Exocrine insufficiency in chronic pancreatitis is usually managed as a symptom problem — enzymes titrated until the steatorrhoea settles — and the consequences that do not produce symptoms go unmeasured. Vitamin D, A, E and K deficiency are common in this population, and so is osteoporosis, at ages where nobody thinks to look for it.
The patients most at risk are exactly the ones least likely to be screened: young adults with long-standing disease, often with poor intake, often smokers, often with no other reason to have a bone density scan requested. A fragility fracture in a 45-year-old with chronic pancreatitis is a foreseeable event that a single test would have flagged years earlier.
The practical version is to make this part of the annual review rather than a response to a symptom: vitamin D, a calcium, bone profile and a DEXA scan at a defined interval, alongside the enzyme dose and the nutritional assessment that is already being done.
- Measure vitamin D at least annually in anyone with exocrine insufficiency, and replace where low
- Arrange bone densitometry at diagnosis of chronic pancreatitis with exocrine insufficiency, regardless of age
- Consider vitamin A, E and prothrombin time as a proxy for K where steatorrhoea is poorly controlled
- Assess and support smoking cessation; it accelerates both the pancreatic disease and the bone loss
- Record the enzyme dose against the nutritional outcome, not only against stool frequency
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