Nutrition in Pancreatitis

Good nutrition plays an important part in recovering from, and living with, pancreatitis. This leaflet explains general dietary advice, foods to favour or limit, what to expect if you need tube (enteral) or intravenous (parenteral) feeding, and how pancreatic enzyme replacement therapy (PERT) works if your pancreas is no longer making enough digestive enzymes. It is general background information and does not replace advice from your own dietitian or clinical team, who will tailor recommendations to you.

Why does pancreatitis affect nutrition?

Your pancreas normally produces enzymes that break down fat, protein and carbohydrate in food, as well as bicarbonate that helps these enzymes work (see our "My Pancreas" leaflet). During and after an episode of pancreatitis (and in chronic pancreatitis) this process can be disrupted in several ways: pain and inflammation can reduce your appetite and ability to eat; the pancreas may temporarily or permanently produce fewer digestive enzymes (pancreatic exocrine insufficiency, or PEI); and, in severe illness, your body's overall energy and protein needs increase at exactly the time eating is hardest. Addressing all of these is an important part of your treatment and recovery.

Eating during and after an acute episode

Current guidance favours getting you eating and drinking again as early as it is safely possible, rather than being kept "nil by mouth" for long periods. If your pain, nausea and vomiting allow it, you will usually be encouraged to try oral fluids and light food early in your admission, progressing your diet as you are able to tolerate it.

When you restart eating, it often helps to begin with small, simple, low-fat meals and build up gradually rather than returning straight to a full, rich diet. Your dietitian may give you specific guidance based on the severity of your episode and its cause.

General dietary advice

Outside of a hospital admission, a generally low-fat, balanced diet (similar to a standard healthy eating pattern) is recommended for most people who have had pancreatitis, particularly if gallstones or high blood fats were the cause. Eating smaller, more frequent meals can be easier to digest than large, heavy ones. The table below gives a general guide; your dietitian can personalise this further.

Foods to choose more often

• Lean meat and poultry (skin removed), fish, eggs
• Low-fat dairy products (skimmed or semi-skimmed milk, low-fat yoghurt)
• Wholegrains: oats, brown rice, wholemeal bread and pasta
• Fruit and vegetables, fresh, frozen or tinned
• Pulses: beans, lentils, chickpeas
• Foods grilled, baked, steamed or poached rather than fried
• Small, frequent meals (5 to 6 a day) rather than 2 to 3 large ones
• Plenty of water; limit caffeine

Foods to limit or avoid

• Fried and battered food, takeaways
• Fatty cuts of red meat, sausages, processed and cured meats
• Full-fat dairy: cream, hard cheese, butter, full-fat milk
• Pastries, cakes, biscuits and other foods high in saturated fat
• Creamy sauces, gravies and dressings
• Crisps and other fried snack foods
• Alcohol in any amount (see below)
• Sugary drinks and excess added sugar

If you have pancreatic exocrine insufficiency and take enzyme replacement therapy correctly (see below), you may not need to restrict fat as strictly, since the enzymes help you digest it. Your dietitian will advise what is right for you, as unnecessarily restricting fat can lead to inadequate calorie intake and weight loss.

A note on alcohol

If alcohol played any part in your pancreatitis, or even if it did not, you will usually be advised not to drink any alcohol, since it can trigger further attacks and worsen pancreatic damage even in people whose pancreatitis had a different cause. If you find this difficult, support is available. Please ask your team about referral to alcohol support services.

Vitamins and minerals

If fat digestion is affected, it can become harder to absorb the fat-soluble vitamins A, D, E and K. Your team may check your levels periodically and recommend a supplement if needed. Do not start high-dose vitamin supplements on your own without checking with your team, as this is best guided by blood tests.

If you can't eat enough: enteral (tube) nutrition

If you are unable to take in enough nutrition by mouth (for example during a severe or moderately severe episode of acute pancreatitis, or if pain, nausea or a slow-emptying stomach make eating difficult), your team may recommend enteral nutrition. This means delivering a specially formulated liquid feed directly into your stomach or small bowel through a fine, soft tube, usually passed through your nose.

• Nasogastric (NG) tube: passed into the stomach; this is the usual first choice, as it is simpler to place and generally works well.
• Nasojejunal (NJ) tube: passed further, into the small bowel; this may be used if you are not tolerating an NG tube, for example because of persistent vomiting or slow stomach emptying.

Feed is usually given continuously over many hours using a small pump, though it can sometimes be given in bolus amounts. Wherever possible, doctors prefer to start enteral feeding early (typically within the first 72 hours if you have moderate or severe pancreatitis) because using the gut, even partially, helps protect the gut lining, reduces the risk of infection, and is generally associated with a smoother recovery compared with intravenous feeding alone.

Tube feeding is usually temporary. As your symptoms settle and you are able to eat and drink more by mouth, the tube feed is reduced and eventually stopped, and the tube removed.

