Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis

Management of chronic pancreatitis

Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.

Management of Pancreatic Calculi in Chronic Pancreatitis: A Review Article

Chronic pancreatitis is a slow, irreversible, and progressive inflammatory condition with abdominal pain, loss of parenchyma, fibrosis, and calculus formation. It also causes loss of exocrine and endocrine function. Gallstones and alcohol is the most frequent cause of chronic pancreatitis. It is also caused by other factors, including oxidative stress, fibrosis, and repeated incidence of acute pancreatitis. Chronic pancreatitis is followed by several sequelae, one of them being formation of calculi in the pancreas. The formation of calculi can occur in the main pancreatic duct, branches of the duct, and parenchyma. The cardinal sign of chronic pancreatitis is pain caused by obstruction of pancreatic ducts and its branches leading to ductal hypertension resulting in pain. The main aim of endotherapy includes pancreatic duct decompression. The management options vary based on the type and size of the calculus. The treatment of choice for small-sized pancreatic calculi is endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction. The large-sized calculi need fragmentation before extraction, which is done by extracorporeal shock wave lithotripsy (ESWL). Surgery can be an option for patients having severe pancreatic calculi if endoscopic therapy fails. For diagnostic purposes, imaging plays a very important role. The treatment options remain complex if the radiological and laboratory findings overlap. Due to advancements in diagnostic imaging, treatment options have become precise and helpful. It can significantly lower the quality of life along with immediate and long-term problems that pose a serious risk to life. This review comprises the various management options available for removing calculi following chronic pancreatitis, including surgical, endoscopic, and medical therapy.

Acute recurrent and chronic pancreatitis in children

Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.

Chronic Pancreatitis: Current Status and Challenges for Prevention and Treatment

This paper reviews the current status of our understanding of the epidemiology, diagnosis, and management of the continuum of pancreatic diseases from acute and recurrent acute pancreatitis to chronic pancreatitis and the diseases that are often linked with pancreatitis including diabetes mellitus and pancreatic cancer. In addition to reviewing the current state of the field, we identify gaps in knowledge that are necessary to address to improve patient outcomes in these conditions.

Smoking Cessation in a Chronic Pancreatitis Population

OBJECTIVES

Smoking is a known risk factor for developing chronic pancreatitis and accelerates disease progression. Smoking cessation remains an important treatment recommendation, but little is known about its effects. This study evaluated smoking cessation in this population and its impact on quality of life.

METHODS

Twenty-seven smokers with chronic pancreatitis participated in a smoking cessation program incorporating the QuitWorks program and individual counseling. Their smoking cessation rates were compared with a control population (n = 200) consisting of inpatients without chronic pancreatitis who smoked. Smokers were also compared with nonsmokers (n = 25) with chronic pancreatitis in terms of quality-of-life indicators.

RESULTS

In 27 patients, 0 had quit smoking at 6 months, 1 at 12 months, and 0 patients at 18 months. There was a 19% quit rate in the control population at the 6-month period. Smokers had a worse quality of life, higher rates of depression and anxiety, and worse coping skills than nonsmokers.

CONCLUSIONS

Smoking cessation in the chronic pancreatitis population is extremely challenging, as shown by our 0% quit rate after 18 months. Given that smokers with chronic pancreatitis also experience a worse quality of life, it becomes even more important to stress the importance of smoking cessation in these patients.

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

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.

Pancreatic Enzyme Supplements Are Not Effective for Relieving Abdominal Pain in Patients with Chronic Pancreatitis: Meta-Analysis and Systematic Review of Randomized Controlled Trials

Background. Pancreatic enzyme supplementation is widely used to treat pain in patients with chronic pancreatitis, despite little evidence for efficacy. We performed a systematic review of the literature and a meta-analysis to investigate its effectiveness. Methods. All randomized controlled parallel or crossover trials in patients with chronic pancreatitis comparing pancreatic enzyme supplementation to placebo were included. The main outcome was improvement in pain score or reduced analgesic consumption. Two independent reviewers extracted data. Mantel-Haenszel random effect model meta-analysis was used whenever methodologically appropriate. Results. Five out of 434 retrieved studies were included in the systematic review. All studies used relatively similar methodology. Four studies using enteric-coated pancreatic enzyme supplementation failed to show any improvement in pain as compared to placebo. The only study using non-enteric-coated enzymes did show reduction in the pain score. There was significant heterogeneity among studies in both analyses. Random model meta-analysis of three studies showed no significant difference in the mean of daily pain score (mean difference: 0.09 (1.57-1.39), p = 0.91) or average weekly analgesic consumption (mean difference: -0.30 (-2.37-1.77), p = 0.77) between the periods of administering pancreatic enzyme supplementation versus placebo. Conclusion. Pancreatic enzyme supplements do not seem to relieve abdominal pain in patients with chronic pancreatitis and should not be prescribed solely for this purpose, given their significant cost and potential side effects.

