Pancreatic Insufficiency

Also indexed as: Pancreatitis (Acute and Chronic)

Pancreatic insufficiency occurs when the pancreas does not secrete enough chemicals and digestive enzymes for normal digestion to occur. When pancreatic insufficiency is severe, malabsorption (impaired absorption of nutrients by the intestines) may result, leading to deficiencies of essential nutrients and the occurrence of loose stools containing unabsorbed fat (steatorrhea).

Severe pancreatic insufficiency occurs in cystic fibrosis, chronic pancreatitis, and surgeries of the gastrointestinal system in which portions of the stomach or pancreas are removed. Certain gastrointestinal diseases, such as stomach ulcers,1 celiac disease,2 and Crohn’s disease,3 and autoimmune disorders, such as systemic lupus erythematosus (SLE),4 5 6 may contribute to the development of pancreatic insufficiency. Mild forms of pancreatic insufficiency are often difficult to diagnose, and there is controversy among researchers regarding whether milder forms of pancreatic insufficiency need treatment.

Pancreatitis is an inflammation of the pancreas that reduces the function of the pancreas, causing pancreatic insufficiency, malabsorption, and diabetes.7 Acute pancreatitis is usually a temporary condition and can be caused by gallstones, excessive alcohol consumption, high blood triglycerides, abdominal injury, and other diseases, and by certain medications and poisons.8 Chronic pancreatitis is a slow, silent process that gradually destroys the pancreas and is most often caused by excessive alcohol consumption.

Checklist for Pancreatic Insufficiency

Rating Nutritional Supplements Herbs
3Stars Digestive enzymes  
2Stars Beta-carotene
Methionine
Selenium
Vitamin C
Vitamin E		  
1Star Grape seed extract  
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of pancreatic insufficiency? People with pancreatic insufficiency may have symptoms of pale, foul-smelling, bulky stools that stick to the side of the toilet bowl or are difficult to flush, oil droplets floating in the toilet bowl after bowel movements, and abdominal discomfort, gas, and bloating. People with pancreatic insufficiency may also have bone pain, muscle cramps, night blindness, and easy bruising.

How is it treated? The conventional treatment includes taking pancreatic enzymes with meals. In advanced cases, doctors may also recommend intravenous nutritional supplements of the fat-soluble vitamins (e.g., vitamins A, D, E, K).

Dietary changes that may be helpful: A low-fat diet (with no more than 30 to 40% of calories from fat) is often recommended to help prevent the steatorrhea that often accompanies pancreatic insufficiency.9 In a controlled study of chronic pancreatitis patients, a very low-fat diet resulted in less than one-fourth as much steatorrhea compared to a more typical fat intake.10 Since a very low-fat diet may not be appropriate for a person with malnutrition, this recommendation should only be followed after consulting a healthcare professional.

A preliminary study of chronic pancreatitis patients reported that a high-fiber diet was associated with a small but significant increase in the amount of fat in the stool.11 The patients all complained of increased flatulence while using this diet, but an undesirable increase in the frequency of bowel movements did not occur. Increases in dietary fiber may not be well tolerated by people with pancreatitis, but more research is needed.

A few preliminary reports suggest that food allergy may cause some cases of acute pancreatitis. Food allergies identified in these cases included beef, milk, potato, eggs,12 fish and fish eggs,13 and kiwi fruit.14 No research has investigated the possible role of food allergy in other causes of pancreatic insufficiency.

Lifestyle changes that may be helpful: Since alcoholism is one known cause of pancreatitis, total abstinence from alcohol is generally recommended to people with this disease.15 In a study of alcoholic chronic pancreatitis patients, pancreatic function declined to a greater degree in those who continued to drink alcohol.16 Another study found that abstinence from alcohol had a significant long-term beneficial effect on some of the problems associated with chronic pancreatitis.17

Cigarette smoking decreases pancreatic secretion18 and increases the risk of pancreatitis19 and pancreatic cancer,20 providing yet another reason to quit smoking.

