Management of Pain in Chronic Pancreatitis

John Baillie, MB, ChB, FRCP, FASGE

Disclosures

April 08, 2008

Question
What is the recommended management for relief of pain associated with chronic pancreatitis?

Response from John Baillie, MB, ChB, FRCP, FASGE
Professor, Wake Forest University Medical Center and Health Sciences, Winston-Salem, North Carolina; Director, Hepatobiliary and Pancreatic Disorders Service, Baptist Medical Center, Winston-Salem, North Carolina


The management of pain in chronic pancreatitis ranges from oral enzyme supplementation to neurosurgery; the approach depends on the pathophysiology of the pain. For the purpose of this brief discussion, I will assume that our hypothetical patient has already failed to respond to standard pharmacologic management, including oral pancreatic enzyme replacement and narcotic analgesia. (In my experience, nonnarcotic pain modulators, ranging from nonsteroidal anti-inflammatory drugs to phenytoin and gabapentin, are inadequate to control severe pancreatic pain.) If there is obstruction to the flow of pancreatic juice (exocrine secretion), endoscopic dilation and stenting of strictures, pancreatic sphincterotomy, and removal of ductal stones may be helpful. Although surgery is the time-honored "gold standard" for managing pain in chronic pancreatitis, endopancreatic therapy is frequently worth a try at first. In my view, it is usually a "bridge" to surgery, especially when complications of acute-on-chronic pancreatitis are present.[1,2]

At least one-third of pancreatic endotherapy patients eventually need surgery for continuing pain. An experienced pancreatic surgeon is central to the multidisciplinary management of pancreatic pain. The standard surgical approach to drainage of the pancreas in chronic pancreatitis is lateral pancreaticojejunostomy (the so-called Puestow procedure), in which the gland is opened longitudinally and a loop of small intestine anastomosed side-to-side to the dilated duct. Unfortunately, the results of endoscopic stenting do not reliably predict the outcome of drainage surgery. If the pain is due to inflammation of the pancreatic parenchyma, draining the duct alone will not improve it. Resecting part (usually the tail) of the pancreas for localized disease is another option. This is usually combined with a drainage procedure. Total pancreatectomy for pain control in chronic pancreatitis seems a drastic intervention, but it is becoming increasingly common.[3] If the patient can be identified before the onset of diabetes mellitus, islet cell harvest and autotransplantation may avoid this complication. However, in my experience, the majority of patients undergoing pancreatectomy and islet cell autotransplantation for chronic pancreatitis end up with at least mild diabetes requiring oral hypoglycemic agents or (more typically) insulin injections. Nonetheless, these patients almost always consider the "trade-off" (diabetes for relief of pain) worthwhile.

Endoscopic ultrasound (EUS) offers a low-risk intervention for pain in chronic pancreatitis: EUS-guided celiac neurolysis. A temporary block of the nerve center through which pancreatic pain signals are thought to be relayed is accomplished using a few cubic centimeters of the local anesthetic, bupivicane, and a long-acting steroid, triamcinolone.[4] The results are variable and unpredictable, and highly dependent on the operator, but in the best cases, benefit ranging from months to over a year of pain relief (or, more typically, reduction) can follow. As a rule, we discourage permanent celiac blocks in young patients with benign disease. These are typically performed by interventional radiologists for severe pain in pancreatic cancer. The short-term benefit in this setting outweighs the potentially debilitating side effects of a permanent celiac block, such as postural hypotension. EUS-guided celiac neurolysis can be repeated multiple times without prejudicing other management options, such as surgery. In rare cases, neurosurgery (eg, transthoracic splanchnicectomy, rhizotomy) may be necessary to deal with severe pain unresponsive to other approaches. Finally, it should be remembered that the onset (or worsening) of pain in chronic pancreatitis may indicate a complication, such as the development of a pseudocyst, a biliary stricture, or even pancreatic cancer. The lifetime risk of malignancy is high in familial (genetic) pancreatitis,[5] and is an indication for prophylactic total pancreatectomy in young patients identified as "at risk."

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