[Recent Advances in Management of Chronic Pancreatitis]

Treatment for chronic pancreatitis (CP) should be started early to prevent further pancreatic fibrosis and managed with a multidisciplinary approach to prevent complications and to maintain a good quality of life. The management strategies of CP can be divided into medical, endoscopic, and surgical treatment. The role of pancreatic enzymes and antioxidants for pain relief is not clearly defined, but their role in maintaining nutritional support by correcting exocrine insufficiency is well established. Endoscopic treatment is applied for resolution of pancreatic or bile duct strictures, clearance of pancreatic duct stones, and pseudocyst drainage. Endosonography-guided celiac plexus or celiac ganglia block for pain relief are known to be safe procedures but evidence for their effectiveness is still lacking. Surgery is commonly recommended when endoscopic therapy fails or there is suspicion of malignancy. New evidence-based guidelines for the management of CP are needed.

Pancreatic enzyme replacement therapy in patients with exocrine pancreatic insufficiency due to chronic pancreatitis: a 1-year disease management study on symptom control and quality of life

OBJECTIVE

Exocrine pancreatic insufficiency (EPI) is frequent in patients with chronic pancreatitis (CP). This 1-year, prospective, multicenter, observational, disease management study aimed to assess symptom improvement and quality of life in patients with CP with EPI who were receiving pancreatic enzyme replacement.

METHODS

Patients with CP and chronic EPI were either assigned to cohort 1 that consisted of patients already taking pancreatin (Kreon; Abbott Arzneimittel GmbH, Hannover, Germany) or cohort 2 that consisted of patients with newly diagnosed EPI without prior pancreatic enzyme treatment. Symptoms were documented, and quality of life was assessed using the gastrointestinal quality of life index (GIQLI) at baseline, 6 months, and 1 year.

RESULTS

A total of 294 patients were evaluated (cohort 1, n = 206; cohort 2, n = 88). The proportion of patients experiencing gastrointestinal symptoms and recurrent pain after 1 year was significantly reduced in both cohorts (P < 0.001). The alleviation of symptoms was reflected in GIQLI score improvements at 1 year in both cohorts (P < 0.001), independent of CP severity and etiology. Improvements in GIQLI score were more pronounced in cohort 2 (P < 0.001).

CONCLUSIONS

Pancreatin demonstrated symptom relief and improvement in quality of life in patients with CP-related EPI in this disease management study.

Treatment options in painful chronic pancreatitis: a systematic review

BACKGROUND

Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options.

METHODS

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction.

RESULTS

A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed.

CONCLUSIONS

First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.

Pain management in chronic pancreatitis: taming the beast

Abdominal pain is a principal and in many cases, the only observable symptom of chronic pancreatitis. Like all chronic pain conditions, managing abdominal pain in chronic pancreatitis remains an onerous task for health care providers. Different mechanisms have been postulated in trying to better understand the pathogenesis of pain in chronic pancreatitis. This review seeks to take a broad look at the various options that are available to providers in trying to achieve pain relief and a better quality of life for chronic pancreatitis patients.

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment)

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Meta-analysis: the placebo rate of abdominal pain remission in clinical trials of chronic pancreatitis

OBJECTIVES

Treatment of the pain caused by chronic pancreatitis (CP) is not standardized. Knowledge of the response to placebo in this setting may aid the design of future trials. We aimed at investigating the placebo effect on abdominal pain remission rates in patients with CP.

METHODS

MEDLINE, EMBASE, and Scopus were searched, and randomized placebo-controlled trials in CP providing data on abdominal pain remission rates in placebo arms were included. Pooled estimates of the placebo rate were calculated using random-effects logistic regression analysis. Stratum-specific rates for different patients and study-level covariates were calculated to account for heterogeneity.

RESULTS

Seven randomized controlled trials (202 placebo-treated patients) met the predefined criteria. The pooled estimate of the placebo rate for pain remission was 19.9% (95% confidence interval, 9%-36%). There was a statistically significant heterogeneity among the studies (I(2) = 76%; P < 0.001). A multicenter design, a run-in period of less than 2 weeks, and absence of a washout in crossover trials were all significant sources of heterogeneity associated with higher placebo responses.

CONCLUSIONS

This meta-analysis identifies for the first time the efficacy of placebo for pain in CP and variables determining it. These data provide a sound basis for designing future placebo-controlled randomized clinical trials for the treatment of pain in CP.

