Chronic pancreatitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
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 couples with amitriptyline and an NSAID.
3.Antioxidants:
4.Specialized approaches:
4.1 Celiac nerve block
4.2 Endoscopic therapy
4.3 Extracorporeal shock wave lithotripsy
4.4 Radiation
Management of Steatorrhea:
1. Dietary modification
2. Lipase supplementation
3. Vitamin supplementation
4. Medium chain triglycerides
Management of glucose intolerance:
Management of other pancreatic complications:
References
- ↑ 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.
- ↑ 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.
- ↑ Steer ML, Waxman I, Freedman S (1995). "Chronic pancreatitis". N. Engl. J. Med. 332 (22): 1482–90. doi:10.1056/NEJM199506013322206. PMID 7739686.
- ↑ 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.
- ↑ Singh VV, Toskes PP (2003). "Medical therapy for chronic pancreatitis pain". Curr Gastroenterol Rep. 5 (2): 110–6. PMID 12631450.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 10.0 10.1 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.
- ↑ Warshaw AL, Banks PA, Fernández-Del Castillo C (1998). "AGA technical review: treatment of pain in chronic pancreatitis". Gastroenterology. 115 (3): 765–76. PMID 9721175.
- ↑ Slaff J, Jacobson D, Tillman CR, Curington C, Toskes P (1984). "Protease-specific suppression of pancreatic exocrine secretion". Gastroenterology. 87 (1): 44–52. PMID 6202586.