Conservative Therapy of Chronic Pancreatitis

Medical treatment of chronic pancreatitis is based on the three main characteristics of the disease, pain and exocrine and endocrine insufficiency. Pain is the leading symptom of chronic pancreatitis. Patients may suffer from continuous pain or relapsing pain in parallel with relapses of the chronic inflammatory process or complications. Pain may decrease over time due to what is called “burn out” disease. Treatment of pain should be based on its pathogenesis. However, in many instances the pathogenesis of pain remains unclear. Pain may be due to an inflammatory mass of the pancreatic head which doesn`t resolve over time and is best treated by resectional surgery; e.g. duodenum preserving pancreatic head resection. Pain due to obstruction of the main pancreatic duct by calcified protein plaques may be treated by ESWL (extracorporal shock wave lithotripsy) with or without endoscopic placement of a stent into the pancreatic duct. These options are discussed in other chapters. Complications of chronic pancreatitis such as development of pseudocysts, bleeding of a pseudoaneurysm of the splenic artery, obstruction of the bile duct leading to cholestasis are generally not amenable to conservative, medical treatment. Cholangitis due to obstruction of the bile duct is primarily treated by endoscopic drainage with sphincterotomy and placing a biliary stent usually in addition to antibiotics. Development of pancreatic cancer may require surgical resection and chemotherapy. Pain not responding to medical treatment may be treated by endoscopic ultrasound-guided celiac plexus blockade. Again, interventional endoscopic possibilities will not be discussed in this chapter. This review on medical treatment of chronic pancreatitis is based on two recent publications of the author (33, 46). Thus, some degree of overlap is inevitable. However, some new clinical studies on treatment are included as well.