Keratomalacia

What Is Pancreatic Insufficiency?

[dropcap]P ancreatic insufficiency is a disorder characterized by insufficient exocrine production of pancreatic enzymes for normal digestion of fats, proteins, and carbohydrates that results in maldigestion of these foodstuffs.

Pancreatic insufficiency also causes malabsorption of the fat-soluble vitamins: vitamin A, vitamin D, vitamin E, and vitamin K.

Q: What are the exocrine enzymes produced by the pancreas?

A: Exocrine enzymes produced by the pancreas include amylase for the digestion of carbohydrates, lipase for the digestion of fats, and protease for the digestion of proteins.

While lipases and amylase are secreted in the active form, proteases are secreted as pro-enzymes (need to be activated). Trypsinogen is converted to its active form trypsin in the duodenum by enterokinase, a protease secreted by the enterocytes (surface cells that line the duodenum), and trypsin in turn activates the other pancreatic proteases.¹

Pancreatic enzymes are released by the pancreas into the internal pancreatic duct that empties into the common bile duct from which they are pumped through the Sphincter of Odi directly into the duodenum as needed. Tthe Sphincter of Odi is a strong circular muscle that controls the entrance of pancreatic enzymes into the duodenum.

After a meal, enzyme secretion into the duodenum increases quickly reaching peak output within the first 20 to 60 minutes, then decreasing to a stable level before reaching an interdigestive level at the end of the digestive period, that is, about 4 hours after meal intake.²

Medical treatment is with medication that contains enzymes to break down carbohydrates, fats, and protein in food at mealtime. This treatment is safe, effective, and has few side effects.

What Is Pancreatic Insufficiency In Celiac Disease and/or Gluten Sensitivity?

• Relationship between pancreatic insufficiency and celiac disease. Pancreatic insufficiency is an associated disorder of celiac disease.
• Relationship between pancreatic insufficiency and malabsorption. Impaired pancreatic function may be a cause of persistently impaired nutrient assimilation into the body with resulting malnutrition.
• Relationship between pancreatic insufficiency and villous atrophy. Pancreatic enzyme measurements were reduced with mucosal atrophy of the small intestine due to celiac disease in study patients and could be inversely correlated with the degree of intestinal damage.³
• Relationship between pancreatic insufficiency and diarrhea. In diarrhea at diagnosis and persisting despite being on a gluten-free diet, study results from 259 patients with diarrhea show that low elastase (a pancreatic enzyme) in stool samples is common in patients with celiac disease and chronic diarrhea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.⁴
• Relationship between pancreatic insufficiency and pancreatitis. Pancreatitis is a cause of pancreatic insufficiency. A nationwide study investigating the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease found that patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.⁵

How Prevalent Is Pancreatic Insufficiency In Celiac Disease and/or Gluten Sensitivity?

It has been estimated that over 20% of children with celiac disease have defective exocrine pancreatic function.³

In a study of 259 patients with diarrhea, the prevalence of a low fecal elastase-1 (test to assess pancreatic function) within the groups who had celiac disease was: 11% of patients newly diagnosed with celiac disease and 30% of celiac disease patients maintaining a gluten free diet.⁴

What Are The Symptoms Of Pancreatic Insufficiency?

Pancreatic insufficiency is marked by these symptoms that usually result when less than 10% of exocrine pancreatic function remains:

• Bulky, foul-smelling oily stools.
• Stool sticks to toilet bowl.
• Pale stool.
• Diarrhea.
• Weight loss.
• Gas.
• Bloating.
• Abdominal pain.

How Does Pancreatic Insufficiency Develop In Celiac Disease and/or Gluten Sensitivity?

• Pancreatic insufficiency results from inflammation and nutritional deficiencies in celiac disease. Impaired secretion and/or release of pancreatic stimulating hormones from the diseased proximal small intestine may be important in development of pancreatic insufficiency.
• Immunohistochemical studies have demonstrated alterations in enteric (small intestinal) endocrine cells, and there is reported an absence of secretin cells in biopsies from patients with untreated celiac disease.
• Studies with test meals in celiac patients have suggested impaired secretion of cholecystokinin-pancreozymin resulting in reduced pancreatic exocrine cell stimulation.
• In addition, a deficiency of amino acids may result from impaired small intestinal amino acid absorption, leading to a reduction in amino acids needed for the body to make pancreatic enzymes.
• Also, protein malnutrition may lead to structural changes in the pancreas, including atrophy of acinar cells which make the pancreatic enzymes and pancreatic fibrosis or scarring which results in impaired pancreatic exocrine function.

Does Pancreatic Insufficiency Respond To Gluten-Free Diet?

Yes. Celiac disease-related pancreatic insufficiency improves on gluten free diet. Pancreatic enzyme supplementation and vitamin therapy for deficiencies if present may provide symptomatic benefit.⁶

6 Steps To Improve Pancreatic Insufficiency In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1 Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both pancreatic insufficiency and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2  Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes. [/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3  Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4  Manage Your Medications Safely:

[box type=”shadow” ]

Pancreatic enzyme medications are safe and without side effects to trouble celiac disease. Ask your doctor or pharmacist about possible adverse effects if you are taking other medications. Do not stop prescribed medications without supervision.

