Treatment of chronic pancreatitis is directed at the problems the disease produces — pain, maldigestion, diabetes and structural complications — because the fibrosis itself cannot be reversed. Alcohol abstinence and smoking cessation are part of every plan: both drive progression, and smoking also raises the risk of pancreatic cancer.
Pain
Pain is managed along the World Health Organization analgesic ladder, introducing drugs of increasing potency until relief is obtained. Paracetamol is the preferred first-step analgesic because it has few side effects. NSAIDs are avoided because of their gastrointestinal toxicity; if a patient is at high risk of peptic ulcer, a proton pump inhibitor can be added. Tramadol is the preferred second step, giving the same analgesia as morphine with fewer gastrointestinal side effects. The third step is strong opioids such as morphine, used at the lowest effective oral dose because dependence and side effects are a real risk, particularly in patients with alcohol-related disease. Opioids fail to relieve pain in a substantial minority — up to about 50% — and when they do not work, treatment should be stopped rather than escalated.
When pain is caused by obstruction of the main pancreatic duct, surgery (open or minimally invasive) is considered first-line, and extracorporeal shockwave lithotripsy is an option for a dominant duct stone when surgery is unsuitable.
Exocrine pancreatic insufficiency
Exocrine insufficiency is treated with pancreatic enzyme replacement therapy (PERT), taken with food. The dose is based on lipase activity: at least 40,000–50,000 PhU (pharmacopoeia units) of lipase with each main meal, and half that dose with snacks. If the response is unsatisfactory, the dose is increased or a proton pump inhibitor is added to reduce gastric acid and protect the enzymes. Assessment by a dietitian and supplementation of fat-soluble vitamins are part of long-term care.
Diabetes
Diabetes in chronic pancreatitis is pancreatogenic (type 3c) diabetes, driven by loss of insulin secretion rather than by insulin resistance. It is managed with diet and, often, insulin, which is commonly the first choice in patients who are severely malnourished because of its anabolic effect. Metformin is an option when hyperglycaemia is mild and insulin resistance is suspected, but it must be avoided in ongoing alcohol abuse because of the risk of lactic acidosis. Sulfonylureas are not used, because they cause severe and prolonged hypoglycaemia.
Structural and long-term complications
- Pseudocysts that cause symptoms are drained endoscopically, under endoscopic ultrasound guidance or transpapillary; surgery is an option when endoscopy is unsuitable or has failed.
- Splenic vein thrombosis can lead to portal hypertension and gastrointestinal bleeding.
- Bone disease is common, so bone density is assessed and vitamin D and calcium deficiencies are corrected.
- Pancreatic cancer is a long-term risk, highest — around 40% lifetime — in hereditary pancreatitis, where annual monitoring is considered.