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{{Chronic-pancreatitis}}
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==Overview==
==Overview==
The goals of chronic pancreatitis management include [[pain]] control, management of [[pancreatic insufficiency]] by pancreatic [[Enzyme replacement therapy|enzyme replacement]] and management of [[complications]]. Pain is managed in a stepwise approach of general recommendations, pancreatic [[Enzyme replacement therapy|enzyme replacement]], [[analgesics]] and invasive procedures. General recommendations usually include smoking cessation, cessation of alcohol intake, small meals and [[hydration]]. Medical therapy includes pancreatic enzyme supplementation, [[analgesics]] and [[antioxidants]]. Specialized approaches include celiac nerve block, [[endoscopic]] therapy, extracorporeal shock wave lithotripsy (ESWL), and radiation. [[Steatorrhea]] can be managed by dietary modification, [[lipase]] supplementation, [[vitamin]] supplementation, and [[medium chain triglycerides]] (MCTs). [[Diabetes]] is usually managed with a trial of oral [[Hypoglycemic agent|hypoglycemic agents]] followed by [[Insulin|insulin therapy]].


==Medical Therapy==
==Chronic pancreatitis management:==
The different treatment modalities for management of chronic pancreatitis are medical measures, therapeutic endoscopy and surgery.<ref name="pmid9721174">{{cite journal |author=American Gastroenterological Association Medical Position Statement |title=American Gastroenterological Association Medical Position Statement: treatment of pain in chronic pancreatitis |journal=Gastroenterology |volume=115 |issue=3 |pages=763–4 |year=1998 |pmid=9721174 |doi=}}</ref> Treatment is directed, when possible, to the underlying cause, and to relief of the pain and malabsorption. [[Diabetes]] may occur and need long term [[insulin]] therapy. ([[Type 1 diabetes]])
The goals of management are:
* Pain control
* Management of pancreatic insufficiency by pancreatic enzyme replacement
* Management of complications<ref name="pmid18319401">{{cite journal |vauthors=Callery MP, Freedman SD |title=A 21-year-old man with chronic pancreatitis |journal=JAMA |volume=299 |issue=13 |pages=1588–94 |year=2008 |pmid=18319401 |doi=10.1001/jama.299.9.jrr80001 |url=}}</ref>


The abdominal pain can be very severe and require high doses of [[analgesic]]s. Disability and mood problems are common, although early diagnosis and support can make these problems manageable.
== Pain management: ==
Pain is managed in a stepwise approach of
* General recommendations
* Pancreatic enzyme replacement
* Analgesics
* Other invasive procedures


===Pancreatic Enzyme Supplementation===  
=== General recommendations: ===
Most of the patients usually improve following the general recommendations with only a few requiring analgesics.


Replacement [[Digestive enzyme#Pancreatic enzymes|pancreatic enzymes]] are often  effective in treating the malabsorption and [[steatorrhea]]. However, the outcome from 6 randomized trials has been inconclusive regarding pain reduction.<ref name="pmid9721175">{{cite journal |author=Warshaw AL, Banks PA, Fernández-Del Castillo C |title=AGA technical review: treatment of pain in chronic pancreatitis |journal=Gastroenterology |volume=115 |issue=3 |pages=765–76 |year=1998 |pmid=9721175 |doi=10.1016/S0016-5085(98)70157-X}}</ref>
====== (a) Smoking cessation: ======
*Smoking cessation may
**Delay the progression of chronic pancreatitis
**Decrease the risk of pancreatic cancer<ref name="pmid15753536">{{cite journal |vauthors=Maisonneuve P, Lowenfels AB, Müllhaupt B, Cavallini G, Lankisch PG, Andersen JR, Dimagno EP, Andrén-Sandberg A, Domellöf L, Frulloni L, Ammann RW |title=Cigarette smoking accelerates progression of alcoholic chronic pancreatitis |journal=Gut |volume=54 |issue=4 |pages=510–4 |year=2005 |pmid=15753536 |pmc=1774435 |doi=10.1136/gut.2004.039263 |url=}}</ref>


