Case Report #47: Chronic pancreatitis

Abdominal pain secondary to chronic pancreatitis is a common cause of hospital admissions. Chronic pancreatitis is an irreversible, fibroinflammatory disorder, usually presenting with intermittent upper abdominal pain¹. In the UK, the primary causative agent is alcohol but there are a variety of other causes. The Recommended Reading’ section for March 2025 includes several papers that explore the clinical features and pathophysiology of the condition.

Management recommendations are outlined in the NICE guidelines on pancreatitis², including the treatment of neuropathic pain as specified in the NICE guideline on neuropathic pain in adults³. A multidisciplinary team approach is advised including gastroenterology, pain specialists, dietetics, psychology and the patient’s GP. 

Differential Diagnoses

Differential diagnoses to consider include cholecystitis, irritable bowel syndrome, intestinal obstruction, peptic ulcer disease and pancreatic cancer⁴.Imaging may be indicated to confirm the diagnosis and assess for complications such as pancreatic duct obstruction and pseudocysts. Additionally, screening for type 3c diabetes should be part of the assessment and this can complicate pain management².

Lifestyle Factors

Lifestyle modifications are central to the management of chronic pancreatitis. Abstinence from alcohol and smoking cessation are recommended, although both can be difficult to achieve⁵.

Pharmacological Management

Opioids are commonly used despite their potential to induce acute pancreatitis⁶ and exacerbate chronic pancreatitis⁷. To optimise pain control and minimise side effects, opioid rotation can be employed rather than increasing the dose⁸. Anti-neuropathic agents, ketamine and clonidine may also offer relief⁹. NSAIDs are frequently used but are associated with risks such as gastric ulceration, renal impairment, and, in rare cases, acute pancreatitis.

Psychological Techniques

Limited evidence exists regarding the use of psychological interventions in chronic pancreatitis pain management. Small trials have shown that cognitive-behavioural therapy and hypnotherapy may be beneficial^{10, 11}. 

Interventional Approaches

Interventional treatments, such as coeliac plexus blocks, splanchnic nerve blocks and erector spinae blocks, may provide relief for patients^{12, 13}. Spinal cord stimulation has been used, though its evidence is limited¹². Coeliac plexus blocks have an estimated efficacy of 50%¹⁴, though they rarely offer long-term relief¹⁵.