What are the management options for chronic pancreatitis pain?

Management Options for Chronic Pancreatitis Pain

Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis, as it provides better long-term outcomes for pain relief and quality of life. 1

Multimodal Pain Management Approach

First-Line Therapies

• Non-opioid analgesics including NSAIDs should be used as initial treatment for pain control in chronic pancreatitis 2, 3
• Oral pain medications should be used for mild pain, while IV pain medications may be necessary for more severe pain 2
• A multimodal approach to pain management should be established prior to initiating opioid therapy to optimize treatment and assist with successful tapering if needed 4

Second-Line Therapies

• Opioid analgesics may be necessary when non-opioid medications fail to provide adequate pain relief, with careful monitoring for dependence 4, 5
• When prescribing opioids, start with the lowest effective dose and regularly reassess the need for continued therapy 4, 6
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients with chronic pancreatitis 2
• Patient-controlled analgesia (PCA) should be integrated with other pain management strategies for better pain control 2

Adjunctive Therapies

• Pancreatic enzyme supplementation can control symptoms in up to 50% of patients 5
• Antioxidants (combination of multivitamins, selenium, and methionine) may help control pain in some patients 5
• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia in a multimodal approach 2

Interventional Procedures

Endoscopic Interventions

• Endoscopic intervention is a reasonable alternative to surgery for suboptimal surgical candidates or those who prefer a less invasive approach 2, 1
• For pancreatic duct stones causing obstruction:
  • Small (≤5 mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction 2, 1
  • Larger stones may require extracorporeal shockwave lithotripsy (ESWL) and/or pancreatoscopy with intraductal lithotripsy 2, 1
• For pancreatic duct strictures, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures 2, 1
  • The preferred approach is placing and sequentially adding multiple plastic stents in parallel (upsizing) 2, 1

Celiac Plexus Block

• Celiac plexus block should not be routinely performed for pain management in chronic pancreatitis 2, 1
• It may be considered only in selected patients with debilitating pain when other therapeutic measures have failed 2, 1
• The efficacy of EUS-guided celiac plexus neurolysis (CPN) is relatively low for chronic pancreatitis (51-59% pain relief) compared to pancreatic cancer (72-80% pain relief) 2
• Repeated injections for chronic pancreatitis should be avoided to prevent development of major complications 2
• Common adverse events include diarrhea and orthostatic hypotension; major adverse events (abscess formation, intravascular injection, paralysis) occur in <1% of patients 1

Surgical Options

• Surgical intervention provides better long-term outcomes for pain relief than endoscopic therapy in patients with painful obstructive chronic pancreatitis 2, 1
• Longitudinal pancreaticojejunostomy is the most appropriate surgical management for chronic pancreatitis with pancreatic duct ectasia 1
• Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from surgical drainage procedures such as pancreaticojejunostomy with or without pancreatic head resection 5

Special Considerations

Mechanism-Based Approach

• Pain in chronic pancreatitis often resembles neuropathic pain disorders, requiring treatments that address altered pain processing rather than just nociceptive deafferentation 7, 8
• Traditional methods based solely on nociceptive deafferentation (surgery and visceral nerve blockade) may become ineffective once aberrant pain processing is established 7

Monitoring and Follow-up

• Regular reassessment of pain control and medication efficacy is essential 4
• Monitor for signs of opioid dependence and consider tapering strategies when appropriate 4
• When tapering opioids, reduce by no greater than 10-25% of the total daily dose at intervals of every 2-4 weeks to avoid withdrawal symptoms 4

Common Pitfalls and Caveats

• Focusing solely on ductal decompression may lead to inadequate pain relief in many patients due to the complex neurobiological mechanisms involved 7, 9
• Delaying appropriate pain management can lead to central sensitization and more difficult-to-treat chronic pain 7, 8
• Opioid therapy should be carefully monitored due to risks of dependence and tolerance 4
• The evidence for celiac plexus block in chronic pancreatitis is limited, and its use should be restricted to carefully selected cases 2, 1