Antioxidants and chronic pancreatitis: theory of oxidative stress and trials of antioxidant therapy

Chronic pancreatitis (CP) is an inflammatory disease characterized by the progressive destruction of pancreatic tissue and resulting in pancreatic exocrine and endocrine insufficiency. Increased oxidative stress has been implicated as a potential mechanism in its etiology and pathology. A number of studies have demonstrated that CP patients have a compromised antioxidant status, which may be a contributing factor to the enhanced oxidative state associated with the disease. Nutrition is an essential consideration in the treatment of CP, especially since diet is a source of several antioxidants and cofactors required for the production of cellular antioxidant enzymes. Many CP patients have an inadequate intake of macro and micronutrients because of abdominal pain and discomfort, which often increase postprandially and discourage eating. Exocrine insufficiency leads to further complications by preventing adequate digestion and absorption of ingested food, thus causing even greater deficiencies and impairment of antioxidant status. The aims of this article are to review the oxidative stress model of CP and to examine the evidence for nutrition, and, particularly, antioxidants, in the treatment of CP.

Update on endoscopic management of main pancreatic duct stones in chronic calcific pancreatitis

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

Modern treatment of patients with chronic pancreatitis

CP remains a challenging disease. Endoscopic and surgical management, along with antioxidants, have helped in reducing chronic pain. Management of exocrine and endocrine insufficiency forms the cornerstone for improving nutrition in these patients. Newer therapeutic targets that will transcend the management of CP beyond just pain control and enzyme supplementation are required in the future.

Pancreatic nociception--revisiting the physiology and pathophysiology

BACKGROUND

Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas.

OBJECTIVES

This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC).

RESULTS

Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms.

CONCLUSIONS

Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.

The rosemont criteria can predict the pain response to pancreatic enzyme supplementation in patients with suspected chronic pancreatitis undergoing endoscopic ultrasoun

Background/Aims

The Rosemont classification system was designed to standardize the endosonographic assessment of chronic pancreatitis. To determine whether the Rosemont classification system can predict the response to pancreatic enzyme supplementation in patients undergoing endoscopic ultrasound (EUS) evaluation of suspected chronic pancreatitis.

Methods

Sixty-five patients were included with abdominal pain undergoing endosonography for suspected chronic pancreatitis were included. Patients completed a questionnaire for evaluation of their abdominal pain. Group 1 (n=13) had EUS findings consistent with or suggestive of chronic pancreatitis. Group 2 (n=45) had EUS findings that were normal or indeterminate in the Rosemont classification system. Patients were given pancreatic enzyme supplementation and then given a follow-up pain questionnaire for a mean of 37 days subsequent to EUS regarding the change in pain.

Results

Group 1 patients were more likely to have a response to pancreatic enzymes (62% vs 24%, p=0.012) and a decrease in their pain scale ratings (2.62 vs 0.29, p=0.01). Computed tomography findings of chronic pancreatitis and narcotic use did not predict the response to pancreatic enzyme supplementation. The individual Rosemont criteria of hyperechoic foci with shadowing (p=0.03), lobularity (p=0.02), and stranding (p=0.001) were associated with improvement of pain after treatment.

Conclusions

The Rosemont classification system can identify patients who are more likely to have improvement in abdominal pain after treatment with pancreatic enzyme supplementation.

Current treatment options for chronic pancreatitis

Chronic pancreatitis (CP) is characterized by progressive and ultimately irreversible pancreatic injury. Alcohol abuse is the most common cause of CP in the Western world. As the pathophysiology of this disorder is better understood, it is probable that the treatment will be more successful. Therapeutic efforts for CP are focused on the treatment of maldigestion, pain, and diabetes. Dosage and timing of enteric-coated pancreatic enzymes are important issues in the treatment of malabsorption due to CP. Non-enteric-coated enzyme preparations along with acid suppression (histamine-2 blockers or proton-pump inhibitors) are of limited to modest effectiveness in treating pain caused by CP but are worth a trial in patients with less advanced disease. Extracorporeal shock wave lithotripsy (ESWL) of calcified stones is sometimes needed to achieve stone fragmentation before endoscopic removal. The role of ESWL alone in relieving calcified CP pain needs further study. Endoscopic therapy is aimed at decompressing the obstructed pancreatic duct and removal of pancreatic stone and is associated with pain relief in many patients. The role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with CP whose pain has not responded to other modalities. Radiation therapy to the whole pancreas for CP pain relief is a revived treatment option that needs further study to confirm the safety and efficacy. Total pancreatectomy followed by autologous islet cell autotransplantation appears to be a potential therapeutic approach but should be considered as the last option in patients with refractory pain who have failed conventional medical, endoscopic, and surgical options.

