Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes

Abstract

One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.

Keywords: Chronic pancreatitis; Clinical trials; Fat malabsorption; Pain; Pancreatic enzyme replacement therapy; Pancreatic insufficiency; Protease; Trypsin.

Figure 1

Flow chart demonstrating recommendations for using pancreatic enzyme replacement therapy in a patient with abdominal pain and chronic pancreatitis. ¹Start with non-enteric coated products such as Viokace along with a PPI. The figure suggests approaching the patient with a three-pronged method. First, one should assess the patient’s pain profile and investigate whether the pain is from chronic pancreatitis alone or from other etiologies, i.e., a developing pseudocyst or malignancy. Next, pain control should be attempted first with conservative measures such as lifestyle changes, enzyme supplementation, NSAIDs, and/or gabapentoids before moving to treat with opioids. If opioids are deemed appropriate for pain control, the decision should be consistently reassessed as to avoid dependency and addiction. Second, one should assess the patient for malabsorption, and if present, the patient should be treated with exogenous enzymes as that may improve absorption and pain symptoms. Lastly, the physician should assess the patient’s nutritional status and correct deficiencies, if present. A non-enteric-coated enzyme such as Viokace along with a proton pump inhibitor is recommend for first-line enzymatic treatment. Alternatively, can use combination of non-enteric-coated and enteric-coated formulations. NSAIDs: Nonsteroidal antiinflammatory drugs; PPI: Proton pump inhibitors.