Pain in chronic pancreatitis has several mechanisms — ductal obstruction by stones or strictures, pseudocysts, inflammatory head mass, central sensitisation, and complications such as duodenal or biliary obstruction. Before escalating analgesia, review cross-sectional imaging for an obstructed main duct or a pseudocyst, both of which may respond to endoscopic or surgical drainage. Stop alcohol and smoking, which drive both pain and progression. Enzyme therapy remains important for malabsorption, but it should be prescribed for steatorrhoea and nutrition, not for pain.
- Review imaging for main duct obstruction, stones or pseudocysts in every patient with persistent pain.
- Refer obstructive disease for endoscopic or surgical drainage assessment.
- Address alcohol and smoking cessation at every visit.
- Prescribe enzymes for malabsorption, and check for diabetes and fat-soluble vitamin deficiency.
Why it matters
Structural causes of pain are treatable, and missing them leads to escalating opioid use.
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