Current Treatment Options in Gastroenterology

, Volume 2, Issue 5, pp 401–408 | Cite as

Chronic pancreatitis

  • Stephen T. Amann
Article
  • 18 Downloads

Opinion statement

Management of chronic pancreatitis is a difficult endeavor for the clinician due to a variety of reasons. These include the variable presentation of symptoms such as chronic pain, recurrent pain, pain associated with malabsorption due to maldigestion, or even maldigestion alone in 15% of patients. It is paramount that the clinician and patient devise appropriate treatment based on prevailing symptoms, and anatomical/functional alterations in the pancreas. Concentrating on symptoms allows the best opportunity to improve the patient’s quality of life. Having an understanding of the patient’s anatomical and functional derangement will assist the clinician in targeting treatment particular to the individual. Awareness of complications associated with chronic pancreatitis is important to allow detection and treatment as they are encountered.

Treatment of chronic pancreatitis involves a stepwise approach. Treatment options that are the least invasive and are proven to work should be tried first, and if they are unsuccessful, appropriate alternative treatments can be employed. First-line therapy involves analgesics, non-narcotic and narcotic, in conjunction with pancreatic enzymes. For the pain-predominant cases, this includes nonenteric-coated enzyme supplements. For the individual with maldigestion as the predominant symptom, this includes entericcoated enzyme supplements. This initial trial should be continued for 3 to 6 months. If this fails to provide adequate improvement, then individualized treatment should involve surgical options and if appropriate in specific instances, endoscopic approaches.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Go VLW, Everhart JE: Pancreatitis. In: Digestive Disorders in the United States: Epidemiology and Impact. Edited by Everhart JE. Washington, DC: US Department of Health and Human Services, National Institutes of Health; 1994:NIH publication no. 94-1447. 691–712.Google Scholar
  2. 2.
    Lowenfels AB, Maisonneuve P, Groves H, et al.: Racial factors and the risk for chronic pancreatitis. Am J Gastroenterol 1999, 94:790–794. Interesting epidemiological look at chronic pancreatitis in three different hospitals and two different countries.PubMedCrossRefGoogle Scholar
  3. 3.
    Lankisch PG, Seidenstocker F, Otto J, et al.: Secretinpancreozymin test (SPT) and Endoscopic Retrograde Cholangiopancreatography (ERCP): Both are necessary for diagnosing or excluding chronic pancreatitis. Pancreas 1996, 12:149–152.PubMedCrossRefGoogle Scholar
  4. 4.
    Toskes PP: Medical management of chronic pancreatitis. Scand J Gastroenterol 1995, 30(suppl 208):74–80.Google Scholar
  5. 5.
    Forsmark CE, Toskes PP: What does an abnormal pancreatogram mean? Gastrointest Endosc Clin N Am 1995, 5:105–123.PubMedGoogle Scholar
  6. 6.
    Walsh TN, Rode J, et al.: Minimal change chronic pancreatitis. Gut 1992, 33:1566–1571.PubMedGoogle Scholar
  7. 7.
    Loser C, Mollgaard A, Folsch et al.: Faecal Elastase 1: a novel, highly sensitive, and specific tubeless pancreatic function test. Gut 1996, 39:580–586.PubMedGoogle Scholar
  8. 8.
    Amann ST, Bishop M, Currington C, et al.: Fecal pancreatic elastase 1 is inaccurate in the diagnosis of chronic pancreatitis. Pancreas 1996, 13:226–230.PubMedCrossRefGoogle Scholar
  9. 9.
    Lankisch PG, Schmidt F, Konig H, et al.: Faecal elastase 1: not helpful in diagnosing chronic pancreatitis associated with mild to moderate pancreatic insufficiency. Gut 1998, 42:551–554.PubMedCrossRefGoogle Scholar
  10. 10.
    Jacobson DG, Currington C, Connery K, et al.: Trypsinlike immunoreactivity as a test for pancreatic insufficiency. N Eng J Med 1984, 310:1307–1309.CrossRefGoogle Scholar
  11. 11.
