Issue 131 pancreatitis

COVER STORY

Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca specialises in gastroenterology Dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

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PANCREATITIS: AN OVERVIEW OF DIETARY MANAGEMENT In this article, Rebecca looks at dietary advice to help manage pancreatitis in both the acute and chronic form.

The pancreas - a small organ found behind our stomach and below our ribcage - has two main functions which allow for the release of enzymes and hormones to aid the digestion of food. The exocrine function produces enzymes to break down carbohydrates, proteins and fats, and the endocrine function homes the islet cells responsible for the release of the hormones insulin and glucagon, to maintain blood glucose levels.

Acute pancreatitis is a condition where the pancreas becomes inflamed over a short period of time and can occur at different severities: mild, moderately severe and severe (see Table 1). In the years 2013 to 2014, the NHS reported that 25,000 people were admitted to hospital with acute pancreatitis.1 Acute pancreatitis is most commonly caused by gallstones or alcohol consumption, and typical symptoms include severe dull abdominal pain which develops quickly, nausea and/ or vomiting, diarrhoea, indigestion and a feverish temperature.1 A small number of cases are caused by neither gallstones nor alcohol consumption and are labelled as idiopathic.5 Most cases of acute pancreatitis resolve quickly, within a week,1 however, 15-20% of patients will go on to develop the complications previously mentioned as a result of the flare up.3 The aim of treatment for acute pancreatitis is to support the body until the inflammation subsides and

following this, treat the cause of the acute episode (for example, gallstones).5 Chronic pancreatitis differs from the acute form as it is an irreversible and long-term inflammation or fibrosis of the pancreas.6 Chronic pancreatitis can lead to endocrine pancreatic insufficiency, resulting from damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), with failure to produce insulin, causing impaired glucose regulation and diabetes mellitus.

Pancreatic exocrine insufficiency (PEI) may also occur from damage to the acinar cells, with failure to produce digestive enzymes, causing malabsorption.6 Chronic pancreatitis has a higher prevalence than acute, with 35,000 hospital admissions reported between the years 2012-2013.7 Similarly, common symptoms include severe abdominal pain, but further complications include diabetes, pseudocysts and an increased risk of pancreatic cancer.8 If PEI is apparent, symptoms caused by malabsorption may occur such as steatorrhea.

Treatment for chronic pancreatitis consists of managing symptoms of pain - this could be through lifestyle changes www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS Table 1: Characteristics of acute pancreatitis2-4 Mild acute pancreatitis

Moderately severe acute pancreatitis

Characterised by the absence of complications, or organ dysfunction and it usually has an uneventful recovery.

Characterised by local complications and/or transient organ dysfunction which resolves within 48 hours.

or with pain relief medications - and may also require treatments such as enzyme replacement therapy, steroids and surgery.7 DIETARY MANAGEMENT - ACUTE

In most cases of acute pancreatitis (around 80%), dietary management includes supportive care with fluid replacement and controlled initiation of regular intake of diet having a positive response on treating the flare up.9 Patients were traditionally started on a clear liquid diet once abdominal pain had subsided and appetite returned, before moving on to a low fat diet.

However, a study by Jacobson et al found that initiating patients on a low fat diet was as safe as a clear liquid diet and resulted in an improved calorific intake.10 For those suffering from severe acute pancreatitis, nutrition support is essential.11 Historically, total parenteral nutrition (TPN) was used to allow for pancreatic rest. However, the use of TPN has been known to carry risks of its own, such as infection and metabolic disturbances.12 In more recent years, studies looking at the use of enteral nutrition as opposed to TPN have been carried out and the results look promising, showing that enteral nutrition may improve outcomes by decreasing the rates of infection, need for surgical intervention, hospital length of stay and overall total cost of care.13,14 Studies by Jiang et al and Kumar et al report that nasogastric (NG) feeding is a suitable method of enteral feeding, as opposed to nasojejenal (NJ) feeding, as it is as well tolerated by patients and as effective in treating severe acute pancreatitis.15,16 NJ feeding may be indicated in patients suffering from prolonged pain and significant pancreatic necrosis.17 Studies discussing the use of enteral nutrition conclude that it should begin early, as 14

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Severe acute pancreatitis Characterised by persistent organ dysfunction (failure to resolve in 48 hours) and can lead to local complications, such as pancreatic necrosis, abscess, pseudocyst formation and multiple organ dysfunction.

it modulates the stress response, promotes more rapid resolution of the disease process and results in better outcomes.17 TPN is not completely ruled out as a treatment; for patients who do not respond to enteral feeding, who meet adequate requirements, or if enteral feeding is inhibited by ileus, TPN can be an effective second line treatment.5,18 A systematic review by Poropat et al found that there was no beneficial effect of specific enteral nutrition formulas, but did note that their evidence was based on low to very low quality.19 Further research into standard, partially digested, elemental or ‘immune enhanced’ formulations has been identified as a need.5 Poropat et al also found that immunonutrition was generally well tolerated and safe and that results showed a reduction in all-cause mortality, but again the findings were based on evidence of low quality.

