Management of chronic pancreatitis: Conservative, endoscopic, and surgical

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Chapter 55B Management of chronic pancreatitis

Conservative, endoscopic, and surgical

Overview

Chronic pancreatitis (CP) is a progressive, destructive, inflammatory process that ends in total destruction of the pancreas and results in malabsorption, diabetes mellitus, and severe pain. Incidence and prevalence of CP varies between continents and countries. Most studies from Western countries show comparable incidence and prevalence rates of around 7 per 100,000 and 28 per 100,000, respectively (Lankisch et al, 2002; Levy et al, 2006). The numbers reported from Asia are markedly higher with a rapidly rising incidence (Otsuki & Tashiro, 2007; Wang et al, 2009). The etiologic factors associated with CP are commonly summarized using the TIGAR-O classification: toxic–metabolic (in the West, alcohol and tobacco are associated in approximately 80% to 90% of cases), idiopathic, genetic (PRSS1, CFTR, or SPINK1 gene mutations), autoimmune, recurrent and severe acute pancreatitis, or obstructive (pancreas divisum, sphincter of Oddi dysfunction, or neoplasm) (Etemad & Whitcomb, 2001). Tropical CP is a common entity in India, southern Africa, and parts of South America and typically affects younger patients. Tropical CP is often classified as idiopathic but may in fact have a mixed etiology that includes nutritional, metabolic, and genetic factors (Mohan et al, 2003). Current evidence suggests that a combination of predisposing factors—environmental, toxic, and genetic—is likely involved in most cases rather than a single factor. The sentinel acute pancreatitis event (SAPE) hypothesis proposes a sentinel event of acute pancreatitis that initiates the inflammatory process, which is then sustained by a combination of the mechanisms mentioned above (Whitcomb, 1999).

Repeated episodes of inflammation initiated by autodigestion, oxidative stress, one or more episodes of severe pancreatitis, and toxic-metabolic factors can lead to activation and continued stimulation of pancreatic stellate cells. Histologically, CP is characterized by inflammatory infiltration, acinar atrophy, formation of metaplastic ductal lesions (tubular complexes and pancreatic intraepithelial neoplasia), extended fibrosis, and in some cases by focal necrosis and cysts (Klöppel, 2007). Furthermore, neural hypertrophy and perineural inflammation can frequently be observed and are the correlate of neuropathic pain (Ceyhan et al, 2009a).

Clinically, the course of CP is characterized by recurrent episodes of upper abdominal pain, which represents the most common indication for endoscopic and surgical intervention. Although pain attacks and intensity might decrease over time, the so called “burnout” of the gland does not regularly occur, and more than 50% of patients will come to medical attention with persistent pain even 15 years after initiation of the disease. Furthermore, patients may be seen with symptoms of endocrine insufficiency (diabetes mellitus) and exocrine insufficiency (diarrhea, steatorrhea, malnutrition, and weight loss).

In the natural course of CP, endocrine and exocrine insufficiency frequently develops secondary to the fibrotic changes of the pancreas. As a result of morphologic changes of the pancreas, patients frequently develop local complications. Inflammatory ductal changes and intraductal calculi (pancreatolithiasis) may result in obstruction of the pancreatic duct or of the intrapancreatic portion of the bile duct. An inflammatory mass of the pancreatic head, as it is regularly observed in European and American series (Beger et al, 1999; Jimenez et al, 2000), frequently results in obstruction of the duodenum and affects the splenic, superior mesenteric, or portal vein with subsequent thrombosis. Development of pancreatic pseudocysts represents another local complication, which results in obstruction, abscess formation, or in ascites or pleural effusions in cases of rupture (see Chapter 54). A rare but severe local complication of CP is vascular erosion presenting as gastrointestinal hemorrhage or, less frequently, as intraabdominal bleeding (see Chapter 19). Finally, CP is a risk factor for the development of pancreatic cancer (see Chapter 58A, Chapter 58B ); patients with CP have a fourfold higher risk of cancer than individuals without it. Especially in the management of patients with an “inflammatory mass,” this differential diagnosis has to be considered (Pedrazzoli et al, 2008).

