Management of Pain, Exocrine and Endocrine Insufficiency in Chronic Pancreatitis

Chronic pancreatitis is the progressive and inflammatory disease which will result in the irreversible destruction and fibrosis of the pancreas. These processes cause chronic pain and pancreatic dysfunctions such as exocrine and endocrine insufficiency. Medical treatment for chronic pancreatitis would be reviewed in this article. Abdominal pain should be accessed by using multidimensional approach including pain intensity, pattern, impact on daily function and quality of life. Abstinence from alcohol and smoking should be strong recommendation. The guideline for analgesic therapy follows the principles of the “pain relief ladder” by World Health Organization. The pancreatic enzyme replacement should be considered when exocrine insufficiency is suspected. Enteric-coated microspheres or mini-microspheres of <2 mm in size with a minimum lipase dose of 40,000–50,000 United States Pharmacopeia are the recommended preparations. These preparations should be taken with main meals. Increasing the oral enzyme dose and the addition of a proton pump inhibitor could be considered in cases of unsatisfactory clinical response. Diabetes mellitus secondary to chronic pancreatitis is classified as Type IIIc diabetes mellitus. Optimal pharmacological treatment has not been established yet but should promote life-style changes, which may improve glucose control and avoid hypoglycemia. In patients with severe malnutrition, insulin therapy is recommended as a first choice. Treatment for chronic pancreatitis can include medication, therapeutic endoscopy, interventional radiology, and surgery. Among them, medical treatment is the most important and should be well understood.

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Chronic pancreatitis

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0336 ◽

2020 ◽

pp. 3218-3227

Author(s):

Marco J. Bruno ◽

Djuna L. Cahen

Keyword(s):

Diabetes Mellitus ◽

Chronic Pancreatitis ◽

Pancreatic Enzyme ◽

Exocrine Insufficiency ◽

Endocrine Insufficiency ◽

Diabetes Mellitus Diagnosis ◽

Permanent Loss ◽

Stimulation Tests ◽

Enteric Coated ◽

Pancreatic Duct Stricture

Chronic pancreatitis is a major source of morbidity, loss in quality of life, and healthcare expenditure. It is most commonly caused by chronic alcoholism in adults and cystic fibrosis in children, but there are many other causes. Patients typically present with severe abdominal pain, but this may vary and even be absent. Exo- and endocrine insufficiency usually occur late in the disease course and reflect permanent loss of pancreatic parenchyma due to ongoing inflammation and fibrosis, exocrine insufficiency manifesting as steatorrhea and weight loss due to fat maldigestion and endocrine insufficiency as diabetes mellitus. Diagnosis is confirmed by imaging investigations such as CT, MRI, and endoscopic ultrasonography. Endoscopic retrograde cholangiopancreatography to diagnose chronic pancreatitis is obsolete. Hormone stimulation tests (e.g. secretin–cholecystokinin stimulation test) to diagnose exocrine insufficiency are largely abandoned because of their complexity and burden to patients. They are replaced by faecal elastase testing, even though this test is less sensitive. Management focuses on the treatment of pain using a stepwise approach. Initially, nonopioid analgesics are prescribed. Next, when feasible, endoscopic therapy is initiated, including pancreatic stone fragmentation by extracorporeal shock-wave lithotripsy, endotherapy to remove stone fragments, and placement of plastic stents to dilate any concomitant pancreatic duct stricture. If that fails or when, for example, the pancreatic head is enlarged, surgical intervention is indicated. Medical management includes enteric-coated pancreatic enzyme preparations and treatment of diabetes mellitus, usually by means of insulin. Abstinence from alcohol and smoking cessation are important predictors of disease and treatment outcome.

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Chronic pancreatitis: review and update of etiology, risk factors, and management

F1000Research ◽

10.12688/f1000research.12852.1 ◽

2018 ◽

Vol 7 ◽

pp. 607 ◽

Cited By ~ 24

Author(s):

Angela Pham ◽

Christopher Forsmark

Keyword(s):

Chronic Pancreatitis ◽

Islet Cells ◽

Pancreatic Insufficiency ◽

Pancreatic Enzyme ◽

Exocrine Insufficiency ◽

Disease Etiology ◽

Enzyme Replacement ◽

Endocrine Insufficiency ◽

Pancreatic Enzyme Replacement Therapy ◽

Pancreatic Exocrine

Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells which can manifest in unrelenting abdominal pain, malnutrition, and exocrine and endocrine insufficiency. The Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute Pancreatitis, Obstructive (TIGAR-O) classification system categorizes known causes and factors that contribute to chronic pancreatitis. Although determining disease etiology provides a framework for focused and specific treatments, chronic pancreatitis remains a challenging condition to treat owing to the often refractory, centrally mediated pain and the lack of consensus regarding when endoscopic therapy and surgery are indicated. Further complications incurred include both exocrine and endocrine pancreatic insufficiency, pseudocyst formation, bile duct obstruction, and pancreatic cancer. Medical treatment of chronic pancreatitis involves controlling pain, addressing malnutrition via the treatment of vitamin and mineral deficiencies and recognizing the risk of osteoporosis, and administering appropriate pancreatic enzyme supplementation and diabetic agents. Cornerstones in treatment include the recognition of pancreatic exocrine insufficiency and administration of pancreatic enzyme replacement therapy, support to cease smoking and alcohol consumption, consultation with a dietitian, and a systematic follow-up to assure optimal treatment effect.

