MKSAP: 60-year-old man with constant low-grade epigastric pain radiating to his back

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 60-year-old man is evaluated for constant low-grade epigastric pain radiating to his back that worsens after he eats fatty foods. He has a 2-year history of chronic pancreatitis. The pain has progressively worsened over the preceding 6 months. His weight is stable. He has a normal bowel movement once every other day. He does not drink alcohol. He continues to smoke 2 packs of cigarettes per day as he has done for 30 years. The patient has a remote history of opioid abuse.

On physical examination, vital signs are normal. Abdominal examination shows tenderness to palpation in the epigastrium.

A contrast-enhanced CT scan of the abdomen shows calcifications throughout the pancreas with no pancreatic mass, no dilated pancreatic duct, and no cystic lesions.

Which of the following is the most appropriate initial treatment?

A. Celiac plexus block
B. NSAIDs, low-fat diet, and smoking cessation
C. Oxycodone
D. Pancreatic enzyme replacement therapy.

MKSAP Answer and Critique

The correct answer is B. NSAIDs, low-fat diet, and smoking cessation.

The most appropriate initial treatment is the use of NSAIDs, a low-fat diet, and smoking cessation. The hallmark symptom of chronic pancreatitis is abdominal pain that often radiates to the back; however, pain can be absent. Pain is typically intermittent, with attacks interrupted by varying pain-free intervals. Constant pain may occur from local anatomic causes (compressing pseudocyst, biliary or pancreatic duct stricture) or from visceral hyperalgesia (increased sensation in response to stimuli) from chronic narcotic use and centralization of pain. Management focuses on reducing pain and detecting and treating complications. Unfortunately, the treatment of persistent pain is difficult, and the evidence supporting most treatment modalities is of low quality and often contradictory. Most authorities recommend that persistent pain be treated in a stepwise approach beginning with lifestyle modification (discontinue alcohol and cigarettes), use of simple analgesics, adding low-dose tricyclic antidepressants, and gabapentinoids (gabapentin and pregabalin). Smoking has been identified as an important and independent risk factor for chronic pancreatitis, and cessation of smoking and alcohol use is recommended to prevent recurrent attacks of pancreatitis. An important goal is to control pain with opioid-sparing adjunctive agents to minimize chronic opioid use, owing to concerns for opioid dependence and gastrointestinal side effects. This would especially be true in a patient with a history of opioid or other substance abuse, such as this patient.

Nerve blocks, such as celiac plexus blocks, and neurolysis procedures are not recommended for the management of pain related to chronic pancreatitis because the response rate is low (15%), and pain relief, if achieved at all, is short-lived.

Opioid pain medications, such as oxycodone, are used in acute pancreatitis and during acute flares of chronic pancreatitis, but they should be avoided in the long-term management of ongoing pain due to the risk for hyperesthesia and the development of tolerance and/or addiction.

Pancreatic enzyme replacement therapy is often recommended for the treatment of persistent pain associated with chronic pancreatitis. A large systematic review found conflicting evidence for the efficacy of pancreatic enzymes in relieving pain in patients with chronic pancreatitis but found that they may improve fat absorption. If used, acid suppression therapy with a proton pump inhibitor should be given as an adjunct to uncoated pancreatic enzymes in order to reduce the inactivation of enzymes by gastric acid. Simple analgesics and lifestyle modifications can be effective for some patients and should be initiated first.

Key Point

  • Treatment of chronic pancreatitis–related persistent pain should proceed in a stepwise approach beginning with lifestyle modifications (discontinue alcohol and cigarettes) and the use of simple analgesics (acetaminophen, NSAIDs).

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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