The treatment of CP is complex; in the majority of cases, an interdisciplinary approach is indicated that includes conservative, endoscopic, and surgical therapy.

Conservative Treatment

Pancreatic Exocrine Dysfunction

In Western countries, the number of patients suffering from pancreatic exocrine insufficiency has increased. The most common cause is an increase in alcohol consumption with a concomitant increase of CP (FitzSimmons, 1993). The main goal of therapy for pancreatic exocrine dysfunction is to avoid fat maldigestion. Reasons for earlier and more severe impairment of fat digestion, compared with protein and carbohydrate digestion, in patients with pancreatic insufficiency are that 1) impairment of pancreatic lipase synthesis and secretion occurs earlier; 2) more rapid and complete inactivation of lipase occurs in the acidic duodenum as a result of impaired bicarbonate output; 3) proteolytic degradation of lipase occurs earlier during aboral transit than with amylase and proteases; 4) impairment of pancreatic bicarbonate secretion decreases duodenal pH, resulting in precipitation of glycine-conjugated bile acids and further deterioration of fat digestion; and 5) extrapancreatic sources of lipase are unable to compensate for loss of pancreatic lipase activity.

For all of the reasons listed, steatorrhea is the leading symptom in patients with pancreatic exocrine insufficiency.

Pancreatic Exocrine Enzyme Supplementation

When weight loss or steatorrhea (≥15 g/day) or both develop, supplementation of pancreatic enzymes is indicated. Dyspepsia, diarrhea, meteorism, and malabsorption of proteins and carbohydrates also have been cited as indications. Another interesting indication for pancreatic enzyme supplementation, although not formally studied, is in the treatment of pain (discussed in the next section). The main goal of the treatment of pancreatic exocrine dysfunction is to ensure that optimal amounts of lipase reach the duodenum with the delivered food. With the currently available pancreatic enzyme supplement preparations, azotorrhea (protein malabsorption) can be eliminated (Brady et al, 1991), whereas steatorrhea usually can be reduced but not totally corrected.

Four different types of pancreatic exocrine enzyme preparations are available. Uncoated preparations show only poor effects because of their inactivation by gastric acid. Huge doses of enzymes are required to have any effect on fat malabsorption. These preparations should be used only in patients with pancreatic exocrine insufficiency and hypochlorhydria or achlorhydria. The use of enteric-coated tablets is strongly discouraged, because these preparations are ineffective for decreasing fat excretion owing to erratic enzyme release. The superiority of enteric-coated microsphere preparations over conventional enzyme preparations with regard to decrease in stool fat excretion has been firmly established (Layer & Holtmann, 1994). Pancreatic enzymes in these preparations are protected at low pH by a special polymer coating. The release of the enzymes occurs only at a pH of at least 4.5. Simultaneous administration of antacids, H2-receptor antagonists, or proton pump inhibitors is unnecessary. Unfortunately, microencapsulation results in a considerable increase in costs. Another problem concerning enteric-coated microspheres might be considerable differences in the diameter of the microspheres and in their physical nature as a result of differences in the manufacturing process; however, clinical differences in the various enteric-coated microsphere preparations have not yet been proofed.

The use of enzyme preparations in combination with acid-reducing compounds also is not justified for many reasons, although additional administration of proton pump inhibitors or H2-receptor antagonists reduces fecal nutrient loss. These preparations are expensive, there is a variability of the effects owing to the acid-reducing therapy, and especially in children, the safety of long-term administration has not been firmly established (Lebenthal et al, 1994).

Certain bacterial and fungal lipases have shown no benefit in the treatment of pancreatic steatorrhea, although they are resistant against acid denaturation and proteolytic digestion. Decreased lipolytic activity of fungal lipase in the presence of bile acids could explain the fact that no superiority over enteric-coated microsphere preparations has been demonstrated to date (Griffin et al, 1989; Zentler-Munro et al, 1992).

