Etiology, Diagnosis, and Modern Management of Chronic Pancreatitis. A Systematic Review
Key PointsQuestion What are the most common etiologies, symptoms, treatments, and outcomes for patients with chronic pancreatitis?
Findings In this systematic review of 75 articles, risk factors for chronic pancreatitis include alcohol abuse, gallstones, and genetic susceptibility, and the most common symptom is abdominal pain. Treatment requires nutritional optimization, pain management, and endoscopic interventions/surgery when conservative measures have failed, and surgery is more effective than endoscopy in long-term pain relief and quality-of-life metrics.
Meaning Management of chronic pancreatitis is multimodal and multidisciplinary; when indicated, surgical intervention may result in long-term pain relief and improved quality of life.
Importance The incidence of chronic pancreatitis is 5 to 12 per 100 000 adults in industrialized countries, and the incidence is increasing. Treatment is multimodal, and involves nutrition optimization, pain management, and when indicated, endoscopic and surgical intervention.
Objectives To summarize the most current published evidence on etiology, diagnosis, and management of chronic pancreatitis and its associated complications.
Evidence Review A literature search of Web of Science, Embase, Cochrane Library, and PubMed was conducted for publications between January 1, 1997, and July 30, 2022. Excluded from review were the following: case reports, editorials, study protocols, nonsystematic reviews, nonsurgical technical publications, studies pertaining to pharmacokinetics, drug efficacy, pilot studies, historical papers, correspondence, errata, animal and in vitro studies, and publications focused on pancreatic diseases other than chronic pancreatitis. Ultimately, the highest-level evidence publications were chosen for inclusion after analysis by 2 independent reviewers.
Findings A total of 75 publications were chosen for review. First-line imaging modalities for diagnosis of chronic pancreatitis included computed tomography and magnetic resonance imaging. More invasive techniques such as endoscopic ultrasonography allowed for tissue analysis, and endoscopic retrograde cholangiopancreatography provided access for dilation, sphincterotomy, and stenting. Nonsurgical options for pain control included behavior modification (smoking cessation, alcohol abstinence), celiac plexus block, splanchnicectomy, nonopioid pain medication, and opioids. Supplemental enzymes should be given to patients with exocrine insufficiency to avoid malnutrition. Surgery was superior to endoscopic interventions for long-term pain control, and early surgery (<3 years from symptom onset) had more superior outcomes than late surgery. Duodenal preserving strategies were preferred unless there was suspicion of cancer.
Conclusions and Relevance Results of this systematic review suggest that patients with chronic pancreatitis had high rates of disability. Strategies to improve pain control through behavioral modification, endoscopic measures, and surgery must also accompany management of the sequalae of complications that arise from endocrine and exocrine insufficiency.