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Chronic pancreatitis – management of pain and complications

AM Mavunda

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Table of contents:

  • Introduction
  • Management of pain in CP
  • Management of complications in CP

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INTRODUCTION

  • Chronic pancreatitis is a progressive fibro-inflammatory process of the pancreas which results in permanent structural damage, leading to impairment of exocrine and endocrine function.
  • Morphologically divided into large duct type or small duct type with or without calcifications.
  • Incidence of CP is 5-10/100 000 inhabitants, with a median survival rate of 20years.[1]
  • Most common cause is alcohol.
  • Pain is a prevalent feature.

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1. Lohr JM et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterology Journal. 2017. Vol. 5(2); 153-199.

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Pain in chronic pancreatitis (CP)

  • Pain in the mid-epigastrium, radiating to the back, progressively getting worse is the cardinal symptom in CP.
  • Present in 85-90% of patients.
  • 15-30min post-prandial. Lasts hours to days, episodic, in some persistent.

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Pathogenesis of pain in CP

  • Progressive destruction of pancreas by repeated flare-ups of mild and sub-clinical types of acute pancreatitis contribute to the pain.
  • Different systems in the body, local & regional complications of the disease, and A/E of treatment are attributed to the persistent pain.

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Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33 Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1470.

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Management of pain in CP

  • Multi-disciplinary approach.
  • Treatment aimed at underlying aetiology, symptoms, complications.
  • Lifestyle modification, medical, and surgical treatment.

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Lohr JM et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). . United European Gastroenterology Journal. 2017. Vol. 5(2); 153-199.

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Management of pain in CP

  • Lifestyle modification: stop alcohol and smoking (synergistic effect).
  • Psychotherapy, Behavioural therapy.

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Management of pain in CP

  • Medical: WHO analgesia ladder
  • Opiods – 50% of patients use opiods daily.

– long term pain relieve not proven.

– opiods dependence and abuse.

– opiod induced hyperalgesia.

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1.Smith J, Lee A, Gupta R, et al. Surgical decision-making in chronic pancreatitis: a clinical algorithm. Journal of Pancreatic Surgery. 2024;18(3):145–152

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Nerve blocks for pain control

  • EUS guided Celiac plexus block – long acting local anaesthetic & steroids. Temporary pain relieve (up to 69days).
  • EUS guided celiac plexus neurolysis – alcohol or phenol. Induce ablation of nerve fibres.
  • EUS-celiac plexus block is more effective (50-60% pain relief in CP) compared to neurolysis.
  • EUS- celiac plexus neurolysis using alcohol is often considered a placebo effect, and associated with severe pain and ischemic complications in benign conditions (CP). More effective in pancreatic cancer pain control (70-80% pain relief).
  • NB! EUS safer than percutaneous route.

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Moutinho-Ribeiro P, Costa-Moerira P et al. Endoscopic ultrasound-guided celiac plexus interventions. GE Port J Gastroenterology. 2020 July 21; 28(1): 32-38

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Endoscopic interventions for pain

  • Relieve of obstruction: sphincterotomy + balloon dilatation +/- stenting.
  • Highly efficient, minimally invasive, immediate pain relief (80-90%) – and long-term pain relieve over 60%.
  • Managing other complications: pseudocyst drainage, necrosectomy, GOO.

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  1. Jafri M, Sachdev A etal. Efficacy of endotherapy in treatment of pain associated with chronic pancreatitis: A systemic review and meta-analysis. JOP. 2017March 30; 18(2): 125-132
  2. Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33- Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1477

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Surgical management of pain

Indications:

  • Unremitting pain
  • Inability to rule out neoplasm
  • Treatment of complications (local obstruction 2o fibrosis – duodenum; aneurysm; fistula; pseudocyst).

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Types:

  • Drainage procedure
  • Resection procedure
  • Combination of two.

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Surgical management of pain

Principle

Principle

Remark

Peustow procedure

Drainage of dilated duct

Distal pancreactectomy + distal pancreaticojejunostomy anastomosis

Partington-Rochelle

Drainage of dilated duct

Modification of Peustow – without distal pancreatectomy

Table constructed by presenter.

Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33- Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1477

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Surgical management of pain

Procedure

Principle

Remark

Beger procedure

Drainage dilated duct, resect bulky HOP

Duodenum preserving resection portion of HOP, pancreas transected at pancreatic neck.