Although rare, possible side effects of pancreatic exocrine enzyme supplementation are sourness of the mouth, perianal irritation, abdominal pain, diarrhea, constipation in infants, allergic reactions to pork proteins, hypersensitivity reactions after inhalation, and fibrosing colonopathy in cystic fibrosis patients (Lebenthal et al, 1994; Loser & Folsch, 1995). In regard to fibrosing colonopathy, it has been recommended that the maximum dose of lipase should not exceed 10,000 IU/kg body weight per day, or 2500 IU/kg body weight per meal.

Substitution Therapy in Chronic Pancreatitis

Approximately 80% of patients with CP can be managed by dietary means and pancreatic enzyme supplements. Some patients (10% to 15%) need oral supplements (polymeric or semielemental), 5% need enteral tube feeding, and approximately 1% need total parenteral nutrition (TPN). Reduction of steatorrhea and supplementation of calories are the main goals of nutritional therapy in CP. Treatment of exocrine insufficiency starts with dietary therapy and pancreatic enzyme supplementation (DiMagno, 1979).

Total abstinence from alcohol and partaking of frequent meals are basic dietary recommendations. The diet should be rich in proteins (1.0 to 1.5 g/kg body weight/day) and carbohydrates, although carbohydrates must be limited when diabetes mellitus is present. In addition, 30% to 40% of calories should be in the form of fats. Medium-chain triglycerides may be used to increase fat absorption, because they are absorbed directly across the small bowel into the portal vein, even in absence of lipase, co-lipase, and bile salts. Vitamins should be supplemented if serum levels indicate a deficiency (Havala et al, 1989). Patients with protein maldigestion and steatorrhea must be supplemented individually with exogenous pancreatic enzymes. Weight control, symptomatic relief of diarrhea, and a decrease in 72-hour fecal fat excretion are practical end points of therapy.

Enteral nutrition (EN) is indicated when a patient is unable to eat, has progressive weight loss despite an adequate dietary regimen, or develops acute complications; EN may also be indicated preoperatively and postoperatively. Only rarely is TPN indicated in patients with CP, such as when gastric emptying is blocked, when the patient needs gastric decompression, when the feeding tube cannot be introduced into the jejunum, or when a complicated fistula is present. In most cases, surgical intervention can solve these problems.

Conservative Treatment of Pain

Pain significantly reduces patients’ quality of life, and pain relief should be one of the main goals of conservative treatment in CP. Pain also may be treated interventionally or surgically, but medical treatment is generally the first-line therapy in patients with painful CP.

Different medical treatment options and therapeutic interventions are available, and these must be integrated into an individualized treatment plan. The pathogenesis of pain especially influences the therapeutic procedure. Two mechanisms are suggested for the generation of pain in the absence of local complications: 1) inflammatory changes of pancreatic parenchyma with intrapancreatic and peripancreatic neural alterations (Bockman et al, 1988; Ceyhan et al, 2009a, 2009b; Di Sebastiano et al, 1997), and 2) ductal and intraparenchymal hypertension (Di Sebastiano et al, 2003; Ebbehoj et al, 1990).

As for the second mechanism, options that reduce the intrapancreatic pressure may lead to a significant reduction of pancreatic pain. In the case of inflammation, a significant number of inflammatory mediators in pancreatic parenchyma and pancreatic nerves are detected in patients with pain (Ceyhan et al, 2009b; Di Sebastiano et al, 2000). Several medical, analgesic, and antiinflammatory treatment options are available, which may be combined with or supported by interventional methods.

Suppression and Inhibition of Pancreatic Secretion

The effect of pancreatic enzyme preparations on pain is uncertain. A meta-analysis of six studies on enzymes for pain treatment concluded that there is no positive effect, but this conclusion is unreliable because of the heterogeneity of the study groups and significant differences in drug preparations (Brown et al, 1997). A more recently published review that also included data from studies published in abstract form came to a similar conclusion (Winstead & Wilcox, 2009). Further studies are needed to prove whether somatostatin and its analogue octreotide have any impact on pain in patients with CP. A proper placebo randomized controlled trial (RCT) must be performed, which should include 1) the classification of patients as to the etiology of their CP, 2) the systematic assessment of quality of life of patients prior to the initiation of therapy and at regular intervals throughout the study, 3) a priori power analysis estimating a placebo response rate of at least 25%, and 4) multiple planned subgroup analysis (Winstead & Wilcox, 2009).