In a large international study, the major risk factors for early death in a group of patients with chronic alcoholic and nonalcoholic pancreatitis included smoking and drinking alcohol.21

Nutritional supplements that may be helpful: The mainstay of treatment for pancreatic insufficiency is replacement of digestive enzymes, using supplements prepared from pig pancreas (pancrelipase) or fungi.22 Enzyme supplements have been shown to reduce steatorrhea23 24 associated with pancreatitis, while pain reduction has been demonstrated in some,25 26 though not all,27 28 double-blind studies. Digestive enzyme preparations that are resistant to the acidity of the stomach are effective at lower doses compared with conventional digestive enzyme preparations.29 Some enzyme preparations are produced with higher lipase enzyme content for improved fat absorption, but one controlled study of chronic pancreatitis found no advantage of this preparation over one with standard lipase content.30 People with more severe pancreatic insufficiency or who attempt to eat a higher-fat diet require more enzymes,31 but large amounts of pancreatic digestive enzymes are known to damage the large intestine in some people with diseases causing pancreatic insufficiency.32 33 34 Therefore, a qualified healthcare practitioner should be consulted about the appropriate and safe amount of enzymes to use.

Many, otherwise healthy people suffer from indigestion, and some doctors believe that mild pancreatic insufficiency can be a cause of indigestion. A preliminary study of people with indigestion reported significant improvement in almost all of those given pancreatic enzyme supplements.35 One double-blind trial found that giving pancreatic enzymes to healthy people along with a high-fat meal reduced bloating, gas, and abdominal fullness following the meal.36

Stomach surgery patients often have decreased pancreatic function, malabsorption, and abdominal symptoms, including steatorrhea, but digestive enzyme supplementation had no effect on steatorrhea in two of three double-blind studies of stomach surgery patients,37 38 39 although some other symptoms did improve.40 41 Patients who have surgery to remove part of the pancreas often have severe steatorrhea that is difficult to control with enzyme supplements.42 In one double-blind study, neither high-dose nor standard-dose pancreatin was able to eliminate steatorrhea in over half of the pancreas surgery patients studied.43

Fat malabsorption in pancreatic insufficiency may result in deficiencies of fat-soluble vitamins, and these deficiencies may not always be prevented by enzyme supplementation.44 45 46 One controlled study found that patients with chronic pancreatitis had vision abnormalities that are associated with vitamin A deficiency.47 A controlled study of patients with steatorrhea found that a water-soluble form of vitamin A was easier to absorb than conventional fat-soluble forms of vitamin A, resulting in vitamin A absorption equal to that of healthy people.48 Two controlled studies of patients with chronic pancreatitis found evidence of vitamin E deficiency in their blood.49 50 People with more severe fat malabsorption tended to have the lowest vitamin E levels. Although doctors sometimes recommend supplementation with fat-soluble vitamins for people with pancreatitis,51 no research has investigated the benefits of these supplements.

Pancreatic enzymes are also necessary for the absorption of vitamin B12.52 While people with pancreatic insufficiency have some malabsorption of this vitamin, true deficiency is considered rare.53 54 55 No research has investigated whether long-term vitamin B12 supplementation is beneficial for chronic pancreatitis.

Free radical damage has been linked to pancreatitis in animal and human studies,56 57 58 suggesting that antioxidants might be beneficial for this disease. One controlled study found that chronic pancreatitis patients consumed diets significantly lower in several antioxidants due to problems such as appetite loss and abdominal symptoms.59 Several controlled studies found lower blood levels of antioxidants, such as selenium, vitamin A, vitamin E, vitamin C, glutathione, and several carotenoids, in patients with both acute and chronic pancreatitis.60 61 62 63 64 65

There are few controlled trials of antioxidant supplementation to patients with pancreatitis. One small controlled study of acute pancreatitis patients found that sodium selenite at a dose of 500 micrograms (mcg) daily resulted in decreased levels of a marker of free radical activity, and no patient deaths occurred.66 In a small double-blind trial including recurrent acute and chronic pancreatitis patients, supplements providing daily doses of 600 mcg selenium, 9,000 IU beta-carotene, 540 mg vitamin C, 270 IU vitamin E, and 2,000 mg methionine significantly reduced pain, normalized several blood measures of antioxidant levels and free radical activity, and prevented acute recurrences of pancreatitis.67 These researchers later reported that continuing antioxidant treatment in these patients for up to five years or more significantly reduced the total number of days spent in the hospital and resulted in 78% of patients becoming pain-free and 88% returning to work.68

In a preliminary report, three patients with chronic pancreatitis were treated with grape seed extract in the amount of 100 mg 2–3 times per day. The frequency and intensity of abdominal pain was reduced in all three patients, and there was a resolution of vomiting in one patient.69

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

References:

1. Wormsley, KG. Pancreatic exocrine function in patients with gastric ulceration before and after gastrectomy. Lancet 1972;7779:682–4.

