Current Gastroenterology Reports

, Volume 5, Issue 2, pp 110–116

Medical therapy for chronic pancreatitis pain

  • Virmeet V. Singh
  • Phillip P. Toskes
Article

Abstract

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.

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References and Recommended Reading

  1. 1.
    Toskes PP, Greenberger NJ: Approach to the patient with pancreatic disease. In Harrison’s Principles of Internal Medicine, edn 15. Edited by Braunwald E, Fauci AS, Kasper DL, et al. New York: McGraw Hill; 2001:1788–1792.Google Scholar
  2. 2.
    Greenberger NJ, Toskes PP: Acute and chronic pancreatitis. In Harrison’s Principles of Internal Medicine, edn 15. Edited by Braunwald E, Fauci AS, Kasper DL, et al. New York: McGraw Hill; 2001:1792–1804.Google Scholar
  3. 3.
    Toskes PP: Update on diagnosis and management of chronic pancreatitis [review]. Curr Gastroenterol Rep 1999 1:145–153.CrossRefGoogle Scholar
  4. 4.
    Walsh TN, Rode J, Theiss BA, Russel RCC: Minimal change chronic pancreatitis. Gut 1992, 33:1566–1571.PubMedGoogle Scholar
  5. 5.
    Whitcomb DC, Garry MC, Preston RA, et al.: Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene. Nat Genet 1996, 14:141–145PubMedCrossRefGoogle Scholar
  6. 6.
    Cohn JA, Friedman KJ, Noone DG, et al.: Relation between mutation of the cystic fibrosis gene and idiopathic pancreatitis. N Engl J Med 1998, 339:653–658PubMedCrossRefGoogle Scholar
  7. 7.
    Freiss H, Yamanaka Y, Buchler M, et al.: Increased expression of acidic and basic fibroblast growth factors in chronic pancreatitis. Am J Pathol 1994, 144:117–128.Google Scholar
  8. 8.
    Di Sebastiano P, di Mola FF, Di Febbo C, et al.: Expression of interleukin 8 (IL-8) and substance P in human chronic pancreatitis. Gut 2000, 47:423–428.PubMedCrossRefGoogle Scholar
  9. 9.
    Chey WY: Neurohormonal control of the exocrine pancreas. Curr Opin Gastroenterol 1997, 13:375–380CrossRefGoogle Scholar
  10. 10.
    Draganov P, Toskes PP: Chronic pancreatitis. Curr Opin Gastroenterol 2002, 18:558–562. A succinct review of the controversial areas in chronic pancreatitis with an emphasis on small duct disease.PubMedCrossRefGoogle Scholar
  11. 11.
    Forsmark CE, Toskes PP: What does an abnormal pancreatogram mean [review]? Gastrointest Endosc Clin N Am 1995, 5:105–123.PubMedGoogle Scholar
  12. 12.
    Chowdhury R, Forsmark CE, Toskes PP, et al: The evaluation of unexplained pain of presumed pancreatic origin [abstract]. Gastroenterology 2001, A-760:120.Google Scholar
  13. 13.
    Verne GN, Chowdhury R, Toskes PP: Prevalence of gastroparesis in patients with small duct chronic pancreatitis. Pancreas 2003, in press.Google Scholar
  14. 14.
    Greenberger NJ: Enzymatic therapy in patients with chronic pancreatitis [review]. Gastroenterol Clin North Am 1999, 28:687–693PubMedCrossRefGoogle Scholar
  15. 15.
    Slaff JI, Wolfe MM, Toskes PP: Elevated fasting cholecystokinin levels in pancreatic exocrine impairment: evidence to support feedback regulation. J Lab Clin Med 1985, 105:282–285.PubMedGoogle Scholar
  16. 16.
    Mossner J: Palliation of pain in chronic pancreatitis: use of enzymes [abstract]. Surg Clin North Am 1999, 79:861–872.PubMedCrossRefGoogle Scholar
  17. 17.
    Smyth RI, Van Velzen D, Smyth AR, et al.: Strictures of ascending colon in cystic fibrosis and high-strength pancreatic enzymes. Lancet 1994, 343:85–86.PubMedCrossRefGoogle Scholar
  18. 18.
    Warshaw AL, Banks PA, Fernandez-Del Castillo C: AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology 1998, 115:765–776.PubMedCrossRefGoogle Scholar
  19. 19.
    Isaksson G, Ihse I: Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis. Dig Dis Sci 1983, 28:97–102PubMedCrossRefGoogle Scholar
  20. 20.
    Slaff J, Jacobson D, Tillman CR, et al.: Protease-specific suppression of pancreatic exocrine secretion. Gastroenterology 1984, 87:44–52.PubMedGoogle Scholar
  21. 21.
    Brown A, Hughes M, Tenner S, et al.: Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis: a meta-analysis. Am J Gastroenterol 1997, 92:2032–2035.PubMedGoogle Scholar
  22. 22.
    Uhl W, Anghelacopoulos SE, Friess H, Buchler MW: The role of octreotide and somatostatin in acute and chronic pancreatitis [review]. Digestion 1999, 60(Suppl 2):23–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Malfertheiner P, Mayer D, Buchler M, et al.: Treatment of pain in chronic pancreatitis by inhibition of pancreatic secretion with octreotide. Gut 1995, 36:450–454.PubMedGoogle Scholar
  24. 24.
    Buchler MW, Binder M, Friess H: Role of somatostatin and its analogues in the treatment of acute and chronic pancreatitis [review]. Gut 1994, 35(Suppl 3):S15-S!9.PubMedGoogle Scholar