Frey procedure

Drainage dilated duct, resect bulky HOP

Modification of Beger – pancreatic neck not transected, parenchyma is extensively cored out from HOP to extent of diseased segment distally, lateral pancreaticojejunostomy.

Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33- Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1477

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Surgical management of pain

Procedure

Principle

Remark

Whipple procedure

Resection (HOP mass)

HOP resection (pancreaticodudenectomy)

Subtotal/Total pancreatectomy

Resection (HOP mass, small PD)

Total pancreatectomy, will require pancreatic enzyme supplementation.

Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33- Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1477

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Clinical trial

  • Surgery is superior to endoscopy in mid- and long-term pain relief in CP. (Grd 2B recommendation)
  • However, no clear consensus of opinion for CP + dilated PD.
  • Endoscopy vs Surgical intervention in CP + dilated PD:

- Surgical group had higher pain relief mid- and long-term (2 and 5yrs). 80% surgery vs 38% endoscopy, P=0.042.

- Improved quality of life.

- No difference: major post-op intervention complications, pancreatic function or mortality.

- Endoscopy group, required re-interventions for pain relief (68% vs 5%, P=0.001).

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Cahen DL, Gouma DJ, Laramee P, et al. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis. Gastroenterology 2011; 141: 1690–1695. 249.

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Clinical trial

  • Surgical intervention vs. Conservative treatment

- surgical group resulted in higher pain relief.

- better preservation of pancreatic function.

-> however trial had relatively small number of participants. (17 surg, 15 conservative)

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Lohr JM et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterology Journal. 2017. Vol. 5(2); 153-199.

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Clinical trial

Duodenum preserving pancreatic head resection (DPPHR) vs. conventional pancreaticoduodenectomy:

  • Available data shows both are equally effective for pain relieve, endocrine and exocrine insufficiency are comparable at short term assessment.
  • However, quality of life improved after DPPHR vs PD.

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Diener MK, Rahbari NN, Fischer L, et al. Duodenum preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: A systematic review and meta-analysis. Ann Surg 2008; 247: 950–961. 255.

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OTHER COMPLICATIONS OF CP

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CP complications:

  • Pancreatic insufficiency w Maldigestion/malabsorption – steatorrhoea, malnutrition, weight loss.
  • Type 3c diabetes
  • CBD strictures
  • Duodenal stenosis
  • Pancreatic pseudocyst
  • Pancreatic ascites
  • Venous thrombosis (splenic vein, portal vein)
  • Adjacent arterial pseudoaneurysm
  • Pancreatic adenocarcinoma

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CP complications:

  • Pancreatic insufficiency
    • Exocrine insufficiency results in inability to digest complex foods or absorb partially digested products.
    • Once >90% function is lost, clinically significant fat and protein insufficiency occurs.
  • Fat malabsorption
    • Steatorrhoea – occurs before protein deficiencies.
    • Loose, grey, foul smelling and floating stool.
    • ADEK malabsorption may occur, but clinically evident deficiency is rare.
  • Weight loss may occur due to nutritional deficiencies.
    • Sarcopenia in particular is an indicator for poor outcomes.
  • Weight loss is likely multimodal – pain on eating also contributes.

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MANAGEMENT: small portions low fat diet; pancreatic enzyme supplements.

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CP Complications

  • Pancreatic diabetes
    • Overt DM usually associated with advanced disease.
    • More often associated with significant calcifications in the pancreas
    • Usually insulin dependant diabetes, however because glucagon producing cells (alpha cells) are also affected they become brittle diabetics – high risk for becoming hypoglycaemic.

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MANAGEMENT: lifestyle choices; dietician; oral hypoglycaemic agents; insulin.

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CP Complications

Complication

Management

Pancreatic pleural effusion

Intercostal drain

Pancreatic ascites

Paracentesis

Ductal complications

Endoscopic interventions

Pseudocyst, aneurysm, fistula, GOO

Surgical management

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Image: Brunicardi FC, Andersen DK et al. Schwartz’s Principles of surgery – Chapter 33- Pancreas. Mc Graw Hill. 2019. 11th edition. Vol 1. pg 1450-1477

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CV

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Summary

  • Chronic pancreatitis is a chronic debilitating condition that requires understanding of its pathophysiology of its symptoms and complications.
  • This allows the treating surgeon to choose the most effective intervention for their patient and decrease morbidities and mortalities as well as improve quality of life.

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Thank you.