Chronic pancreatitis is an ongoing inflammation of the pancreas, an organ located behind the stomach that produces digestive enzymes and hormones like insulin. This persistent inflammation causes irreversible damage to the pancreas over time, leading to scarring and impaired function. Unlike acute pancreatitis, which is a sudden and temporary inflammation, chronic pancreatitis involves long-term, progressive changes to the organ. The main goals of treatment are to alleviate symptoms, manage potential complications, and prevent further damage to the pancreas.
Lifestyle and Dietary Management
Managing chronic pancreatitis often begins with lifestyle adjustments. Dietary changes are recommended to reduce the workload on the pancreas, which can help lessen pain and complications such as steatorrhea. A low-fat diet, limiting fat intake to around 40 grams per day, with small, frequent meals is advised. This approach helps the impaired pancreas process food more easily.
Complete cessation of alcohol consumption is important. Alcohol is a major factor in the progression of chronic pancreatitis and can worsen pain. Support programs, such as counseling or self-help groups like Alcoholics Anonymous, can assist individuals in achieving abstinence.
Quitting smoking is also an important step in managing the condition, as tobacco use accelerates pancreatic damage and increases the risk of pancreatic cancer. Smoking has been linked to an earlier onset of complications like calcifications and diabetes. Quitting can help slow disease progression and improve overall quality of life. Healthcare providers can offer resources and support, including nicotine replacement therapy or other medications, to aid in quitting.
Medical Management
Medical management for chronic pancreatitis focuses on two areas: addressing the body’s inability to digest food properly and controlling pain. Pancreatic enzyme replacement therapy (PERT) is a common treatment for exocrine pancreatic insufficiency, a complication where the pancreas no longer produces enough digestive enzymes. These supplements, taken with meals and snacks, contain enzymes that help the body break down fats and proteins, preventing malabsorption and malnutrition. The recommended dose ranges from 40,000 to 80,000 European Pharmacopoeia (Eur. Pharm) lipase units per main meal, with half that amount for snacks.
Pain management in chronic pancreatitis follows a stepped-care approach, starting with less potent options and progressing to stronger medications if needed. Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, are the first line of treatment. If these are insufficient, prescription non-opioid medications may be considered. For severe and persistent pain, opioids might be used, but their use is approached cautiously due to the risk of addiction. Other medications like certain antidepressants or anticonvulsants can be prescribed to help manage chronic nerve pain.
Endoscopic Procedures
When lifestyle changes and medical management are not sufficient, endoscopic procedures offer a less invasive option for addressing specific complications of chronic pancreatitis. These procedures are performed using an endoscope, a thin, flexible tube with a camera, inserted through the mouth to access the digestive tract. The goal is to relieve pain and resolve blockages within the pancreatic or bile ducts.
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a common technique used to diagnose and treat issues within these ducts. During ERCP, instruments can be passed through the endoscope to remove stones that are blocking the pancreatic duct, which contribute to pain. Stents, small tubes, can also be placed to widen narrowed areas (strictures) in the pancreatic or bile ducts, ensuring proper flow of digestive juices. Endoscopic techniques are also used to drain fluid collections, known as pseudocysts, that cause symptoms like bloating and pain.
Surgical Interventions
Surgical interventions for chronic pancreatitis are considered when other treatments, including medical and endoscopic approaches, have not provided adequate pain relief or when serious complications arise. These procedures are more invasive and are reserved for specific cases. Surgery aims to either improve drainage of pancreatic fluids or remove damaged portions of the pancreas.
One category of surgical procedures involves drainage, designed to relieve pressure within the pancreatic duct by improving the flow of digestive juices. This approach is used when the pancreatic duct is dilated and obstructed due to long-term stones. A common technique involves connecting the dilated pancreatic duct directly to a loop of the small intestine, allowing enzymes to bypass blockages and drain into the digestive tract.
The second main category is resection, which involves removing a part or, in severe cases, the entire damaged pancreas. Resection procedures are considered when there is severe inflammation, calcification, or fibrosis causing a collapsed duct that drainage procedures cannot address. Examples include partial pancreatic resection or total pancreatectomy. Total pancreatectomy is rarely performed due to the high risk of complications and is combined with autologous islet cell transplantation to help manage post-surgical diabetes.