26. Pain in chronic pancreatitis

Chronic pancreatitis is defined as a progressive inflammatory response of the pancreas that has lead to irreversible morphological changes of the parenchyma (fibrosis, loss of acini and islets of Langerhans, and formation of pancreatic stones) as well as of the pancreatic duct (stenosis and pancreatic stones). Pain is one of the most important symptoms of chronic pancreatitis. The pathogenesis of this pain can only partly be explained and it is therefore often difficult to treat this symptom. The management of pain induced by chronic pancreatitis starts with lifestyle changes and analgesics. For the pharmacological management, the three-step ladder of the World Health Organization extended with the use of co-analgesics is followed. Interventional pain management may consist of radiofrequency treatment of the nervi splanchnici, spinal cord stimulation, endoscopic stenting or stone extraction possibly in combination with lithotripsy, and surgery. To date, there are no randomized controlled trials supporting the efficacy of radiofrequency and spinal cord stimulation. The large published series reports justify a recommendation to consider these treatment options. Radiofrequency treatment, being less invasive than spinal cord stimulation, could be tested prior to considering spinal cord stimulation. There are several other treatment possibilities such as endoscopic or surgical treatment, pancreatic enzyme supplementation and administration of octreotide and antioxidants. All may have a role in the management of pain induced by chronic pancreatitis.

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

BACKGROUND

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients.

AIM

To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres.

METHODS

Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians.

RESULTS

Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%.

CONCLUSIONS

Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

Pancreatic enzymes for chronic pancreatitis

BACKGROUND

The efficacy of pancreatic enzymes in reducing pain and improving steatorrhoea is debatable and the evidence base for their utility needs to be determined.

OBJECTIVES

To evaluate the efficacy of pancreatic enzymes in patients with chronic pancreatitis. The specific objectives were to compare the following: 1) pancreatic enzyme versus placebo; 2) different pancreatic enzyme preparations and 3) different dosage schedules of the enzyme preparations. We evaluated the following outcomes: change in frequency of abdominal pain, duration of pain episodes, intensity of pain, weight loss, steatorrhoea, faecal fat and quality of life.

SEARCH STRATEGY

We devised a search strategy to detect all published and unpublished literature and the search included CENTRAL (The Cochrane Library 2009, issue 1), MEDLINE (1965 to February 2009) and EMBASE (1974 to Feburary 2009). We handsearched reference lists and published abstracts from conference proceedings to identify further relevant trials. The date of the last search was April 2009.

SELECTION CRITERIA

Randomised controlled trials with or without blinding. We included abstracts or unpublished data if sufficient information was available.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted and pooled the data pertinent to study outcomes. We combined continuous data using standardised mean difference (SMD) with 95% confidence interval (CI) and calculated the odds ratio (OR) for dichotomous data (95% CI).

MAIN RESULTS

Ten trials, involving 361 participants, satisfied the inclusion criteria. All the trials were randomised; two had a parallel design while the remainder had a cross-over design. Although some individual studies reported a beneficial effect of pancreatic enzyme over placebo in improving pain, incidence of steatorrhoea and analgesic consumption, the results of the studies could not be pooled for these outcomes. With the use of pancreatic enzymes, we observed a non-significant benefit for weight loss (kg) (SMD 0.06; 95% CI -0.23 to 0.34); a significant reduction in faecal fat (g/day) (SMD -1.03; 95% CI -1.60 to -0.46) and non-significant difference in subjects' Clinical Global Impression of Disease Symptom Scale (SMD -0.63; 95% CI -1.41 to 0.14). We found no significant benefit in reducing faecal fat with any particular schedule of enzyme preparation or type of enzyme.Another small study did not show any significant benefit of timing the administration of enzyme preparations in relation to meals on faecal fat.

AUTHORS' CONCLUSIONS

The role of pancreatic enzymes for abdominal pain, weight loss, steatorrhoea, analgesic use and quality of life in patients with chronic pancreatitis remains equivocal. Good quality, adequately powered studies are much warranted.