When tube feeding isn't possible: parenteral (intravenous) nutrition

Parenteral nutrition delivers nutrients (carbohydrate, protein, fat, vitamins and minerals) directly into your bloodstream through a drip, bypassing your gut altogether. It is only used if enteral (tube) feeding has failed or is not possible, for example because of a prolonged bowel obstruction or ileus, or another problem preventing safe use of the gut.

Parenteral nutrition is generally avoided where possible, and used for the shortest time necessary, because it carries its own risks: infection related to the intravenous line, blood clots, and metabolic disturbances such as abnormal blood sugar or liver test results. If you need parenteral nutrition, you will be monitored closely with regular blood tests, and your team will move you back to tube or oral feeding as soon as your gut allows it; the general principle is "if the gut works, use it."

Pancreatic enzyme replacement therapy (PERT)

What is pancreatic exocrine insufficiency?

Pancreatic exocrine insufficiency (PEI) means the pancreas is no longer producing enough digestive enzymes to break down food properly, particularly fat. It can occur after severe or repeated episodes of acute pancreatitis, in chronic pancreatitis, or after some types of pancreatic surgery. Symptoms can include:

• Loose, pale, oily or foul-smelling stools that are difficult to flush (steatorrhoea)
• Bloating, cramping or excess wind
• Unintended weight loss
• Fatigue and, over time, symptoms of vitamin deficiency

If you have these symptoms, tell your team. PEI is diagnosed using your symptoms, sometimes alongside a stool test (faecal elastase), and is very treatable.

How PERT works

Pancreatic enzyme replacement therapy replaces the missing enzymes with capsules taken with food. Each capsule contains many tiny enteric-coated granules designed to survive the acid in your stomach and release their enzymes in the small bowel, where they mix with food and help digest fat, protein and carbohydrate, similarly to your own pancreatic enzymes.

• With main meals: around 25,000 to 50,000 units of lipase (commonly 2 capsules of a 25,000-unit enzyme preparation)
• With snacks: around 10,000 to 25,000 units of lipase (commonly 1 capsule of a 25,000-unit preparation)
• Long or fatty meals: your team may advise splitting the dose across the meal, or adding extra capsules for particularly fatty food

These are typical starting doses only. Your team will adjust your dose based on your symptoms, weight and stool pattern, and doses are often increased gradually if needed. Do not adjust your dose substantially on your own without discussing it with your team.

How to take PERT correctly

Do:

• Take your capsules during each meal or snack that contains any fat; spread the dose across the meal if it is a long one.
• Swallow capsules whole with a cold or cool drink; do not chew them or let them sit in your mouth.
• If you struggle to swallow capsules, ask your team about opening them and sprinkling the granules onto a small amount of soft, acidic food such as apple purée, but do not chew the granules, and take this straightaway.
• Keep well hydrated, as enzyme therapy can occasionally make constipation more likely.
• Tell your team if your symptoms (loose stools, bloating, weight loss) are not improving; your dose or timing may need adjusting.

Don't:

• Don't take PERT on an empty stomach, well before or long after eating; it needs to mix with food to work.
• Don't crush, chew, or mix the granules into very hot food or drink, as this can damage the enzymes or the protective coating.
• Don't stop or restart PERT, or change your dose significantly, without checking with your team.
• Don't skip doses with snacks that contain fat, even small ones, if you have been advised to take enzymes with snacks.

If your symptoms continue despite taking an adequate, correctly timed dose, your team may check that you are taking it correctly, review the dose, or consider adding a medicine that reduces stomach acid; a highly acidic stomach environment can reduce how well the enzymes work for some people.

When to seek help

• Unintentional weight loss that continues despite following dietary and enzyme advice
• Persistent diarrhoea, greasy or foul-smelling stools despite taking PERT as prescribed
• Signs of dehydration (reduced urine output, dizziness, dry mouth) if you are relying on tube or intravenous feeding
• Problems with a feeding tube: for example, it falls out, becomes blocked, or the site becomes red or painful
• New or worsening abdominal pain, fevers, or feeling generally unwell

Key points to remember

• Eating early, in small and frequent low-fat meals, is generally encouraged as soon as it is safe to do so.
• A low-fat, balanced diet, avoiding alcohol completely, is the usual long-term dietary advice.
• Enteral (tube) feeding is preferred over intravenous feeding whenever the gut can be used, and is usually temporary.
• Intravenous (parenteral) nutrition is reserved for when tube feeding is not possible, due to its higher risks.
• Pancreatic enzyme replacement therapy (PERT) treats pancreatic exocrine insufficiency. Take it with every meal and fat-containing snack, exactly as advised.
• Tell your team about ongoing symptoms such as weight loss, greasy stools, or bloating, as your enzyme dose or diet plan may need adjusting.
• A dietitian is a core part of your care team for pancreatitis; do ask to be referred if you have not already seen one.

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