PHM 424 PANCREATITIS AND DILD
What is steatorrhea?
-bulky, foul-smelling stool with oil droplets
-3-4 stools per day
-may be associated with fat-soluble vitamin deficiencies
How is chronic pancreatitis evaluated for with lab results?
-CBC to evaluate for infection (pseudocyst)
-serum amylase and lipase: usually normal or only slightly elevated, low specificity for chronic
pancreatitis
-total bilirubin, alkaline phosphatase, hepatic transaminases may be elevated with ductal
obstruction
How is chronic pancreatitis evaluated for with imaging?
-noninvasive: ultrasound, CT, MRI
-invasive: endoscopic ultrasonography (EUS), endoscopic retrograde
cholangiopancreatography (ERCP)
What is the gold standard for diagnosing chronic pancreatitis in patients where the clinical and
functional evidence of CP is strong but imaging is inconclusive?
- histology
What is the clinical course of chronic pancreatitis?
-exocrine insufficiency when lipase secretion is <10% of normal values; hereditary CP: occurs
at young age; alcohol CP: onset after 5yrs, burnout after 10yrs
-diabetes occurs later than exocrine insufficiency
-shorter life expectancy, death from other chronic diseases, pancreatic malignancy
,What are the treatment goals for chronic pancreatitis?
-control pain
-treat malabsorption and steatorrhea (weight gain)
-prevent/manage weight loss and micronutrient deficiencies
-prevent/manage diabetes
What are the guidelines for chronic pancreatitis treatment?
-alcohol cessation (improves pain but may not alter progression)
-smoking cessation (decrease in pancreatic calcification progress if stop smoking early in
diagnosis)
-eat smaller, more frequent meals
-reduce dietary fat
-enteral nutrition if NPO
How is pain managed in chronic pancreatitis?
-short acting analgesics before meals to prevent postprandial pain
-acetaminophen and NSAID
-add adjuvant agents (can also treat concomitant depression): pregabalin, SSRIs, SNRIs, TCAs
-opioids for refractory pains when all other options have been exhausted
How are opioids dosed in chronic pancreatits?
-begin at lowest dose
-can be used with acetaminophen/NSAID
-caution: additive effects with alcohol
What is the purpose of antioxidants in chronic pancreatitis?
-use is recommended for patients with pain
-thought to reduce oxidative stress and provide anti-inflammatory effect
-consider adding when patient needs opioids to manage pain
How is refractory pain managed in chronic pancreatitis?
, -celiac plexus block: injection of local anesthetic and steroid like bupivacaine and
triamcinolone into and around celiac ganglia
-one treatment may reduce pain for 3-6 months, may be repeated prn after 3 months
-surgery (total pancreatectomy with islet autotransplant) for patients with uncontrollable
refractory pain
What are the guidelines for pancreatic enzymes in CP?
-guidelines do NOT suggest use of pancreatic enzyme supplements to improve pain in CP
-used in patients with CP and exocrine insufficiency to improve malabsorption
How is pancreatic enzyme treatment initiated?
-begin when steatorrhea is documented and persistent weight loss despite dietary
modifications
-[lipase] delivered to duodenum should be ~10% of normal pancreatic output
-dosing based on units of lipase component
-titrate to effect
-enteric coated capsules preferred as lipase is destroyed at low pH
What is the dosing of pancreatic enzyme supplements?
-25,000-50,000 USP of lipase with each meal (half dose for snacks) (adequate dosing
considered 40,000-50,000 USP with each meal)
-administer at beginning of or during meals
-max dose: 90,000 USP lipase per meal
-antisecretory agent: famotidine or omeprazole used with nonenteric coated pancreatic
enzyme capsules or if no improvement with max dose of enzyme
-dosage forms are NOT equivalent/interchangeable
Viokace
- regular release pancreatic enzyme tablets (use with PPI)
Zenpep
What is steatorrhea?
-bulky, foul-smelling stool with oil droplets
-3-4 stools per day
-may be associated with fat-soluble vitamin deficiencies
How is chronic pancreatitis evaluated for with lab results?
-CBC to evaluate for infection (pseudocyst)
-serum amylase and lipase: usually normal or only slightly elevated, low specificity for chronic
pancreatitis
-total bilirubin, alkaline phosphatase, hepatic transaminases may be elevated with ductal
obstruction
How is chronic pancreatitis evaluated for with imaging?
-noninvasive: ultrasound, CT, MRI
-invasive: endoscopic ultrasonography (EUS), endoscopic retrograde
cholangiopancreatography (ERCP)
What is the gold standard for diagnosing chronic pancreatitis in patients where the clinical and
functional evidence of CP is strong but imaging is inconclusive?
- histology
What is the clinical course of chronic pancreatitis?
-exocrine insufficiency when lipase secretion is <10% of normal values; hereditary CP: occurs
at young age; alcohol CP: onset after 5yrs, burnout after 10yrs
-diabetes occurs later than exocrine insufficiency
-shorter life expectancy, death from other chronic diseases, pancreatic malignancy
,What are the treatment goals for chronic pancreatitis?
-control pain
-treat malabsorption and steatorrhea (weight gain)
-prevent/manage weight loss and micronutrient deficiencies
-prevent/manage diabetes
What are the guidelines for chronic pancreatitis treatment?
-alcohol cessation (improves pain but may not alter progression)
-smoking cessation (decrease in pancreatic calcification progress if stop smoking early in
diagnosis)
-eat smaller, more frequent meals
-reduce dietary fat
-enteral nutrition if NPO
How is pain managed in chronic pancreatitis?
-short acting analgesics before meals to prevent postprandial pain
-acetaminophen and NSAID
-add adjuvant agents (can also treat concomitant depression): pregabalin, SSRIs, SNRIs, TCAs
-opioids for refractory pains when all other options have been exhausted
How are opioids dosed in chronic pancreatits?
-begin at lowest dose
-can be used with acetaminophen/NSAID
-caution: additive effects with alcohol
What is the purpose of antioxidants in chronic pancreatitis?
-use is recommended for patients with pain
-thought to reduce oxidative stress and provide anti-inflammatory effect
-consider adding when patient needs opioids to manage pain
How is refractory pain managed in chronic pancreatitis?
, -celiac plexus block: injection of local anesthetic and steroid like bupivacaine and
triamcinolone into and around celiac ganglia
-one treatment may reduce pain for 3-6 months, may be repeated prn after 3 months
-surgery (total pancreatectomy with islet autotransplant) for patients with uncontrollable
refractory pain
What are the guidelines for pancreatic enzymes in CP?
-guidelines do NOT suggest use of pancreatic enzyme supplements to improve pain in CP
-used in patients with CP and exocrine insufficiency to improve malabsorption
How is pancreatic enzyme treatment initiated?
-begin when steatorrhea is documented and persistent weight loss despite dietary
modifications
-[lipase] delivered to duodenum should be ~10% of normal pancreatic output
-dosing based on units of lipase component
-titrate to effect
-enteric coated capsules preferred as lipase is destroyed at low pH
What is the dosing of pancreatic enzyme supplements?
-25,000-50,000 USP of lipase with each meal (half dose for snacks) (adequate dosing
considered 40,000-50,000 USP with each meal)
-administer at beginning of or during meals
-max dose: 90,000 USP lipase per meal
-antisecretory agent: famotidine or omeprazole used with nonenteric coated pancreatic
enzyme capsules or if no improvement with max dose of enzyme
-dosage forms are NOT equivalent/interchangeable
Viokace
- regular release pancreatic enzyme tablets (use with PPI)
Zenpep