  25. 25.
    Toskes PP, Forsmark CE, DeMeo MT, et al.: A multi-center controlled trial of octreotide for the pain of chronic pancreatitis [abstract]. Pancreas 1993, 8:774.Google Scholar
  26. 26.
    De las Heras Castano G, Garciade la Paz A, Fernandez MD, Fernandez Forcelledo JL: Use of antioxidants to treat pain in chronic pancreatitis. Rev Esp Enferm Dig 2000, 92:375–385.PubMedGoogle Scholar
  27. 27.
    Uden S, Bilton D, Guyan PM, et al.: Rationale for antioxidant therapy in pancreatitis and cystic fibrosis. Adv Exp Med Biol 1990, 264:555–572.PubMedGoogle Scholar
  28. 28.
    McCleane GJ: The cholecystokinin antagonist proglumide has an analgesic effect in chronic pancreatitis. Pancreas 2000, 21:324–325.PubMedCrossRefGoogle Scholar
  29. 29.
    Toskes PP, Curington C, Cintron M, et al.: Oral administration of the CCK-antagonist MK329.substantiates feedback control of pancreatic secretion in chronic pancreatitis patients [abstract]. Gastroenterology 1990, 98:237.Google Scholar
  30. 30.
    Shiratori K, Takeuchi T, Satake K, Matsuno S: Clinical evaluation of oral administration of a cholecystokinin-a receptor antagonist (loxiglumide) to patients with acute, painful attacks of chronic pancreatitis: a multicenter dose-response study in Japan. Pancreas 2002, 25:E1-E5. A provocative study suggesting that CCK antagonists may have a role in the management of chronic pancreatitis pain.PubMedCrossRefGoogle Scholar
  31. 31.
    Rosch T, Daniel S, Scholz M, et al.: Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up. Endoscopy 2002, 34:765–771.PubMedCrossRefGoogle Scholar
  32. 32.
    Kasmin FE, Siegel JH: Endoscopic therapy for chronic pancreatitis [review]. Surg Clin North Am 2001, 81:421–430.PubMedCrossRefGoogle Scholar
  33. 33.
    Binmoeller KF, Rathod VD, Soehendra N: Endoscopic therapy of pancreatic strictures [review]. Gastrointest Endosc Clin North Am 1998, 8:125–142.Google Scholar
  34. 34.
    Gress F, Schmitt C, Sherman S, et al.: Endoscopic ultrasoundguided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol 2001, 96:409–416. A well-done study demonstrating that EUS-guided celiac plexus block may be effective for short-term management of pain in some patients with chronic pancreatitis. Patients aged under 45 years and those with prior pancreatic surgery do not appear to benefit.PubMedCrossRefGoogle Scholar
  35. 35.
    Gress F, Schmitt C, Sherman S, et al.: A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain. Am J Gastroenterol 1999, 94:900–905.PubMedCrossRefGoogle Scholar
  36. 36.
    Abedi M, Zfass AM: Endoscopic ultrasound-guided (neurolytic) celiac plexus block. J Clin Gastroenterol 2001, 32:390–393.PubMedCrossRefGoogle Scholar
  37. 37.
    Leksowski K: Thoracoscopic splanchnicectomy for the relief of pain due to chronic pancreatitis. Surg Endosc 2001, 15:592–596.PubMedCrossRefGoogle Scholar
  38. 38.
    Maher JW, Johlin FC, Heitshusen D: Long-term follow-up of thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surg Endosc 2001, 15:706–709.PubMedCrossRefGoogle Scholar
  39. 39.
    Buscher HC, Jansen JB, van Dongen R, et al.: Results of bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis. Br J Surg 2002, 89:158–162. A study in 44 patients in which thoracoscopic splanchnicectomy proved effective in decreasing the abdominal pain of chronic pancreatitis. The pain eventually recurred in approximately 50% of patients.PubMedGoogle Scholar
  40. 40.
    Howell JG, Johnson LW, Sehon JK, Lee WC: Surgical management for chronic pancreatitis. Am Surg 2001, 67:487–490.PubMedGoogle Scholar
  41. 41.
    Massucco P, Calgaro M, Bertolino F, et al.: Outcome of surgical treatment for chronic calcifying pancreatitis. Pancreas 2001, 22:378–382.PubMedCrossRefGoogle Scholar
  42. 42.
    Friess H, Berberat PO, Wirtz M, Buchler MW: Surgical treatment and long-term follow-up in chronic pancreatitis. Eur J Gastroenterol Hepatol 2002, 14:971–977.PubMedCrossRefGoogle Scholar
  43. 43.
    Sakorafas GH, Farnell MB, Farley DR, et al.: Long-term results after surgery for chronic pancreatitis. Int J Pancreatol 2000, 27:131–142.PubMedGoogle Scholar
  44. 44.
    Izbicki JR, Bloechle C, Knoefel WT, et al.: Surgical treatment of chronic pancreatitis and quality of life after operation [review]. Surg Clin North Am 1999, 79:913–944.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2003

Authors and Affiliations

  • Virmeet V. Singh
  • Phillip P. Toskes
    • 1
  1. 1.Department of Medicine, Division of Gastroenterology, Hepatology and NutritionUniversity of FloridaGainesvilleUSA

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