●Chronic pancreatitis is an ongoing process of pathologic response to pancreatic injury. Abdominal pain is the most common clinical symptom. As chronic pancreatitis progresses, patients may develop exocrine pancreatic insufficiency (steatorrhea, maldigestion) and diabetes. Complications of chronic pancreatitis include pancreatic pseudocyst, bile duct or duodenal obstruction, visceral artery pseudoaneurysm, pancreatic ascites and pancreatic pleural effusions, gastric varices due to thrombosis of the splenic vein, and pancreatic malignancy.
●We screen patients with chronic pancreatitis for smoking and alcohol use and advise cessation. In addition, patients with chronic pancreatitis are advised to consume low-fat meals, small meals, and avoid dehydration.
●Prior to initiating therapy in a patient with chronic pancreatitis who presents with abdominal pain, it is necessary to confirm that the symptoms are in fact due to chronic pancreatitis and not an alternative etiology. Initial evaluation should include a detailed history to assess for the presence of abdominal pain at baseline, the character of pain, severity, and impact on quality of life. To identify alternative reversible causes of abdominal pain, we perform high-quality computed tomography (CT) or magnetic resonance imaging (MRI).
●The majority of patients with pain due to chronic pancreatitis require analgesics. We use a stepwise approach to treatment with the goal of avoiding high-dose opioids for pain control. We begin with acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) for initial management of abdominal pain due to chronic pancreatitis. In patients with pain requiring opioid therapy, we use suggestive adjunctive agents to minimize the use of opioid analgesia and treat coexisting depression. Adjunctive agents including tricyclic antidepressants, serotonin reuptake inhibitors (SSRIs), and combined serotonin and norepinephrine reuptake inhibitors (eg, duloxetine) or gabapentoids (pregabalin or gabapentin).
●In patients with pain due to chronic pancreatitis who fail to respond to initial medical management alone, subsequent management is individualized depending on pancreatic ductal anatomy, available expertise, and patient preference.
•Patients with a non-dilated pancreatic duct who prefer nonoperative therapy may continue medical therapy with a celiac plexus block. Surgical management in patients with a non-dilated main pancreatic duct (<6 to 7 mm) involves resection of the involved pancreas.
•In patients with refractory pain due to chronic pancreatitis and an obstructed, dilated pancreatic duct, we suggest initial endoscopic drainage rather than surgical therapy (Grade 2C). Emerging data suggest that surgical therapy is more effective and more durable than endoscopic approaches. However, in practice, many patients still choose endoscopic therapy due to a reluctance to undergo surgery, and many surgeons only operate once endoscopic approaches to pancreatic drainage have been exhausted or unsuccessful.
●Patients with exocrine pancreatic insufficiency require pancreatic enzyme supplementation. A reasonable starting dose for pancreatic enzyme supplementation in patients with exocrine pancreatic insufficiency is 40,000 to 50,000 USP units with each meal, and one-half that amount with snacks. The effectiveness of enzyme supplementation is generally gauged clinically by an improvement in stool consistency, loss of visible fat in the stool, improvement in fat-soluble vitamin levels, and gain in muscle strength and body weight.
●Patients with chronic pancreatitis may suffer from type 2 diabetes mellitus, but are also prone to diabetes from destruction of pancreatic islets from the chronic pancreatitis (type 3c diabetes). This can produce a brittle diabetes, with a high risk of treatment-induced hypoglycemia. Metformin may lower the risk of secondary pancreatic carcinoma in these patients. However, insulin is often needed to control diabetes
