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.
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.
Dietary changes that may be helpful for pancreatic insufficiency
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 for pancreatic insufficiency
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 for pancreatic insufficiency
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 with pancreatic insufficiency?
Refer to the individual supplement for information about any side effects or interactions.