation in the small intestine ^[1].
• Analgesics: For pain management.
• Lipase and/or Medium-Chain Triglyceride Supplementation: To improve lipid absorption in cases of steatorrhea ^[1].