What are the treatment options for chronic pancreatitis?

From the Guidelines

The treatment of chronic pancreatitis should prioritize a multifaceted approach, including pain management, pancreatic enzyme replacement therapy, and nutritional support, with surgical intervention considered for patients with painful obstructive chronic pancreatitis, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Pain management: begins with acetaminophen and progresses to NSAIDs like ibuprofen or naproxen, with opioids considered for severe pain, while being cautious of addiction risk, as noted in the expert review 1.
• Pancreatic enzyme replacement therapy (PERT): essential for treating malabsorption, with typical dosing of 25,000-40,000 units of lipase per meal and 10,000-25,000 units with snacks, taken during meals, as supported by the ESPEN guidelines 1.
• Nutritional support: small, frequent, low-fat meals recommended, with alcohol abstinence mandatory to prevent disease progression, and diabetes management necessary as pancreatic beta cells are damaged, as emphasized in the clinical practice update 1.

Considerations for Intervention

• Endoscopic interventions (stenting, stone removal) or surgery (drainage procedures, partial resection) may be considered for complications like strictures, pseudocysts, or intractable pain, with surgical intervention favored for long-term treatment of patients with painful obstructive chronic pancreatitis, as advised in the best practice guidance 1.
• Celiac plexus block should not be routinely performed for pain management, but may be considered on a case-by-case basis for selected patients with debilitating pain, as recommended in the expert review 1.

Importance of Recent Guidelines

The most recent guidelines, such as those from 2022 1, provide the best evidence for treatment approaches, and should be prioritized in clinical decision-making, as they reflect the latest research and expert consensus on managing chronic pancreatitis.

From the Research

Treatment Options for Chronic Pancreatitis

• The treatment of chronic pancreatitis is multimodal and involves nutrition optimization, pain management, and when indicated, endoscopic and surgical intervention 2.
• First-line imaging modalities for diagnosis of chronic pancreatitis include computed tomography and magnetic resonance imaging, while more invasive techniques such as endoscopic ultrasonography allow for tissue analysis 2.
• Nonsurgical options for pain control include behavior modification, celiac plexus block, splanchnicectomy, nonopioid pain medication, and opioids 2.
• Supplemental enzymes should be given to patients with exocrine insufficiency to avoid malnutrition, although pancreatic enzyme supplements do not seem to relieve abdominal pain in patients with chronic pancreatitis 3, 2.
• Surgery is superior to endoscopic interventions for long-term pain control, and early surgery (<3 years from symptom onset) has more superior outcomes than late surgery 2.

Conservative Treatment Approaches

• A practical approach to the management of chronic pancreatitis involves a multidisciplinary specialist context, addressing multiple and complex medical co-morbidities 4.
• The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis 5.
• Endoscopic therapies can help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts 5.
• Lifestyle interventions, dietary supplements, and drug interventions can also be effective in managing chronic pancreatitis, although the quality of evidence for these interventions varies 6.

Management of Complications

• Chronic pancreatitis encompasses high rates of disability, and strategies to improve pain control must accompany management of the sequelae of complications that arise from endocrine and exocrine insufficiency 2.
• Complications such as pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures can be managed with endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies 5.
• Invasive treatments for specific complications of chronic pancreatitis, such as biliary decompression, ductal decompression, and pseudocyst decompression, can be effective in managing these complications 6.