Treatment for acute pancreatitis may include nutritional support with feeding tubes or intravenous (IV) nutrition, antibiotics, and pain medications. Surgery is sometimes needed to treat complications. Treatment for chronic pancreatitis may involve IV fluids; pain medication; a low-fat, nutritious diet; and enzyme supplements. Surgery may be necessary to remove part or all of the pancreas.
IV fluids, Enteral Nutrition, TPN
To allow the pancreas to recover and to prevent damage and irritation, patients with pancreatitis may need to temporarily receive intravenous fluids for hydration. If you are unable to eat for more than 5-7 days, or if you are malnourished, you may begin enteral nutrition via a small tube placed through the nose. This will deliver nutrition formula to your stomach or small intestines. Sometimes enteral nutrition is contraindicated or not tolerated. Under these circumstances, parenteral (intravenous) nutrition is indicated, and is better than no nutrition.
The bile duct is a small tube that carries bile, which is produced in the liver, from the liver and gall-bladder to the small intestine. The pancreatic ducts are small tubes that carry pancreatic juices to the small intestine. These fluids help to break down food, and the two ducts usually join before emptying into the small intestine. If the ducts are narrowed or blocked due to gallstones, a tumor, infection, scarring, pseudocysts, or other trauma or illness, the fluids can build up and cause pancreatitis.
It may be necessary to open the blocked bile or pancreatic duct using a stent, which is a small plastic or metal tube placed within the duct to keep it open. See ERCP for information about this procedure.
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x rays to diagnose and treat pancreatitis and other problems of the pancreatic ducts. ERCP may be performed if a person's bile or pancreatic ducts are suspected of being narrowed or blocked due to pancreatitis or other causes.
During ERCP, a flexible, lighted endoscope is inserted into the esophagus, through the stomach, and into the duodenum (the first part of the small intestine). Contrast dye is injected into the ducts, and x-ray video (fluoroscopy) allows physicians to see any areas of narrowed or blocked flow from the bile duct or pancreatic ducts. If a problem is found, the physicians can then insert special tools through the endoscope to open blocked ducts, break up or remove gallstones, remove tumors in the ducts, or insert stents to restore the flow of pancreatic or bile fluid. A biopsy may also be taken through the endoscope, in order to evaluate cells for infection or cancer.
If gallstones are the cause of pancreatitis, they may be removed during ERCP, to be followed by removal of the gallbladder (called cholecystectomy).
The Pancreas Center is a national leader in the performance of ERCP and other interventional gastrointestinal procedures.
The pancreas is normally stimulated to release pancreatic enzymes when there is undigested food in the intestine. These enzymes join with bile and begin breaking down food in the small intestine.
Enzyme supplements begin predigesting food while it is in the stomach, helping to reduce stimulation of the pancreas caused by food intake. If a patient has digestive enzyme deficiency, enzyme supplements help food to be better absorbed, which improves nutritional intake. Avoiding stimulation of the pancreas also helps to reduce pain associated with pancreatitis.
The Pancreas Center works to find the optimal pain management regimen that enables each patient to remain active and at home rather than in the hospital or unable to maintain normal levels of activity.
Many patients take a regimen of more than one kind of medication. Oral medications include narcotics such as Percocet and oxycodone, and these may be used in conjunction with non-narcotic medicines such as muscle relaxants and antidepressants. Oral methadone is a very good medication for managing chronic pain.
Once an oral regimen is established, acute flare-ups can be managed by temporarily adding medications. If oral medicines can't be tolerated, patients may need to be admitted to the hospital for intravenous medications. Nerve blocks may be used to manage pain for several months at a time: nerve blocks entail the insertion of a needle through the skin in the back to block the signals of the main nerves going to the pancreas. This procedure can also be done endoscopically, in which the bundle of nerves to the pancreas is injected with long-acting pain medication that lasts several months. This is performed using an endoscope through the stomach. Nerve blocks destroy the nerves, but in time they grow back so patients need repeated treatments.
Another approach to managing pain is the use of implantable pain pumps in the spine. Most implantable pumps deliver constant low doses to keep pain manageable, and they may be used in conjunction with oral medications.
Importance of taking pain medications
Some patients express concern about not wanting to become addicted to pain medications. It is important to understand that severe ongoing pain needs to be addressed so that patients can maintain active lives, and a true need for pain medication does not constitute a psychological addiction. Some patients must always use medications, because chronic pancreatitis does not go away and the pain needs to be managed in order for them to function. When chronic pancreatitis is caused by microscopic inflammation of the pancreas, management of ongoing pain does not constitute a social addiction, but rather it is a needed therapy like taking blood pressure medication. Our team tries to use constellations of different medications in order to keep narcotic dosages as low as possible.
Depending on the cause of pancreatitis, the patient's anatomy, level of pain, and other factors, surgery may be an appropriate treatment.
If gallstones are the cause of pancreatitis, surgery to remove the gallstones and possibly the gallbladder may be required. Surgery may be needed to drain pseudocysts, or accumulations of fluid and tissue in the pancreatic area.
Removal of the entire pancreas (total pancreatectomy) may be performed in order to reduce or eliminate intractable pain associated with chronic pancreatitis. Total Pancreatectomy relieves pain in 90% of cases, but causes patients to become diabetic.
To improve the lives of patients who undergo pancreatectomy, the Pancreas Center now offers autologous islet cell transplantation, an innovative process of extracting the patient's own insulin-producing cells and then reinjecting them into the liver after removal of the pancreas. By reinfusing the pancreatic islet cells, this procedure may allow patients to retain some of their insulin-producing function, thereby preventing the difficult-to-treat form of diabetes known as brittle diabetes.