gastrointestinal disorders
Chronic Pancreatitis
Treatment of Chronic Pancreatitis
Pain control Pancreatic enzyme supplements Management of diabetes Management of other complications The prognosis for chronic pancreatitis is variable. Pain control is the most challenging task in the management of patients with chronic pancreatitis. First, vigorous efforts and appropriate referrals to encourage smoking cessation and alcohol abstinence should be made for patients with chronic pancreatitis in an effort to slow the disease progression as early as possible. Second, treatable complications of chronic pancreatitis such as duodenal or biliary obstruction that can cause similar symptoms should be sought. Patients should consume a low-fat (< 25 g/day) diet to reduce secretion of pancreatic enzymes. Patients with chronic pancreatitis should be educated about healthy lifestyle practices, and this should be reinforced at each visit. Pancreatic enzyme supplementation may reduce chronic pain by suppressing the release of cholecystokinin from the duodenum, thereby reducing the secretion of pancreatic enzymes. Enzyme therapy is more likely to be successful in patients with less advanced disease, in women, and in patients with idiopathic pancreatitis than in patients with alcoholic pancreatitis. Although enzyme therapy is often tried because of its safety and minimal adverse effects, it may not provide substantial benefit in improving pain. Often these measures do not relieve pain, requiring increased amounts of opioids, which increases the risk of addiction. Adjunctive pain drugs, such as tricyclic antidepressants,gabapentin,pregabalin, and selective serotonin reuptake inhibitors, have been used alone or combined with opioids to manage chronic pain; results are variable. Drug treatment of pain in chronic pancreatitis is often unsatisfactory. Glucocorticoidsmay be used to treat autoimmune pancreatitis. Other treatment modalities include endoscopic therapy, lithotripsy, celiac plexus nerve block, and surgery. Endoscopic therapyis aimed at decompressing a pancreatic duct obstructed by stricture, stones, or both and may provide pain relief in carefully selected patients with appropriate ductal anatomy. If there is significant stricture at the papilla or distal pancreatic duct, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, stent placement, or dilation may be effective. Pseudocysts can cause chronic pain. Some pseudocysts can be drained endoscopically. Lithotripsy(extracorporeal shock wave lithotripsy or intraductal lithotripsy) is usually needed to treat large or impacted pancreatic stones. Percutaneous or endoscopic ultrasound-guided nerve blockadeof the celiac plexus with a corticosteroid and long-acting anesthetic may provide short-term pain relief in some patients with chronic pancreatitis. Surgical treatmentmay be effective for pain relief. Surgical options should be reserved for patients who have stopped using alcohol and who can manage diabetes that may be intensified by pancreatic resection. A variety of surgical options involve resection and/or decompression. The choice of surgical procedure depends on the anatomy of the pancreatic duct, consideration of local complications, the surgical history of the patient, and local expertise. For example, if the main pancreatic duct is dilated > 5 to 8 mm, a lateral pancreaticojejunostomy (Puestow procedure) or Partington-Rochelle modification of the Puestow procedure relieves pain in about 70 to 80% of patients. If the pancreatic duct is not dilated, a variation of the modified Puestow procedure called a V-plasty or Hamburg procedure can be done. Other surgical approaches include a partial resection such as a distal pancreatectomy (for extensive disease at the tail of the pancreas), a Whipple procedure (for extensive disease at the head of the pancreas), a pylorus-sparing pancreaticoduodenectomy (similar to a Whipple procedure), a duodenum-preserving pancreatic head resection (Beger procedure), or a total pancreatectomy with autotransplantation of islets. Overall, surgical drainage is more effective than endoscopic approaches in relieving obstruction and achieving pain relief ( Treatment reference ). In patients with exocrine pancreatic insufficiency, malabsorption of fat is more severe than malabsorption of proteins and carbohydrates. Fat malabsorption also results in a deficit of fat-soluble vitamins (A, D, E, and K). Pancreatic enzyme replacement therapy (replacement of deficient hormones to treat pancreatic insufficiency) is used to treat steatorrhea. Various preparations are available, and a dose of 75,000 to 150,000 United States Pharmacopeia units (25,000 to 50,000 international units) lipase per meal and half that amount with snacks is needed for appropriate fat absorption. The treatment should be started at these (low) doses with subsequent titration based on clinical response. The preparations should be taken with meals. An H2 blocker or proton pump inhibitor should be given to patients taking nonenteric–coated preparations to prevent acid breakdown of the enzymes. Favorable clinical responses include weight gain, fewer bowel movements, elimination of oil droplet seepage, increases in levels of fat-soluble vitamins, and improved well-being. Clinical response can be documented by showing a decrease in stool fat after enzyme replacement therapy. If steatorrhea is particularly severe and refractory to these measures, medium-chain triglycerides can be provided as a source of fat because they are absorbed without pancreatic enzymes and other dietary fats should be reduced proportionally. Supplementation with fat-soluble vitamins A, D, and K should be given, includingvitamin E, which may minimize inflammation. The patient should be referred to an endocrine specialist for the management of diabetes.Insulinshould be given cautiously because the coexisting deficiency ofglucagonsecretion by alpha cells can result in unopposed and prolonged hypoglycemia, which is the hallmark of pancreatogenic diabetes (type 3c diabetes). Oral hypoglycemic drugs rarely help treat diabetes caused by chronic pancreatitis. 1.Yang CJ, Bliss LA, Freedman SD, et al: Surgery for chronic pancreatitis: The role of early surgery in pain management.Pancreas44(5):819–823, 2015. doi: 10.1097/MPA.0000000000000333 