What is the treatment for chronic pancreatitis?

Treatment of Chronic Pancreatitis

The optimal treatment for chronic pancreatitis includes surgical intervention over endoscopic therapy for patients with painful obstructive chronic pancreatitis, as surgery provides better long-term outcomes for pain relief and quality of life. 1, 2

Pain Management

• First-line pain management includes alcohol abstinence, smoking cessation, and analgesics such as NSAIDs and weak opioids like tramadol 3
• Pain medications should be taken before meals, as reduction in postprandial pain results in increased food intake 4
• A trial of pancreatic enzymes and antioxidants (multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients 3
• Celiac plexus block should not be routinely performed but may be considered in selected patients with debilitating pain when other therapeutic measures have failed, with pain relief in 50-60% of patients lasting up to 6 months 2

Nutritional Management

• Normal food is sufficient in most cases, with pancreatic enzyme supplementation taken with meals 4
• Diet should be rich in carbohydrates and protein (1.0-1.5 g/kg), with fat intake at about 30% of total calories 4
• Frequent small meals are important to achieve adequate intake 4
• If weight gain cannot be achieved and steatorrhea persists, medium chain triglycerides (MCT) can be administered 4
• The diet should be low in fiber, as fibers absorb enzymes and lead to reduced nutrient intake 4
• Fat-soluble vitamins (A, D, E, K) and other micronutrients should be supplemented if clinical deficits are apparent 4
• Enteral nutrition is indicated in approximately 5% of patients who cannot ingest sufficient calories due to pain, anatomical issues, or complications 4

Surgical Management

• Longitudinal pancreaticojejunostomy is the most appropriate surgical management for chronic pancreatitis with pancreatic duct ectasia 1, 2
• Surgical intervention should be considered before addiction to opiates occurs 5
• Duodenum-preserving resections offer benefits compared to pancreaticoduodenectomy for patients with an expanded pancreatic head 6
• Total pancreatectomy with islet cell autotransplantation is a valid option for small duct/minimal change disease, producing excellent long-term results for pain control, endocrine status, and quality of life 6

Endoscopic Management

• Endoscopic intervention may be considered as an alternative to surgery for suboptimal surgical candidates or those who prefer a less invasive approach 1, 2
• For small (≤5 mm) pancreatic duct stones, conventional stone extraction techniques are often sufficient 4
• For larger stones, extracorporeal shock wave lithotripsy (ESWL) and/or pancreatoscopy with intraductal lithotripsy may be required 4
• ESWL is highly effective at stone fragmentation (>90%), with complete clearance achievable in more than two-thirds of patients 4
• For pancreatic duct strictures, prolonged stent therapy (6-12 months) with sequential upsizing can be effective for symptom relief and duct remodeling 4, 2

Management of Complications

• Exocrine pancreatic insufficiency manifests as steatorrhea and requires pancreatic enzyme replacement therapy 4
• Glucose intolerance occurs in 40-90% of cases with severe pancreatic insufficiency, with manifest diabetes in 20-30% of patients 4
• Most patients with chronic pancreatitis and diabetes require insulin treatment 5
• In cases of therapeutic resistance despite adequate diet and enzyme supplementation, H2-antagonists or proton-pump inhibitors can be added 4

Multidisciplinary Approach

• Interdisciplinary specialist treatment teams should be established for diagnosis, assessment, and interventional procedures 5
• Due to the complexity of the disease, comprehensive individual patient assessment is crucial to determine the appropriate surgical approach based on the morphological disease variant 6