Delayed release pancrelipase for treatment of pancreatic exocrine insufficiency associated with chronic pancreatitis

Pancreatic enzyme supplements (PES) are used in chronic pancreatitis (CP) for correction of pancreatic exocrine insufficiency (PEI) as well as pain and malnutrition. The use of porcine pancreatic enzymes for the correction of exocrine insufficiency is governed by the pathophysiology of the disease as well as pharmacologic properties of PES. Variability in bioequivalence of PES has been noted on in vitro and in vivo testing and has been attributed to the differences in enteric coating and the degree of micro-encapsulation. As a step towards standardizing pancreatic enzyme preparations, the Food and Drug Administration now requires the manufacturers of PES to obtain approval of marketed formulations by April 2010. In patients with treatment failure, apart from evaluating drug and dietary interactions and compliance, physicians should keep in mind that patients may benefit from switching to a different formulation. The choice of PES (enteric coated versus non-enteric coated) and the need for acid suppression should be individualized. There is no current standard test for evaluating adequacy of therapy in CP patients and studies have shown that optimization of therapy based on symptoms may be inadequate. Goals of therapy based on overall patient presentation and specific laboratory tests rather than mere correction of steatorrhea are needed.

Clinical trials of pancreatic enzyme replacement for painful chronic pancreatitis--a review

Painful chronic pancreatitis is a challenging problem for clinicians and patients. Many patients receive a therapeutic trial of pancreatic enzyme supplementation at some point in the course of their disease, but it is unclear what the expected outcome of such a trial should be and whether or not all patients should receive a trial of pancreatic enzymes. We searched PubMed for all studies of pancreatic enzyme supplementation for painful chronic pancreatitis from 1980 to the present. We also searched the references of identified manuscripts and requested additional information from study authors when necessary. Manuscripts were assessed for study design, bias, pain assessment, and pain management protocol. The results are described in full.

Review article: pain and chronic pancreatitis

BACKGROUND

Pain in chronic pancreatitis chronic pancreatitis is a frustrating and challenging symptom for both the patient and clinician. It is the most frequent and most significant symptom. Many patients fail the currently available conservative options and require opiates or endoscopic/surgical therapy. Aim To highlight the pathophysiology and management of chronic pancreatitis pain, with an emphasis on recent developments and future directions.

METHODS

Expert review, utilizing in addition a comprehensive search of PubMed utilizing the search terms chronic pancreatitis and pain, treatment or management and a manual search of recent conference abstracts for articles describing pain and chronic pancreatitis.

RESULTS

Pancreatic pain is heterogenous in its manifestations and pathophysiology. First-line medical options include abstinence from alcohol and tobacco, pancreatic enzymes, adjunctive agents, antioxidants, and non-opiate or low potency opiate analgesics. Failure of these options is not unusual. More potent opiates, neurolysis and endoscopic and surgical options can be considered in selected patients, but this requires appropriate expertise. New and better options are needed. Future options could include new types of pancreatic enzymes, novel antinociceptive agents nerve growth factors, mast cell-directed therapy, treatments to limit fibrinogenesis and therapies directed at the central component of pain.

CONCLUSIONS

Chronic pancreatitis pain remains difficult to treat. An approach utilizing conservative medical therapies is appropriate, with more invasive therapies reserved for failure of this conservative approach. Treatment options will continue to improve with new and novel therapies on the horizon.

Pain management in chronic pancreatitis

Abdominal pain is a major clinical problem in patients with chronic pancreatitis. The cause of pain is usually multifactorial with a complex interplay of factors contributing to a varying degree to the pain in an individual patient and, therefore, a rigid standardized approach for pain control tends to lead to suboptimal results. Pain management usually proceeds in a stepwise approach beginning with general lifestyle recommendations. Low fat diet, alcohol and smoking cessation are encouraged. Analgesics alone are needed in almost all patients. Maneuvers aimed at suppression of pancreatic secretion are routinely tried. Patients with ongoing symptoms may be candidates for more invasive options such as endoscopic therapy, and resective or drainage surgery. The role of pain modifying agents (antidepressants, gabapentin, peregabalin), celiac plexus block, antioxidants, octreotide and total pancreatectomy with islet cell auto transplantation remains to be determined.

Pancreatic enzyme pharmacotherapy

Supplemental pancreatic enzyme preparations are provided to patients with conditions of pancreatic exocrine deficiency such as chronic pancreatitis and cystic fibrosis. These patients frequently experience steatorrhea, which occurs from inadequate fat absorption. The delivery of sufficient enzyme concentrations into the duodenal lumen simultaneously with meals can reduce nutrient malabsorption, improve the symptoms of steatorrhea, and in some cases alleviate the pain associated with chronic pancreatitis. Current clinical practices dictate administration of lipase 25,000-40,000 units/meal by using pH-sensitive pancrelipase microspheres, along with dosage increases, compliance checks, and differential diagnosis in cases of treatment failure. Despite the large number of specialty enzyme replacements available commercially, many patients remain dissatisfied with standard therapy, and future developments are needed to optimize treatment in these individuals.