In addition to this, the review concluded that routine use of probiotic supplements to enteral nutrition should be avoided on the basis of current available evidence because of safety concerns, and that there is some evidence (again, of low or very low quality) for the effects of nutrition over no nutritional support in reduction of all-cause mortality.19 However, the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines released in 2016 challenges this, stating that the use of probiotics should be considered in patients with severe acute pancreatitis who are receiving early enteral nutrition.32 This was based on a number of RCTs which showed a reduction in infections, sepsis and multiple-organ dysfunction when probiotics were used..33,34 The UK guidelines for acute pancreatitis summarise that there is no benefit from enteral feeding in mild pancreatitis and that these patients have no dietary restrictions. Enteral

PERT (pancreatic enzyme replacement therapy) works by mimicking the physiological conditions of a healthy pancreas, allowing the correct amount of enzymes to be delivered to the duodenum, where they are activated with food allowing it to be absorbed. feeding is indicated in some patients with severe acute pancreatitis and suggests that enteral feeding via NG route should be used if tolerated.5 DIETARY MANAGEMENT - CHRONIC

Upon diagnosis of chronic pancreatitis, the initial dietary advice is to reduce alcohol intake and stop smoking, if necessary.8 Even if alcohol has not been the cause of the pancreatitis, reducing intake, or abstaining completely, can reduce pain and the risk of further complications.7 Tobacco has been linked to contributing to complications associated with chronic pancreatitis, due to pancreatic calcifications and ductal changes20 and, similarly, continued alcohol consumption has been linked to acceleration of progression of disease and an increased risk of malignancy.21 It is recommended that patients are referred to suitable services to help quit smoking and reduce alcohol intake.21 A major consequence of chronic pancreatitis is PEI, with 50% of patients who suffer from chronic alcoholic pancreatitis developing it after 12 years.22 Not all patients will show signs of malabsorption due to PEI (some may only have pain); however, those who do, should be offered pancreatic enzyme replacement therapy (PERT).23 The main symptoms associated with PEI are steatorrhea (stools that are loose, fatty and pale in colour), gastrointestinal pain and weight loss24 and the treatment for these symptoms is to commence PERT. The treatment goals of PERT for PEI are to treat symptoms and improve nutritional status, including increase fat

absorption and reduce steatorrhea, reduce stool frequency and improve stool consistency.25 PERT works by mimicking the physiological conditions of a healthy pancreas, allowing the correct amount of enzymes to be delivered to the duodenum, where they are activated with food allowing it to be absorbed.26 Published treatment guidelines for chronic pancreatitis and pancreatic cancer recommend initiating patients on 40,000 to 50,000 lipase units per meal and 10,000 to 25,000 lipase units per snack,27 but this is often titrated to higher doses depending on symptom control. The amount of PERT may also need to be adjusted depending on the size or the fat content of meals, and patients may split the dose of their PERT if consuming a particularly large meal, for example take some at the beginning of the meal and some half way through.26 It is estimated that a healthy human pancreas produces around 720,000 units of lipase with each meal,26 so really, the usual starting dose of PERT is low in comparison. The supplementation of fat soluble vitamins is also thought to be appropriate in those with PEI.21 Traditionally, it was thought that first-line treatment for steatorrhea was to restrict dietary fat intake to less than 20g per day. However, this is now not recommended, as studies have shown that containing fat in the diet in addition to PERT improves the effectiveness, as the half-life of the enzyme activity is enhanced,28 and one study (although this was a study on dogs, not humans) demonstrated that fat digestion and absorption www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS was higher when enzyme supplements were taken together with a high fat diet compared with a low fat diet.29 Further to this, the inclusion of fat-soluble vitamins from the diet of patients with PEI is of high importance, as these are already malabsorbed30 and often patients present with a low body mass index (BMI) as a result of the malabsorption.24 Patients with chronic pancreatitis also have an increased risk of developing osteoporosis,31 therefore, bone density assessments and healthy lifestyle choices are advised, including vitamin D and calcium supplementation.21 The main role that healthcare professionals play in providing dietary support for chronic pancreatitis is to promote a healthy balanced diet, achieving optimum nutritional status, as well as reducing the symptoms of malabsorption and educating regarding the adverse effects that alcohol and tobacco may have. The management of patients with chronic pancreatitis has improved in the last decade, partly due to more focus on using a multidisciplinary team approach.21

CONCLUSION

Dietary management in pancreatitis remains of high importance, to manage symptoms and improve a patient’s quality of life.

In acute pancreatitis, fluid support and reintroduction of diet once symptoms have improved is an appropriate course of action, but the use of a clear liquid diet is not needed.

In severe acute pancreatitis, early feeding via an enteral form - this can be NG or NJ - is advised and surpasses old evidence of TPN being used as a first line treatment. Further research into specific feeds would be of benefit.

Dietary advice for chronic pancreatitis includes alcohol and tobacco cessation and general healthy eating advice, including calcium and vitamin D sources for bone health. For those patients suffering from PEI, the use of PERT can help to manage symptoms and achieve optimum nutritional status. A multidisciplinary approach is essential for providing patients with the best possible care.

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