While the outcome of trials regarding pain reduction with pancreatic enzyme replacement is inconclusive, some patients do have pain reduction with enzyme replacement and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients. Treatment may be more likely to be successful in those without involvement of large ducts and those with idiopathic pancreatitis. Patients with alcoholic pancreatitis may be less likely to respond. <ref name=UpTo/>
===== (b) Cessation of alcohol intake: =====
*Alcohol cessation may help in symptomatic improvement particularly in alcohol induced chronic pancreatitis.
*Alcohol intake is associated with increased mortality in pateints with alcohol induced chronic pancreatitis.<ref name="pmid7739686">{{cite journal |vauthors=Steer ML, Waxman I, Freedman S |title=Chronic pancreatitis |journal=N. Engl. J. Med. |volume=332 |issue=22 |pages=1482–90 |year=1995 |pmid=7739686 |doi=10.1056/NEJM199506013322206 |url=}}</ref>
====== (c) Small meals: ======
* Dietary preference in chronic pancreatitis should be small meals with low fat content
* Medium chain triglyceride (MCTs) supplementation is particularly helpful because;
** Its antioxidant effects
**  Minimal increase in plasma CCK levels
** It may prevent weight loss in patients
 
====== (d) Hydration: ======
* Keeping the patients well hydrated may help in preventing the development of acute flares pf pancreatitis.
 
== Medical Therapy: ==
 
===1.Pancreatic Enzyme Supplementation:===
* Pancreatic enzyme supplementation is associated with pain alleviation and may be used when the general recommendations fail.
* It decreases the release of CCK and thus reduces the stimulation-induced pancreatic pain but mixed results have been observed from various clinical trials.<ref name="pmid7914921">{{cite journal |vauthors=Owyang C |title=Negative feedback control of exocrine pancreatic secretion: role of cholecystokinin and cholinergic pathway |journal=J. Nutr. |volume=124 |issue=8 Suppl |pages=1321S–1326S |year=1994 |pmid=7914921 |doi= |url=}}</ref><ref name="pmid12631450">{{cite journal |vauthors=Singh VV, Toskes PP |title=Medical therapy for chronic pancreatitis pain |journal=Curr Gastroenterol Rep |volume=5 |issue=2 |pages=110–6 |year=2003 |pmid=12631450 |doi= |url=}}</ref><ref name="pmid6825540">{{cite journal |vauthors=Isaksson G, Ihse I |title=Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis |journal=Dig. Dis. Sci. |volume=28 |issue=2 |pages=97–102 |year=1983 |pmid=6825540 |doi= |url=}}</ref><ref name="pmid3633631">{{cite journal |vauthors=Halgreen H, Pedersen NT, Worning H |title=Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis |journal=Scand. J. Gastroenterol. |volume=21 |issue=1 |pages=104–8 |year=1986 |pmid=3633631 |doi= |url=}}</ref><ref name="pmid1289173">{{cite journal |vauthors=Mössner J, Secknus R, Meyer J, Niederau C, Adler G |title=Treatment of pain with pancreatic extracts in chronic pancreatitis: results of a prospective placebo-controlled multicenter trial |journal=Digestion |volume=53 |issue=1-2 |pages=54–66 |year=1992 |pmid=1289173 |doi= |url=}}</ref><ref name="pmid9362186">{{cite journal |vauthors=Brown A, Hughes M, Tenner S, Banks PA |title=Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis: a meta-analysis |journal=Am. J. Gastroenterol. |volume=92 |issue=11 |pages=2032–5 |year=1997 |pmid=9362186 |doi= |url=}}</ref><ref name="pmid6640255">{{cite journal |vauthors=Leung JW, Bowen-Wright M, Aveling W, Shorvon PJ, Cotton PB |title=Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis |journal=Br J Surg |volume=70 |issue=12 |pages=730–2 |year=1983 |pmid=6640255 |doi= |url=}}</ref><ref name="pmid9721175">{{cite journal |vauthors=Warshaw AL, Banks PA, Fernández-Del Castillo C |title=AGA technical review: treatment of pain in chronic pancreatitis |journal=Gastroenterology |volume=115 |issue=3 |pages=765–76 |year=1998 |pmid=9721175 |doi= |url=}}</ref>
*It is particularly beneficial in the management of patients with idiopathic chronic pancreatitis.<ref name="pmid6202586">{{cite journal |vauthors=Slaff J, Jacobson D, Tillman CR, Curington C, Toskes P |title=Protease-specific suppression of pancreatic exocrine secretion |journal=Gastroenterology |volume=87 |issue=1 |pages=44–52 |year=1984 |pmid=6202586 |doi= |url=}}</ref><ref name="pmid6640255">{{cite journal |vauthors=Leung JW, Bowen-Wright M, Aveling W, Shorvon PJ, Cotton PB |title=Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis |journal=Br J Surg |volume=70 |issue=12 |pages=730–2 |year=1983 |pmid=6640255 |doi= |url=}}</ref>
 