2. Dimagno, EP, Go, VLW, Summerskill WHJ. Impaired cholecystokinin-pancreozymin secretion, intraluminal dilution, and maldigestion of fat in sprue. Gastroenterology 1972;63:25–32.

3. Hegnhoj J, Hansen CP, Rannem T, et al. Pancreatic function in Crohn’s disease. Gut 1990;31:1076–9.

4. D’Ambrosi A, Verzola A, Gennaro P, et al. Functional reserve of the exocrine pancreas in Sjögren’s syndrome. Recenti Prog Med 1997;88:21–5 [in Italian].

5. Dreiling DA, Soto JM. The pancreatic involvement in disseminated “collagen” disorders. Am J Gastroenterology 1976;66:546–53.

6. Watts RA, Isenberg DA. Pancreatic disease in the autoimmune rheumatic disorders. Semin Arthritis Rheum 1989;19:158–65 [review].

7. Apte MV, Keogh GW, Wilson JS. Chronic pancreatitis: complications and management. J Clin Gastroenterol 1999;29:225–40.

8. Sleisenger MH, Feldman M, Scharschmidt BF. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management. Philadelphia, PA: W.B. Saunders Company, 1998, 818.

9. Scolapio JS, Malhi-Chowla N, Ukleja A. Nutrition supplementation in patients with acute and chronic pancreatitis. Gastroenterol Clin North Am 1999;28:695–707 [review].

10. Nakamura T, Tando Y, Yamada N, et al. Study on pancreatic insufficiency (chronic pancreatitis) and steatorrhea in Japanese patients with low fat intake. Digestion 1999;60 Suppl 1:93–6.

11. Dutta SK, Hlasko J. Dietary fiber in pancreatic disease: effect of high fiber diet on fat malabsorption in pancreatic insufficiency and in vitro study of the interaction of dietary fiber with pancreatic enzymes. Am J Clin Nutr 1985;41:517–25.

12. Matteo A, Sarles H. Is food allergy a cause of acute pancreatitis? Pancreas 1990;5:234–7.

13. Iwata F, Odajima Y. Acute pancreatitis associated with food allergy. Eur J Pediatr 1997;156:506 [letter].

14. Gastaminza G, Bernaola G, Camino ME. Acute pancreatitis caused by allergy to kiwi fruit. Allergy 1998;53:1104–5.

15. Scolapio JS, Malhi-Chowla N, Ukleja A. Nutrition supplementation in patients with acute and chronic pancreatitis. Gastroenterol Clin North Am 1999;28:695–707 [review].

16. Gullo L, Barbara L, Labo G. Effect of cessation of alcohol use on the course of pancreatic dysfunction in alcoholic pancreatitis. Gastroenterology 1988;94:1063–8.

17. Kankisch PG, Lohr-Happe A, Otto J, Creutzfeldt W. Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion 1993;54:148–55.

18. Brown P. The influence of smoking on pancreatic function in man. Med J Aust 1976;2:290–3.

19. Talamini G, Bassi C, Falconi M, et al. Cigarette smoking: an independent risk factor in alcoholic pancreatitis. Pancreas 1996;12:131–7.

20. Hart AR. Pancreatic cancer: any prospects for prevention? Postgrad Med J 1999;75:521–6 [review].

21. Lowenfels AB, Maisonneuve P, Cavallini G, et al. Prognosis of chronic pancreatitis: an international multicenter study. International pancreatitis study group. Am J Gastroenterol 1994;89:1467–71.

22. Scolapio JS, Malhi-Chowla N, Ukleja A. Nutrition supplementation in patients with acute and chronic pancreatitis. Gastroenterol Clin North Am 1999;28:695–707 [review].

23. Nakamura T, Tandoh Y, Terada A, et al. Effects of high-lipase pancreatin on fecal fat, neutral sterol, bile acid, and short-chain fatty acid excretion in patients with pancreatic insufficiency resulting from chronic pancreatitis. Int J Pancreatol 1998;23:63–70.

24. Schneider MU, Knoll-Ruzicka ML, Domshke S, et al. Pancreatic enzyme replacement therapy: comparative effects of conventional and enteric-coated microspheric pancreatin and acid-stable fungal enzyme preparations on steatorrhea in chronic pancreatitis. Hepatogastroenterology 1985;32:97–102.