Analgesics

Guidance for analgesic treatment in patients with CP is based on the consensus report of the German Society of Gastroenterology (Mössner et al, 1998) and the recommendation of the World Health Organization (WHO, 1990). One physician should be responsible for the administration of analgesics. For the first step in pain management, nonnarcotic agents, such as acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs), are recommended. Opioids are often necessary further along. Every patient requires an individualized type and dose of analgesic drug, starting with the lowest dose necessary to control pain. In patients with pain mainly caused by inflammation and by invasion of inflammatory cells, antiinflammatory drugs such as NSAIDs may be helpful. Some patients with CP have depression, which lowers the visceral pain threshold. An additional antidepressant therapy may have an effect on pain and generally increases the effects of opiates.

Interventional Procedures to Treat Pancreatic Pain

Of patients with pancreatic pain, 40% to 70% seem to benefit from medical treatment (Ammann et al, 1984). This percentage may increase by combining medical therapy and interventional procedures (van der Hule et al, 1994). Pancreatic pain may also be improved by the combination of interventional endoscopy and lithotripsy, although a recent RCT demonstrated increased costs but no outcome benefit when systematic endoscopy was added to lithotripsy (Dumonceau et al, 2007). Some studies showed a significant difference in improvement of pain among patients with successful or unsuccessful lithotripsy (Delhaye et al, 1992; Costamagna et al, 1997; Johanns et al, 1996; Ohara et al, 1996; Sauerbruch et al, 1992; Schneider et al, 1994; Smits et al, 1996). Other studies did not report this difference (Adamek et al, 1999).

Celiac plexus neurolysis and celiac block involve injecting an agent at the celiac axis, with the aim of either selectively destroying the celiac plexus or temporarily blocking visceral afferent nociceptors. Agents most commonly used for this purpose include alcohol or phenol for neurolysis and bupivacaine and triamcinolone for a temporary block. Methods to administer such agents to the celiac ganglion include CT imaging, percutaneous ultrasound, fluoroscopy, or endoscopic ultrasound (EUS). Whereas the EUS-guided technique may be superior compared with the other methods, response rates in general are relatively low (Gress et al, 1999; Noble & Gress, 2006; Santosh et al, 2009).

Autoimmune Pancreatitis

A type of CP that might be caused by an autoimmune mechanism was first described by Sarles and collegues (1961) and was termed primary inflammatory sclerosis of the pancreas. Since then, a growing body of evidence suggests that autoimmune pancreatitis (AIP) is distinct from obstructive or calcifying forms of CP. Two clinical and histologic patterns of AIP can be distinguished (Park et al, 2009). Type 1 is characterized by the histologic key features of dense periductal lymphoplasmacytic infiltrate, swirling or storiform fibrosis, and obliterative venulitis; serum levels of the immunoglobulin G4 (IgG4) subclass of IgG are typically increased (Hamano et al, 2001). Type 1 AIP fits the classic description of the disease reported in Japan, also known as lymphoplasmacytic sclerosing pancreatitis. Type 1 AIP appears to be the pancreatic manifestation of a systemic disease that may also affect other organs, including the bile duct, retroperitoneum, kidney, lymph nodes, and salivary glands. Type 2 AIP is typically characterized by a duct-destructive pathology with infiltrating neutrophils, lymphocytes, and plasma cells. Typical serologic markers seen in type 1 AIP are not elevated in type 2 AIP (Park et al, 2009). Typical imaging features—a diffuse, sausage-shaped, enlarged pancreas with delayed and peripheral enhancement—only show up in about 50% of patients. Furthermore, classic features of lymphoplasmacytic sclerosing pancreatitis are found in just 20% of core biopsies, and false-positive IgG4 immunostaining has also been reported in the setting of cancer. Thus the preoperative differentiation from pancreatic carcinoma is a diagnostic challenge. In highly suspected or histologically confirmed cases of AIP, steroid therapy (prednisolone, initially 30 to 40 mg/day) may ameliorate symptoms and imaging findings within two weeks. Importantly, the similarity to pancreatic carcinoma and the absence of specific diagnostic parameters may result in surgical treatment of this disease. Because reports about patients misdiagnosed as having AIP are increasingly encountered, surgery should always be considered in doubtful cases (Gardner et al, 2009).