Pain in chronic pancreatitis and pancreatic cancer

Chronic, debilitating abdominal pain is arguably the most important component of chronic pancreatitis, leading to significant morbidity and disability. Attempting to treat this pain, which is too often unsuccessful, is a frustrating experience for physician and patient. Multiple studies to improve understanding of the pathophysiology that causes pain in some patients but not in others have been performed since the most recent reviews on this topic. In addition, new treatment modalities have been developed and evaluated in this population. This review discusses new advances in neuroscience and the study of visceral pain mechanisms, as well as genetic factors that may play a role. Updates of established therapies, as well as new techniques used in addressing pain from chronic pancreatitis, are reviewed. Lastly, outcome measures, which have been highly variable in this field over the years, are addressed.

[Pathogenesis and treatment of pain in chronic pancreatitis]

Chronic pancreatitis is an inflammatory, usually painful disease characterized by progressive fibrosis and the loss of exocrine and endocrine functions. Pain influences the quality of life of patients and may lead to inability to work and frequent hospitalisation. The pathogenesis of pain in chronic pancreatitis is still unclear. Several different mechanisms of pain have been proposed, but pain in chronic pancreatitis is most probably multifactorial. Pain management in chronic pancreatitis is difficult. This is due to the multifactorial origin, there are no standardized methods to quantify pain and patients are often addicted to alcohol in chronic pancreatitis. This review summarises the different hypotheses of pain and the possibilities of pain management in chronic pancreatitis.

Role of CCK/gastrin receptors in gastrointestinal/metabolic diseases and results of human studies using gastrin/CCK receptor agonists/antagonists in these diseases

In this paper, the established and possible roles of CCK1 and CCK2 receptors in gastrointestinal (GI) and metabolic diseases are reviewed and available results from human agonist/antagonist studies are discussed. While there is evidence for the involvement of CCK1R in numerous diseases including pancreatic disorders, motility disorders, tumor growth, regulation of satiety and a number of CCK-deficient states, the role of CCK1R in these conditions is not clearly defined. There are encouraging data from several clinical studies of CCK1R antagonists in some of these conditions, but their role as therapeutic agents remains unclear. The role of CCK2R in physiological (atrophic gastritis, pernicious anemia) and pathological (Zollinger-Ellison syndrome) hypergastrinemic states, its effects on the gastric mucosa (ECL cell hyperplasia, carcinoids, parietal cell mass) and its role in acid-peptic disorders are clearly defined. Furthermore, recent studies point to a possible role for CCK2R in a number of GI malignancies. Current data from human studies of CCK2R antagonists are presented and their potential role in the treatment of these conditions reviewed. Furthermore, the role of CCK2 receptors as targets for medical imaging is discussed.

Childhood pancreatitis

Inflammation of the pancreas has many presentations in children and adolescents. The etiology is often elusive, with a great number of cases being idiopathic. However, there have been a number of recent advances in the areas of cell biology, genetics and imaging technology, which should be highlighted. Herein is provided a review for the reader with particular emphasis on some of these newer advances.

Management of pain in small duct chronic pancreatitis

Small duct chronic pancreatitis (CP) is defined by a nondilated main pancreatic duct, and the morphological and clinical features of chronic pancreatitis with pain are the most prominent symptoms. Current treatment strategies are based on pain history and the location and extent of disease. Traditionally, radical pancreatic resectional procedures have been carried out for small duct CP, especially with an associated head mass of uncertain aetiology. Based on the information from five randomized trials, the duodenum-preserving pancreatic head resection and its modifications have proven to provide excellent long-term pain relief and to be superior to more radical operations. Therefore, these procedures can be considered the standard for small duct CP with head dominant disease. The longitudinal V-shaped excision of the ventral pancreas combines extensive drainage and a limited resection and offers good pain relief in diffuse small duct CP. However, long-term results and larger series are awaited for definite conclusions. Thoracoscopic splanchnicectomy and endosonography-guided celiac plexus blocks require controlled trials before their routine use. This article provides an overview about the current and evidence-based pain management in small duct CP.

Diagnosis and management of chronic pancreatitis

Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.

