IBD and Pancreatitis

By Wayne Persky

RSS Feed

Personally, I have long held the opinion that many of us have pancreatic inflammation associated with our microscopic colitis (MC), especially if our disease is not put into remission promptly. Decades ago, when I developed MC, I'm reasonably certain that I had an inflamed pancreas, because I obviously didn't have the enzymes needed to properly digest my food (and I had several of the symptoms mentioned below). Back then, it rarely occurred to gastroenterologists to even test for pancreatic insufficiency. But there was no reason to be concerned, because those enzyme deficiencies were slowly resolved after I eliminated the foods from my diet that were causing my immune system to produce antibodies.

And I've always felt that it's typical for problems caused by an inflamed pancreas to resolve for most of us, when our MC is put into remission. But these days, gastroenterologists are beginning to diagnose pancreatitis in MC, and other inflammatory bowel disease (IBD) patients with increasing frequency. And although the pancreatitis is associated with the IBD, they choose to treat it as if it were a separate issue. But is the extra cost and inconvenience experienced by the patient worth it? Let's consider the facts

Published research shows a common association.

There's substantial published medical evidence showing that pancreatic disorders are more common in patients with IBD, including acute pancreatitis, chronic pancreatitis, and autoimmune pancreatitis. In many cases, these are claimed to represent extra-intestinal manifestations of IBD (in other words, gastroenterologists believe that they're are not associated with IBD) or result from treatment side effects. Patients with IBD have a 3–4 times increased risk of developing acute pancreatitis compared to the general population, and the risk is slightly greater for Crohn’s disease than ulcerative colitis (Antonini, Pezzilli, Angelelli, and Macarri, 2016).1

A systematic review found a clear association between IBD and pancreatic disease, including acute pancreatitis and chronic pancreatitis, with common causes being gallstones and medication side effects (Massironi et al., 2022).2 In this study, an analysis of over 516,000 IBD patients showed 2.3% experienced pancreatitis, with rates 2–6 times higher than in the general population. Chronic pancreatitis risk is also elevated. In Taiwan, IBD patients had a 10-fold higher incidence of chronic pancreatitis than non-IBD individuals.​

Some medications used to treat IBD trigger pancreatitis.

Common IBD medications such as azathioprine, 6-mercaptopurine, and some biologics,can trigger acute pancreatitis, typically within 90 days of initiation (Wikipedia, n.d.).3 Especially in Chron's disease (due to terminal ileal disease), gallstone formation can cause acute pancreatitis, independent of medications (Antonini, Pezzilli, Angelelli, and Macarri, 2016). Note that similar to Crohn's disease, MC typically concentrates the highest concentration of inflammation in the ileum, in many (possibly most) cases.

But remember, all the studies cited here excluded MC patients, so we can only make an educated guess as to whether MC has a greater or lesser chance of causing pancreatic inflammation. But based on our own experiences, as evidenced by the shared experiences found in the database of the discussion and support forum associated with the Microscopic Colitis Foundation, a relatively high percentage of us appear to have issues associated with an inflamed pancreas when our disease is in a flare.​

Research shows that pancreatitis resolves when IBD is in remission.

The evidence suggests that in most cases,especially when pancreatitis is directly linked to medications, gallstones, or autoimmune causes, pancreatic inflammation resolves alongside IBD remission, or after the offending factor is removed. In a cohort of ulcerative colitis (UC) patients, those who developed type 2 autoimmune pancreatitis were typically treated with corticosteroids (Kim et al., 2017).4 All patients recovered uneventfully, with no recurrence during follow-up (median 28 months), even while UC remained in remission.​

In cases where pancreatitis appears as an extra-intestinal manifestation of IBD (described above), especially in Crohn’s disease, some studies show that pancreatic complications improve in tandem with bowel inflammation, although specific remission data is limited (Daniluk et al., 2023).5 This pediatric research also indicates that elevation in pancreatic enzyme levels frequently subsides once IBD goes into remission, supporting a parallel disease course.

So is treating pancreatitis beneficial for MC patients?

Unfortunately, that's not an easy question to answer. The best answer may be, "It depends".
With or without diagnosis and treatment, pancreatitis will usually resolve when MC goes into remission. And because intestinal healing is slow, due to stem cell damage caused by the chronic inflammation, digestive system healing time is going to be slow, with or without any intervention, including diet changes.

That said, in cases where weight loss due to incomplete digestion is a major problem, treating pancreatitis (assuming that it's causing significant digestive enzyme deficiencies) may be beneficial, for several reasons:

Incomplete digestion causes:

• Watery diarrhea
• ​Malabsorption
• Fatty stools (steatorrhea
• Gas generation, bloating, and urgency
  

​Treating pancreatitis could help restore digestive enzyme output, improve nutrient absorption, and reduce diarrhea or urgency, (if pancreatic insufficiency is a contributing factor).

