Management of Chronic Pancreatitis

Introduction to Pancreatic Enzyme Replacement Therapy

The American Gastroenterological Association recommends pancreatic enzyme replacement therapy (PERT) as the most important supplement for patients with chronic pancreatitis who have pancreatic exocrine insufficiency (PEI), along with specific vitamin and mineral supplementation based on deficiency status 1
PERT should be initiated when PEI is diagnosed through clinical signs/symptoms and/or laboratory tests of malabsorption, with a preferred formulation of pH-sensitive, enteric-coated microspheres that protect enzymes from gastric acidity and allow disintegration at pH >5.5 in the duodenum 1
Mini-microspheres 1.0-1.2 mm in diameter have higher therapeutic efficacy compared to larger microspheres 1

A high protein (1.0-1.5 g/kg body weight), high energy diet in five to six small meals per day is recommended for patients with chronic pancreatitis 2
There is no need for dietary fat restriction unless steatorrhea symptoms cannot be controlled, and very high fiber diets should be avoided as they may inhibit pancreatic enzyme replacement therapy 2
If malabsorption persists despite adequate enzyme supplementation, medium-chain triglycerides (MCT) can be administered 2

The American College of Gastroenterology recommends monitoring and supplementing fat-soluble vitamins (A, D, E, K) if low concentrations are detected or clinical signs of deficiency occur in patients with chronic pancreatitis 3
Vitamin D deficiency is particularly common (58-78% of patients) and should be monitored, with oral supplementation of 38 μg (1520 IU)/day or intramuscular injection of 15,000 μg (600,000 IU) as an effective treatment 4
Blind supplementation of all fat-soluble vitamins is not advised, as some patients may have excess levels (particularly vitamin A) 3

Water-soluble vitamin deficiencies are less common but thiamine deficiency should be considered, especially with concomitant alcoholism, and minerals including magnesium, iron, selenium, and zinc should be monitored and supplemented if deficiencies are detected 3
Magnesium deficiency may correlate with exocrine failure and should be monitored 3

Enteral nutrition is indicated in approximately 5% of patients with chronic pancreatitis, and pancreatic enzymes should be supplemented if signs of exocrine failure manifest 5
Semi-elemental enteral formulas with MCTs are more suitable for jejunal nutrition compared to polymeric formulas, and long-term jejunostomy access (PEG-J or DPEJ) can be used for those requiring enteral nutrition for more than 30 days 3

Failure to recognize PEI can lead to malnutrition and fat-soluble vitamin deficiencies despite adequate caloric intake, and patients with chronic pancreatitis often have altered gut microbiota with decreased levels of beneficial bacteria like Bifidobacteria and Lactobacilli, which may contribute to malabsorption 1
For patients with diabetes secondary to chronic pancreatitis, careful monitoring of blood glucose is essential when adjusting diet and PERT 6