The pancreas is a gland inside the abdomen, located behind the stomach, that plays a dual role in the digestive and endocrine systems. As an exocrine gland, the pancreas produces and secretes digestive enzymes into the small intestine that aid digestion and absorption of dietary fats. As an endocrine gland, the pancreas secretes insulin and glucagon, hormones that regulate blood sugar. (26)
Acute and chronic pancreatitis, characterized by inflammation of the pancreas, are responsible for 361,000 hospital stays annually in the United States. The incidence of pancreatitis is increasing globally; between 1990 and 2017, the number of prevalent cases roughly doubled to over six million. Although less common than acute pancreatitis, chronic pancreatitis has serious health ramifications that must be considered. Early diagnosis and intervention can help manage disease progression and are crucial to alleviating discomfort, supporting health, and improving the quality of life for those affected by the condition.
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What is Chronic Pancreatitis?
Chronic pancreatitis (CP) is a progressive pancreatic disorder from continuous or episodic inflammation. CP can cause permanent changes to and scarring of the pancreas, leading to challenges in digestion, absorption of nutrients, and glycemic control.
It's important to recognize that chronic and acute pancreatitis are two distinct forms of pancreatic inflammation, differing in their causes, symptoms, and long-term implications. Acute pancreatitis develops suddenly and is a short-term condition that resolves with proper management. Single episodes of acute pancreatitis don't usually lead to permanent pancreatic changes. However, repeat episodes of acute pancreatitis can lead to chronic inflammation and CP. (17)
Chronic Pancreatitis Signs and Symptoms
The classic signs and symptoms of CP include:
- Intense upper abdominal pain that radiates to the back, often worse after eating
- Indigestion
- Nausea and vomiting
- Abdominal tenderness with palpation
- Steatorrhea (loose, fatty stool)
Pancreatitis can lead to serious complications if not managed properly. Approximately 70% of patients with CP may develop diabetes mellitus due to changes in pancreatic endocrine function. Exocrine pancreatic insufficiency (lack of digestive enzymes) can result in malabsorption, malnutrition, weight loss, and increased risk of osteoporosis and bone fractures. Chronic pancreatitis is a major risk factor for pancreatic cancer; the incidence of pancreatic cancer in patients with CP in Western countries has been estimated to be 1.0-2.6%.
What Are the Possible Causes of Chronic Pancreatitis?
Pancreatitis occurs when the digestive enzymes synthesized by the pancreas become activated within the gland rather than in the small intestine, where they are supposed to function. This activation, called autodigestion, leads to the digestion of pancreatic tissue, inflammation, and changes to the organ.
The pathogenesis of chronic pancreatitis involves genetic and environmental factors. Genetic variations in PRSSI, SPINK1, CFTR, CTRC, and CASR genes have been identified as strong risk factors for disease development. However, research suggests that a single factor rarely causes pancreatitis, and instead, the coupling of genetic risk with environmental stressors more strongly predicts disease onset. (14)
Excessive alcohol consumption and cigarette smoking are two of the strongest environmental risk factors associated with pancreatitis. Alcohol accounts for 60-70% of CP cases in the Western world. Ethanol appears to cause pancreatic enzymes and proteins to precipitate in pancreatic ducts, leading to fibrosis, stenosis, and pseudocyst formation. It is estimated that 60-80 mL of alcohol daily puts people at risk of developing CP. Smoking is an individual risk factor for disease onset and progression. (3)
Excessive oxidative stress is involved in the pathogenesis of CP, and newer evidence supports this theory by highlighting the link between antioxidant deficiency and CP. Additionally, exposure to environmental toxins, such as volatile hydrocarbons, and the downstream production of free radicals has been suggested as a cause of pancreatitis.
Severe and recurrent acute pancreatitis can affect the pancreas. Risk factors and causes of acute pancreatitis include alcoholism, gallstones, hypertriglyceridemia, hypercalcemia, use of certain medications, infection, abdominal surgery, and abdominal injury.
Functional Medicine Labs to Test for Root Cause of Chronic Pancreatitis
Diagnosis of pancreatitis involves a combination of medical history, physical examination, blood tests to assess enzyme levels, imaging tests such as CT scans or ultrasound to visualize the pancreas, and sometimes endoscopic procedures (31).
Pancreatic Enzymes
Measuring pancreatic digestive enzymes, amylase and lipase, in the blood can help diagnose pancreatitis and assess its severity. Elevated levels greater than three times the upper limit of normal suggest recurrent acute pancreatitis episodes.
Comprehensive Metabolic Panel (CMP)
Among other biomarkers, a CMP includes serum glucose (blood sugar), liver and gallbladder function markers, and calcium. Abnormal results can indicate the presence of diabetes, gallstones, and hypercalcemia, prompting additional laboratory investigation.
Excessive drinking can cause liver inflammation, resulting in fatty liver. Elevations in liver enzymes, AST and ALT, especially with an AST:ALT ratio greater than two, indicate liver inflammation and alcoholic liver disease. Gamma-glutamyltransferase (GGT) and carbohydrate-deficient transferrin (CDT) can also be used as markers of alcohol use for patients in whom you suspect alcohol-related pancreatitis.
Hyperparathyroidism can cause elevated blood calcium levels. Measuring high parathyroid hormone (PTH) can help make this diagnosis.
Lipid Panel
In the absence of gallstones or significant alcohol use, triglyceride levels greater than 1,000 mg/dL, measured on a lipid panel, may be considered as a cause of pancreatitis.
