Chronic pancreatitis medical therapy: Difference between revisions

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* Long-acting agents, such as continuous morphine sulphate or fentanyl patch, are usually recommended for chronic pain management.
* Long-acting agents, such as continuous morphine sulphate or fentanyl patch, are usually recommended for chronic pain management.
* Adjuvat therapy with Pregabalin is also found to be effective in some clinical trials.
* Adjuvat therapy with Pregabalin is also found to be effective in some clinical trials.<ref name="pmid21683078">{{cite journal |vauthors=Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM |title=Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial |journal=Gastroenterology |volume=141 |issue=2 |pages=536–43 |year=2011 |pmid=21683078 |doi=10.1053/j.gastro.2011.04.003 |url=}}</ref><ref name="pmid21950372">{{cite journal |vauthors=Graversen C, Olesen SS, Olesen AE, Steimle K, Farina D, Wilder-Smith OH, Bouwense SA, van Goor H, Drewes AM |title=The analgesic effect of pregabalin in patients with chronic pain is reflected by changes in pharmaco-EEG spectral indices |journal=Br J Clin Pharmacol |volume=73 |issue=3 |pages=363–72 |year=2012 |pmid=21950372 |pmc=3370341 |doi=10.1111/j.1365-2125.2011.04104.x |url=}}</ref>


=== 3.Antioxidants: ===
=== 3.Antioxidants: ===

Revision as of 22:31, 7 November 2017

Chronic pancreatitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Chronic pancreatitis management:

The goals of management are:

  • Pain control
  • Management of pancreatic insufficiency by pancreatic enzyme replacement
  • Management of complications[1]

Pain management:

Pain is managed in a stepwise approach of

  • General recommendations
  • Pancreatic enzyme replacement
  • Analgesics
  • Other invasive procedures

General recommendations:

Most of the patients usually improve following the general recommendations with only a few requiring analgesics.

(a) Smoking cessation:
  • Smoking cessation may
    • Delay the progression of chronic pancreatitis
    • Decrease the risk of pancreatic cancer[2]
(b) Cessation of alcohol intake:
  • Alcohol cessation may help in symptomatic improvement particularly in alcohol induced chronic pancreatitis.
  • Alcohol intake is associated with increased mortality in pateints with alcohol induced chronic pancreatitis.[3]
(c) Small meals:
  • Dietary preference in chronic pancreatitis should be small meals with low fat content
  • Medium chain triglyceride (MCTs) supplementation is particularly helpful because;
    • Its antioxidant effects
    •  Minimal increase in plasma CCK levels
    • It may prevent weight loss in patients
(d) Hydration:
  • Keeping the patients well hydrated may help in preventing the development of acute flares pf pancreatitis.

Medical Therapy:

1.Pancreatic Enzyme Supplementation:

  • Pancreatic enzyme supplementation is associated with pain alleviation and may be used when the general recommendations fail.
  • It decreases the release of CCK and thus reduces the stimulation-induced pancreatic pain but mixed results have been observed from various clinical trials.[4][5][6][7][8][9][10][11]
  • It is particularly beneficial in the management of patients with idiopathic chronic pancreatitis.[12][10]

2.Analgesics:

  • Analgesics are usually required when pancreatic enzyme replacement therapy fails to manage pain in chronic pancreatitis.
  • Pain cycle may be disrupted by:
    • Opiates coupled with amitriptyline and an NSAID.[13][14]
    • NPO and short-term hospitalization of the patient.
  • Long-acting agents, such as continuous morphine sulphate or fentanyl patch, are usually recommended for chronic pain management.
  • Adjuvat therapy with Pregabalin is also found to be effective in some clinical trials.[15][16]

3.Antioxidants:

4.Specialized approaches:

4.1 Celiac nerve block
4.2 Endoscopic therapy
4.3 Extracorporeal shock wave lithotripsy 
4.4 Radiation

Management of Steatorrhea:

1. Dietary modification
2. Lipase supplementation
3. Vitamin supplementation 
4. Medium chain triglycerides

Management of glucose intolerance:

