A 52-year-old man comes to the office for 6 months of abdominal pain. The pain is intermittent, epigastric, radiating to the back, exacerbated by eating, and associated with nausea. He has no diarrhea, hematochezia, or melena. Medical and family history are both unremarkable. The patient has smoked cigarettes for 20 years and drinks 7 or 8 beers a day. Temperature is 37.4 C (99.3 F), blood pressure is 134/82 mm Hg, heart rate is 78/min, and respirations are 13/min. BMI is 28 kg/m². Physical examination reveals anicteric sclera, moist mucosal membranes, and normal heart and lung sounds. The abdomen is mildly tender to palpation in the epigastrium but without rebound or guarding. Laboratory results are as follows: CT scan of the abdomen shows pancreatic atrophy along with multiple calcifications in the pancreatic parenchyma. MR cholangiopancreatography (MRCP) reveals a nondilated pancreatic duct without intraductal stones. In addition to lifestyle modification, which of the following is the best next step in management?

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This patient has intermittent abdominal pain that radiates to the back and is worsened with eating. In association with imaging demonstrating pancreatic atrophy and calcifications, this presentation is consistent with chronic pancreatitis, which occurs most commonly from long standing alcohol abuse. The destruction of acinar and islet cells results in pancreatic exocrine insufficiency. Pancreatic secretion is stimulated by cholecystokinin (CCK). Normally, pancreatic enzymes breakdown CCK-releasing protein, thereby limiting CCK release. In patients with pancreatic insufficiency, pancreatic enzyme deficiency leads to the release of high volumes of CCK, resulting in a loop of pancreatic hyperstimulation. In association with pancreatic inflammation and ischemia, this results in the characteristic post-prandial abdominal pain common in patients with chronic pancreatitis. Pancreatic enzyme supplementation, which typically contains lipase, protease, and amylase, helps alleviate pain by reducing pancreatic hyperstimulation and improves nutrient digestion; additionally, fat malabsorption and steatorrhea (if present) typically improve. The ingestions of frequent, small meals that are low in fat may also improve pain. Secondary options for treating chronic pancreatitis pain include pregabalin, nortriptyline, and amitriptyline. Further management includes alcohol and tobacco cessation and treatment of diabetes (if present). (Choice A) A celiac plexus block (with glucocorticoids or alcohol) is useful for pancreatic cancer pain but has limited efficacy in chronic pancreatitis. In addition, there is increased risk for hypotension and infection. (Choices B and E) Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and/or stent placement may improve pain in patients with evidence of an obstructed pancreatic duct, and surgery (eg, pancreatic resection) can be considered if ERCP is unsuccessful. However, this patient's imaging reveals a nondilated pancreatic duct, and therefore neither surgical nor endoscopic interventions are appropriate. (Choice D) Although chronic pain medication may be required in patients who fail to obtain relief with pancreatic enzyme supplementation, opiate medications carry significant risks (eg, sedation, dependence). If the patient fails to respond to pancreatic enzyme supplementation, non-opiate therapy (eg, pregabalin, nortriptyline) is a more appropriate next step. Educational objective: Chronic pancreatitis is characterized by intermittent epigastric pain that radiates to the back and worsens after meals. In more advanced cases, patients develop pancreatic exocrine insufficiency with associated abdominal pain from pancreatic hyperstimulation. Pancreatic enzyme supplementation (ie, lipase, protease, amylase) is used to treat both exocrine insufficiency and pain. References: Management of chronic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23622138)

A 52-Year-Old Man Comes to the Office for 6 Months