=== 2.Analgesics: ===
* Analgesics are usually required when pancreatic enzyme replacement therapy fails to manage pain in chronic pancreatitis.
* Pain cycle may be disrupted by:
** Opiates coupled with amitriptyline and an NSAID.<ref name="pmid19796802">{{cite journal |vauthors=Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL |title=Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial |journal=Lancet |volume=374 |issue=9697 |pages=1252–61 |year=2009 |pmid=19796802 |doi=10.1016/S0140-6736(09)61081-3 |url=}}</ref><ref name="pmid12077076">{{cite journal |vauthors=Fioramonti J, Bueno L |title=Centrally acting agents and visceral sensitivity |journal=Gut |volume=51 Suppl 1 |issue= |pages=i91–5 |year=2002 |pmid=12077076 |pmc=1867729 |doi= |url=}}</ref>
** NPO and short-term hospitalization of the patient.
 
* Long-acting agents, such as continuous morphine sulphate or fentanyl patch, are usually recommended for chronic pain management.
* Adjuvat therapy with Pregabalin is also found to be effective in some clinical trials.<ref name="pmid21683078">{{cite journal |vauthors=Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM |title=Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial |journal=Gastroenterology |volume=141 |issue=2 |pages=536–43 |year=2011 |pmid=21683078 |doi=10.1053/j.gastro.2011.04.003 |url=}}</ref><ref name="pmid21950372">{{cite journal |vauthors=Graversen C, Olesen SS, Olesen AE, Steimle K, Farina D, Wilder-Smith OH, Bouwense SA, van Goor H, Drewes AM |title=The analgesic effect of pregabalin in patients with chronic pain is reflected by changes in pharmaco-EEG spectral indices |journal=Br J Clin Pharmacol |volume=73 |issue=3 |pages=363–72 |year=2012 |pmid=21950372 |pmc=3370341 |doi=10.1111/j.1365-2125.2011.04104.x |url=}}</ref>
 
=== 3.Antioxidants: ===
*Antioxidant therapy has no established effective role in the management of chronic pancreatitis as various studies have shown conflicting results.<ref name="pmid2103755">{{cite journal |vauthors=Uden S, Bilton D, Nathan L, Hunt LP, Main C, Braganza JM |title=Antioxidant therapy for recurrent pancreatitis: placebo-controlled trial |journal=Aliment. Pharmacol. Ther. |volume=4 |issue=4 |pages=357–71 |year=1990 |pmid=2103755 |doi= |url=}}</ref><ref name="pmid9444547">{{cite journal |vauthors=Banks PA, Hughes M, Ferrante M, Noordhoek EC, Ramagopal V, Slivka A |title=Does allopurinol reduce pain of chronic pancreatitis? |journal=Int. J. Pancreatol. |volume=22 |issue=3 |pages=171–6 |year=1997 |pmid=9444547 |doi=10.1007/BF02788381 |url=}}</ref><ref name="pmid18952082">{{cite journal |vauthors=Bhardwaj P, Garg PK, Maulik SK, Saraya A, Tandon RK, Acharya SK |title=A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis |journal=Gastroenterology |volume=136 |issue=1 |pages=149–159.e2 |year=2009 |pmid=18952082 |doi=10.1053/j.gastro.2008.09.028 |url=}}</ref><ref name="pmid21083584">{{cite journal |vauthors=Burton F, Alkaade S, Collins D, Muddana V, Slivka A, Brand RE, Gelrud A, Banks PA, Sherman S, Anderson MA, Romagnuolo J, Lawrence C, Baillie J, Gardner TB, Lewis MD, Amann ST, Lieb JG, O'Connell M, Kennard ED, Yadav D, Whitcomb DC, Forsmark CE |title=Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States |journal=Aliment. Pharmacol. Ther. |volume=33 |issue=1 |pages=149–59 |year=2011 |pmid=21083584 |pmc=3142582 |doi=10.1111/j.1365-2036.2010.04491.x |url=}}</ref><ref name="pmid22683257">{{cite journal |vauthors=Siriwardena AK, Mason JM, Sheen AJ, Makin AJ, Shah NS |title=Antioxidant therapy does not reduce pain in patients with chronic pancreatitis: the ANTICIPATE study |journal=Gastroenterology |volume=143 |issue=3 |pages=655–663.e1 |year=2012 |pmid=22683257 |doi=10.1053/j.gastro.2012.05.046 |url=}}</ref>
 
