A 60-year-old man comes to the physician complaining of shaking of his right hand. This problem began several months ago and has progressed over time. He says it is worse while watching TV, but that he frequently forgets about it while working or doing his regular daily activities. He is an accountant who works at a bank. His past medical history is significant for left hip osteoarthritis for which he occasionally takes naproxen to relieve the pain. His mother has diabetes mellitus. His father died of a heart attack at age 60. His blood pressure is 125/68 mm Hg in both arms and heart rate is 72/min. His BMI is 27 kg/m². Physical examination shows a right hand tremor that diminishes with movement, and involuntary resistance to flexion of the right wrist and right arm. No sensory abnormalities are present. Muscle strength is preserved on both sides. Plantar reflexes are flexor bilaterally.The patient confirms his strong intention to follow all recommendations. Which of the following is the most appropriate next step in management of this patient's abdominal pain?

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Explanation: 11ec2b69_bf27_f4de_8f63_0701e4cf6260_MD0005_00 After confirming the diagnosis of chronic pancreatitis (CP) with magnetic resonance cholangiopancreatography, the first step in treatment is lifestyle and dietary modification. The management of CP focuses on improving the symptoms of both abdominal pain and malabsorption. The mainstays of pain control include abstinence from both alcohol and smoking as well as eating small, low-fat meals. Malabsorption is treated similarly with small, low-fat meals but also fat-soluble vitamin supplementation, and, in the setting of significant pancreatic exocrine insufficiency (low fecal elastase-1 levels), pancreatic enzyme supplementation. Enzyme supplementation may also help improve pain. In early CP, these interventions alone may be sufficient to control pain and minimize symptoms of malabsorption. For patients who do not achieve adequate relief after a trial of the above recommendations, a number of other pain control options exist, including nonopioid analgesics such as tricyclic antidepressants (eg, amitriptyline), nonsteroidal anti-inflammatory drugs, and pregabalin (Choice B). Opiate analgesics should be considered only for patients with severe pain that does not improve with other medications. Other more specialized interventions, such as celiac nerve blocks, ductal decompression therapy, extracorporeal shock wave lithotripsy, and surgical resection, can also be considered (Choice C). (Choice A) Surgical options include decompression of the pancreatic duct by anastomosing it to the jejunum, partial or complete pancreatic resection, duodenal-preserving resection of the pancreatic head, and denervation of the afferent nerve fibers leaving the pancreas. None of these options are first-line treatment and should not be pursued until less invasive interventions have proven to be ineffective. (Choice E) Although opiate analgesics are taken by many patients with CP, they carry considerable risks, especially in those with a history of addiction, and should not be considered as an initial treatment option. Educational objective: Alcohol and tobacco cessation, along with dietary modifications, is the first-line treatment of chronic pancreatitis. Pancreatic enzyme replacement and analgesics should be considered if conservative measures are unsuccessful. A variety of minimally invasive and surgical interventions is available for patients with refractory disease. References: The management of acute and chronic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/20567557)

A 60-Year-Old Man Comes to the Physician Complaining of Shaking