Additional Lab Tests
Once a diagnosis of chronic pancreatitis has been established, additional labs can be used to assess for the presence of disease complications and tailor customized management plans.
Blood Sugar
Hemoglobin A1c (HbA1c) is the three-month average of blood sugar used to diagnose and monitor prediabetes and diabetes. Insulin and C-peptide can also be measured in the blood to quantify how much insulin your pancreas makes. Diminished levels suggest changes in the endocrine capacity of the pancreas's insulin-producing cells, even in the absence of overt diabetes.
Comprehensive Stool Test
Measuring levels of fecal fat and pancreatic elastase with a comprehensive stool test provides insight into pancreatic function. When the exocrine functions of the pancreas are affected in CP, the body may be unable to digest and absorb fat efficiently. Low levels of pancreatic elastase and increased fecal fat are typical findings of CP.
Micronutrients Panel
Complementary to comprehensive stool testing, a micronutrients panel can be used to assess the nutritional adequacy of the patient. Maldigestion, malabsorption, and malnutrition secondary to CP may cause deficiencies of many essential vitamins, minerals, and antioxidants - especially the fat-soluble ones.
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Conventional Management for Chronic Pancreatitis
The conventional approach to managing chronic pancreatitis involves strategies to address the symptoms, support health, and improve the patient's quality of life. Pain management is a primary focus, often achieved through pain medications, lifestyle modifications, and nerve blocks. Nutritional support is essential to address the impaired digestion caused by reduced enzyme production. Enzyme replacement therapy is prescribed to aid digestion and absorption of nutrients. Abstaining from alcohol and adopting a low-fat diet can help reduce stress on the pancreas. In cases of severe complications, surgical interventions might be considered to address complications like pseudocysts or obstructed ducts. Overall, the goal is to alleviate discomfort, ensure proper nutrition, manage underlying causes, and minimize the risk of and address complications associated with chronic pancreatitis. (5)
Integrative Medicine Protocol for Chronic Pancreatitis
An integrative medicine approach for managing chronic pancreatitis combines conventional medical treatments with complementary and alternative therapies to address the condition's physical, emotional, and mental aspects. This approach aligns with conventional management goals to improve symptom management, enhance overall well-being, and support health. Functional medicine doctors, when possible, may rely on natural supplements over prescription medications and invasive procedures to achieve these goals. In addition to the nutritional recommendations and supplements discussed in detail below, other modalities that may be included in an integrative medicine protocol include mind-body stress reduction techniques, acupuncture, chiropractic care, and psychotherapy.
Therapeutic Diet for Chronic Pancreatitis
As significant risk factors for pancreatitis and perpetuating pancreatic inflammation, abstinence from smoking and alcohol is important if the patient is not already doing so. Unfortunately, there are no randomized control trials, systematic reviews, or meta-analyses specifically evaluating whether smoking or alcohol cessation improves clinical outcomes in CP. However, case series have suggested reduced pancreatic calcification progression with smoking cessation and improved pain with alcohol cessation. One randomized control trial also has demonstrated that abstaining from alcohol can help manage recurrent acute pancreatitis in chronic alcoholics. (9)
A low-fat diet is recommended to reduce the strain on the pancreas. Limit fats and oils, such as butter, margarine, mayonnaise, and salad dressings, to one tablespoon per meal. Choose lean protein sources, such as skinless poultry, fish, tofu, and legumes. Eat plenty of vegetables, fruits, whole grains, legumes, and antioxidant-rich foods (e.g., leafy greens, dark berries). Use cooking methods like baking, steaming, grilling, or boiling over frying. Eating smaller, more frequent meals instead of several larger meals can reduce the workload on the pancreas and CP discomfort. (2, 11)
Best Supplements for Managing Chronic Pancreatitis
A high-quality multivitamin/mineral supplement may be considered for patients with CP to support nutrient absorption, help prevent nutrient deficiencies, and relieve malnutrition-associated symptoms (such as fatigue). Furthermore, the American College of Gastroenterology (ACG) suggests using antioxidants, included in a multivitamin, to support CP patients with discomfort.
The following supplements may also be considered for managing CP:
Digestive Enzymes
The primary approach for exocrine pancreatic insufficiency (EPI) is pancreatic replacement enzyme therapy (PERT), which includes lipase, protease, and amylase enzymes. A 2009 systematic review noted improved fat absorption with pancreatic enzyme therapy in patients with CP. One such example is Pancreatic Enzymes by Vital Nutrients, dosed as follows:
Dose: 2 capsules with each meal
Duration: Ongoing
Fish Oil
Fish oil is high in omega-3 fatty acids. While human studies investigating the efficacy of fish oil supplementation in managing CP are not available, animal studies suggest that supplementation may support CP. Additionally, omega-3 fatty supplementation may help manage inflammation and support health for patients with acute pancreatitis.
Dose: 1-2 tablespoons daily
Duration: Ongoing
Ginger
Inflammation-modulating herbs are considered for addressing the underlying inflammation in CP. Ginger root has been studied extensively for its potential anti-inflammatory, analgesic, and anti-nausea effects. Studies have shown ginger may be as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) for discomfort management.
Dose: 750-2,000 mg daily
Duration: Ongoing or as needed
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Summary
Chronic pancreatitis is a digestive disorder characterized by chronic inflammation of the pancreas and a resulting change in pancreatic function. By synergizing conventional medical expertise with complementary therapies, patients can achieve comprehensive symptom relief, enhanced well-being, and a more proactive role in managing their condition. Integrative strategies tailored to individual needs emphasize diet, lifestyle, and natural supplements to target the underlying factors of CP.
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