=== 4.Specialized approaches: ===
 
====== 4.1 Celiac nerve block ======
*Celiac nerve block is not a proven therapy as <ref name="pmid6640255">{{cite journal |vauthors=Leung JW, Bowen-Wright M, Aveling W, Shorvon PJ, Cotton PB |title=Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis |journal=Br J Surg |volume=70 |issue=12 |pages=730–2 |year=1983 |pmid=6640255 |doi= |url=}}</ref><ref name="pmid2624751">{{cite journal |vauthors=Busch EH, Atchison SR |title=Steroid celiac plexus block for chronic pancreatitis: results in 16 cases |journal=J Clin Anesth |volume=1 |issue=6 |pages=431–3 |year=1989 |pmid=2624751 |doi= |url=}}</ref><ref name="pmid10201454">{{cite journal |vauthors=Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G |title=A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain |journal=Am. J. Gastroenterol. |volume=94 |issue=4 |pages=900–5 |year=1999 |pmid=10201454 |doi=10.1111/j.1572-0241.1999.01042.x |url=}}</ref><ref name="pmid11232683">{{cite journal |vauthors=Gress F, Schmitt C, Sherman S, Ciaccia D, Ikenberry S, Lehman G |title=Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience |journal=Am. J. Gastroenterol. |volume=96 |issue=2 |pages=409–16 |year=2001 |pmid=11232683 |doi=10.1111/j.1572-0241.2001.03551.x |url=}}</ref>
**It may cause serious complications
**Recurrence may occur
**It has limited success in chronic pancreatitis
*It can be achieved by using alcohol or steroid via
**Percutaneous approach or
**Endoscopic approach
 