Endoscopic Treatment In Chronic Pancreatitis

Pancreatic ductal obstruction by fibrotic stenoses and/or calculi are the most frequent indications for endoscopic therapy. Interventional treatment modalities aim to decompress and drain the pancreatic ductal system. Endoscopic interventions (see Chapters 14 and 27)—such as stone extraction, dilations, and stenting—have to be repeated on a regular basis in almost all patients. As a consequence, patients suffer from frequent rehospitalizations.

Two recent RCTs demonstrated the superiority of surgical versus endoscopic therapy in primary success rate, pain relief, and quality of life in patients with duct obstruction in the pancreatic head (Cahen et al, 2007; Dite et al, 2003). On the other hand, a large multicenter study in 1018 patients reported success of endoscopic therapy (multiple sessions) in 65% of patients, with the necessity for surgery in only 24% (Rösch et al, 2002). A study of 61 patients with CP and bile duct stenosis reported a 1-year success rate of 59% with endoscopic stenting and stent replacement every 3 months, but failure of endoscopic therapy occurred in the majority of cases with presence of calcifications, with a success rate of only 7.7%; moreover, 49% of patients who had an unsuccessful interventional therapy underwent surgery within a year (Kahl et al, 2003). In patients with symptomatic pseudocysts and no ductal obstruction, endoscopic drainage procedures may be as safe and effective as surgical drainage but superior to external drainage, as reported in a recent retrospective study (Johnson et al, 2009). However, this result needs confirmation in a larger-scale randomized trial.

Available data suggest recommendations concerning endoscopic versus surgical treatment in CP as follows:

1) Patients with proximal stenosis and no calcifications or inflammatory mass may be treated endoscopically. If two to three repetitive endoscopic treatments fail, the option of surgery must be evaluated.

2) In patients with distal duct obstruction, calcifications, or local complications, surgery is superior to endoscopic treatment. Patients should undergo surgery early in the course of the disease to prevent further deterioration of exocrine or endocrine function.

3) Pancreatic pseudocysts may be treated endoscopically. If endoscopic treatment fails, a surgical drainage procedure is recommended.

Endoscopic treatment options and their possible indications are summarized in Table 55B.1. Endoscopic therapy for pancreatic pseudocysts and common bile duct stenosis associated with CP is discussed in detail here.

Table 55B.1 Interventional and Endoscopic Therapy: Options and Indications

Options Indications
Interventional External Drainage Temporary treatment of a pancreatic abscess or an infected pseudocystFrequently followed by definitive surgical treatmentIf internal drainage is not possible
 
 
Internal Drainage Effective therapy of pseudocysts; no RCTs with comparison to surgery
Endoscopic cystogastrostomy/cystroduodenostomy If anatomically possible: less invasive than surgeryProblems with recurrence and catheter dislocation
 
Endoscopic Ductal Drainage  
ePT Pancreas divisum, sphincter of Oddi dysfunction
ePT plus dilation + stenting of pancreatic duct Proximal stenosis of pancreatic duct
ePT plus lithotripsy and stone extraction Pancreatolithiasis
ePT plus bile duct stenting Bile duct stenosis
Indicators of Poor Outcome  
Distal stenosis of pancreatic duct  
Parenchymal calcifications  
Unsuccessful management after 1 year  

RCT, Randomized, controlled trial; ePT, endoscopic papillotomy

Decompression of Pancreatic Pseudocysts

Pancreatic pseudocysts are a late complication of CP. The main techniques for decompression of pancreatic pseudocysts include transgastric and transduodenal approaches (Sahel, 1990; Dohmoto & Rupp, 1992); these require a clear bulging of the cyst into the gastric or duodenal cavity to ensure a short distance between the cystic wall and the intestinal tract. In this context, endosonography has been shown to reduce the risk of cyst perforation and hemorrhage (Binmoeller et al, 1994; Etzkorn et al, 1995; Grimm et al, 1992).

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