INTRODUCTION:

Pancreatitis simply means inflammation of pancreas. If the pancreas becomes scarred during the attack of acute pancreatitis, it cannot return to its normal state. The damage to the gland continues, worsening over time and leads to chronic pancreatitis. Chronic pancreatitis is a progressive fibro inflammatory disease [1] and it is a heterogeneous complex disease [2] resulting in exocrine and endocrine insufficiency and chronic pain [3]. This disease exists in large duct (often with intra ductal calculi) or in small ducts. The causes of chronic pancreatitis are diverse. It is a condition characterized by permanent and irreversible damage [2]. The etiology is multi fractional [3]. Pain is the main symptom and this pain is in the form of recurrent attacks or constant pain or disabling pain. Management of pain is empirical, involving potent analgesics, endoscopy or surgical and partial or total pancreatectomy [1].

Received on 15.05.2015 Modified on 14.06.2015

Research J. Pharm. and Tech. 8(8): August, 2015; Page 1083-1086

DOI: 10.5958/0974-360X.2015.00188.2

The treatment or management may be medical, surgical or endoscopy. Endoscopic management in chronic pancreatitis consists of procedures aimed at reducing neurogenic sensation, such as celiac plexus block, or drainage procedures aimed at alleviating outflow obstruction of the pancreatic duct. Therapeutic endoscopy is indicated for symptomatic or complicated pseudocyst, biliary obstruction and decompression of pancreatic duct. Surgery includes decompression of large duct disease and resection for small duct disease [3]. However, steroids rapidly reduce the symptoms in patients with autoimmune pancreatitis [1]. Patients with chronic pancreatitis are at a high risk of pancreatic neoplasm [3]. Thus, the natural history of chronic pancreatitis is bleak. Most therapies are aimed at the resting of the pancreas by minimizing exocrine secretion, unfortunately this is relatively ineffective. The goals of treatment include pain management, pancreatic insufficiency. Therapy is similar in patients with acquired and hereditary pancreatitis.[4]

REVIEW OF LITERATURE:

Chronic Pancreatitis management options:

MANAGEMENT TYPE	OPTIONS
Medical	Analgesics Antidepressants Cessation of alcohol and tobacco use Using antioxidants Insulin (for pancreatic diabetes) Low-fat diet and small meals Pancreatic enzymes Steroid therapy Vitamin supplementation.
Endoscopic	Celiac plexus block Pancreatic sphincterotomy Transampullary or transgastric Drainage of pseudocyst
Surgical	*Decompression:* Cystenterostomy Lateral pancreaticojejunostomy (most common) *Resection:* Distal or total pancreatectomy Pancreatoduodenectomy (Whipple procedure)

MEDICAL:

Non-narcotic analgesics (e.g., nonsteroidal anti-inflammatory drugs, acetaminophen, and tramadol) is used in managing painful chronic pancreatitis[5]. Analgesics coupled with antidepressants also can be used. People diagnosed with chronic pancreatitis are strongly advised to stop drinking alcohol[6]. Drinking alcohol is critical because continuous use can hasten disease progression, aggravate chronic pain, and increase mortality. The role of smoking in the progression of fibrosis and functional impairment has also been found. Therefore smoking cessation should also be strongly advised[5]. Patients with confirmed chronic pancreatitis were given treatment with Antox, which contains the antioxidants selenium, betacarotene, L-methionine. Treatment with Antox was associated with significant improvements in quality of life and reduce pain in chronic pancreatitis[7]. Endocrine dysfunction and pancreatic diabetes (diabetes mellitus) requires insulin and dietary restrictions. This occurs when the pancreas does not produce sufficient insulin, the body needs to regulate its blood sugar, and insulin injections may be necessary. A high carbohydrate and low fat diet and eating small amount of frequent meals help prevent aggravating the pancreas. If a person has trouble with this diet, pancreatic enzymes in pill form may be given to help digest the food[6]. Malabsorption is treated with pancreatic enzyme replacement of at least 30,000 units of lipase with each meal[8]. Pancreatic enzymes of approximately 40,000 units of lipase are also used for the treatment of steatorrhea[1].

Anabolic steroid treatment has been suggested for chronic pancreatitis. Anabolic steroids like metandrostendiol is being used in review by Tuzhilin and Dreiling[12].

Vitamin C and E supplements are also given to patients with chronic pancreatitis. Vitamin D deficiencies with chronic pancreatitis are rare but recent reports have suggested an increased risk of vitamin D deficiency; therefore, one-time screening for bone density and vitamin D levels may be considered[13,14].

ENDOSCOPIC:

The celiac plexus lies anterior to the aorta at the level of the celiac artery. Most of the sensory nerves returning from the pancreas and other intraabdominal viscera pass through the celiac ganglion and splanchnic nerves. Interruption of these fibers may lessen pain in patients with chronic pancreatitis [15]. Long acting local anesthetic into the celiac plexus can be used to control pain associated with chronic pancreatitis. But Celiac plexus nerve block and transcutaneous electricalnerve stimulation (TENS) generally are unsatisfactory [8].Therapeutic endoscopy is used for the transampullary or transgastric drainage of pseudocyst in chronic pancreatitis. Ductal decompression by sphincterotomy or stent placement offers pain relief in most patients[16-18].

SURGICAL:

Decompression:

1) Lateral pancreatico-jejunostomy involves

*Unroofing of major and minor pancreatic ducts.

*Side to side Pancreatico-jejunostomy with Roux loop of jejunum

*Short term pain relief in patients.[19,20]

However pain recurred within 3 to 5 years in small amount of patients[19,20]. The principal cause for the failure of this operation was lack of adequate decompression of proximal ducts in HOP and presence of head mass [21].

2) Cystenterostomy is indicated for symptomatic, enlarging, or complicated pseudocyst[1].

Resection:

Pancreatic resection is for patients with disease of the small duct and pain unresponsive to medical therapy. The Whipple procedure and distal pancreatectomy have been used in the past to treat patients with small-duct CP. Newer resection techniques have offered substantial relief of pain related to an inflamed and scarred gland, with preservation of surrounding structures[22].

1)Distal pancreatectomy or total pancreatectomy:

Indication:

*Predominantlydistal pancreatic disease with small duct.

*Failed LPJ.

*Pseudocyst with pseudo-aneurysm in tail pancreas.

*Suspicious of malignancy in tail of pancreas .

The procedure is associated with significant risk of symptomatic recurrence. Long term pain relief is achieved in most of the patient, and completion pancreatectomy is needed in some patients[23],in addition endocrine and exocrine insufficiency develops in half of the patients[24].Total pancreatectomy has been performed increasingly with islet cell transplantation.

2)Total pancreatoduodenectomy:

*Last resort procedure.

*Severe morbidity with total pancreatoduodenectomy is brittle in Diabetes mellitusand lethal episodes of hypoglycaemia[24].

3) Pancreatoduodenectomy: (Whipple’s procedure)

Pancreatoduodenectomy achieves long-term pain improvement and permits return to normal activities[25].

Indication:

*Chronic inflammatory mass involving the uncinate process and ventral pancreas 

* Failure of LPJ ( longitudinal pancreatic ojejunostomy) with undrained uncinate process.

*Duodenal stenosis

Short term pain relief is achieved in most of the patients[26]. The morbidity rate however remains at about 40% and the mortality rate less than 5% at high volume centers[27].

CONCLUSION:

The main problem of Chronic pancreatitis will be pain,lack of exocrine and endocrine insufficiency therefore the management methods such as medical, endoscopical and surgical are being used.

REFERENCES:

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