====== 4.2 Endoscopic therapy ======
*Pain releif can also be acheived by decompression of an obstructed duct via endoscopic approach.<ref name="pmid10882956">{{cite journal |vauthors=Okolo PI, Pasricha PJ, Kalloo AN |title=What are the long-term results of endoscopic pancreatic sphincterotomy? |journal=Gastrointest. Endosc. |volume=52 |issue=1 |pages=15–9 |year=2000 |pmid=10882956 |doi=10.1067/mge.2000.106669 |url=}}</ref><ref name="pmid2070994">{{cite journal |vauthors=Geenen JE, Rolny P |title=Endoscopic therapy of acute and chronic pancreatitis |journal=Gastrointest. Endosc. |volume=37 |issue=3 |pages=377–82 |year=1991 |pmid=2070994 |doi= |url=}}</ref><ref name="pmid12085037">{{cite journal |vauthors=Choudari CP, Nickl NJ, Fogel E, Lehman GA, Sherman S |title=Hereditary pancreatitis: clinical presentation, ERCP findings, and outcome of endoscopic therapy |journal=Gastrointest. Endosc. |volume=56 |issue=1 |pages=66–71 |year=2002 |pmid=12085037 |doi= |url=}}</ref><ref name="pmid12244496">{{cite journal |vauthors=Rösch T, Daniel S, Scholz M, Huibregtse K, Smits M, Schneider T, Ell C, Haber G, Riemann JF, Jakobs R, Hintze R, Adler A, Neuhaus H, Zavoral M, Zavada F, Schusdziarra V, Soehendra N |title=Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up |journal=Endoscopy |volume=34 |issue=10 |pages=765–71 |year=2002 |pmid=12244496 |doi=10.1055/s-2002-34256 |url=}}</ref><ref name="pmid15812411">{{cite journal |vauthors=Gabbrielli A, Pandolfi M, Mutignani M, Spada C, Perri V, Petruzziello L, Costamagna G |title=Efficacy of main pancreatic-duct endoscopic drainage in patients with chronic pancreatitis, continuous pain, and dilated duct |journal=Gastrointest. Endosc. |volume=61 |issue=4 |pages=576–81 |year=2005 |pmid=15812411 |doi= |url=}}</ref><ref name="pmid16733106">{{cite journal |vauthors=Adler DG, Lichtenstein D, Baron TH, Davila R, Egan JV, Gan SL, Qureshi WA, Rajan E, Shen B, Zuckerman MJ, Lee KK, VanGuilder T, Fanelli RD |title=The role of endoscopy in patients with chronic pancreatitis |journal=Gastrointest. Endosc. |volume=63 |issue=7 |pages=933–7 |year=2006 |pmid=16733106 |doi=10.1016/j.gie.2006.02.003 |url=}}</ref>
*Surgery is more effective when compared to endoscopic therapy.<ref name="pmid17301298">{{cite journal |vauthors=Cahen DL, Gouma DJ, Nio Y, Rauws EA, Boermeester MA, Busch OR, Stoker J, Laméris JS, Dijkgraaf MG, Huibregtse K, Bruno MJ |title=Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis |journal=N. Engl. J. Med. |volume=356 |issue=7 |pages=676–84 |year=2007 |pmid=17301298 |doi=10.1056/NEJMoa060610 |url=}}</ref>
 
====== 4.3 Extracorporeal shock wave lithotripsy (ESWL) ======
*Pain can also be relieved by using ESWL.<ref name="pmid19820418">{{cite journal |vauthors=Parsi MA, Stevens T, Lopez R, Vargo JJ |title=Extracorporeal shock wave lithotripsy for prevention of recurrent pancreatitis caused by obstructive pancreatic stones |journal=Pancreas |volume=39 |issue=2 |pages=153–5 |year=2010 |pmid=19820418 |doi=10.1097/MPA.0b013e3181bb1733 |url=}}</ref>
*It causes millimetric fragmentation of pancreatic stones.
*Its role in chronic pancreatitis management is still unclear due to the limited studies done in this area.
 
====== 4.4 Radiation ======
*Radiotherapy is also helpful in pain relief due to its anti-inflammatory properties.<ref name="pmid19190609">{{cite journal |vauthors=Guarner L, Navalpotro B, Molero X, Giralt J, Malagelada JR |title=Management of painful chronic pancreatitis with single-dose radiotherapy |journal=Am. J. Gastroenterol. |volume=104 |issue=2 |pages=349–55 |year=2009 |pmid=19190609 |doi=10.1038/ajg.2008.128 |url=}}</ref>
 
== Management of Steatorrhea: ==
*In chronic pancreatitis, pancreatic enzyme replacement is usually dependent upon
**The size and nature of the meal 
**The residual function of the pancreas
**The goals of therapy (elimination of steatorrhea, reduction in the abdominal symptoms of maldigestion or acheivement of nutritional goals)
====== 1. Dietary modification ======
* The degree of fat intake restriction is usually dependent upon the  severity of malabsorption.
* Medical therapy is considered if steatorrhea persists after dietary restriction.
* Fat intake of ≤ 20 grams per day is sufficient to prevent steatorrhea.
 
