Chronic Pancreatitis Pain Management and Treatment

Pain Management

Significant pain associated with chronic pancreatitis can seriously reduce a patient’s quality of life. It is important to treat chronic pancreatitis as soon as it is diagnosed because repeated episodes of inflammation can cause irreversible damage, and pain relief becomes much less effective. Pain relief can be achieved with medication, often using the World Health Organization’s 3-step ladder approach to pain relief:

  1. Pain medication begins with nonopioids (like acetaminophen, ibuprofen, or both).
  2. If nonopioids do not relieve pain, mild opioids (like codeine) are given.
  3. If mild opioids do not relieve pain, strong opioids (like morphine) are given.

Many patients with chronic pancreatitis receive antioxidants with their pain medicine, which has been shown to help with pain relief.3-5 There are other options for pain relief, such as a celiac plexus block, which may provide another option for significant pain relief. The celiac plexus block is achieved via injection and prevents the nerves that travel from the pancreas from reporting pain signals back to the brain.

If there is a narrowing of the pancreatic duct, placement of a plastic tube called a stent into the duct can be helpful in alleviating pain symptoms.

Limited Role of Endoscopic Retrograde Cholangiopancreatography (ERCP)

An ERCP test, in which a flexible endoscope is placed into the intestine and a catheter is used to inject dye into the pancreas, should generally not be used in chronic pancreatitis, and it should never be used to diagnose chronic pancreatitis because injecting dye into the pancreas can cause pancreatitis. For more information about ERCP, please click here.

Surgery

When medical therapy fails to provide relief to patients with chronic pancreatitis, surgical therapy may be an option. A lateral pancreaticojejunostomy (modified Puestow procedure) can result in pain relief in up to 80% of patients.

Whipple Procedure

Another surgical procedure, which can remove inflammation and masses on the head of the pancreas, is the classic Whipple procedure; however, this procedure does remove a lot of important tissue and can be associated with complications such as increased risk of death. When possible, modified Whipple procedures are performed to save more tissue compared to the classic Whipple procedure, and can be successful for pain relief and return to daily activity. To read more, please visit Whipple Procedure.

TPIAT

For appropriately selected patients whose pain remains incapacitating despite standard medical and surgical approaches, total pancreatectomy with islet auto-transplantation (TP-IAT) – while not a panacea – yields significant relief of symptoms. For more information on this, please visit TPIAT.

Antioxidant therapies

Basic and clinical evidence suggests that the development of both acute pancreatitis (AP) and chronic pancreatitis (CP) can be associated with oxidative stress. Findings show that free radical activity and oxidative stress indices are higher in the blood and duodenal juice of patients with pancreatitis.

Based on these findings, the idea of using antioxidant regimens in the management of both AP and CP as a supplement and complementary in combination with its traditional therapy is reasonable. In practice, however, the overall effectiveness of antioxidants is not known, and the best mixture of agents and dosages is not clear. Currently, a trial of a mixture of antioxidants containing vitamin C, vitamin E, selenium, and methionine is reasonable as one component of overall medical management.

In summation, there is no definite consensus on the dosage, length of therapy, and ultimately, the benefits of antioxidant therapy in the management of AP or CP. Further well-designed clinical studies are needed to determine the appropriate combination of agents, time of initiation, and duration of therapy.

Bilateral Thoracoscopic Splanchnicectomy

This is an option for intractable, chronic pain but it is not widely available.  Is is a surgical resection of one or more of the splanchnicnerves for the treatment of intractable pain. It is usually performed by a thoracic surgeon when it is done.