Treatment of alcoholic pancreatitis

Chronic pancreatitis is characterized by progressive and irreversible loss of pancreatic exocrine and endocrine function. The majority of cases in the Western world are related to alcohol consumption. Treatment of alcoholic chronic pancreatitis has been difficult, since the mechanisms of disease progression and the causes of pain are poorly understood. The conservative management of chronic pancreatitis focuses on (a) avoidance of precipitating factors such as alcohol and smoking; (b) treatment of pain, and (c) replacement of exocrine and endocrine function. There is a lack of good controlled, randomized treatment trials in alcoholic pancreatitis. However, there is good evidence that lifestyle changes, such as alcohol cessation, hamper progression of the disease. Conservative treatment of pain should be based on a stepwise approach; however, underlying causes such as pseudocysts may require endoscopic or surgical therapy. Treatment of exocrine insufficiency requires pancreatic enzyme supplementation and adjustment to several smaller meals per day, while treatment of endocrine insufficiency requires insulin treatment.

Surgical management of chronic pancreatitis and the role of islet cell autotransplantation

Chronic pancreatitis is a disease characterized by disabling pain, inability to eat, steatorrhea, and eventual malnutrition. This often results in repeated hospitalizations and attempts to control symptoms with various analgesic regimens. As a result, the medical treatment of chronic pancreatitis is one of symptomatic management. Eventually, in some, nutritional supplementation becomes a necessity. For a fortunate few, the disease apparently burns itself out in time, lessening pain and improving appetite. In many patients, frustration over pain management and repeated hospitalizations leads to surgical treatment. Various procedures have been devised but, generally, fall into 2 categories: operations to decompress dilated ducts and operations to resect diseased pancreas. Results with either approach are unpredictable and often unsuccessful. For those without dilated ducts or with recurrent pain after surgery, total pancreatectomy has been suggested to remove all inflammatory tissue. This can be coupled with islet cell autotransplantation to avoid the dangers of pancreatogenic diabetes. Appropriate care of the removed pancreas and islet cell separation and purification are critical to this procedure to produce viable cells. Dispersed islets have been shown to successfully engraft and function for indefinite periods of time. Although insulin independence may not be achieved, easier maintenance of blood glucose can usually be realized.

Tropical pancreatitis

Tropical pancreatitis is a special type of chronic pancreatitis that is seen mainly in tropical countries. The prevalence of tropical pancreatitis is about 126/100,000 population in southern India. It occurs usually in young people, involves the main pancreatic duct and results in large ductal calculi. The etiology is not known, but genetic mutations such as the SPINK1 gene mutation and environmental factors are likely causes. Clinically, >90% of patients present with abdominal pain. About 25% of patients develop diabetes which generally requires insulin for its control but is ketosis-resistant. Painless diabetes is another clinical presentation in some patients. Most patients develop malnutrition during the course of the disease. Steatorrhea is less common. Patients with tropical pancreatitis may develop pancreatic cancer as a long-term complication. The diagnosis can be established by plain radiography of the abdomen, ultrasonography, computerized tomography scan of the abdomen or endoscopic retrograde cholangiopancreatography. Management is directed towards relief from pain and control of diabetes and steatorrhea. Pain relief can be obtained by analgesics and enzyme supplementation with preparations rich in proteases. Endotherapy coupled with stone fragmentation by extracorporeal shock wave lithotripsy is an effective therapy for those who fail to respond to medical therapy. Surgical decompression of the main pancreatic duct by lateral pancreato-jejunostomy is reserved for patients with severe pain non-responsive to other forms of therapy.

An enteral therapy containing medium-chain triglycerides and hydrolyzed peptides reduces postprandial pain associated with chronic pancreatitis

BACKGROUND/AIM

Pain in patients with chronic pancreatitis is difficult to manage. We examined if an enteral formulation containing medium-chain triglycerides (MCT) and hydrolyzed peptides would (1) minimally stimulate the exocrine pancreas by blunting cholecystokinin release and (2) decrease pain in patients with chronic pancreatitis.

METHODS

In the first part of the study, on separate days, 6 healthy controls consumed a standard enteral formulation, an enteral formulation containing MCT and hydrolyzed peptides, and a high-fat meal. Baseline and postprandial plasma cholecystokinin (CCK) concentrations were analyzed. Subsequently, 8 patients with chronic pancreatitis were enrolled and instructed to complete a visual analog pain assessment for a baseline period of 2 weeks followed by three cans per day of the enteral formulation containing MCT and hydrolyzed peptides for 10 weeks.

RESULTS

Mean CCK levels for our control subjects were 0.46 +/- 0.29 pM at baseline, 10.75 +/- 0.45 pM in response to the high-fat meal, and 7.9 +/- 1.25 pM in response to the standard enteral formulation. Of note, CCK levels were 1.43 +/- 0.72 pM in response to the enteral supplement containing MCT and hydrolyzed peptides. In patients with chronic pancreatitis, the average improvement in pain scores from baseline to the conclusion of the study was 61.8% (p = 0.01). This corresponded to a clinical improvement in 6 of the 8 patients.