====== 2. Lipase supplementation ======
* The pancreas normally responds with between 700,000 and 1,000,000 lipase units (USP) per meal.<ref name="pmid15951527">{{cite journal |vauthors=Keller J, Layer P |title=Human pancreatic exocrine response to nutrients in health and disease |journal=Gut |volume=54 Suppl 6 |issue= |pages=vi1–28 |year=2005 |pmid=15951527 |pmc=1867805 |doi=10.1136/gut.2005.065946 |url=}}</ref>
*10% of normal pancreatic lipase replacement (70,000 to 100,000 USP) can manage the symptoms of steatorrhea even when all of the pancreatic function has been lost.
* Usually 30,000 international units (IU) or 90,000 United States Pharmacopeia units (USP) of lipase per meal (5-10%) are sufficient to correct the malabsorption in chronic pancreatitis.
* 90,000 USP of lipase per meal (5-10%) is sufficient to abolish steatorrhea in chronic pancreatitis.
* Dosing is usually dependent upon:
** The individual's weight
** The degree of pancreatic insufficiency
** The size and fat content of a meal
 
* Creon-24,000 lipase, enteric coated formulations, one to two capsules with meals and one capsule with a snack
* Viokace Lipase 20,880, non-enteric coated formthree tablets with meals and one to two tablets with a snack
 
====== NOTE: ======
* Non-enteric supplements may require H2 antagonist or proton pump inhibitor.
* Non-enteric supplements may be more useful in achlorhydric patients or those with dyssynchronous gastric emptying (eg, Billroth II anatomy).
 
====== 3. Vitamin supplementation ======
* Patients with severe steatorrhea may require vitamin supplementation.
* Calcifediol, a naturally occurring analogue of vitamin D (25-hydroxylated form) is more polar and potent than vitamin D2 or D3.
* It is important to monitor serum cacium levels for the first few week of therapy due to increased risk of developing hypercalcemia.
 
====== 4. Medium chain triglycerides (MCTs) ======
* Medium chain triglycerides are preferred over long chain triglycerides as
** MCTs do not need the presence of bile for their degradation
** MCTs may be degraded easily by gastric and pancreatic lipase
** MCTs can be absorbed directly from the intestinal mucosa
** MCTs have a weak stimulatory affect on pancreatic secretions
 
== Management of glucose intolerance: ==
* Glucose intolerance usually develops in the early course of disease while overt diabetes may develop in the late course of disease.
* Patients are usually managed with a trial of oral hypoglycemic agents followed by insulin therapy.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 02:11, 16 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

The goals of chronic pancreatitis management include pain control, management of pancreatic insufficiency by pancreatic enzyme replacement and management of complications. Pain is managed in a stepwise approach of general recommendations, pancreatic enzyme replacement, analgesics and invasive procedures. General recommendations usually include smoking cessation, cessation of alcohol intake, small meals and hydration. Medical therapy includes pancreatic enzyme supplementation, analgesics and antioxidants. Specialized approaches include celiac nerve block, endoscopic therapy, extracorporeal shock wave lithotripsy (ESWL), and radiation. Steatorrhea can be managed by dietary modification, lipase supplementation, vitamin supplementation, and medium chain triglycerides (MCTs). Diabetes is usually managed with a trial of oral hypoglycemic agents followed by insulin therapy.

Chronic pancreatitis management:

The goals of management are:

  • Pain control
  • Management of pancreatic insufficiency by pancreatic enzyme replacement
  • Management of complications[1]

Pain management:

Pain is managed in a stepwise approach of

  • General recommendations
  • Pancreatic enzyme replacement
  • Analgesics
  • Other invasive procedures

General recommendations:

Most of the patients usually improve following the general recommendations with only a few requiring analgesics.

(a) Smoking cessation:
  • Smoking cessation may
    • Delay the progression of chronic pancreatitis
    • Decrease the risk of pancreatic cancer[2]
(b) Cessation of alcohol intake:
  • Alcohol cessation may help in symptomatic improvement particularly in alcohol induced chronic pancreatitis.
  • Alcohol intake is associated with increased mortality in pateints with alcohol induced chronic pancreatitis.[3]
(c) Small meals:
  • Dietary preference in chronic pancreatitis should be small meals with low fat content
  • Medium chain triglyceride (MCTs) supplementation is particularly helpful because;
    • Its antioxidant effects
    •  Minimal increase in plasma CCK levels
    • It may prevent weight loss in patients
(d) Hydration:
  • Keeping the patients well hydrated may help in preventing the development of acute flares pf pancreatitis.

