5 links between Constipation & Pancreatitis (Acute & Chronic).

Patients with acute and chronic pancreatitis may suffer from constipation.

Today, we will discuss the most common causes of constipation in such patients.

Possible causes of constipation with pancreatitis include opioid analgesics, paralytic ileus, bowel obstruction, dehydration, hypercalcemia, and cystic fibrosis. Occasional constipation can also occur with chronic pancreatitis.

1. Pain medications used for pancreatitis pain commonly cause constipation.

In patients with acute pancreatitis, the pain is often extreme, persistent, and intolerable.

To help with pain, doctors often prescribe potent intravenous analgesics.

Acute pancreatitis pain is so severe that traditional pain killers (such as ibuprofen and ketorolac) are ineffective.

So, doctors often use a stronger category of patin killers called opioid analgesics. Opioid analgesics are safer and more effective than common nonsteroidal anti-inflammatory drugs (NSAIDs).

Examples of opioid analgesics used to control pancreatitis pain:

• Morphine.
• Meperidine (after morphine in acute pancreatitis).
• Hydromorphone.
• Fentanyl.

They are given either as intravenous shots or as patient-controlled intravenous continuous pumps.

The major side effect of opioid analgesics is severe constipation. Opioid-induced constipation in patients with acute pancreatitis is often severe and difficult to treat.

Clinical studies show that 60 to 90% of patients receiving opioid analgesics suffer from constipation.

Some patients may progress to complete loss of motility of their intestine (paralytic ileus) because of opioid analgesics.

The larger the dose and the more prolonged the course of opioid analgesics, the more severe constipation becomes.

The slowing of the gut motility not only causes constipation. But it also induces bloating and severe nausea in patients with acute pancreatitis.

Other factors that increase the risk of constipation with acute pancreatitis:

• Severe dehydration (a lack of proper IV fluids during the disease) also contributes to constipation in patients with acute pancreatitis.
• Local complications of pancreatitis such as pancreatic abscess, bleeding, perforation, etc.
• Lack of oral intake (fibers).
• The lack of mobility (bed-ridden patients are more likely to develop constipation).

Treatment and prevention of opioid-induced constipation:

• Decrease the dose to the least effective dose.
• Talk with your doctor about changing the type of opioids as some types are less constipating than others.
• Try an osmotic laxative such as lactulose, magnesium sulfate, or PEG (MiraLAX).
• Docusate laxative is suitable for people with hard and dry stools.
• After your doctor excludes intestinal obstruction, He may prescribe a bulk-forming laxative (such as psyllium).
• Avoid dehydration.
• Mineral oil enemas also help.
  
  

2. Hypercalcemia (with parathyroid diseases).

Increased blood calcium levels above normal limits are called (hypercalcemia). The most common cause is a hyperactive parathyroid gland.

The parathyroid gland regulates calcium in your blood, bones, and other tissues.

Increased activity of the parathyroid glands (hyperparathyroidism) is the most common cause of hypercalcemia.

Hypercalcemia causes both constipation and pancreatitis. But first, let’s list the causes.

Causes of hypercalcemia (reference):

• Adenoma or hyperplasia of the parathyroid gland (a benign tumor that secretes PTH hormones): is the most common cause of hypercalcemia.
• Familial hypercalcemia (genetic disease).
• Parathyroid cancer.
• Multiple myeloma (a malignant blood disease).
• Other cancers such as leukemia, lymphomas, kidney cancer, etc.
• Hypervitaminosis D.

Hypercalcemia causes both:

• Constipation: increased calcium levels decrease the motility of the gastrointestinal tract resulting in constipation, upset stomach, nausea, and maybe vomiting.
• Pancreatitis: the sharp rise in calcium can induce acute pancreatitis(reference).

So, patients who get pancreatitis secondary to hypercalcemia may also have constipation.

Symptoms of hypercalcemia:

• Persistent thirst sensation.
• Frequent urination.
• Constipation, nausea, and gastric upset.
• Headache, fatigue, confusion, and coma in severe cases.
• Weak bones, bone pain, easy fractures.
• Mood changes (depression).
• Muscle weakness.
• Rarely, it may affect the heart, causing fainting, and irregular or very rapid heartbeats.
• Chronic hypercalcemia may cause kidney stones, osteoporosis, or even kidney failure.