CONCLUSIONS

A complete enteral supplement containing MCT and hydrolyzed peptides minimally increases plasma CCK levels. This therapy may be effective in reducing postprandial pain associated with chronic pancreatitis.

Pathogenesis of pain in chronic pancreatitis: ongoing enigma

The pathogenesis of pain in chronic pancreatitis remains an enigma. The cause of pain is almost certainly multifactorial and may vary at different stages of the disease process. These factors may include the release of excessive oxygen-derived free radicals, tissue hypoxia and acidosis, inflammatory infiltration with influx of pain transmittent substances into damaged nerve ends, and the development of pancreatic ductal and tissue fluid hypertension due to morphological changes of the pancreas. Investigations into the causes of pain have been limited by changes in the dynamics with the progression of the disease process, limitations in studying functional and morphological changes of the pancreas in the clinical setting, and the psychosomatic profile of patients. Many of these patients are addicted to alcohol, and suffer from personality disorders. The difficulty in quantifying pain, which is at best subjective, further compounds the issue, especially when assessing the efficacy of treatment.

Treatment of pancreatic exocrine deficiency

In treating pancreatic exocrine insufficiency the diagnosis of a cause, wherever possible, is a first step. If there is an obstructing lesion, then its relief may be curative. Adequate management depends on dietary manipulation and enzyme replacement. A reduction in fat intake, with accentuation of protein and carbohydrate consumption, is recommended. For enzyme replacement, enteric-coated microspheres are required, taken with adequate acid-suppression with a proton-pump inhibitor. The enzyme supplements, using standard preparations of pancreatin, usually of porcine source, may be as much as 4 to 8 tablets per meal and should be taken with food. Endocrine insufficiency usually requires insulin.

Prevalence of gastroparesis in patients with small duct chronic pancreatitis

INTRODUCTION

The most common symptoms of chronic pancreatitis are abdominal pain, diarrhea, and weight loss. The abdominal pain has no consistent pattern, and nausea and vomiting commonly occur simultaneously. Gastroparesis may produce similar symptoms. These similar symptoms may cause diagnostic confusion, particularly with regard to patients with small-duct chronic pancreatitis, for whom diagnosis of chronic pancreatitis is most difficult. We have observed that coexistent gastroparesis may also interfere with the effectiveness of pancreatic enzyme therapy by failing to deliver proteases into the duodenum and therefore not restoring feedback control of pancreatic secretion.

AIM

To estimate the prevalence of gastroparesis in patients with minimal-change chronic pancreatitis.

METHODOLOGY

Patients with chronic pancreatitis diagnosed on the basis of secretin test results but with otherwise normal pancreatic imaging (ultrasonographic or computed tomographic) findings who had also undergone a gastric emptying study were retrospectively identified. An abnormal secretin test value was defined as a peak bicarbonate concentration in pancreatic secretions of <80 mEq/L after secretin stimulation. Gastroparesis was defined as an emptying half-time greater than 90 minutes.

RESULTS

Fifty-six patients were identified. Twenty-five of the 56 patients (44%) had concomitant gastroparesis and small-duct chronic pancreatitis. Twenty-four of these 25 were women, and 22 of the 25 had idiopathic small-duct chronic pancreatitis.

CONCLUSION

In our referral population, gastroparesis is frequently seen in patients with small-duct chronic pancreatitis. For patients with small-duct disease whose abdominal pain does not respond to pancreatic enzyme therapy, clinicians should consider an evaluation for gastroparesis.

Medical therapy for chronic pancreatitis pain

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.

Involvement of cholecystokinin/gastrin-related peptides and their receptors in clinical gastrointestinal disorders

In this paper the possible roles of cholecystokinin (CCK), gastrin, or gastrin-related peptides and their receptors in human gastrointestinal diseases are reviewed. For CCK/CCK(A) receptors (CCK(A)-R), the evidence for their proposed involvement in diseases caused by impaired CCK release or CCK(A)-R mutations, pancreatic disorders (acute/chronic pancreatitis), gastrointestinal motility disorders (gallbladder disease, irritable bowel syndrome), pancreatic tumor growth and satiety disorders, is briefly reviewed. The evidence that has established the involvement of gastrin/CCK(B)-R in mediating the action of hypergastrinaemic disorders, mediating hypergastrinaemic effects on the gastric mucosa (ECL hyperplasia, carcinoids, parietal cell mass), and acid-peptic diseases, is reviewed. The evidence for their possible involvement in mediating growth of gastric and pancreatic tumours and possible involvement of gastrin-related peptides in colon cancers, is reviewed briefly.