IBS caused by pancreatic insufficiency?

[Glen__0]

  I was diagnosed with IBS several years ago and my doctor's treatment was limited to prescribing a sublingual "muscle relaxer" for the intestines. (I can't remember the name.) After the bouts of severe diarrhea, gas and cramping got worse, my sister (who manages the local GNC) kept having me try different types of supplements and enzimes.  After a lot of failures, I found that a Pancreatin enzyme helped a great deal, but certainly not a cure.  I mentioned this to my family doctor and asked if he thought I needed to see a specialist to determine the cause.  He said no, that he didn't see the need, that the only thing that can be done for a pancreas that doesn't produce enough enzyme is to use a supplement like I am doing.  After three to four years I have found that it takes about 4200 mg of Pancreatin in tablet form after each meal to fairly well eliminate the symptoms.  Is this about the normal amount to supplement a pancreas that has shut down?  Are there other enzymes I should try or should I see a gastroenterologist?  Thanks in advance,  Glen.

[HFHSM.D.-rf]

_
Dear Glen,
Your letter raised interesting questions regarding the role of the pancreas in the production of irritable bowel symptoms.  The pancreas produces and releases into the duodenum enzymes that are necessary to digest fat, carbohydrate and protein.  Failure to release sufficient lipase ( the important enzyme for fat digestion) will result in weight loss and malabsorption of fat soluble vitamins, especially vitamin K and D.  Inadequate levels of vitamin K result in a tendency to easy bruising and bleeding.  Vitamin D deficiency is associated with bone changes.  
Impaired digestion of carbohydrate (due to multiple possible causes of which pancreratic insufficiency is just one) can lead to symptoms of gas, bloating, cramps and diarrhea.  These symptoms are identical to those seen with IBS and could lead to the conclusion that pancreatic insufficiency is a cause of IBS.  In practice, however, the dominant symptoms of pancreatic insufficiency are usually related to fat malabsorption.  Because the symptoms of fat malabsorption are so different from those of IBS we usually do not think of IBS as a manifestation of pancreatic insufficiency.
Pancreatic insufficiency is usually symptomatic when 95% of the pancreas has been destroyed.  In North America the most common cause of pancreatic insufficiency is alcohol-induced pancreatitis, although other diseases can produce the same end result.  If you are concerned that you might have pancreatic insufficiency, you should see a gastroenterologist.  Your physician is correct, however, that the only treatment for pancreatic insufficiency is the replacement of pancreatic enzymes when eating.  The amount of enzyme required depends on the type of diet and the amount of  residual functioning pancreas.  If 4200 mg of Pancreatin controls your symptoms, then you should rermain on this dose.  REMEMBER, HOWEVER,THAT YOU IMPROVEMENT OF YOUR SYMPTOMS DOES NOT NECESSARILY MEAN THAT YOU HAVE PANCREATIC INSUFFICENCY
This response is offered for your general information and should not replace the conclusions drawn from a careful and complete evaluation by your physician.

If you wish to be seen at our institution, Henry Ford Hospital, please call our PHYSICIAN REFERRAL LINE at(313) 876-2393 and request consultation with Dr Fogel, one of our experts in intestinal disease.  He can arrange the appropriate evaluations to determine if you have pancreatic insufficiency.
HFHSM.D.-rf
*keywords: irritable bowel syndrome, malabsorption, pancreatic insufficiency
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