Treatment of "chronic pancreatitis", the latest Japanese guidelines give these recommendations (Part 2)

Chronic pancreatitis (CP) refers to persistent inflammation of the parenchyma of the pancreas, resulting in extensive fibrosis of the glands, atrophy of acinar and islet cells, resulting in impaired endocrine and exocrine functions of the pancreas, and often calcified and pseudocyst formation
.

Typical symptoms are recurrent abdominal pain, dyspepsia, diarrhea, and wasting, with pancreatic cysts, diabetes, or jaundice
in the late stages.

Due to the lack of simple and specific diagnostic methods, diagnosis is difficult and often misdiagnosed
.
The revised 2021 edition of the Japanese Guidelines for Chronic Pancreatitis is revised based on the 2019 Japanese Diagnostic Criteria for Chronic Pancreatitis and mainly provides guidance and recommendations
for the diagnosis and treatment of chronic pancreatitis.
This article sorts out
the main points of the "Treatment" section of the guideline.

• Is smoking cessation guidance recommended for CP patients?

Smoking cessation guidance
is recommended in patients with CP.
Recommended Intensity: Strong, Evidence Grade: C

• Are non-opioid analgesics, opioids, and analgesics recommended for pain treatment of CP?

If nonsteroidal anti-inflammatory drugs (NSAIDs) are ineffective, weak opioids
are recommended.
Recommended intensity: weak, evidence grade: C
If adequate amounts of NSAIDs or weak opioids do not respond, endoscopic treatment or surgery
is considered.

Strong opioids should be reserved for patients who
are not applicable to these treatments.
Recommended intensity: weak, level of evidence: D

• Is pancreatic enzyme replacement therapy recommended for pain?

Pancreatic enzyme replacement therapy is not recommended for the treatment of pain
in cp patients.

However, it may be beneficial in relieving abdominal symptoms associated with pancreatic exocrine dysfunction, such as abdominal distention and flatulence
.
Recommended intensity: weak, evidence grade: C

• Are proteolytic enzyme inhibitors recommended for pain treatment of CP?

Proteolytic enzyme inhibitors are recommended for pain
.
Recommended intensity: weak, evidence grade: D

• Is long-term repetitive endoscopy recommended for pain treatment of CP?

Long-term repetitive endoscopic therapy (more than 2 to 3 years) is not recommended for pain management
in CP patients.
Recommended intensity: weak, evidence grade: C

• Is pain treatment for surgical CP recommended when endoscopic therapy is ineffective?

For patients who do not respond to endoscopic therapy for pain relief, surgery is recommended
.
Recommended Strength: Strong, Evidence Grade: B

• Is fat-restricted diet therapy recommended for the treatment of pancreatic exocrine insufficiency?

A unified fat-restricted diet is not recommended for patients with CP decompensation with pancreatic exocrine insufficiency
.
Recommended strength: strong, evidence grade: D

• Is pancreatic lipase recommended for the treatment of pancreatic exocrine insufficiency?

Pancreatic lipase is a highly potent pancreatic enzyme preparation that is recommended for the treatment of patients
with pancreatic exocrine insufficiency with steatorrhea and weight loss.
Recommended intensity; Strong, evidence grade: A

• Is acid suppressor drugs recommended for the treatment of pancreatic exocrine insufficiency?

If pancreatic enzyme replacement therapy is not effective in patients with exocrine insufficiency,_H2 receptor antagonists or proton-pump inhibitors
may be used.
Recommended intensity: weak, evidence grade: C

• When pancreatic exocrine insufficiency is complicated by diabetes, is caloric restriction similar to that of primary diabetes recommended?

Considering the risk of malnutrition and hypoglycemia, uniform caloric restriction
in patients with pancreatic diabetes mellitus is not recommended.

Glycemic control should be carried out
in combination with treatment of appropriate energy intake for pancreatic exocrine insufficiency.
Recommended strength: strong, evidence grade: D

• Is oral hypoglycemic drugs recommended for diabetes secondary to CP?

Oral hypoglycemic agents are recommended for pancreatic diabetes
, regardless of whether the patient is insulin resistant or has normal insulin secretion.
Recommended intensity: weak, evidence grade: D

• Is insulin recommended for pancreatic diabetes?

Insulin therapy is recommended for patients with insulin-dependent diabetes mellitus
.
Recommended Intensity: Strong, Evidence Grade: C

• Is drainage of CP-associated pseudocysts recommended?

For symptomatic pseudocysts, endoscopic drainage
is recommended.
Recommended Intensity: Strong, Evidence Grade: C

• Is pancreatic duct stent recommended for the treatment of intrapancreatic fistula?

Placement of pancreatic tube stents is recommended as the initial treatment for intrapancreatic fistula
.
Recommended intensity: weak, evidence grade: C

• Is bile duct stent recommended for the treatment of CP-associated bile duct stenosis?

Cp-associated biliary stenosis is recommended for the treatment of CP-associated biliary stenosis
with a fully coated self-expanding metal stent (FCSEMS).
Recommended intensity: weak, level of evidence: B References: Shimizu K, Ito T, Irisawa A, et al.
Evidence-based clinical practice guidelines for chronic pancreatitis 2021[J].
Journal of Gastroenterology, 2022: 1-16.