THE MANAGEMENT OF

CHRONIC PANCREATITIS
 INTRODUCTION

 Chronic pancreatitis (CP) is the result of long-standing or

recurrent inflammation of the pancreas  fibrosis and loss of
both islet and acinar cells

 Smoking- or alcohol-related pancreatitis  higher of

progression to chronic disease

 The diagnosis  missed in the early stages

 Although patients with CP vary in the presentation and

severity of symptoms, the disease can significantly impact
quality of life for many patients.
 MANAGEMENT GOALS

 Ef fective treatment of CP requires recognition of

 the diagnosis, addressing modifiable causes for the disease (to slow
progression), and management of symptoms and complications with
a multidisciplinary team.

 Recognizing the disease and confirming the diagnosis is the

first step in management.
 A biopsy of the pancreas is not required and is not available in many
centers.
 Findings of fibrosis and atrophy  asymptomatic patients, elderly
patients, patients who smoke, and renal failure or diabetes.
 Imaging findings or tests of pancreatic function can be used  CP 
may be negative in the early stages of the disease.
 Imaging features, such as atrophy of the pancreas, dilatation
of the pancreatic duct, and pancreatic calcifications , can take
between 5 and 10 years to develop and are pathognomonic of
CP

 Pancreatic calcifications may be missed on imaging with

MRI/magnetic resonance cholangiopancreatography (MRCP)
but are visualized well on computed tomography (CT) scans
with a pancreatic contrast protocol or on radiograph
 Calcifications are more likely to be seen in patients with
pancreatitis due to alcohol and or smoking and may be seen
in hereditary or tropical pancreatitis.
 Pancreatic ductal anatomy is well visualized by MRI/MRCP.
 Endoscopic ultrasonography (EUS) is highly sensitive in
detecting changes of CP.
 The Rosemont criteria describe a scheme for interpreting
major and minor imaging features  diagnose CP

such as progression
to adenocarcinoma
 Indirect tests of pancreatic function ,
 fecal elastase  pancreatic exocrine insufficiency, a common
complication of CP.
 Fecal elastase is a sensitive test for pancreatic insufficiency
 may also be abnormal in patients with prior small bowel surgeries or
diarrhea of other causes

 Direct tests of pancreatic function

 analysis for bicarbonate concentration and secretion of various
proteins.
 Fr o m C o nw e l l D L , L e e L S , Ya d av D , et a l . A m e r i c a n P a n c r e a t ic A s s o c i a t io n P r a c t i ce
G u i d e l in e s i n C h r o n i c P a n c r e a t it i s : E v i d e n c e - B a s e d Re p o r t o n D i a g n o s t i c G u i d e l i n e s .
P a n c r e a s 2 01 4 ; 4 3 ( 8 ) : 1 1 4 3 – 6 2 ; w i t h p e r m i s s i o n
 Management of symptoms is key in impacting quality of life in
patients with CP

 The main symptom experienced by patients with CP is chronic

abdominal pain, often postprandial in nature
 Symptoms exocrine :fatty diarrhea, malabsorption, and weight loss,
 endocrine insufficiency : diabetes

abstinence from alcohol and tobacco exposure

 PHARMACOLOGIC AND MEDICAL STRATEGIES
PA I N M A NAG E MENT

 Previous studies have shown a 33% to 50% pain relief rate

with only medical therapy

 In patients with CP, the mechanism of pain is complex.

 Emerging literature  larger nociceptive neurons with surrounding
inflammation  stimulated by trypsin (pancreatic enzyme)
 This stimulation increases the sensation of pain, caused by inflammation
and ischemia.
 Hyperalgesia
 neuromodulating agents
 gabapentoids, and selective serotonin reuptake inhibitors (SSRIs)
may be effective in reducing pain in patients with CP

 cohort and cross-sectional studies that approximately half of

patients with CP are treated with opioids.
 Opioids should be avoided if possible.
 Longterm use often paradoxically increases the perception of pain as
tolerance develops.
 recommended to begin with lower doses and less potent agents, such
as tramadol (200–400 mg per day).
 THE GOAL SHOULD BE REDUCTION OF
PAIN AND NOT ELIMINATION OF PAIN.
 Patients with a history of addictive behavior, such as alcohol
abuse or smoking, are at the highest risk of addiction to
opioids.

 In a randomized controlled trial of patients with CP

 pregabalin 300 mg twice daily reduced pain compared with placebo
and allowed for reduction of opioid use.

