Review Question - QID 102967

This patient presents with a history and diagnostic imaging suggestive of chronic pancreatitis secondary to alcohol abuse. The first step in management is implementation of lifestyle modification with alcohol cessation, adhering to a low fat diet, and enzyme supplementation for pancreatic insufficiency.

Chronic pancreatitis is a progressive inflammatory disease of the pancreas with destruction of pancreatic exocrine and endocrine cells leading to malnutrition and diabetes. Alcohol abuse is the leading cause of chronic pancreatitis in the Unites States. Diagnosis is made with a CT abdomen demonstrating ductal calcifications, pathognomonic for chronic pancreatitis. Management involves alcohol cessation, and a low fat diet with pancreatic enzyme and insulin therapy as necessary for malabsorption and diabetes. Surgery is reserved for disabling pain refractory to medical management or in cases where concurrent malignancy is suspected. Pain management is approached in a step-up approach.

Nair et al. discuss the diagnosis and management of chronic pancreatitis, specifically they recommend use of pancreatic enzyme supplementation in the event of steatorrhea and malabsorption, as it may not only improve nutrition, but also help relieve pain. Additional therapies target vitamin deficiencies, with repletion of vitamins A,D,E,K, and B12. Of import, the authors comment on the importance of treating concurrent depression, which can be approached with selective serotonin reuptake inhibitors (SSRIs). There should be a low threshold for consultation with a pain specialist, as narcotic dependence is a common consequence of pain management.

Wilder-Smith et al. conducted a randomized control trial to evaluate the efficacy of pain control with oral morphine and tramadol. This study found that a statistically significant greater number of patients rated their analgesia as excellent when treated with tramadol vs. morphine. Additionally, orocecal transit was unchanged after five days with tramadol therapy, whereas it was increased with morphine (P < 0.05). Additionally, more patients had prolonged colonic transit time. These findings drove the authors to conclude that 1) tramadol interfered significantly less with gastrointestinal function compared to oral morphine, and 2) tramadol was more often rated as an excellent analgesic compared to oral morphine.

Figure A shows an axial reconstruction of a CT abdomen demonstrating a highly calcified pancreas, highly suggestive of chronic pancreatitis.

Incorrect Answer:
Answer 2: This patient does not have a pancreatic pseudocyst, and thus requires no decompressive procedure.
Answer 3: This patient has no evidence of biliary obstruction (normal total bilirubin), as such ERCP and stenting is not indicated.
Answer 4: Steroids are used in the management of autoimmune pancreatitis. Additionally, analgesia should be approached through a step-up from acetaminophen and NSAIDs, and when possible incorporating tramadol before narcotics.
Answer 5: Surgical resection is a last resort for patients with intractable pain and symptoms refractory to medical management.