But treating pancreatitis can be a two edge sword,

if the treatment introduces gut-disrupting medications (for example, PPIs, antibiotics, or NSAIDs), it may slow down healing or reactivate inflammation, or even cause an MC flare. Treatments such as:

1. Enzyme replacement therapy (for example, pancrelipase):

• Is usually safe and often beneficial in chronic or subclinical pancreatitis
• Rarely causes flares unless additives (such as lactose or artificial coloring) are problematic for sensitive MC patients

2. Steroids (for example, prednisone or budesonide),
Used for autoimmune pancreatitis or severe flares could either help or hurt:

• May help both conditions by suppressing immune overactivity
• But long-term use or tapering can destabilize MC if not managed carefully

3. Antibiotics (for example, if used for infected pancreatic necrosis):

• Certain antibiotics are known to cause or exacerbate microscopic colitis(for example, amoxicillin, cephalosporins, macrolides)
• Could trigger an MC flare in susceptible patients, especially if used without a clear need

4. NSAIDs (sometimes used for pain):

• Well-documented triggers for MC
• Should be avoided whenever possible

5. Changes in diet:

• Pancreatitis treatment often involves a low-fat diet, which may already be part of an MC patient’s routine
• ​But introducing new processed low-fat foods could inadvertently include triggers (due to gums, additives, soy, gluten, casein, or some other allergen)

MC patients with severe weight loss may need special treatment.

It's quite plausible, and in some cases likely, that microscopic colitis (MC) patients with severe, unexplained weight loss may have underlying pancreatic insufficiency or pancreatitis, especially if they exhibit certain overlapping symptoms. This connection is often underdiagnosed or overlooked in clinical practice (gastroenterologists tend to view MC treatment as a one-size-fits-all situation. A connection between MC and pancreatitis (or pancreatic insufficiency) makes sense in this situation because there can be:

1. Shared mechanisms of inflammation:

• Both MC and pancreatitis may be driven by immune system dysregulation, including autoimmune syndromes, mast cell activation, or lymphocytic infiltration.
• Some IBD-related cases (especially Crohn’s) are associated with autoimmune pancreatitis, and similar patterns may apply in MC, despite not being studied by dedicated research projects.

2. Malabsorption and weight loss

Pancreatic insufficiency causes fat malabsorption, which leads to:

• Steatorrhea (greasy, floating stools)
• Deficiencies in fat-soluble vitamins (A, D, E, K)
• Muscle wasting and progressive weight loss
• These symptoms can mimic or compound MC, making it difficult to separate the causes without specific testing.

3. Overlapping symptoms

• Chronic watery diarrhea
• Weight loss
• Abdominal pain (esp. upper)
• Fatty, foul-smelling stools
• Nutrient deficiencies

Clues that pancreatic issues may benefit from treatment:

• Persistent weight loss despite MC being in remission
• Low serum levels of fat-soluble vitamins (especially D or A)
• Normal colonoscopy/biopsy but worsening symptoms
• Normal inflammatory markers, suggesting malabsorption rather than active inflammation
• Failure to respond to budesonide or dietary interventions

The bottom line.

For most of us, whether or not our pancreas might be inflamed because of the inflammation caused by our MC, is irrelevant, due to the fact that after we put our MC into remission, any pancreatic issues will probably be automatically resolved. But for those of us who have severe weight loss, or despite having MC in remission for many months, are still unable to gain any weight (assuming that more than enough calories are being ingested), treating a pancreatitis issue could be beneficial. It might be time to ask our gastroenterologist to test for pancreatitis.

References:

1. Antonini, F., Pezzilli, R., Angelelli, L., and Macarri, G. (2016). Pancreatic disorders in inflammatory bowel disease. World Journal of Gastrointestinal Pathophysiology, 7(3), pp 276–282. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC4981767/

2. Massironi, S., Fanetti, I., Viganò, C., Pirola, L., Fichera, M., Cristoferi, L., . . . Danese, S. (2022). Systematic review-pancreatic involvement in inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 55(12), pp 1478–1491. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9322673/

3. Wikipedia, (n.d.). Chron's disease. Wikipedia, Retrieved from https://en.wikipedia.org/wiki/Crohn%27s_disease

4. Kim, J. W., Hwang, S. W., Park, S. H., Song, T. J., Kim, M-H., Lee, H.-S., . . . Yang, S.-K (2017). Clinical course of ulcerative colitis patients who develop acute pancreatitis. World Journal of Gastroenterology, 23(19), pp 3505–3512. Retrieved from https://www.wjgnet.com/1007-9327/full/v23/i19/3505.htm

5. Daniluk, U., Krawiec, P., Pac-Kożuchowska, E., Dembiński, Ł., Bukowski, J. S., Banaszkiewicz, A., , , , Lebensztejn, D. M. (2023). Pancreatic Involvement in the Course of Inflammatory Bowel Disease in Children—A Multi-Center Study. Journal of Clinical Medicine, 12(13), 4174. Retrieved from https://www.mdpi.com/2077-0383/12/13/4174