The basic principle of treatment is to remove the cause of the disease and focus on symptom control, improving pancreatic function and treating complications; emphasize the treatment plan based on the principle of individualized treatment; pay attention to a combination of local and systemic treatment, and carry out a combination of etiological and symptomatic treatment, conservative treatment and surgical treatment. At present, most of the treatments are aimed at reducing pancreatic exocrine secretion in order to let the pancreas “rest”, however, the effect is not good. The basic purpose of treatment is to reduce pain, correct pancreatic insufficiency and manage complications.
1.General treatment
(1) Patients with chronic pancreatitis must absolutely abstain from alcohol and avoid overeating.
(2) Caution in the use of certain drugs that may be related to the onset of the disease: salbutamol, estrogen, glucocorticoids, indomethacin, hydrochlorothiazide, methyldopa, etc.
(3) Patients with chronic pancreatitis often have weight loss and malnutrition due to loss of appetite, malabsorption and diarrhea, especially steatorrhea, and should be given a high calorie, high protein, high sugar, high vitamin and low fat diet. The prerequisite to ensure the total daily calorie supply is the supplementation of pancreatic enzyme preparation. Forty percent of the total calories should be supplied by sugar, and the daily protein supplement should be at least 100-200g, half of which should be animal protein, such as fish, meat and eggs.
The supply of fat should emphasize the supplementation of water-soluble, easily absorbed medium-chain fatty acids, which are absorbed into the portal vein rather than the intestinal lymphatic system. Certain long-chain fatty acids have strong stimulating effects and should not be used. For patients with chronic steatorrhea, attention should be paid to the supplementation of adequate fat-soluble vitamins, such as A, D, E, K and B vitamins, and the appropriate supplementation of various trace elements.
For a few patients with advanced chronic pancreatitis with severe loss of pancreatic exocrine function, the therapeutic measures of parenteral nutrition (TPN) can also be used, that is, glucose, medium-chain fatty milk preparations, amino acids and albumin, electrolytes, fat-soluble vitamins, etc. are given from the intravenous route to ensure the supply of calories. TNP therapy can last for weeks or months, and has also been reported to be maintained for several years.
(4) Antibiotics should be used during acute attacks, especially in patients with biliary tract infection. If the acute attack shows severe manifestations, close monitoring should be carried out and growth inhibitors and other drugs should be selected for active treatment.
2, abdominal pain treatment Abdominal pain is the most important symptom of chronic pancreatitis. The degree of pain can range from occasional postprandial discomfort to persistent epigastric pain with nausea, vomiting and weight loss. Abdominal pain severely affects the patient’s quality of life and may lead to addiction to narcotic painkillers.
(1) Causes of abdominal pain.
(1) Acute inflammation of the pancreas: Chronic pancreatitis can often occur multiple times with acute inflammation and similar symptoms in each episode, but generally the subsequent episodes have less abdominal pain than the first and second.
(2) Nervous system involvement: Inflammation of the nervous system innervating the pancreas is another important cause of pain in chronic pancreatitis. It has been found that the number and diameter of interlobular and intralobular nerve bundles in the pancreas increase, and there is disintegration of the myelin sheath of peripheral nerves. When the myelin sheath is disintegrated, inflammatory cells gather around the nerves and release inflammatory mediators to stimulate nerve endings, resulting in pain; however, it is not clear why similar changes also occur in patients without pain.
(iii) Increased pressure in the pancreatic duct: many studies have observed a significant increase in pressure in the pancreatic duct in dilated pancreatic ducts, in pseudocysts, and in the pancreatic parenchyma in chronic pancreatitis with abdominal pain, which can be found at the time of surgery for chronic pancreatitis and return to normal pressure after surgery.
(4) Stenosis of the duodenum or common channel: usually caused by fibrosis of the pancreatic head, also associated with abdominal pain, see “Complications and their management”.
(2) Treatment: The treatment of abdominal pain should depend on the degree and duration of the patient’s pain. In some cases, pain control is very difficult, and it should be noted that placebo treatment has been found to be effective in nearly 30% of cases in many studies. Current treatment is a combination of measures.
The main methods are.
① Analgesic drugs: Generally, a small amount of non-narcotic analgesics are used first, such as aspirin, Somigold tablets (depot pain tablets), indomethacin, acetaminophen and other non-steroidal anti-inflammatory drugs, as well as stronger analgesics such as brucizine (prednisolone) and tramadol.
If the abdominal pain is severe and does affect the quality of life, narcotic analgesics such as cocaine, opium poppyine hydrochloride, pethidine and other opioid derivatives can be applied as appropriate, and small doses of morphine extended-release tablets such as mescaline can also be used, while large doses of morphine can increase the tone of the Oddi sphincter and should not be used. Physicians should minimize the potential for addiction when giving pain medications, especially narcotics.
In addition, when using pain medication, care should be taken to prevent constipation, and it is possible that abdominal discomfort due to constipation may be considered as abdominal pain and be added to pain medication again.
②Reducing pancreatic parenchymal inflammation: If chronic pancreatitis is worsened by acute inflammation, the treatment is the same as for acute pancreatitis, and there is no specific diet to prevent acute inflammatory episodes.
③ Alcohol prohibition: alcohol prohibition is necessary, especially for alcoholic pancreatitis, absolute prohibition of alcohol can relieve pain symptoms in 75% of patients. If patients with alcoholic pancreatitis continue to drink alcohol, their morbidity and mortality rates are greatly increased.
④Lower the pressure in the pancreatic duct.
⑤ Blocking the celiac nerve: ethanol or steroid hormone is injected into the celiac plexus via percutaneous puncture or endoscopically. When the celiac plexus is blocked, it can relieve or alleviate pain for several hours or months, but the overall effect is not ideal. Moreover, injection of ethanol can trigger upright hypotension and mild hemiparesis.
Therefore, this method is limited in its application; it is recommended for combined pancreatic cancer when other treatments are less effective. Nerve blockade with steroid hormones is more effective than ethanol, but also provides only partial relief of pain in up to 50% of patients. In those patients who do respond, their symptoms often recur within 2 to 6 months, but retreatment is effective.
(6) Antioxidant therapy: Some data suggest that patients with chronic pancreatitis have an antioxidant deficiency. Some reports suggest that antioxidant therapy may relieve pain to some extent, but further observational studies are needed.
In conclusion: for most patients with abdominal pain in chronic pancreatitis, medical treatment is unsatisfactory; endoscopic treatment is promising, but further observational studies are needed; surgical treatment can significantly improve symptoms, but it must also be compared with other treatments in a prospective randomized trial to analyze their effects; by improving nerve conduction is generally ineffective, but its approach can be improved.
Most patients with chronic pancreatitis do not require strong treatment. Patients with abdominal pain that occurs only once or twice every 3 to 6 months and whose quality of life is not compromised may be treated with traditional pain medications. Early surgical or endoscopic treatment may protect pancreatic function, but it should not be assumed that its indications can be relaxed.