Video: Pancreatitis Caused By “Complex Genetics,” Brings Extreme Pain

In this video, Dr. David C. Whitcomb, Chief of the Division of Gastroenterology, Hepatology and Nutrition at the University of Pittsburgh Medical Center, describes the “complex genetics” underlying pancreatitis, as well as the personalized care that UPMC offers.

Dr. Whitcomb also explains why pancreatitis is so painful and debilitating — something patients know well but often have a hard time getting others to understand.

UPMC is one of the leaders when it comes to pancreatitis diagnosis and treatment.  They play a large role in pancreas.org and its Pancreas Education and Research Newsletter (with the passably clever acronym PEaRL), as well as the annual PancreasFest conference.  They are clearly worth watching when it comes to new research and novel approaches to care.

Experimental Pain Treatment for Chronic Pancreatitis: Brain Stimulation

Doctors at Beth Israel Deaconess Medical Center have experimented with a non-invasive pain treatment for chronic pancreatitis.   Called “transcranial magnetic stimulation” or TMS, it involves directing a focused beam of magnetic stimulation to a certain region of the brain.  Their study of the procedure showed improvement in approximately 70% of patients suffering from idiopathic chronic pancreatitis.

The approach is based on the idea that chronic pain leads to changes in the nervous system.  Therefore, “approaches aimed at the modulation of the nervous system, rather than the ones interfering with the inflammatory pathways, may be more effective for chronic pain treatment.”  (Find an abstract of the study here.) In other words, they target how the brain processes signals from the pancreas, rather than the problem region itself.

The study was published in 2006.   Since then, other researchers have confirmed that this approach may hold promise.  (See Noninvasive Transcranial Brain Stimulation and Pain.)  However, while the FDA has approved TMS to treat depression, it remains experimental for the treatment of chronic pancreatitis.  (Steven Freedman, one of the authors of the study and a professor of Harvard Medical School, gave a very informative talk on chronic pancreatitis entitled Breaking It Down: Improving Diagnosis and Treatment of Chronic Pancreatitis.  It is well worth reading.)

The procedure is non-invasive and seems to offer a relatively effective way to treat an incredibly vexing problem.  Hopefully efforts are underway to test further and obtain approval.  Chronic pain can be debilitating for people suffering from chronic pancreatitis, and help is desperately needed.

Nutrition for Chronic Pancreatitis: Further Thoughts from the Article’s Author

This past week’s post —Nutrition for Chronic Pancreatitis: Some Startling New Insights — received a lot of attention and comment (largely on the Facebook communities for pancreatitis, which you can find on this page).  Much of the feedback regarded the statement in the Journal of Practical Gastroenterology’s article stating that ““Low fat diets are neither palatable nor necessary and are not recommended.”

I reached out to one of the authors of that article, Sinead Duggan, a research dietitian with Trinity College of Dublin who specializes in nutrition for chronic pancreatitis.   She was kind enough to respond in detail.  Her comments, set forth below, are very helpful and instructive — not only on the issue of fat intake, but all of the points highlighted in the earlier post.  Our thanks to Ms. Duggan for taking the time to provide this further insight.

 

From Sinead Duggan, BSc., co-author of A Practical Guide to the Nutritional Management of Chronic Pancreatitis

I read your article and noted the areas that you find controversial.

Regarding the fat issue, I realise that many physicians still ask patients to follow a fat free or low fat (by this I mean as low as 20 g per day) diet.  I don’t believe the evidence supports this. Not least, remember that not all fats are ‘bad’, some like mono-unsaturates and omega 3 poly-unsaturates are very important for health.

However this should not be misinterpreted as a recommendation to follow a high-fat diet. Patients with chronic pancreatitis clearly must ensure that they do not take high fat foods, especially in large portions. For example, adding cheese, oil, butter, cream or heavy sauces to food, or taking fried foods, or junk food.

However, the ‘normal diet’ consumed by many ‘healthy people’ is very high in fat and not recommended. So to compare patients with chronic pancreatitis to the general public then, yes, they must reduce their fat intake.

Perhaps as importantly, they must take moderately sized meals (avoiding large portions at each time).

For those who report flare-ups or severe pain after high fat foods I would say they should certainly avoid those foods, however, I’d also be interested in what their normal diet is like, their enzyme use, portion size, typical symptoms etc. Assessment by an [Registered Dietitian or “RD”] would help.

The most recent studies have suggested that many patients do not take adequate enzymes. They must be taken appropriately, and with adequate acid-suppression meds if applicable. Regarding the maximum dose, this is very high as you pointed out, but most patients will never reach this (or ever need to), but it is good to have a maximum level nevertheless to reassure patients that they may increase their enzyme intake if they need to.

