From the Guidelines
Chronic pancreatitis can be managed to improve quality of life, but it is a progressive disease with no cure, and treatment focuses on controlling symptoms, addressing nutritional deficiencies, and treating complications. The management of chronic pancreatitis involves a multidisciplinary approach, including pain control, nutritional support, and treatment of complications such as diabetes and malabsorption. Pain management typically begins with acetaminophen and NSAIDs, progressing to weak opioids like tramadol, and then stronger opioids such as morphine or oxycodone for severe pain, as seen in studies 1. Adjuvant medications including pregabalin (150-300 mg daily) or gabapentin (900-1800 mg daily) may help with neuropathic pain.
Key Components of Management
- Pancreatic enzyme replacement therapy (PERT) is essential, with typical dosing of 25,000-40,000 units of lipase with meals and 10,000-25,000 units with snacks, adjusted based on response, as recommended by guidelines 1.
- Nutritional support includes a low-fat diet (less than 30% of calories from fat), abstinence from alcohol, smoking cessation, and supplementation with fat-soluble vitamins (A, D, E, K) 1.
- Diabetes management may be necessary as pancreatic endocrine function declines, with studies indicating that glucose intolerance occurs in 40–90% of all cases with severe pancreatic insufficiency 1.
- Endoscopic interventions like stenting or surgical procedures (such as lateral pancreaticojejunostomy) may be required for ductal strictures, pseudocysts, or intractable pain, with recent studies suggesting that early surgical intervention is superior to endoscopic therapy for pain relief in patients with obstructive chronic pancreatitis 1.
Treatment Goals
- Improve quality of life by controlling symptoms and preventing complications.
- Address nutritional deficiencies and prevent malnutrition.
- Manage diabetes and other complications of chronic pancreatitis.
- Reduce the risk of osteoporosis and fractures, which are common in patients with chronic pancreatitis, as noted in studies 1.
Overall, the goal of treatment is to improve quality of life and prevent further complications, rather than to cure the disease, as chronic pancreatitis is a progressive condition with no cure, but with proper management, patients can experience significant improvement in their symptoms and quality of life 1.
From the Research
Management of Chronic Pancreatitis
Chronic pancreatitis is a progressive and permanent destruction of the pancreas, resulting in exocrine and endocrine insufficiency and chronic disabling pain 2. The management of chronic pancreatitis begins with lifestyle modifications, such as cessation of alcohol and tobacco use, and dietary changes, followed by analgesics and pancreatic enzyme supplementation.
Treatment Options
- Lifestyle modifications: cessation of alcohol and tobacco use, and dietary changes 2, 3
- Analgesics: nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol 3
- Pancreatic enzyme supplementation: to control symptoms in up to 50% of patients 3
- Antioxidants: a combination of multivitamins, selenium, and methionine 3
- Endoscopic therapy: aimed at decompressing the obstructed pancreatic duct and removal of pancreatic stone 2, 4
- Surgical procedures: decompression for large duct disease and resection for small duct disease 2
Complications and Surveillance
- Diabetes: occurs in 38% to 40% of patients with chronic pancreatitis 3
- Exocrine insufficiency: occurs in 30% to 48% of patients with chronic pancreatitis 3
- Pancreatic neoplasm: patients with chronic pancreatitis are at increased risk, and regular surveillance is sometimes advocated 2
- Malnutrition: patients with chronic pancreatitis should be re-evaluated for malnutrition at least once a year 5
Interdisciplinary Approach
The management of chronic pancreatitis requires an interdisciplinary approach, including primary care practitioners, gastroenterologists, surgeons, radiologists, pain specialists, and nutritional therapists 5. Patients with chronic pancreatitis should be seen at least once a year and re-evaluated for causal risk factors, symptom control, and complications.