Pancreatitis%20-%20chronic Treatment

Abstinence from Alcohol and Tobacco

• Patients should be encouraged to abstain from drinking alcohol and smoking  
• Mortality has been found to increase with continued smoking and abuse of alcohol 
  • Alcohol abuse speeds up the development of pancreatic dysfunction
  • Smoking accelerates disease progression and may increase pancreatic cancer risk 
• Diminishing alcohol intake has been seen to result in decreased pain associated with chronic pancreatitis 

Diet

• Adequate hydration is helpful
• Malnourished patients should consume 5-6 meals/day of high-energy, high-protein food  
• Dietary fat need not be restricted unless steatorrhea is uncontrolled
• Oral nutritional supplements with medium chain triglycerides (MCTs) can be given to patients if adequate supplementation with enzymes does not improve malabsorption  
  • MCTs improve pain by minimally increasing CCK  levels or through its antioxidant effect
• Patients with malabsorption can be supplemented with water-soluble (thiamine, folic acid, vitamin B12) and fat-soluble (vitamins A, D, E, K) vitamins and minerals (eg iron, magnesium, selenium, zinc)  
• As patients with chronic pancreatitis are at risk for osteoporosis, patients are advised to take adequate calcium and vitamin D, and if warranted, pancreatic enzyme supplementation  

Nutrition

• Patients with malnutrition unresponsive to oral nutritional support should be given enteral nutrition
  • May be administered via a nasojejunal tube in patients with pain, persistent N/V, delayed gastric emptying and gastric outlet syndrome  
  • Patients needing enteral nutrition should be supplemented with pancreatic enzymes if signs of exocrine failure are present  
• Parenteral nutrition, preferably via a central venous access, may be given to patients intolerant of enteral nutrition or in those with gastric outlet obstruction or complex fistulating disease

• Patient’s symptoms should be regularly assessed so that failure of any treatment intervention may be quickly identified and timely institution of invasive measures can be done in order to prevent unnecessary progression of the disease and development of complex pain syndromes 

Analgesics 

• Pain relief is a primary priority in the management of disease
• Goal of treatment is control of pain to a satisfactory or tolerable level rather than total elimination of pain  
• Considered if pain was unresponsive to pancreatic enzyme supplementation
• Non-narcotic agents may be tried initially; however, most patients need more potent agents for pain relief eg narcotics/opiates 
  • Consider giving opiates to patients with painful chronic pancreatitis only when all other therapeutic options have failed  
• Pregabalin or Gabapentin may be considered as adjuvant therapy if pain is unresponsive to narcotics 
• Pain medication should not be withheld even if there is concern regarding possible addiction 

Pancreatic Enzyme Supplements

• Initiated in patients with diagnosed pancreatic exocrine insufficiency 
• Goal is to give at least 10% of normal pancreatic output with every meal
• Non-enteric-coated preparations are preferred for the treatment of pain while enteric-coated preparations are used more frequently for the treatment of exocrine insufficiency
• Action: Negative feedback inhibition of the pancreas
  • Administered enzymes denature CCK-releasing peptide which results in reduced CCK release
  • CCK release is thought to increase pancreatic pain
• Because neural control also plays a role in controlling pancreatic secretion, suppression of secretion through this method is not complete and may be variable
• It has been shown that pancreatic enzyme replacement provided pain relief when given early in the course of the disease and may be indicated prior to the onset of clinically detectable exocrine insufficiency 
  • Some studies have shown that response is generally poor in patients with advanced chronic disease or with significant abnormalities of the pancreatic duct (“big-duct” disease)
• A trial of treatment may be beneficial for patients with less advanced disease who have failed more simple medical measures
• Concomitant treatment with gastric acid-suppressing agents is recommended to avoid inactivation of non-enteric-coated pancreatic enzymes by gastric acid
• Efficacy of supplementation may be assessed with improvement of patient’s gastrointestinal symptoms and nutritional status  

Inhibitors of Gastric Acid Secretion

• Action: Inhibition of acid secretion leads to a higher duodenal pH, which may in turn reduce pancreatic secretion and pain
• Histamine₂-receptor antagonists (H₂RAs) and proton pump inhibitors (PPIs) may be used
• There is no definite evidence showing the effectiveness of this therapy, but it is commonly tried due to its safety and ease of administration
• Concomitant acid suppression is also recommended during therapy with non-enteric-coated pancreatic enzymes to prevent enzyme inactivation by gastric acid
• If increase in pancreatic enzyme dose or addition of a PPI fails to improve patient’s clinical response, consider excluding other causes of malabsorption, eg small intestinal bacterial overgrowth

Adjunctive Therapy

Antidepressants 

• Depression may lower the pain threshold of some patients
• Pain may also have important psychiatric, psychosocial and psychosomatic components
• Antidepressants, eg selective serotonin reuptake inhibitors or tricyclic antidepressants, may be used as adjunctive therapy to alleviate depression and to potentiate the effect of narcotics

Antioxidants

• May be considered in the treatment of pain in patients with early chronic pancreatitis  
• Antioxidants used in clinical trials include ascorbic acid, beta-carotene, methionine and selenium  
• Studies have not yet determined optimal type of antioxidants and dosage for treatment

• Goal of treatment is to improve pancreatic duct drainage by relieving obstruction that may be caused by ampullary stenosis, stones or strictures
• Pancreatic duct decompression achieves lower ductal pressures which may then result in reduced pain
• A trial of therapy is usually indicated in patients whose pain cannot be adequately controlled by medical therapy ie analgesics, narcotics
• Patients who are most likely to benefit are those who have advanced structural defects of the pancreatic duct
• Specific endoscopic therapies include stent placement, stone removal, stricture dilation, and duct sphincterotomy
• Endoscopic ultrasound-guided celiac plexus block or neurolysis can also decrease pain for weeks to months, may decrease or eliminate the need for oral analgesia, and can be repeated as needed