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Clinical and pharmacological approaches to the management of exocrine pancreatic insufficiency in chronic pancreatitis

Medical Council ◽

10.21518/2079-701x-2021-15-58-67 ◽

2021 ◽

pp. 58-67

Author(s):

V. N. Drozdov ◽

E. V. Shikh ◽

A. A. Astapovskiy ◽

Yu. V. Kotlyachkova ◽

L. E. Dobrovolskaya ◽

...

Keyword(s):

Chronic Pancreatitis ◽

Enzyme Replacement Therapy ◽

Replacement Therapy ◽

Pancreatic Insufficiency ◽

Fibrous Tissue ◽

Pancreatic Enzyme ◽

The United States ◽

Exocrine Insufficiency ◽

Enzyme Replacement ◽

Endocrine Insufficiency

Chronic pancreatitis is a multifactorial disease in which repeated episodes of inflammation of the pancreas contribute to the development of fibrous tissue, leading to chronic pain, as well as exocrine and endocrine insufficiency. The incidence and prevalence of chronic pancreatitis in the world are growing, as evidenced by current statistics. In addition, the annual costs associated with the treatment of exocrine and endocrine insufficiency are also increasing. In the United States alone, the annual cost of treating these complications is $ 75.1 million. Exocrine insufficiency is one of the most frequent complications, which is characterized by a deficiency of pancreatic enzymes, leading to the development of malabsorption syndrome (impaired absorption of nutrients, vitamins and minerals). Due to the increased incidence and deterioration of the quality of life associated with this condition, the goal of treatment is to compensate for the deficiency of exocrine enzymes with oral pancreatic enzyme replacement therapy. The core of this therapy is to deliver activated, unbroken enzymes directly to the small intestine during a meal. Many studies have shown that prescribing enzyme replacement therapy improves symptoms associated with exocrine insufficiency, reduces the progression of osteopenia, and improves survival in such patients. The use of pancreatin contributes to the correction of exocrine insufficiency in patients with chronic pancreatitis. The data presented in the article indicate that the drug is a safe and effective agent, meets all modern standards and requirements, and can be used to correct enzymatic pancreatic insufficiency.

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Pancreatic disease

Oxford Handbook of Nutrition and Dietetics ◽

10.1093/med/9780198800132.003.0027 ◽

2020 ◽

pp. 679-688

Keyword(s):

Pancreatic Cancer ◽

Acute Pancreatitis ◽

Chronic Pancreatitis ◽

Enzyme Replacement Therapy ◽

Replacement Therapy ◽

Pancreatic Enzyme ◽

Pancreatic Disease ◽

Pancreatic Function ◽

Enzyme Replacement ◽

Pancreatic Enzyme Replacement Therapy

Pancreatic function, Chronic pancreatitis, Acute pancreatitis, Pancreatic cancer, Pancreatic enzyme replacement therapy

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Pancreatic disease

Oxford Handbook of Nutrition and Dietetics ◽

10.1093/med/9780199585823.003.0027 ◽

2011 ◽

pp. 611-618

Keyword(s):

Pancreatic Cancer ◽

Acute Pancreatitis ◽

Chronic Pancreatitis ◽

Enzyme Replacement Therapy ◽

Replacement Therapy ◽

Pancreatic Enzyme ◽

Pancreatic Disease ◽

Enzyme Replacement ◽

Pancreatic Enzyme Replacement Therapy ◽

Pancreatic Disorders

Pancreatic disorders 612 Pancreatic enzyme replacement therapy 616 See Table 27.1. The major pancreatic disorders include pancreatitis and pancreatic cancer. Pancreatitis results from the auto-digestion of the pancreas by activated pancreatic enzymes. It can be categorized as: • Chronic pancreatitis (CP). • Acute pancreatitis: •...

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A Case of Chronic Pancreatic Insufficiency Due to Valproic Acid in a Child

Canadian Journal of Gastroenterology ◽

10.1155/2001/687087 ◽

2001 ◽

Vol 15 (2) ◽

pp. 127-130 ◽

Cited By ~ 5

Author(s):

Mary Anne Cooper ◽

Aubrey Groll

Keyword(s):

Valproic Acid ◽

Weight Loss ◽

Acute Pancreatitis ◽

Abdominal Pain ◽

Chronic Pancreatitis ◽

Pancreatic Insufficiency ◽

Pancreatic Enzyme ◽

Exocrine Pancreatic Insufficiency ◽

Radiological Evaluation ◽

Enzyme Replacement

A 14-year-old child treated with valproic acid over several years for a seizure disorder developed abdominal pain with radiological evidence of acute pancreatitis. The association with valproic acid was not recognized, and the child continued to take the drug. The patient eventually developed steatorrhea and weight loss that improved with pancreatic enzyme replacement. Radiological evaluation showed an atrophic pancreas. Without evidence of other etiological factors, valproic acid by itself appeared to be the cause of chronic pancreatitis with exocrine pancreatic insufficiency in this patient.

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