As you know, the pancreatic enzyme supplements contain enzymes which digest protein and carbohydrate, not just fat. Apart from symptoms of fat malabsorption, patients with chronic pancreatitis may suffer from bloating, wind, and general discomfort after eating (many patients will attest to this) and this may be in part due to carbohydrate malabsorption. The undigested carbs enter the large bowel where they are acted upon by the resident microflora. This causes release of large amounts of gas leading to the symptoms above. A very low fat diet will undoubtedly be high in carbohydrate (you have to eat something!) Importantly, pancreatic enzymes can also help to reduce these symptoms.

So to summarise, a moderate fat intake (not high fat, not fat free) along with careful control of portions, and correct / appropriate usage of enzymes, should help to alleviate the symptoms resulting from this condition.

As mentioned, assessment by an RD should help patients reach a balance of foods, enzymes and supplements. This is not an exact science and requires trial and error. Remember that all patients are different: they have a different degree of severity, different co-morbidities (diabetes, heart disease), some may be underweight and some overweight or obese, and therefore, monitoring by a pancreatologist and team (including RD) should help to make sure that the patients individual situation is considered.

You also mentioned fibre in your piece. Restriction of fibre would only be required where enzyme supplementations appears to be inadequate after checking for appropriate use, adequate acid suppressions, dietary intake etc. We know that dietary fibre can bind the enzymes so it is something that could be tried in the context of dietetic intervention. It may help some patients, if their fibre intake was particularly high, for example.

Briefly regarding type 3 [diabetes, or “DM”], this is a recent classification of the DM that accompanies pancreatic disease. It is an acknowledgement that it differs from type 1 and type 2. For example, in type 3, patients tend to have hypos (like type 1), but milder hyperglycaemia (like type 2). It lies somewhere in the middle in terms of classification. Patients shouldn’t be alarmed at this newer term. Their Pancreatologist will undoubtedly be taking all their clinical situations into account for management.

 

Nutrition for Chronic Pancreatitis: Some Startling New Insights

If you suffer from chronic pancreatitis, diet and nutrition rule your life.  Most experts agree that diet can affect your symptoms and that nutrition — or really malnutrition — is a concern as the disease progresses.  Beyond that, the advice on nutrition is scant, and the experts disagree as to many specifics, often leaving patients to negotiate their diets without clear guidelines.  (See our page on Diet & Nutrition for the best guidelines we’ve found.)

A recent article in the Journal of Practical Gastroenterology offers some new insights into the issue of nutrition for CP.   (“A Practical Guide to the Nutritional Management of Chronic Pancreatitis,” published June 2013)  The article starts by noting that most of the research into nutrition for pancreatitis focuses on the acute form, and that in comparison research into chronic pancreatitis is “older and of lower quality” — but of critical importance.    The authors call nutrition a “problem area” for CP, with effects on quality of life and very serious risk factors.

The article provides a good analysis of the tools available for assessing pancreatic function.  CP can eventually lead to loss of pancreatic function, which can in turn lead to malabsorption and eventually diabetes.  But the article then goes on to reach some conclusions that I found significant…and at odds with some of the conventional wisdom.  Some of the more startling conclusions:

Patients with pancreatic enzyme insufficiency “tend to be undertreated, and [pancreatic enzyme supplements] underprescribed.”  The authors recommend starting with 40,000-50,000 U of lipase per meal and 10,000-25,000  U per snack and increasing the dosage from there — up to a limit of 10,000 U per kg of body weight.  For a 150 lb. person (68 kg), that amounts to a whopping 680,000 U.

In up to 50% of cases, chronic pancreatitis can evolve into a specific subclass of diabetes:  Type 3.  The authors contend that this is often misclassified as Type 1 or Type 2, but that Type 3 has its own unique patient characteristics and its own management principles (described in a table in the article).

As CP progresses, the need for nutrition increases.  The resting energy expenditure is 30-50% higher for advanced chronic pancreatitis patients compared to normal adults.   The authors recommend that such patients increase their caloric intake to 35 Kcal per kg of weight.  (This only translates into 2,380 calories for a 150 lb. person, which seems in the normal range.)

“Low fat diets are neither palatable nor necessary and are not recommended.”  This seems to contradict the recommendations of many experts — see the excellent sources on our Nutrition page.  Instead, they recommend moderate fat intake with enzyme supplements to promote digestion.  They contend that there is no evidence that vegetable fats are any better tolerated than animal fats.  They also caution against too much fiber if enzyme supplements are used.

New Note:  This last conclusion is indeed controversial, and has already generated strong feedback to this post.  Most doctors and patients (though not all) believe that fat taxes the pancreas and causes flare-ups.  Their assertion requires clarification and/or backup, which I will try to find.

The authors propose an algorithm (flow chart) for assessing and managing nutritional issues for CP, which seems sorely needed and seldom used.  As important, however, the article points out holes in the current research and some prevalent misconceptions, both of which cry out for more study.

The article is available in full here.

Further note:  I was able to reach one of the article’s authors, who responded with some helpful clarification.  You can read the author’s comments here.