How to get good results with conservative management of chronic pancreatitis?
For about a decade, we have been managing patients with chronic pancreatitis and developed a protocol which has benefited many patients. Most of the patients with chronic pancreatitis can be managed without operative or endoscopic interventions. We differ in our goal for the treatment of chronic pancreatitis from other teams. Our goal is weight gain and less frequent acute pain episodes. These goals have worked well for our patients and though they are more resource consuming on the medical system that we have, we continue to do it for the benefit of our patients.
Our initial evaluation starts with the exclusion of cancer and other diseases with specific treatment and consists of blood tests - ESR, IgG4, rheumatoid factor, ANA, and anti-smooth muscle antibody titer and a CT scan of the abdomen - a standard 3 phase evaluation. Once these patients have no cancer or autoimmune pancreatitis or IPMN, we evaluate for complications that would not have been picked up by imaging - Steatorrhea. we do this by assessing fecal elastase and we use the standard level < 200 mcg/g - to be diagnostic of steatorrhea. If there is clinical steatorrhea, we forego this evaluation as we feel it does not add much to the management of the patient.
Most of the patients with chronic pancreatitis are enrolled on the no alcohol, no smoking program in our center in which we provide counseling for alcohol and smoking and help them quit. We also continue to follow them up for 2 years after the diagnosis and support them till good sobriety is achieved. Persistence in these efforts pay in the long run.
The key dietary factors that a patient with chronic pancreatitis has to follow is to take small frequent meal with high protein intake. It is important to supplement this with at least 3 L water intake per day. In India, we encourage our patients to cook meat in coconut oil, to enhance fat uptake (Coconut oil contains MCT). We also provide them with meal supplements in the form of Peptamen for 10 weeks, especially in the presence of weight loss. In the initial 12 weeks of treatment, we initiate PPI - twice daily, for reducing the acid. We do not continue the medicine indefinitely and use them as needed in the later treatment interventions.
We encourage the patients to follow normal diet patterns as much as possible. No diet is excluded. In India, we find that the protein intake is low and we encourage protein intake as much as possible. All patients undergo a baseline evaluation for diabetic state and are treated as per the results.
We also tell our patients that it is okay to have minor pain episodes as long as it does not become severe to stop them from their regular lifestyle. For any acute episodes, it is better to report to the clinic earlier so that the pain cycle is aborted at the earliest. For patients who have chronic pain, the initial bundle of treatment includes Amitryptiline 10 mg at night for 4 weeks and analgesics based on WHO ladder. We have never given pain medications more than 3 months to any of our patients. We also add pregabalin if needed to support pain management. These medications have to be taken only under medical supervision.
I believe in minimising the operative intervention for chronic pancreatitis and do it under clear indications. Chronic pancreatitis is not curable by surgery and should be undertaken only for severe pain and complications.
Our initial evaluation starts with the exclusion of cancer and other diseases with specific treatment and consists of blood tests - ESR, IgG4, rheumatoid factor, ANA, and anti-smooth muscle antibody titer and a CT scan of the abdomen - a standard 3 phase evaluation. Once these patients have no cancer or autoimmune pancreatitis or IPMN, we evaluate for complications that would not have been picked up by imaging - Steatorrhea. we do this by assessing fecal elastase and we use the standard level < 200 mcg/g - to be diagnostic of steatorrhea. If there is clinical steatorrhea, we forego this evaluation as we feel it does not add much to the management of the patient.
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| Chronic pancreatitis in a 20 year old engineer for whom we did a Frey operation. The recovery time was 5 days. Even though, surgical results can be excellent, we still believe in using medical methods first ahead of surgical treatements. |
Most of the patients with chronic pancreatitis are enrolled on the no alcohol, no smoking program in our center in which we provide counseling for alcohol and smoking and help them quit. We also continue to follow them up for 2 years after the diagnosis and support them till good sobriety is achieved. Persistence in these efforts pay in the long run.
The key dietary factors that a patient with chronic pancreatitis has to follow is to take small frequent meal with high protein intake. It is important to supplement this with at least 3 L water intake per day. In India, we encourage our patients to cook meat in coconut oil, to enhance fat uptake (Coconut oil contains MCT). We also provide them with meal supplements in the form of Peptamen for 10 weeks, especially in the presence of weight loss. In the initial 12 weeks of treatment, we initiate PPI - twice daily, for reducing the acid. We do not continue the medicine indefinitely and use them as needed in the later treatment interventions.
We encourage the patients to follow normal diet patterns as much as possible. No diet is excluded. In India, we find that the protein intake is low and we encourage protein intake as much as possible. All patients undergo a baseline evaluation for diabetic state and are treated as per the results.
Pancreatic ductal stones removed from a single patient. |
We also tell our patients that it is okay to have minor pain episodes as long as it does not become severe to stop them from their regular lifestyle. For any acute episodes, it is better to report to the clinic earlier so that the pain cycle is aborted at the earliest. For patients who have chronic pain, the initial bundle of treatment includes Amitryptiline 10 mg at night for 4 weeks and analgesics based on WHO ladder. We have never given pain medications more than 3 months to any of our patients. We also add pregabalin if needed to support pain management. These medications have to be taken only under medical supervision.
I believe in minimising the operative intervention for chronic pancreatitis and do it under clear indications. Chronic pancreatitis is not curable by surgery and should be undertaken only for severe pain and complications.
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