25. Isaksson G, Ihse I. Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis. Dig Dis Sci 1983;28:97–102.

26. Slaff J, Jacobson D, Tillman CR, et al. Protease-specific suppression of pancreatic exocrine secretion. Gastroenterol 1984;87:44–52.

27. Halgreen H, Pedersen NT, Worning H. Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis. Scand J Gastroenterol 1986;21:104–8.

28. Mossner J. Is there a place for pancreatic enzymes in the treatment of pain in chronic pancreatitis? Digestion 1993;54 Suppl 2:35–9.

29. Schneider MU, Knoll-Ruzicka ML, Domshke S, et al. Pancreatic enzyme replacement therapy: comparative effects of conventional and enteric-coated microspheric pancreatin and acid-stable fungal enzyme preparations on steatorrhea in chronic pancreatitis. Hepatogastroenterology 1985;32:97–102.

30. Dellhaye M, Meuris S, Gohimont AC, et al. Comparative evaluation of a high lipase pancreatic enzyme preparation and a standard pancreatic supplement for treating exocrine pancreatic insufficiency in chronic pancreatitis. Eur J Gastroenterol Hepatol 1996;8:699–703.

31. Malesci A, Mariani A, Mezzi G, et al. New enteric-coated high-lipase pancreatic extract in the treatment of pancreatic steatorrhea. J Clin Gastroenterol 1994;18:32–5.

32. Bansi DS, Price A, Russell C, Sarner M. Fibrosing colonopathy in an adult owing to over use of pancreatic enzyme supplements. Gut 2000;46:283–5.

33. Littlewood JM, Wolfe SP. Control of malabsorption in cystic fibrosis. Paediatr Drugs 2000;2:205–22.

34. Borowitz DS, Grand RJ, Durie PR. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. Consensus committee. J Pediatr 1995;127:681–4.

35. Cruz Pinho A. Dispepsia e terapeutica enzimatica de substituicao. Cadernos Generalista (Lisboa) 1990;78:43–47 [in Portugese].

36. Suarez F, Levitt MD, Adshead J, Barkin JS. Pancreatic supplements reduce symptomatic response of healthy subjects to a high fat meal. Dig Dis Sci 1999;44:1317–21.

37. Bragelmann R, Armbrecht U, Rosemeyer D, et al. The effect of pancreatic enzyme supplementation in patients with steatorrhea after total gastrectomy. Eur J Gastroenterol Hepatol 1999;11:231–7.

38. Armbrecht U, Lundell L, Stockbruegger RW. Nutrient malassimilation after total gastrectomy and possible intervention. Digestion 1987;37 Suppl 1:56–60.

39. Armbrecht U, Lundell L, Stockbrugger RW. The benefit of pancreatic enzyme substitution after total gastrectomy. Aliment Pharmacol Ther 1988;2:493–500.

40. Armbrecht U, Lundell L, Stockbruegger RW. The benefit of pancreatic enzyme substitution after total gastrectomy. Aliment Pharmacol Ther 1988;2:493–500.

41. Bragelmann R, Armbrecht U, Rosemeyer D, et al. The effect of pancreatic enzyme supplementation in patients with steatorrhea after total gastrectomy. Eur J Gastroenterol Hepatol 1999;11:231–7.

42. Ghaneh P, Neoptolemos JP. Exocrine pancreatic function following pancreatectomy. Ann N Y Acad Sci 1999;880:308–18 [review].

43. Neoptolemos JP, Ghaneh P, Andren-Sandberg A, et al. Treatment of pancreatic exocrine insufficiency after pancreatic resection. Results of a randomized, double-blind, placebo-controlled, crossover study of high vs standard dose pancreatin. Int J Pancreatol 1999;25:171–80.

44. Dutta SK, Bustin MP, Russell RM, Costa BS. Deficiency of fat-soluble vitamins in treated patients with pancreatic insufficiency. Ann Intern Med 1982;97:549–52.

45. Nakamura T, Takebe K, Imamura K, et al. Fat-soluble vitamins in patients with chronic pancreatitis (pancreatic insufficiency). Acta Gastroenterol Belg 1996;59:10–4.

46. Layer P, Keller J. Pancreatic enzymes: secretion and luminal nutrient digestion in health and disease. J Clin Gastroenterol 1999;28:3–10 [review].

47. Toskes PP, Dawson W, Curington C, et al. Non-diabetic retinal abnormalities in chronic pancreatitis. N Engl J Med 1979;300:942–6.

