What are the treatment options for chronic pancreatitis?

Treatment Options for Chronic Pancreatitis

The management of chronic pancreatitis requires a comprehensive approach focusing on pancreatic enzyme replacement therapy, pain control, nutritional support, and in selected cases, surgical or endoscopic intervention for ductal obstruction. 1, 2

First-Line Treatment Options

Lifestyle Modifications

• Alcohol and tobacco cessation - Essential first step as these are major risk factors for disease progression 1, 2
• Dietary modifications:
  • Frequent small meals (rich in carbohydrates and protein)
  • Normal fat content (30% of total energy intake) with pancreatic enzyme supplementation
  • Low fiber diet (as fiber can absorb enzymes and reduce nutrient intake) 1

Medical Management

Pancreatic Enzyme Replacement Therapy (PERT)

• Primary treatment for exocrine pancreatic insufficiency 1, 3
• More than 80% of patients can be adequately treated with normal food supplemented by pancreatic enzymes 1
• Dosing:
  • Typically 72,000 lipase units per main meal and 36,000 lipase units per snack 3
  • Should be taken with meals to improve fat absorption 1, 3
• Benefits:
  • Significantly improves coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) 3
  • Reduces steatorrhea and malnutrition 1, 2

Pain Management

• Analgesics should be administered before meals to reduce postprandial pain 1
• NSAIDs and weak opioids (such as tramadol) are first-line pain medications 4
• Antioxidants (combination of multivitamins, selenium, and methionine) may help control symptoms in up to 50% of patients 4

Nutritional Support

• 10-15% of patients require oral nutritional supplements (ONS) 1
• If whole protein supplements are not tolerated, peptide-based ONS can be tried 1
• Tube feeding is indicated in approximately 5% of patients 1
• Fat-soluble vitamins (A, D, E, K) and other micronutrients should be supplemented if deficiencies are present 1

Interventional Treatments for Ductal Obstruction

Surgical Management

• Surgical intervention is preferred over endoscopic therapy for long-term treatment of painful obstructive chronic pancreatitis 1, 2
• Indications for surgery:
  • Persistent pain despite medical management
  • Ductal obstruction with dilation (≥7 mm)
  • Suspicion of malignancy 5
• Surgical options:
  • Decompressive procedures (lateral pancreaticojejunostomy/Puestow procedure) for dilated ducts 2, 6
  • Resection procedures (pancreaticoduodenectomy/Whipple procedure) for small duct disease or pancreatic head enlargement 5

Endoscopic Management

• Reasonable alternative for patients who are poor surgical candidates or prefer less invasive approaches 1
• Options include:
  • For small pancreatic duct stones (≤5 mm): Conventional stone extraction techniques 1
  • For larger stones: Extracorporeal shock wave lithotripsy (ESWL) and/or pancreatoscopy with intraductal lithotripsy 1
  • For pancreatic duct strictures: Prolonged stent therapy (6-12 months) with sequential upsizing of stents 1
  • For biliary strictures: ERCP with stent insertion (fully covered self-expanding metal stents preferred over multiple plastic stents) 1

Treatments with Limited Evidence

Celiac Plexus Block

• Should not be routinely performed for pain management in chronic pancreatitis 1, 2
• May be considered on a case-by-case basis for selected patients with debilitating pain when other measures have failed 1
• Pain relief may be achieved in 50-60% of patients but typically lasts less than 6 months 1

Management of Complications

Diabetes Management

• Glucose intolerance occurs in 40-90% of cases with severe pancreatic insufficiency 1
• Manifest diabetes occurs in 20-30% of patients 1
• Patients with pancreatic diabetes are more susceptible to hypoglycemia during insulin treatment due to impaired glucagon release 1

Pseudocyst Management

• Endoscopic or surgical drainage for symptomatic pseudocysts 1

Common Pitfalls and Caveats

1. Undertreatment of exocrine insufficiency: Inadequate PERT dosing is common; adjust based on clinical response and persistent steatorrhea 1, 3

2. Overreliance on celiac plexus block: Despite its use in practice, evidence for long-term benefit is limited 1, 2

3. Delayed surgical referral: Patients with ductal obstruction should be considered for surgery earlier rather than later in the disease course 1, 2

4. Inadequate pain control: Pain management should be aggressive and multimodal, as chronic pain significantly impacts quality of life 7

5. Missing pancreatic cancer: Patients with chronic pancreatitis have an increased risk of pancreatic cancer; evaluate weight loss or jaundice thoroughly 5

6. Neglecting nutritional support: Malnutrition is common and requires proactive management with dietary counseling and supplementation 1