Pain in chronic pancreatitis: What can we do today?

Abstract

The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient’s quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain’s management is challenging considering all these complex aspects and the lack of international protocols.

Keywords: Chronic pancreatitis; Pain; Multifactorial mechanism; Stepwise approach; Endoscopic treatment; Early surgery

Core Tip: The aim of this review is to analyse and discuss treatment options in chronic pancreatitis management. Lifestyle change represents the starting point in uncomplicated chronic pancreatitis (CP). Medical treatment should be the first considered in a stepwise approach. The use of nonsteroidal anti-inflammatory drugs is the gold standard, but opioids, antioxidants, neuromodulators have important roles as well. Endoscopic retrograde cholangiopancreatography, extracorporeal shock wave lithotripsy with or without endoscopy, sphincterotomy with stent placement or transgastric drainage can be chosen in complicated CP patients with obstructions or pseudocysts. A decompressive or resection operation can be chosen in surgical treatment. In conclusion, CP pain management is an ongoing challenge because of lack of international consensus on protocols. Nowadays, a tailored step-up treatment discussed in a multidisciplinary setting is considered the best approach.