48. Johnson EJ, Krasinski SD, Howard LJ, et al. Evaluation of vitamin A absorption by using oil-soluble and water-miscible vitamin A preparations in normal adults and in patients with gastrointestinal disease. Am J Clin Nutr 1992;55:857–64.

49. Kalvaria I, Labadarios D, Shephard GS, et al. Biochemical vitamin E deficiency in chronic pancreatitis. Int J Pancreatol 1986;1:119–28.

50. Nakamura T, Takebe K, Imamura K, et al. Fat-soluble vitamins in patients with chronic pancreatitis (pancreatic insufficiency). Acta Gastroenterol Belg 1996;59:10–4.

51. Beers MH, Berkow R. The Merck Manual of Diagnosis and Therapy, 17th ed. Whitehouse Station, NJ: Merck & Co, 1999, 275.

52. Festen HP. Intrinsic factor secretion and cobalamin absorption. Physiology and pathophysiology in the gastrointestinal tract. Scand J Gastroenterol 1991;188:1S–7S [review].

53. Gueant JL, Champigneulle B, Gaucher P, Nicolas JP. Malabsorption of vitamin B12 in pancreatic insufficiency of the adult and of the child. Pancreas 1990;5:559–67 [review].

54. Bang Jorgensen B, Thorsgaard Pedersen N, Worning H. Short report: lipid and vitamin B12 malassimilation in pancreatic insufficiency. Aliment Pharmacol Ther 1991;5:207–10.

55. Loew D, Wanitschke R, Schroedter A. studies on vitamin B12 status in the elderly—prophylactic and therapeutic consequences. Int J Vitam Nutr Res 1999;69:228–33.

56. Schoenberg MH, Birk D, Beger HG. Oxidative stress in acute and chronic pancreatitis. Am J Clin Nutr 1995;62:1306S–14S [review].

57. Schulz H, Niederau C, Klonowski-Stumpe H, et al. Oxidative stress in acute pancreatitis. Hepato-Gastroenterology 1999;46:2736–2750 [review].

58. Wallig MA. Xenobiotic metabolism, oxidant stress and chronic pancreatitis. Digestion 1998;59(suppl 4):13–24 [review].

59. Rose P, Fraine E, Hunt LP, et al. Dietary antioxidants and chronic pancreatitis. Hum Nutr Clin Nutr 1986;40:151–64.

60. Morris-Stiff GJ, Bowrey DJ, Oleesky D, et al. The antioxidant profiles of patients with recurrent acute and chronic pancreatitis. Am J Gastroenterol 1999;94:2135–40.

61. Gut A, Shiel N, Kay PM, et al. Heightened free radical activity in blacks with chronic pancreatitis at Johannesburg, South Africa. Clin Chim Acta 1994;230:189–99.

62. Bonham MJ, Abu-Zidan FM, Simovic MO, et al. Early ascorbic acid depletion is related to the severity of acute pancreatitis. Br J Surg 1999;86:1296–301.

63. Tsai K, Wang SS, Chen TS, et al. Oxidative stress: an important phenomenon with pathogenetic significance in the progression of acute pancreatitis. Gut 1998;42:850–6.

64. Braganza JM, Schofield D, Snehalatha C, Mohan V. Micronutrient antioxidant status in tropical compared with temperate-zone chronic pancreatitis. Scand J Gastroenterol 1993;28:1098–104.

65. Mathew P, Wyllie R, Van Lente F, et al. Antioxidants in hereditary pancreatitis. Am J Gastroenterol 1996;91:1558–62.

66. Kulinski B, Buchner M, Schweder R, Nagel R. Acute pancreatitis—a free radical disease. Decrease in fatality with sodium selenite (Na2SeO3) therapy. Z Gesamte Inn Med 1991;46:145–9 [in German].

67. Uden S, Bilton D, Nathan L, et al. Antioxidant therapy for recurrent pancreatitis: placebo-controlled trial. Aliment Pharmacol Ther 1990;4:357–71.

68. McCloy R. Chronic pancreatitis at Manchester, UK. Focus on antioxidant therapy. Digestion 1998;59(suppl 4):36–48 [review].

69. Banerjee B, Bagchi D. Beneficial effects of a novel IH636 grape seed proanthocyanidin extract in the treatment of chronic pancreatitis. Digestion 2001;63:203–6.