How to manage radiating pain in chronic calcific pancreatitis?

Management of Radiating Pain in Chronic Calcific Pancreatitis

Start with a stepwise analgesic ladder using non-opioid analgesics (NSAIDs, acetaminophen) first, then progress to weak opioids (tramadol), and finally strong opioids (dilaudid preferred) for moderate-to-severe pain, while avoiding routine celiac plexus block which has limited efficacy (51-59% pain relief) in chronic pancreatitis. 1, 2, 3

Initial Medical Management

Foundational measures:

• Ensure complete abstinence from alcohol as the fundamental first step in pain management 2
• Administer analgesics before meals to reduce postprandial pain and improve food intake 2
• Start with non-opioid analgesics including NSAIDs and acetaminophen for initial pain control 2, 3, 4

Progression of analgesic therapy:

• For mild pain: oral non-opioid medications 2
• For moderate pain: add weak opioids such as tramadol 3
• For severe pain: progress to strong opioids, with dilaudid preferred over morphine or fentanyl in non-intubated patients 2
• For very severe pain requiring IV therapy: consider patient-controlled analgesia (PCA) integrated with other pain management strategies 2

Adjunctive therapies:

• Pancreatic enzyme supplements should be provided to maintain weight and increase quality of life 1, 2
• Consider a trial of antioxidants (multivitamins, selenium, methionine) which can control symptoms in up to 50% of patients 3

Interventional Options (When Medical Management Fails)

Celiac plexus procedures - use with extreme caution:

• EUS-guided celiac plexus neurolysis (CPN) is NOT recommended for routine pain management in chronic pancreatitis 1, 2
• The efficacy is relatively low: only 51-59% pain relief in chronic pancreatitis compared to 72-80% in pancreatic cancer 1, 2
• If considered at all, it should be only in selected patients with debilitating pain when other therapeutic measures have failed 2
• A temporary block using bupivacaine should be performed first to observe for any effect before proceeding with neurolysis 1
• Repeated injections should be avoided to prevent major complications including abscess formation, intravascular injection, and paralysis 2
• Common adverse events include diarrhea and orthostatic hypotension 2

Alternative interventional approaches:

• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia in a multimodal approach 2
• For patients with pancreatic duct obstruction: endoscopic intervention is reasonable for suboptimal surgical candidates 2
• Small pancreatic duct stones (≤5 mm) can be treated with conventional ERCP and stone extraction 2
• Larger stones may require extracorporeal shockwave lithotripsy (ESWL) 2

Surgical Consideration

When to consider surgery:

• Surgical intervention should be considered over endoscopic therapy for long-term treatment of painful obstructive chronic pancreatitis, as it provides better long-term outcomes for pain relief and quality of life 2
• Longitudinal pancreaticojejunostomy is the most appropriate surgical management for chronic pancreatitis with pancreatic duct ectasia 2
• Surgery should be considered when nonoperative measures fail to alleviate pain and pain significantly interferes with quality of life 5

Critical Pitfalls to Avoid

Common mistakes in management:

• Do not routinely perform celiac plexus block - the evidence is limited and efficacy poor for chronic pancreatitis 1, 2
• Do not use morphine or fentanyl as first-line strong opioids when dilaudid is available 2
• Do not neglect pancreatic enzyme supplementation - this improves quality of life independent of pain control 1, 2
• Do not delay surgical referral in patients with ductal obstruction who fail medical management - surgery provides better long-term outcomes than endoscopic therapy 2

Important nuance: While older guidelines from 2005 suggested celiac plexus block could be effective for pancreatic pain 1, more recent evidence from 2018 and 2025 clearly demonstrates this applies primarily to pancreatic cancer, not chronic pancreatitis 1, 2. The Asian EUS Group consensus (2018) and current practice guidelines explicitly state that EUS-CPN for chronic pancreatitis has limited efficacy and is not recommended for routine use 1, 2.