Management of other pancreatic complications:

References

  1. Callery MP, Freedman SD (2008). "A 21-year-old man with chronic pancreatitis". JAMA. 299 (13): 1588–94. doi:10.1001/jama.299.9.jrr80001. PMID 18319401.
  2. Maisonneuve P, Lowenfels AB, Müllhaupt B, Cavallini G, Lankisch PG, Andersen JR, Dimagno EP, Andrén-Sandberg A, Domellöf L, Frulloni L, Ammann RW (2005). "Cigarette smoking accelerates progression of alcoholic chronic pancreatitis". Gut. 54 (4): 510–4. doi:10.1136/gut.2004.039263. PMC 1774435. PMID 15753536.
  3. Steer ML, Waxman I, Freedman S (1995). "Chronic pancreatitis". N. Engl. J. Med. 332 (22): 1482–90. doi:10.1056/NEJM199506013322206. PMID 7739686.
  4. Owyang C (1994). "Negative feedback control of exocrine pancreatic secretion: role of cholecystokinin and cholinergic pathway". J. Nutr. 124 (8 Suppl): 1321S–1326S. PMID 7914921.
  5. Singh VV, Toskes PP (2003). "Medical therapy for chronic pancreatitis pain". Curr Gastroenterol Rep. 5 (2): 110–6. PMID 12631450.
  6. Isaksson G, Ihse I (1983). "Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis". Dig. Dis. Sci. 28 (2): 97–102. PMID 6825540.
  7. Halgreen H, Pedersen NT, Worning H (1986). "Symptomatic effect of pancreatic enzyme therapy in patients with chronic pancreatitis". Scand. J. Gastroenterol. 21 (1): 104–8. PMID 3633631.
  8. Mössner J, Secknus R, Meyer J, Niederau C, Adler G (1992). "Treatment of pain with pancreatic extracts in chronic pancreatitis: results of a prospective placebo-controlled multicenter trial". Digestion. 53 (1–2): 54–66. PMID 1289173.
  9. Brown A, Hughes M, Tenner S, Banks PA (1997). "Does pancreatic enzyme supplementation reduce pain in patients with chronic pancreatitis: a meta-analysis". Am. J. Gastroenterol. 92 (11): 2032–5. PMID 9362186.
  10. 10.0 10.1 Leung JW, Bowen-Wright M, Aveling W, Shorvon PJ, Cotton PB (1983). "Coeliac plexus block for pain in pancreatic cancer and chronic pancreatitis". Br J Surg. 70 (12): 730–2. PMID 6640255.
  11. Warshaw AL, Banks PA, Fernández-Del Castillo C (1998). "AGA technical review: treatment of pain in chronic pancreatitis". Gastroenterology. 115 (3): 765–76. PMID 9721175.
  12. Slaff J, Jacobson D, Tillman CR, Curington C, Toskes P (1984). "Protease-specific suppression of pancreatic exocrine secretion". Gastroenterology. 87 (1): 44–52. PMID 6202586.
  13. Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL (2009). "Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial". Lancet. 374 (9697): 1252–61. doi:10.1016/S0140-6736(09)61081-3. PMID 19796802.
  14. Fioramonti J, Bueno L (2002). "Centrally acting agents and visceral sensitivity". Gut. 51 Suppl 1: i91–5. PMC 1867729. PMID 12077076.
  15. Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM (2011). "Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial". Gastroenterology. 141 (2): 536–43. doi:10.1053/j.gastro.2011.04.003. PMID 21683078.
  16. Graversen C, Olesen SS, Olesen AE, Steimle K, Farina D, Wilder-Smith OH, Bouwense SA, van Goor H, Drewes AM (2012). "The analgesic effect of pregabalin in patients with chronic pain is reflected by changes in pharmaco-EEG spectral indices". Br J Clin Pharmacol. 73 (3): 363–72. doi:10.1111/j.1365-2125.2011.04104.x. PMC 3370341. PMID 21950372.


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