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:
- 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
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.
- ↑ Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL (2009). "Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial". Lancet. 374 (9697): 1252–61. doi:10.1016/S0140-6736(09)61081-3. PMID 19796802.
- ↑ Fioramonti J, Bueno L (2002). "Centrally acting agents and visceral sensitivity". Gut. 51 Suppl 1: i91–5. PMC 1867729. PMID 12077076.
- ↑ Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM (2011). "Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial". Gastroenterology. 141 (2): 536–43. doi:10.1053/j.gastro.2011.04.003. PMID 21683078.
- ↑ Graversen C, Olesen SS, Olesen AE, Steimle K, Farina D, Wilder-Smith OH, Bouwense SA, van Goor H, Drewes AM (2012). "The analgesic effect of pregabalin in patients with chronic pain is reflected by changes in pharmaco-EEG spectral indices". Br J Clin Pharmacol. 73 (3): 363–72. doi:10.1111/j.1365-2125.2011.04104.x. PMC 3370341. PMID 21950372.
- ↑ Uden S, Bilton D, Nathan L, Hunt LP, Main C, Braganza JM (1990). "Antioxidant therapy for recurrent pancreatitis: placebo-controlled trial". Aliment. Pharmacol. Ther. 4 (4): 357–71. PMID 2103755.
- ↑ Banks PA, Hughes M, Ferrante M, Noordhoek EC, Ramagopal V, Slivka A (1997). "Does allopurinol reduce pain of chronic pancreatitis?". Int. J. Pancreatol. 22 (3): 171–6. doi:10.1007/BF02788381. PMID 9444547.
- ↑ Bhardwaj P, Garg PK, Maulik SK, Saraya A, Tandon RK, Acharya SK (2009). "A randomized controlled trial of antioxidant supplementation for pain relief in patients with chronic pancreatitis". Gastroenterology. 136 (1): 149–159.e2. doi:10.1053/j.gastro.2008.09.028. PMID 18952082.
- ↑ 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.
- ↑ Siriwardena AK, Mason JM, Sheen AJ, Makin AJ, Shah NS (2012). "Antioxidant therapy does not reduce pain in patients with chronic pancreatitis: the ANTICIPATE study". Gastroenterology. 143 (3): 655–663.e1. doi:10.1053/j.gastro.2012.05.046. PMID 22683257.