............................................x-82 - triplehelix

[ArchivalUser]

A 55-year-old male alcoholic has recurrent attacks
of severe mid-epigastric pain after eating. Serum amylase
determinations after such attacks have been in the normal
range. The examination reveals mild cachexia but is otherwise
unremarkable. On further questioning, the patient
states that he has been sober for the past 10 years but prior
to that time had multiple episodes of alcohol-induced pancreatitis.
He is currently taking pancreatic replacement enzymes
by mouth. An ERCP reveals a stricture of the pancreatic
duct but is otherwise unremarkable. Computed
tomography of the abdomen reveals calcifications in the
pancreas but does not show any evidence of malignancy.
The patient is taking 30 mg of continuous-release morphine
sulfate twice a day. The best strategy at this point
would be to
(A) double the dose of morphine
(B) double the dose of pancreatic replacement enzymes
© resect the head of the pancreas
(D) institute a low-fat diet
(E) begin a continuous search for other causes of
abdominal pain

[ArchivalUser]

C)

[ArchivalUser]

BBBB

[ArchivalUser]

actually bst statergy for the pain is analgesia and low fat diet?

[ArchivalUser]

the best answer is stenting of the stricture but it isnot one of the options

[ArchivalUser]

c...or d?

[ArchivalUser]

d

[ArchivalUser]

The answer is C. (Chap. 304. Steer, N Engl J Med 332:1482, 1995.) This patient has
chronic pancreatitis requiring narcotic analgesia, based on historical features and CT revealing
calcifications in the pancreas. Pain management for patients with chronic pancreatitis
is fraught with the problems of chronic narcotic use. The attacks of abdominal pain
in patients with chronic pancreatitis should be treated similarly to those of patients with
acute pancreatitis. Alcohol should be avoided completely, as should large meals rich in
fat. If a stricture of the pancreatic duct is demonstrated in ERCP, local resection may
ameliorate the pain. Although such a finding is unusual, dealing in an anatomic fashion
with patients who have such ductal obstruction can lead to long-term pain relief in about
50%. In some patients resection of most of the pancreas is required. Such radical surgery
is contraindicated in those who are depressed or continue to drink alcohol. Furthermore,
the cost of the pain relief achieved by surgery is pancreatic endocrine and exocrine insuf-
ficiency. Nonsurgical anatomic approaches such as sphincterotomy, dilatation of strictures,
removal of calculi, and extension of the ventral or dorsal pancreatic duct are associated
with significant complications and have not yet been shown to be definitively effective.
Nonanatomic approaches include pancreatic enzyme treatment, diet restriction (moderate
fat, high protein and carbohydrate, restriction of long-chain triglycerides), and non-narcotic
analgesics. Although the cost of chronic pancreatitis to society is great, most patients do
well with vigorous enzyme replacement therapy and abstention from alcohol.