    Warshaw AL, Banks PA, Fernandez del Castillo C: AGA technical review: Treatment of pain in chronic pancreatitis. Gastroenterology 1998, 115:765–776. Critical review data regarding current pain management options in chronic pancreatitis.PubMedCrossRefGoogle Scholar
  12. 12.
    Warshaw AL: AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology 1998, 115(3):765–776. Rational consensus statement regarding treatment of chronic pancreatitis.PubMedCrossRefGoogle Scholar
  13. 13.
    Glasbrenner B, Adler G: Evaluating pain and the quality of life in chronic pancreatitis. Int J Pancreatol 1997, 22:163–170. Describes the importance of standardized pain and quality of life measures in chronic pancreatitis.PubMedGoogle Scholar
  14. 14.
    Isaksson G, Inse I: Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis. Dig Dis Sci 1983, 28:97–102.PubMedCrossRefGoogle Scholar
  15. 15.
    Slaff J, Jacobson D, Tillman C, et al.: Protease specific suppression of pancreatic exocrine secretion. Gastroenterology 1984, 87:44–52.PubMedGoogle Scholar
  16. 16.
    Guarner L, Rodriguez R, Guarner F, et al.: Fate of oral enzymes in pancreatic insufficiency. Gut 1993, 34:708–712.PubMedGoogle Scholar
  17. 17.
    Lowenfels AB, Maisonneuve P, Cavallini G, et al.: Prognosis of chronic pancreatitis: an international multicenter study. Am J Gastroenterol 1994, 89:1467–1471.PubMedGoogle Scholar
  18. 18.
    Ammann RW, Meullhaupt B, Zurich Pancreatitis Study Group: The natural history of pain in alcoholic pancreatitis. Gastroenterology 1999, 116:1132–1140. A detailed longitudinal study of alcohol-induced chronic pancreatitis including a description of pain patterns and outcome.PubMedCrossRefGoogle Scholar
  19. 19.
    Lankisch PG, Lohruttupe A, Otto J, et al.: Natural course in chronic pancreatitis: pain, exocrine and endocrine insufficiency and prognosis of the disease. Digestion 1993, 54:148–155.PubMedCrossRefGoogle Scholar
  20. 20.
    Moran CE, Sosa EG, Martinez SM, et al.: Bone mineral density in patients with pancreatic insufficiency and steatorrhea. Am J Gastroenterol 1997, 92:867–871.PubMedGoogle Scholar
  21. 21.
    Hedeles L, Hochhaus G, Kazerounian S: Generic and alternative brand-name pharmaceutical equivalents: select with caution. Am J Hosp Pharm 1993, 50:323–329.Google Scholar
  22. 22.
    Littlewood JM: Update on intestinal strictures. J R Soc Med 1999, 92(suppl 37):41–49. Review of pancreatic enzymes and clarification of the risk associated with colonic strictures.PubMedGoogle Scholar
  23. 23.
    Carr-Locke D: Endoscopic therapy of chronic pancreatitis. Gastrointest Endosc 1999, 45:S77–80. Recommended reading for interventional endoscopists. Reviews current literature and adds perspective to endoscopic treatment of chronic pancreatitis.CrossRefGoogle Scholar
  24. 24.
    Adams DB, Ford MC, Anderson MC: Outcome after lateral pancreatojejunostomy for chronic pancreatitis. Ann Surg 1994, 219:487–489.CrossRefGoogle Scholar
  25. 25.
    Toskes PP, Forsmark CE, DeMeo MT, et al.: An openlabel trial of octreotide for the pain of chronic pancreatitis. Gastroenterology 1994, 106:A326.Google Scholar
  26. 26.
    McCloy R: Chronic pancreatitis at Manchester, U.K.: Focus on antioxidant therapy. Digestion 1998, 59(4):36–48.PubMedCrossRefGoogle Scholar
  27. 27.
    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
  28. 28.
    Bradely EL, Reynhout JA, Peer GL: Thoracoscopic splanchnicectomy for “small duct” chronic pancreatitis: case selection by differential epidural analgesia. J Gastrointest Surg 1998, 2:88–94.CrossRefGoogle Scholar
  29. 29.
    Whitcomb DC, Gorry MC, Preston RA, et al.: Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene. Nat Genet 1996, 24:141–145.CrossRefGoogle Scholar
  30. 30.
    Cohn JA, Friedman KJ, Noome PG, et al.: Relation between mutations of the cystic fibrosis gene and idiopathic pancreatitis. N Eng J Med 1998, 339(10):653–658.CrossRefGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • Stephen T. Amann
    • 1
  1. 1.North Mississippi Medical Center, Digestive Health Specialists, PATupelo

Personalised recommendations