From the Guidelines
Patients with pancreatic insufficiency are at high risk of developing deficiencies in fat-soluble vitamins (A, D, E, and K) due to impaired fat digestion and absorption, and treatment with pancreatic enzyme replacement therapy (PERT) and vitamin supplementation is essential to prevent complications related to malnutrition and improve quality of life. The relationship between vitamin deficiency and pancreatic insufficiency (PEI) is well-established, with impaired fat digestion and absorption leading to deficiencies in fat-soluble vitamins 1.
Clinical Features of PEI
The clinical features of PEI include steatorrhea with or without diarrhea, weight loss, bloating, excessive flatulence, fat-soluble vitamin deficiencies, and protein-calorie malnutrition 1.
Diagnosis of PEI
The diagnosis of PEI can be made using the fecal elastase test, which is the most appropriate initial test and must be performed on a semi-solid or solid stool specimen 1.
Treatment of PEI
Treatment of PEI involves PERT, such as pancrelipase (Creon, Zenpep) taken with meals at an initial dose of at least 40,000 USP units of lipase during each meal in adults, adjustable based on response 1. Additionally, vitamin supplementation is essential, including vitamin A, vitamin D, vitamin E, and vitamin K, as well as water-soluble vitamin B12 supplementation if necessary 1.
Monitoring and Follow-up
Regular monitoring of vitamin levels every 6-12 months is recommended to adjust supplementation, and baseline measurements of nutritional status, including body mass index, quality-of-life measure, and fat-soluble vitamin levels, should be obtained 1. A baseline dual-energy x-ray absorptiometry scan should also be obtained and repeated every 1-2 years to monitor for metabolic bone disease 1.
Importance of Early Treatment
Early identification and treatment of PEI are crucial to prevent complications related to malnutrition and improve quality of life 1. Untreated PEI can result in complications related to fat malabsorption and malnutrition, having a negative impact on quality of life 1.
Multidisciplinary Evaluation
A multidisciplinary evaluation, including a dietary assessment from a certified dietitian and coordination of care with an endocrinologist if necessary, is helpful to establish the state of the patient's digestive and endocrine systems and determine nutritional needs and specific deficits 1.
From the Research
Relationship Between Vitamin Deficiency and Pancreatic Insufficiency
The relationship between vitamin deficiency and pancreatic insufficiency (PEI) is complex and multifaceted. Key findings from various studies include:
- Vitamin D deficiency is common in patients with exocrine pancreatic insufficiency due to chronic pancreatitis, with serum 25(OH)D concentrations <30 ng/ml in 93% of patients 2.
- Fat-soluble vitamin deficiencies, including vitamins A, D, E, and K, are frequent in patients with pancreatic insufficiency, even in those receiving oral pancreatic enzyme therapy 3.
- The prevalence of fat-soluble vitamin deficiencies varies among patients with chronic pancreatitis, with vitamin D deficiency being the most common 4, 5.
- Deficiencies in fat-soluble vitamins can lead to decreased bone mineral density and increased risk of osteopenia and osteoporosis in patients with chronic pancreatitis 5.
- Vitamin B12 deficiency is relatively rare in patients with chronic pancreatitis and does not strictly depend on the degree of exocrine pancreatic insufficiency 6.
Fat-Soluble Vitamin Deficiencies
Fat-soluble vitamin deficiencies are a significant concern in patients with pancreatic insufficiency. Key findings include:
- Vitamins A, D, E, and K deficiencies can occur in patients with pancreatic insufficiency due to malabsorption of fat 3, 4, 5.
- Vitamin D deficiency is widespread in patients with chronic pancreatitis, with a prevalence of 53% in one study 5.
- Vitamins A and E deficiencies are also common, although less frequent than vitamin D deficiency 3, 5.
- Vitamin K deficiency is relatively rare, but can occur in patients with severe pancreatic insufficiency 5.
Screening and Supplementation
Screening and supplementation strategies for vitamin deficiencies in patients with pancreatic insufficiency are crucial. Key findings include:
- Routine screening for fat-soluble vitamin deficiencies is recommended for all patients with chronic pancreatitis, regardless of exocrine pancreatic function 4, 5.
- Supplementation with oral vitamin D can increase serum 25(OH)D concentrations into the normal range in patients with pancreatic insufficiency 2.
- Individualized supplementation strategies may be necessary, as some patients may require higher doses of vitamin D or other fat-soluble vitamins 2, 4.