Medical Therapy:

1.Pancreatic Enzyme Supplementation:

  • Pancreatic enzyme supplementation is associated with pain alleviation and may be used when the general recommendations fail.
  • It decreases the release of CCK and thus reduces the stimulation-induced pancreatic pain but mixed results have been observed from various clinical trials.[4][5][6][7][8][9][10][11]
  • It is particularly beneficial in the management of patients with idiopathic chronic pancreatitis.[12][10]

2.Analgesics:

  • Analgesics are usually required when pancreatic enzyme replacement therapy fails to manage pain in chronic pancreatitis.
  • Pain cycle may be disrupted by:
    • Opiates coupled with amitriptyline and an NSAID.[13][14]
    • NPO and short-term hospitalization of the patient.
  • Long-acting agents, such as continuous morphine sulphate or fentanyl patch, are usually recommended for chronic pain management.
  • Adjuvat therapy with Pregabalin is also found to be effective in some clinical trials.[15][16]

3.Antioxidants:

  • Antioxidant therapy has no established effective role in the management of chronic pancreatitis as various studies have shown conflicting results.[17][18][19][20][21]

4.Specialized approaches:

4.1 Celiac nerve block
  • Celiac nerve block is not a proven therapy as [10][22][23][24]
    • It may cause serious complications
    • Recurrence may occur
    • It has limited success in chronic pancreatitis
  • It can be achieved by using alcohol or steroid via
    • Percutaneous approach or
    • Endoscopic approach
4.2 Endoscopic therapy
  • Pain releif can also be acheived by decompression of an obstructed duct via endoscopic approach.[25][26][27][28][29][30]
  • Surgery is more effective when compared to endoscopic therapy.[31]
4.3 Extracorporeal shock wave lithotripsy (ESWL) 
  • Pain can also be relieved by using ESWL.[32]
  • It causes millimetric fragmentation of pancreatic stones.
  • Its role in chronic pancreatitis management is still unclear due to the limited studies done in this area.
4.4 Radiation
  • Radiotherapy is also helpful in pain relief due to its anti-inflammatory properties.[33]

Management of Steatorrhea:

  • In chronic pancreatitis, pancreatic enzyme replacement is usually dependent upon
    • The size and nature of the meal 
    • The residual function of the pancreas
    • The goals of therapy (elimination of steatorrhea, reduction in the abdominal symptoms of maldigestion or acheivement of nutritional goals)
1. Dietary modification
  • The degree of fat intake restriction is usually dependent upon the severity of malabsorption.
  • Medical therapy is considered if steatorrhea persists after dietary restriction.
  • Fat intake of ≤ 20 grams per day is sufficient to prevent steatorrhea.
2. Lipase supplementation
  • The pancreas normally responds with between 700,000 and 1,000,000 lipase units (USP) per meal.[34]
  • 10% of normal pancreatic lipase replacement (70,000 to 100,000 USP) can manage the symptoms of steatorrhea even when all of the pancreatic function has been lost.
  • Usually 30,000 international units (IU) or 90,000 United States Pharmacopeia units (USP) of lipase per meal (5-10%) are sufficient to correct the malabsorption in chronic pancreatitis.
  • 90,000 USP of lipase per meal (5-10%) is sufficient to abolish steatorrhea in chronic pancreatitis.
  • Dosing is usually dependent upon:
    • The individual's weight
    • The degree of pancreatic insufficiency
    • The size and fat content of a meal
  • Creon-24,000 lipase, enteric coated formulations, one to two capsules with meals and one capsule with a snack
  • Viokace Lipase 20,880, non-enteric coated formthree tablets with meals and one to two tablets with a snack
NOTE:
  • Non-enteric supplements may require H2 antagonist or proton pump inhibitor.
  • Non-enteric supplements may be more useful in achlorhydric patients or those with dyssynchronous gastric emptying (eg, Billroth II anatomy).
3. Vitamin supplementation 
  • Patients with severe steatorrhea may require vitamin supplementation.
  • Calcifediol, a naturally occurring analogue of vitamin D (25-hydroxylated form) is more polar and potent than vitamin D2 or D3.
  • It is important to monitor serum cacium levels for the first few week of therapy due to increased risk of developing hypercalcemia.
4. Medium chain triglycerides (MCTs)
  • Medium chain triglycerides are preferred over long chain triglycerides as
    • MCTs do not need the presence of bile for their degradation
    • MCTs may be degraded easily by gastric and pancreatic lipase
    • MCTs can be absorbed directly from the intestinal mucosa
    • MCTs have a weak stimulatory affect on pancreatic secretions

