Chronic Pancreatitis

Pancreatitis is a  major issues which is often considered very difficult to deal with.  There are many causes of pancreatitis.  Pancreatitis is  inflammation of the pancreas. Often times  patients with repeated attacks of pancreatitis will develop chronic pancreatitis.  With progressive inflammatory changes from chronic pancreatitis, the pancreas will undergo  permanent structural damage, which can lead to impairment of exocrine and endocrine function.

Chronic alcoholism  is the most common cause of chronic pancreatitis. Often times, Gallstones can also cause chronic pancreatitis.

Chronic pancreatitis usually presents with ongoing abdominal pain, requiring long term pain medications.  The pain is typically in the upper abdomen, often radiates to the spine and associated with nausea and vomiting. Also fat malabsorption is common which leads to loose, greasy, foul smelling stool that usually floats in the toilet pan. Malabsorption of the fat soluble vitamins (A, D, E, K) and vitamin B12 may also occur,

Patients with chronic pancreatitis can become overt diabetic often requiring daily subcutaneous insulin.

In early course of disease, following intervention will help prevent disease progression.

 

  • Cessation of smoking
  • Alcohol cessation
  • take small meal low in fat
  • Pancreatic enzyme supplements    pancreatic enzyme supplements ( eg. Creon, Zenpepp ) may help patients with pain persisting after the above interventions. They help with  control of diarrhea, fatty stools.  Enteric coated formulations such as Creon-24,000 lipase, one to two capsules with meals and one capsule with a snack, or a non-enteric coated form such as Viokace Lipase 20,880, three tablets with meals and one to two tablets with a snack. This dose is typically sufficient to improve symptoms.  Non-enteric coated form must be taken with ranitidine or omeprazole.
  • Analgesics :  Analgesia can be considered if pancreatic enzyme therapy fails to control pain
  • Treatment with acid suppression (Ranitidine, Omeprazole, pantoprazole ) should be given along with pancreatic enzyme supplements to reduce inactivation from gastric acid.
  • Treatment of pain : Celiac nerve block

Percutaneous or endoscopic celiac nerve blocks with either alcohol or steroids have had very limited role and  may be considered as a last resort.

  • Steatorrhea (fat malabsorption)

If you suffer from fat malabsorption, restrict the amount  of fat intake (to less than 20 g per day)

If the diarrhea doesnot  get better with dietary restriction,   lipase supplementation  should be started.  As a general rule, 30,000 international units (IU) of pancreatic lipase (90,000 United States Pharmacopeia units [USP]) swallowed during each meal should suffice in reducing steatorrhea and preventing weight loss.

Medium chain triglycerides (MCTs)  [ MCT Oil,  Liquigen, Betaquik ] can provide extra calories in patients with weight loss and a poor response to diet and pancreatic enzyme therapy. This will help build some nutrition.

 

Surgery Decompression procedures have generally been recommended for patients with refractory pain who have a dilated main pancreatic duct. The normal pancreatic duct ranges from 2 to 4 mm in diameter (most narrow in the tail, enlarging as it passes toward the ampulla). A dilated duct (from a surgical standpoint) is one that would permit anastomosis to a loop of jejunum.

Puestow procedure

Surgery has generally been considered for patients who fail medical therapy if the pancreatic duct is dilated, approximately 80 percent of patient benefit with pain control. As we master the art of complex pancreatic surgery, complications related to this procedure is very minimal.

 

About Chronic Pancreatitis

Pancreatitis is a  major issues which is often considered very difficult to deal with.  There are many causes of pancreatitis.  Pancreatitis is  inflammation of the pancreas. Often times  patients with repeated attacks of pancreatitis will develop chronic pancreatitis.  With progressive inflammatory changes from chronic pancreatitis, the pancreas will undergo  permanent structural damage, which can lead to impairment of exocrine and endocrine function.

Chronic alcoholism  is the most common cause of chronic pancreatitis. Often times, Gallstones can also cause chronic pancreatitis.

Symptoms

Chronic pancreatitis usually presents with ongoing abdominal pain, requiring long term pain medications.  The pain is typically in the upper abdomen, often radiates to the spine and associated with nausea and vomiting. Also fat malabsorption is common which leads to loose, greasy, foul smelling stool that usually floats in the toilet pan. Malabsorption of the fat soluble vitamins (A, D, E, K) and vitamin B12 may also occur,

Patients with chronic pancreatitis can become overt diabetic often requiring daily subcutaneous insulin.

Medical Treatment

In early course of disease, following intervention will help prevent disease progression.

 

  • Cessation of smoking
  • Alcohol cessation
  • take small meal low in fat
  • Pancreatic enzyme supplements    pancreatic enzyme supplements ( eg. Creon, Zenpepp ) may help patients with pain persisting after the above interventions. They help with  control of diarrhea, fatty stools.  Enteric coated formulations such as Creon-24,000 lipase, one to two capsules with meals and one capsule with a snack, or a non-enteric coated form such as Viokace Lipase 20,880, three tablets with meals and one to two tablets with a snack. This dose is typically sufficient to improve symptoms.  Non-enteric coated form must be taken with ranitidine or omeprazole.
  • Analgesics :  Analgesia can be considered if pancreatic enzyme therapy fails to control pain
  • Treatment with acid suppression (Ranitidine, Omeprazole, pantoprazole ) should be given along with pancreatic enzyme supplements to reduce inactivation from gastric acid.
  • Treatment of pain : Celiac nerve block

Percutaneous or endoscopic celiac nerve blocks with either alcohol or steroids have had very limited role and  may be considered as a last resort.

  • Steatorrhea (fat malabsorption)

If you suffer from fat malabsorption, restrict the amount  of fat intake (to less than 20 g per day)

If the diarrhea doesnot  get better with dietary restriction,   lipase supplementation  should be started.  As a general rule, 30,000 international units (IU) of pancreatic lipase (90,000 United States Pharmacopeia units [USP]) swallowed during each meal should suffice in reducing steatorrhea and preventing weight loss.

Medium chain triglycerides (MCTs)  [ MCT Oil,  Liquigen, Betaquik ] can provide extra calories in patients with weight loss and a poor response to diet and pancreatic enzyme therapy. This will help build some nutrition.

 

Surgical Treatment

Surgery Decompression procedures have generally been recommended for patients with refractory pain who have a dilated main pancreatic duct. The normal pancreatic duct ranges from 2 to 4 mm in diameter (most narrow in the tail, enlarging as it passes toward the ampulla). A dilated duct (from a surgical standpoint) is one that would permit anastomosis to a loop of jejunum.

Puestow procedure

Surgery has generally been considered for patients who fail medical therapy if the pancreatic duct is dilated, approximately 80 percent of patient benefit with pain control. As we master the art of complex pancreatic surgery, complications related to this procedure is very minimal.