What are the diagnosis and treatment options for chronic pancreatitis (chronic inflammation of the pancreas)?

Diagnosis and Treatment of Chronic Pancreatitis

Endoscopic ultrasound is the preferred diagnostic test for chronic pancreatitis, while surgical intervention should be considered over endoscopic therapy for long-term treatment of painful obstructive chronic pancreatitis. 1, 2

Diagnosis

Initial Diagnostic Approach

• After unrevealing initial evaluation (history, physical exam, lab tests), endoscopic ultrasound (EUS) is the preferred diagnostic test 1
• Magnetic resonance imaging (MRI) with contrast and magnetic resonance cholangiopancreatography (MRCP) is a reasonable alternative or complement to EUS 1
• Contrast-enhanced computed tomography (CT) is the best initial imaging modality, showing:
  • Pancreatic calcifications
  • Ductal dilation
  • Pancreatic atrophy 3

Diagnostic Challenges

• Early-stage chronic pancreatitis may show subtle changes on imaging
• CT may be inconclusive in early stages, requiring additional modalities:
  • MRI/MRCP
  • EUS with or without biopsy 3

Treatment

First-Line Management

1. Lifestyle modifications:

   • Alcohol and tobacco cessation (essential first step) 2
   • Dietary modifications: frequent small meals, normal fat content with enzyme supplementation 2

2. Pain management:

   • Analgesics before meals to reduce postprandial pain 2
   • NSAIDs and weak opioids (e.g., tramadol) as first-line analgesics 4

3. Pancreatic enzyme replacement therapy (PERT):

   • Essential for managing steatorrhea and malnutrition 2
   • Should be taken with meals to improve fat absorption 2
   • Note: PERT is insufficient for pain management in patients with ductal obstruction 2

Interventional Management

Surgical Approaches

• 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
  • Suspicion of malignancy 2

• Specific surgical procedures:

  • Decompressive procedures (e.g., lateral pancreaticojejunostomy/Puestow procedure): indicated for large duct disease (pancreatic ductal dilation ≥7 mm) 2, 3
  • Resection procedures (e.g., Whipple procedure): indicated for small duct disease or pancreatic head enlargement 3

Endoscopic Management

• Alternative for poor surgical candidates or those preferring less invasive approaches 1, 2
• Options include:
  • For small stones (<5mm): conventional stone extraction techniques 1
  • For larger stones: extracorporeal shockwave lithotripsy (ESWL) and/or pancreatoscopy with intraductal lithotripsy 1
  • For strictures: prolonged stent therapy (6-12 months) with multiple plastic stents in parallel 1
  • For benign biliary stricture: fully covered self-expanding metal stents (FCSEMS) preferred over multiple plastic stents 1

Management of Complications

1. Exocrine insufficiency:

   • PERT with meals 2
   • Nutritional support: oral supplements in 10-15% of patients 2
   • Tube feeding indicated in approximately 5% of patients 2

2. Endocrine insufficiency (diabetes):

   • Monitor for glucose intolerance (occurs in 40-90% of cases with severe pancreatic insufficiency) 2
   • Caution with insulin therapy due to increased risk of hypoglycemia 2

3. Pseudocysts:

   • Endoscopic or surgical drainage for symptomatic pseudocysts 2

Common Pitfalls to Avoid

• Undertreatment of exocrine insufficiency
• Overreliance on celiac plexus block (should not be routinely performed) 1, 2
• Delayed surgical referral
• Inadequate pain control
• Missing pancreatic cancer (increased risk in chronic pancreatitis patients) 2, 3
• Neglecting nutritional support 2

Long-term Monitoring

• Monitor for disease progression despite treatment
• Screen for pancreatic cancer, especially in patients with hereditary pancreatitis 3
• Continued PERT and diabetes management even after surgical intervention 2