Management of chronic pancreatitis

Abstract

Chronic pancreatitis is a chronic inflammatory disorder in which irreversible changes result in fibrosis leading to endocrine and exocrine insufficiency. Pain is often the dominant symptom and as the disease is irreversible all therapy is directed at relieving pain. Lifestyle changes include the modification of diet as well as cessation of alcohol and smoking. A stepup approach in accordance with the WHO pain ladder is ideal for relief of pain. Exocrine deficiency is seen 6–15 years after the onset of chronic pancreatitis (CP) and clinically presents as steatorrhea, weight loss, and specific nutrient deficiency. Lipase is the rate-limiting enzyme and deficiency occurs when over 90% of the pancreatic tissue is lost. Pancreatic enzyme replacement therapy is the therapy of choice and coated microspheres are the mode of delivery for enzyme replacement. The enzyme preparations are best taken between meals and an acid suppressant such as proton pump inhibitor facilitates in better absorption and delivery as these enzymes act best in a high pH. The management of sequalae of CP such as PD strictures, common bile duct strictures, pancreatic leaks, and calculi is individualized, and endotherapy offers an excellent option in properly selected cases. Endoscopic retrograde cholangiopancreatoscopy (ERCP) and subsequent stenting of the pancreatic or biliary ducts is rewarding in strictures as well as in PD leaks. Large calculi are fragmented at ESWL before clearing the duct at ERCP. Endoscopic ultrasound is a rapidly evolving technology, now being increasingly used in the management of consequences of CP. Surgery is advised for patients not amenable or responding to endotherapy.

Keywords

• chronic pancreatitis
• common bile duct
• endoscopic retrograde cholangiopancreaticography
• endoscopic ultrasound
• pancreatic duct
• pancreatic enzyme replacement therapy