What is the initial management for patients with chronic pancreatitis?

Initial Management of Chronic Pancreatitis

The initial management of chronic pancreatitis should focus on three core pillars: adequate pain control, nutritional support with normal food supplemented by pancreatic enzyme replacement therapy (PERT), and addressing the underlying etiology. 1

Pain Management

• Start with conventional analgesics including NSAIDs and weak opioids such as tramadol as first-line therapy 2
• For severe pain not responding to conventional analgesics, consider epidural analgesia 1
• A trial of pancreatic enzymes and antioxidants (combination of multivitamins, selenium, and methionine) can control pain symptoms in up to 50% of patients 2
• Consider endoscopic or surgical drainage procedures for patients with pancreatic ductal obstruction due to stones or strictures who fail medical management 2

Nutritional Support and Dietary Modifications

• More than 80% of patients can be managed adequately with normal food supplemented by pancreatic enzymes 1
• Implement a low-fat diet with less than 30% of total energy intake from fat, preferably from vegetable sources, to minimize pancreatic stimulation 1
• Early oral feeding is strongly recommended rather than keeping patients nil per os 1
• For patients unable to tolerate adequate oral intake (approximately 10-15% of patients), add oral nutritional supplements 1
• Enteral tube feeding is indicated in only approximately 5% of patients, typically those with severe malnutrition or persistent pain with oral intake 1

Pancreatic Enzyme Replacement Therapy (PERT)

• PERT is the mainstay of nutritional management for chronic pancreatitis with exocrine insufficiency 1
• Early identification and treatment of steatorrhea with PERT is key to preventing malnutrition 1
• Monitor for signs of malabsorption including steatorrhea, weight loss, and fat-soluble vitamin deficiencies 1

Management of Exocrine Insufficiency

• Supplement fat-soluble vitamins (A, D, E, K) in patients with documented deficiencies 1
• Consider calcium and vitamin D supplementation to prevent osteoporosis/osteopenia, which affects approximately two-thirds of chronic pancreatitis patients 1
• Regular monitoring for vitamin deficiencies is essential, particularly fat-soluble vitamins 1

Management of Endocrine Insufficiency

• Monitor for development of type 3c (pancreatogenic) diabetes, which occurs in 38-40% of patients later in the disease process 1, 2
• Type 3c diabetes management requires special consideration due to concurrent decreased glucagon secretion and increased risk of hypoglycemia 1

Addressing Underlying Etiology

• For alcohol-induced chronic pancreatitis, complete alcohol cessation is essential to prevent disease progression 1
• Smoking cessation is critical, as smoking is strongly associated with chronic pancreatitis (OR 4.59 for >35 pack-years) 2
• For gallstone-related pancreatitis, consider appropriate biliary interventions 1

Common Pitfalls to Avoid

• Do not delay PERT initiation—exocrine insufficiency develops in 30-48% of patients and early treatment prevents malnutrition 2
• Do not overlook vitamin deficiencies, particularly fat-soluble vitamins, which are frequently underrecognized and undertreated 3
• Do not use total parenteral nutrition routinely—the majority of patients can be managed with oral intake and enzyme supplementation 4
• Do not forget to screen for osteoporosis, as bone disease is highly prevalent in this population 1