[/box]

• [dropcap]5 Nutritional Supplements That May Help:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin A as prescribed following blood test for status.
• Vitamin D3 as prescribed following blood test for status.
• Vitamin E as prescribed following blood test for status.
• Vitamin K as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6 Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion. However, because it increases blood sugar levels, it should not be used by persons with insulin resistance or diabete.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Pancreatic Insufficiency In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Patients with celiac disease have an increased risk for pancreatitis.” This nationwide study investigating the risk for any pancreatitis or subtype of pancreatitis among patients with biopsy-verified celiac disease found that patients with celiac disease have an almost 3-fold increase in risk of developing pancreatitis, compared with the general population.

Researchers analyzed data from patients in Sweden with celiac disease (n = 28,908) who were identified on the basis of small intestinal biopsy records from 28 pathology departments (those with villous atrophy, Marsh 3). Biopsies were performed from 1969 to 2008, and biopsy report data were collected from 2006 to 2008. Patients with pancreatitis were identified on the basis of diagnostic codes in the Swedish Patient Register and records of pancreatic enzyme use in the Swedish Prescribed Drug Register. Data were matched with those from 143,746 individuals in the general population; Cox regression was used to estimate hazard ratios (HRs) for pancreatitis.

Of the total number, 406 patients with celiac disease were later diagnosed with pancreatitis (and 143 with expected pancreatitis) (HR, 2.85; 95% confidence interval [CI], 2.53-3.21). The absolute risk of any pancreatitis among patients with celiac disease was 126/100,000 person-years, with an excess risk of 81/100,000 person-years. The HR for gallstone-related acute pancreatitis was 1.59 (95% CI, 1.06-2.40), for non-gallstone-related acute pancreatitis HR was 1.86 (95% CI, 1.52-2.26), for chronic pancreatitis HR was 3.33 (95% CI, 2.33-4.76), and for supplementation with pancreatic enzymes HR was 5.34 (95% CI, 2.99-9.53). The risk of any pancreatitis within 5 years of diagnosis was 2.76 (95% CI, 2.36-3.22).⁹

“Is exocrine pancreatic insufficiency in adult celiac disease a cause of persisting symptoms?” This study investigating whether exocrine pancreatic insufficiency causes persisting symptoms compared with controls, we determined whether pancreatic enzyme supplementation provided symptomatic benefit in celiac patients with chronic diarrhea. Results show that low fecal elastase is common in patients with celiac disease and chronic diarrhea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.

Subjects: 259 were subdivided into four groups: (a) 57 new celiac disease, (b) 86 celiac disease patients on a gluten-free diet without gastrointestinal symptoms, (c) 66 celiac disease patients on a gluten-free diet with chronic diarrhea and (d) 50 patients with chronic diarrhea without celiac disease. Stool frequency and weight, before and after treatment with pancreatic enzyme supplementation were recorded.

The prevalence of a low fecal elastase-1 within the groups was: group (A) six of 57 (11%), group (B) five of 86 (6%), group (C) 20 of 66 (30%) and group (D) two of 50 (4%). Low fecal elastase-1 was more frequent in celiac disease patients with chronic diarrhea vs. other subgroups of celiac disease and controls. In 18 of 20 stool frequency reduced following pancreatic enzyme supplementation from four per day to one. No weight increase was observed.⁴

“Celiac sprue among US military veterans: associated disorders and clinical manifestations.” This study investigating the clinical manifestations of celiac disease related to malnutrition and analyzing the associations between celiac disease and other diagnoses, revealed statistically significant occurrence of pancreatic insufficiency.¹⁰

Sources:

1. Fieker A, Philpott J, Armand M. Enzyme replacement therapy for pancreatic insufficiency: present and future. Clin Exp Gastroenterol. 2011;4:55-73. doi: 10.2147/CEG.S17634. [↩]
2. Fieker A, Philpott J, Armand M. Enzyme replacement therapy for pancreatic insufficiency: present and future. Clin Exp Gastroenterol. 2011;4:55-73. doi: 10.2147/CEG.S17634. [↩]
3. Hugh James Freeman. Hepatobiliary and pancreatic disorders in celiac disease. ISSN 1007-9327 CN 14-1219/R World J Gastroenterol. 2006 March 14;12(10):1503-1508 [↩] [↩]
4. Leeds JS, Hopper AD, Hurlstone DP, Edwards SJ, McAlindon ME, Lobo AJ, Donnelly MT, Morley S, Sanders DS. Is exocrine pancreatic insufficiency in adult celiac disease a cause of persisting symptoms? Aliment Pharmacol Ther. 2007 Feb 1;25(3):265-71. [↩] [↩] [↩]
5. Sadr-Azodi O, Sanders DS, Murray JA, Ludvigsson JF. Patients with celiac disease have an increased risk for pancreatitis. Clin Gastroenterol Hepatol. 2012 Oct;10(10):1136-1142.e3. doi: 10.1016/j.cgh.2012.06.023. [↩]
6. Leeds JS, Hopper AD, Hurlstone DP, Edwards SJ, McAlindon ME, Lobo AJ, Donnelly MT, Morley S, Sanders DS. Is exocrine pancreatic insufficiency in adult celiac disease a cause of persisting symptoms? Aliment Pharmacol Ther. 2007 Feb 1;25(3):265-71. [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Sadr-Azodi O, Sanders DS, Murray JA, Ludvigsson JF. Patients with celiac disease have an increased risk for pancreatitis. Clin Gastroenterol Hepatol. 2012 Oct;10(10):1136-1142.e3. doi: 10.1016/j.cgh.2012.06.023. [↩]
10. Delco F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Digestive Diseases and Sciences. May 1999;44(5):966-72. [↩]