An ASGE Clinical Symposium on Sunday morning, Controversies in Chronic Pancreatitis, featured a multidisciplinary panel of experts who discussed medical and nutritional therapies for pain management, the efficacy of endoscopic interventions and when to consider surgery for patients with chronic pancreatitis.

The pain associated with chronic pancreatitis presents challenges on multiple levels and requires a personalized and holistic approach to treatment, according to Suresh Chari, MD, professor of medicine and head of the Pancreas Interest Group in the division of gastroenterology and hepatology at the Mayo Clinic, Rochester, MN.

“The pain of chronic pancreatitis can be disabling and devastating to those who suffer from it, affecting the physical, social, psychological and emotional well being of patients,” Dr. Chari said.

A personalized approach to pain, he said, requires understanding its multidimensional components and looking beyond the traditional biomedical model, which focuses on the physical processes and structural causality for pain, to a more holistic “biopsychosocial resilience” model of chronic pain.

“Pain is processed in some of the same areas of the brain as thoughts and emotions — structural damage or inflammation are not essential to experience pain,” Dr. Chari said. “To understand pain, you have to take into account the role of social factors or individual subjectivity, such as the patient’s perception of pain or suffering, the pain’s impact on their life, their social support and their coping mechanisms.”

Bret T. Petersen, MD, FASGE, professor of medicine and consultant, Pancreas Clinic and Advanced Endoscopy Practice Group at the Mayo Clinic, followed with a discussion of the role of endoscopic intervention for pain management and complications in chronic pancreatitis patients.

“There are an array of potential complications in chronic pancreatitis, with pain being the dominant issue in many cases. The natural history of pain in chronic pancreatitis is one of persistence, with 80 to 90 percent prevalence, especially in the upper abdomen or back and frequent episodic post-prandial exacerbations,” Dr. Petersen said. “Treatment is challenging because the data regarding the course of the pain is quite divergent, with widely differing results from studies regarding duration, etiology, morphology and the association with, or non-association with, exocrine or endocrine function.”

Overall, he said, endoscopic interventions for chronic pancreatitis pain are generally safe and moderately efficacious, although somewhat less so than surgery, noting that better prognostic indicators are ultimately needed for treatment selection.

Similarly, when it comes to surgical interventions, timing and proper patient selection are challenging when deciding when to send a chronic pancreatitis patient for surgery, said Jeffrey B. Matthews, MD, FACS, Dallas B. Phemister Professor of Surgery and chairman of the department of surgery, University of Chicago Medicine, IL.

“Refractory pain is the most common reason for consultation; however, the natural history of disease and individual pain patterns are highly variable and unpredictable,” Dr. Matthews said. “And while there is no consensus on timing and threshold for surgical intervention, most agree that ‘severe and disabling’ pain is an indication for operation.”