Management of glucose intolerance:

  • Glucose intolerance usually develops in the early course of disease while overt diabetes may develop in the late course of disease.
  • Patients are usually managed with a trial of oral hypoglycemic agents followed by insulin therapy.

References

  1. ↑ Callery MP, Freedman SD (2008). "A 21-year-old man with chronic pancreatitis". JAMA. 299 (13): 1588–94. doi:10.1001/jama.299.9.jrr80001. PMID 18319401.
  2. ↑ Maisonneuve P, Lowenfels AB, Müllhaupt B, Cavallini G, Lankisch PG, Andersen JR, Dimagno EP, Andrén-Sandberg A, Domellöf L, Frulloni L, Ammann RW (2005). "Cigarette smoking accelerates progression of alcoholic chronic pancreatitis". Gut. 54 (4): 510–4. doi:10.1136/gut.2004.039263. PMC 1774435. PMID 15753536.
  3. ↑ Steer ML, Waxman I, Freedman S (1995). "Chronic pancreatitis". N. Engl. J. Med. 332 (22): 1482–90. doi:10.1056/NEJM199506013322206. PMID 7739686.
  4. ↑ Owyang C (1994). "Negative feedback control of exocrine pancreatic secretion: role of cholecystokinin and cholinergic pathway". J. Nutr. 124 (8 Suppl): 1321S–1326S. PMID 7914921.
  5. ↑ Singh VV, Toskes PP (2003). "Medical therapy for chronic pancreatitis pain". Curr Gastroenterol Rep. 5 (2): 110–6. PMID 12631450.
  6. ↑ Isaksson G, Ihse I (1983). "Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis". Dig. Dis. Sci. 28 (2): 97–102. PMID 6825540.
  7. ↑ Halgreen H, Pedersen NT, Worning H (1986). "Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis". Scand. J. Gastroenterol. 21 (1): 104–8. PMID 3633631.
  8. ↑ Mössner J, Secknus R, Meyer J, Niederau C, Adler G (1992). "Treatment of pain with pancreatic extracts in chronic pancreatitis: results of a prospective placebo-controlled multicenter trial". Digestion. 53 (1–2): 54–66. PMID 1289173.
  9. ↑ Brown A, Hughes M, Tenner S, Banks PA (1997). "Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis: a meta-analysis". Am. J. Gastroenterol. 92 (11): 2032–5. PMID 9362186.
  10. ↑ 10.0 10.1 10.2 Leung JW, Bowen-Wright M, Aveling W, Shorvon PJ, Cotton PB (1983). "Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis". Br J Surg. 70 (12): 730–2. PMID 6640255.
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  20. ↑ Burton F, Alkaade S, Collins D, Muddana V, Slivka A, Brand RE, Gelrud A, Banks PA, Sherman S, Anderson MA, Romagnuolo J, Lawrence C, Baillie J, Gardner TB, Lewis MD, Amann ST, Lieb JG, O'Connell M, Kennard ED, Yadav D, Whitcomb DC, Forsmark CE (2011). "Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States". Aliment. Pharmacol. Ther. 33 (1): 149–59. doi:10.1111/j.1365-2036.2010.04491.x. PMC 3142582. PMID 21083584.
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