Hypercalcemia is diagnosed by checking the blood levels of calcium. When it is severe enough, your doctor may order other investigations to detect the cause, such as PTH levels, imaging of the parathyroid gland, cancer screen, etc.

Hypercalcemia treatment during acute pancreatitis

• Good hydration (intravenous fluids).
• Calcitonin (Miacalcin): a hormone that lowers calcium levels in the blood.
• Calcimimetics (as cinacalcet): to control a hyperactive parathyroid gland.
• Bisphosphonates: a common drug used in the treatment of osteoporosis. It helps rapid lowering of blood calcium.
• Others such as Denosumab and prednisolone.
• Treatment of the cause: such as surgical removal of the parathyroid gland.

Constipation due to hypercalcemia is managed in a way similar to opioid-induced constipation with laxatives and fibers.

3. Paralytic ileus and bowel obstruction with acute pancreatitis.

Paralytic ileus is a condition in which the muscles of the small intestine cease to move properly.

Paralysis of the small intestine is more common than true bowel obstruction in patients with acute pancreatitis.

Both conditions can cause severe constipation in patients with acute pancreatitis.

The most common site of intestinal obstruction is the left colon (at the splenic flexure near the pancreas). The obstruction is often due to the direct damage mediated by digestive enzymes on the colon.

Symptoms of paralytic ileus and bowel obstruction with acute pancreatitis include:

• Absolute constipation (often for several days).
• Diffuse abdominal colics.
• Severe abdominal distension and bloating.
• Persistent nausea and vomiting.
• Sings of dehydration (thirst sensation, peeing little urine, dry mouth, etc.).

The diagnosis of bowel obstruction is often made by abdominal imaging (plain X-rays, abdominal ultrasound, contrast-enhanced CT, etc.).

Paralytic ileus is often treated by:

• Bowel rest.
• Parenteral nutrition.
• Prokinetic medications to stimulate motility.
• Correction of electrolyte disturbances (particularly serum potassium and calcium levels).
• Nasogastric tube insertion to evacuate the stomach and intestinal secretions and prevent vomiting.

Severe cases of true bowel obstruction may need surgery to relieve the construction and treat constipation.

4. Cystic fibrosis.

Cystic fibrosis is one of the most common genetic diseases among people of Northern European descent (about one in every 2000 or 3000 live births).

The disease affects the secretions of the mucus membranes found in the digestive system, lungs, pancreas, liver, and reproductive system.

Patients with cystic fibrosis commonly have chronic constipation and are at a very high risk of acute pancreatitis.

Symptoms:

• Recurrent chest infections.
• Chronic sinusitis.
• Recurrent cough, expectoration, and shortness of breath.
• The disease starts to manifest in children. As a result, patients with cystic fibrosis often fail to thrive and lose weight.
• Jaundice.
• Recurrent constipation (or diarrhea). The stool is often bulky and offensive.
• Higher risk of pancreatitis.
• Diabetes.
• Osteoporosis (weak bones with easy fractures).
• Infertility.

Diagnosis of cystic fibrosis is based on clinical features and tests such as sweat chloride, testing for gene mutations, etc.

Patients with severe constipation and pancreatitis with cystic fibrosis are at higher risk of bowel obstruction.

5. Constipation in chronic pancreatitis.

Patients with chronic pancreatitis may suffer from chronic or recurrent constipation due to various causes.

The most common causes of constipation with chronic pancreatitis include:

• Chronic opioid analgesic use.
• Exocrine pancreatic insufficiency leads to abnormal digestion and absorption, which manifests as diarrhea or constipation.
• Lack of proper fiber intake.
• Dehydration.

The treatment of constipation with chronic pancreatitis includes:

• Good hydration.
• Avoidance of opioid analgesics as possible.
• Increasing dietary fiber intake.
• Fiber supplements such as psyllium
• Traditional laxatives such as PEG (MiraLAX).