 Providers should also monitor patients for signs of addictive

behavior and reassess the need to initiate adjunctive
medications or therapies
 nonanalgesic medications may be helpful for pain control in
patients with CP.

 Octreotide has had mixed results in 4 randomized studies, is

expensive and injection based, and is not considered standard
therapy.

 Antioxidants have been evaluated in 2 large randomized

trials, in which they seemed to demonstrate ef ficacy for pain
relief in the trial with younger patients with idiopathic
pancreatitis; however, they were not beneficial in a trial with
older patients with alcohol- or tobacco-related pancreatitis
EXOCRINE INSUFFICIENCY MANAGEMENT

 Exocrine insufficiency may manifest with steatorrhea or diarrhea,

weight loss, or with other signs of malabsorption and
malnutrition, such as vitamin and mineral deficiency or loss of
bone health.

 Most commonly, exocrine insufficiency develops in patients who

have had CP for more than 5 to 10 years.

 diagnosed by a low fecal elastase level less than 200 mg/g of

stool or low serum trypsin less than 20 ng/mL

 A proton-pump inhibitor or H2-blocker is recommended to protect

the pH-sensitive delivery capsules from the acidic environment of
the stomach to allow breakdown and release in the duodenum
for maximal effect where absorption is taking place.
 ENDOCRINE INSUFFICIENCY
MANAGEMENT
 Endocrine insuf ficiency may also develop over time in patients
with CP.
 may also have type 2 diabetes mellitus due to other comorbidities,
such as obesity.
 type I diabetes mellitus develop CP.
 Type 3 diabetes mellitus develops in patients with long-standing CP
or patients who have significant pancreatic resection

 This risk may be abated by hyperglycemia control with

metformin

 screen annually for diabetes with fasting plasma glucose and

hemoglobin A1c levels in patients with CP and to refer to an
endocrinologist for treatment if appropriate.
 NONPHARMACOLOGIC STRATEGIES

 Nonpharmacologic options for patients with symptoms

refractory to medical therapy include endoscopic therapy,
surgical management, and/or nerve block.

 stones or strictures causing pancreatic duct obstruction 

causes of pain in CP.

 Endoscopic retrograde cholangiopancreatography (ERCP) with

stone extraction, lithotripsy, and stricture dilation, with or
without transpapillary stent placement, or surgical ductal
drainage are 2 potential therapies to treat pain in CP.
 ENDOSCOPIC THERAPY

 dilatated main pancreatic duct (more than 5–6 mm) with an

obstructing stone and/or stricture.

 Brushing for cytology to rule out malignancy may be

considered for new strictures.

 Challenges to endoscopic therapy include large, impacted, or

multiple stones, which may require extracorporeal shock wave
lithotripsy (ESWL) or intraductal lithotripsy.

 Lithotripsy is an adjunctive therapy to ERCP.

 Pain control can also be achieved endoscopically with EUS-
guided neurolysis or nerve block.

 This pain control is achieved by injection of bupivacaine and

corticosteroids in the area of the celiac plexus under EUS
guidance.

 Neurolysis with injection of absolute alcohol and

thoracoscopic splanchnicectomy is not the first-line therapy
but may be considered in some situations for patients with
painful CP.
 SURGICAL THERAPY

 Surgery may be a suitable option for treatment of pain and

also for complications, such as biliary or bowel obstruction.

 Dilatation of the pancreatic duct of at least 6 mm is typically

required for this surgery.

 This surgery results in pain relief for 80% of patient with 50%
maintaining pain relief at 5 or more years postoperatively.
 EVALUATION, ADJUSTMENT, AND
RECURRENCE
 For patients with pain, reevaluation of symptoms, and the
response to therapy should be performed at each visit, with
adjustments to doses of analgesics as needed

 Screening for pancreatic malignancy with MRI or EUS  patients

with hereditary causes of CP.

 Dietary modification and healthy lifestyle choices are critical.

 supplementation of vitamin D and calcium and a bone density 
osteopenia, osteoporosis, and fractures.

 steroid therapy for autoimmune pancreatitis

 complications  pseudocysts, biliary obstruction, duodenal

obstruction, or malignancy.
 SUMMARY AND FUTURE
CONSIDERATIONS
 The management of CP may require medical, endoscopic, and
surgical modalities of treatment. .

 Management should focus on abstinence from exposures, such

as alcohol and tobacco.

 Dietary recommendations include multiple small meals per

day and healthy, low -fat foods.

 Endocrine and exocrine insuf ficiency  medical therapy,

pancreatic enzyme replacement therapy, and vitamin
supplementation.

 A pain control regimen should  narcotic medications.