What are the management options for chronic pancreatitis pain?

Management of 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, 2

Multimodal Pain Management Approach

First-Line Treatments

• Begin with non-opioid analgesics including NSAIDs as initial treatment for pain control 1
• Ensure abstinence from alcohol as a fundamental first step in pain management 3, 4
• Provide pancreatic enzyme supplements to improve nutritional status and quality of life 3
• Normal food with pancreatic enzyme supplementation is sufficient in most cases (>80% of patients) 3

Pharmacological Management

• Follow a progressive analgesic ladder from non-opioids to opioids for moderate-to-severe pain 3, 5
• Administer analgesics before meals to reduce postprandial pain and improve food intake 3
• Consider gabapentinoids for central pain sensitization, though side effects may limit use 6, 5
• For severe pain, IV pain medications may be necessary with patient-controlled analgesia (PCA) integration 1

Interventional Procedures

Neurolytic Procedures

• Neurolytic celiac plexus block is NOT recommended for routine pain management in chronic pancreatitis 3, 1
• EUS-guided celiac plexus neurolysis (CPN) has relatively low efficacy (51-59%) for chronic pancreatitis compared to pancreatic cancer (72-80%) 3, 1
• Avoid repeated injections for chronic pancreatitis to prevent major complications 3, 1
• Consider celiac plexus block only in carefully selected patients with debilitating pain when other therapeutic measures have failed 1, 2

Endoscopic Management

• Endoscopic intervention may be considered for suboptimal surgical candidates or those preferring less invasive approaches 3, 1
• For pancreatic duct stones ≤5mm, conventional ERCP with standard stone extraction techniques can be effective 3, 1
• For stones >5mm, extracorporeal shock wave lithotripsy (ESWL) with or without subsequent ERCP is supported by evidence 3, 1
• For pancreatic duct strictures, prolonged stent therapy (6-12 months) can be effective 1, 2

Surgical Options

• Surgical intervention provides better long-term outcomes for pain relief than endoscopic therapy in obstructive chronic pancreatitis 3, 1, 2
• Longitudinal pancreaticojejunostomy is appropriate for chronic pancreatitis with pancreatic duct ectasia 1, 2
• The ESCAPE trial and other randomized studies demonstrated higher complete or partial pain relief with early surgery compared to endotherapy 3

Radiation Therapy

• Consider chemoradiation for severe pain, particularly when pain recurs after celiac plexus blockade 3

Nutritional Support

• Provide pancreatic enzyme supplements to maintain weight and increase quality of life 3
• Consider medium chain triglycerides (MCT) if adequate weight gain cannot be achieved and steatorrhea persists 3
• Diet should be rich in carbohydrates and protein (1.0-1.5 g/kg), with moderate fat (30% of calories) 3
• Frequent small meals are important to achieve adequate intake 3

Monitoring and Follow-up

• Monitor for complications including diabetes mellitus, which occurs in 20-30% of patients with severe pancreatic insufficiency 3
• Assess for vitamin deficiencies (A, D, E, K) resulting from steatorrhea 3
• Evaluate for depression, which is common in pancreatic cancer patients and may require specific treatment 3