The treatment of severe pancreatic pain.

The management of four patients with severe pancreatic pain is discussed. Bilateral coeliac plexus block with alcohol gave effective pain relief to the three patients with pancreatic carcinoma and the one patient with acute pancreatitis. The treatment of the pain of acute and chronic pancreatitis is reviewed.     

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??Medical treatment of chronic pancreatitis LAI Ya-min,QIAN Jia-ming. Department of Gastroenterology, Chinese Academy of Medical Sciences, China Peking Union Medical College,Peking Union Medical College Hospital, Beijing100730,China
Corresponding author??QIAN Jia-ming, E-mail qjiaming57@gmail.com
Abstract Chronic pancreatitis (CP) is an ongoing in?amatory disorder characterized by irreversible destruction of the pancreas associated with disabling chronic pain and permanent loss of exocrine and endocrine function. The treatment of patients with CP revolves around control of pain, diabetes and steatorrhea. Pain relief is the most common and most difficult problem. The initial approach should consist of non-opioid analgesics and supplementation with pancreatic enzymes containing high amounts of proteases. Enzymes significantly reduce fat excretion and stool frequency and improve fat absorption. Dosing and timing are important. Although the medical treatment of CP is frustrating in most cases and the role of pancreatic enzyme replacement therapy and anti-oxidants is uncertain,the benefit of pancreatic endotherapy for CP is encouraging. The modalities include pancreatic sphincterotomy, stenting and ESWL to break large calculi. With growing expertise in endoscopic techniques, refinements in equipment and promising results from uncontrolled studies, patients should be offered opportunities of endoscopic therapy before subjecting them to surgical treatment. Both alcohol and smoking cessation are likely to be beneficial to CP patient. A low-fat diet may contribute to development of fat-soluble vitamin deficiencies and is an unnecessary intervention for treatment of steatorrhoea.     

慢性胰腺炎的手术适应证和术式选择

目的提高慢性胰腺炎的外科治疗效果. 方法回顾性总结分析55例慢性胰腺炎外科治疗资料.发病因素:嗜酒5年以上、胆系结石、急性胰腺炎病史分别占38.2%,29.1%和20.0%.主要临床表现:慢性腹痛、梗阻性黄疸、体重减轻、消化不良、糖尿病分别为98.2%,38.2%,34.5%,20.0%和10.9%.全组均因慢性腹痛或伴有胰管和(/或)胆管梗阻、结石、胰腺钙化、肿块、假性囊肿等行外科治疗,共采用了10种术式. 结果无手术死亡和严重并发症.术后效果良好43例(78.2%),症状减轻好转10例(18.2%),无效2例(3.6%). 结论慢性胰腺炎长期慢性腹痛并胰胆管梗阻、结石、肿块、假性囊肿适于外科治疗,应根据病变类型和特点选择不同的术式.胰管梗阻扩张、结石或假性囊肿宜行胰管或囊肿空肠吻合,胰头肿块并胆、胰管梗阻可行胰头十二指肠切除或胆胰管空肠吻合术.     

Chronic pancreatitis

Chronic pancreatitis (CP) is a progressive, disabling, fibro-inflammatory disease of the pancreas of variable clinical course and is usually associated with permanent loss of exocrine and endocrine function over a period of time. The incidence is increasing. There are various aetiological risk factors that cause CP, chronic alcoholism being the most common risk factor. The TIGAR-O classification identifies all the risk factors and aetiology. Most susceptible patients have a sentinel acute pancreatitis event which initiates chronic progressive inflammation, scarring and fibrosis, though some may present insidiously with symptoms of functional loss – diabetes or steatorrhoea. Intractable abdominal pain, steatorrhoea, weight loss and (type 3c) diabetes mellitus are late manifestations of the disease. Diagnosis is made with a combination of clinical history, examination, cross sectional imaging combined with pancreatic function tests (in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms and venous thrombosis. Patients with CP have increased risk of developing pancreatic adenocarcinoma. Management includes making the diagnosis, identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, gastrointestinal physician and pancreatic surgeon) if initial steps do not control the symptoms.     

Pancreatic duct drainage in 100 patients with chronic pancreatitis.

Although the development of islet cell autotransplantation has focused attention on extended resections of the pancreas, drainage of a dilated pancreatic duct remains an effective means of relieving intractable pain of chronic pancreatitis. Between 1954 and 1980, 98 men and two women with chronic pancreatitis were treated for pain with ductal drainage. All patients had a history of chronic alcoholism. Pancreatic calculi were found in 68 patients. Operative procedures include: seven caudal pancreaticojejunostomies, 42 longitudinal pancreaticojejunostomies, and 54 side-to-side pancreaticojejunostomies. Two caudal pancreaticojejunostomies were converted to longitudinal pancreaticojejunostomies, and one longitudinal pancreaticojejunostomy required revision. The operative mortality rate was 4%. Follow-up studies, lasting up to 24 years, were conducted for all but seven patients. Eighty per cent of these patients have had substantial improvement or complete resolution of their pain. Diabetes, as evidence by an elevated fasting blood sugar level, was present prior to operation in 30% of the patients, and developed after operation in 14%. Only nine of 21 insulin-dependent diabetics in this series did not require insulin prior to pancreaticojejunostomy. Pancreatic enzyme replacement was needed for control of steatorrhea in 18 patients. Four patients with continued pain underwent total or near total pancreatectomies. Three of these patients died of uncontrolled diabetes. Only one patient with a drainage procedure alone has died of uncontrolled diabetes. In patients with dilated pancreatic ducts, pancreaticojejunostomy is a safe, reliable means of providing pain relief, with minimal loss of endocrine and exocrine function.     

Pancreatic enzymes replacement therapy in chronic pancreatitis: an update

Chronic pancreatitis is the major cause of exocrine pancreatic insufficiency which should be compensated by pancreatic enzyme replacement therapy. There are now available a great number of pancreatic enzyme preparations, but encapsulated enteric-coated microspheres and minimicrospheres are considered the enzyme treatment of choice. However, full compensation of pancreatic exocrine insufficiency with enzyme replacement therapy cannot be obtained in all patients with chronic pancreatitis.     

胰管结石性慢性胰腺炎的临床特点与外科治疗

目的探讨胰管结石性慢性胰腺炎的临床特点及外科术式选择与疗效。方法回顾性分析我院外科1983年1月至2006年12月间收治并手术治疗的31例胰管结石性慢性胰腺炎患者的临床资料、手术方式和疗效。结果胰管结石性慢性胰腺炎患者多见于酗酒所致的酒精性胰腺炎,腹痛为最突出临床表现,胰腺内外分泌功能减退较为常见。B超及CT为最常用的检查手段,对胰管结石的诊断准确率分别达到96.8%（30/31）和100%（26/26）,患者多同时存在胰腺萎缩及钙化、胰管扩张等。31例患者共接受32例次手术,胰管取石＋括约肌成形术2例,胰尾空肠吻合3例,改良Puestow术13例,Whipple手术9例,Frey手术5例。手术效果满意。结论胰管结石性慢性胰腺炎临床表现复杂,病因以酒精性为主,腹部B超和CT检查多可明确诊断。手术治疗是缓解症状的主要治疗手段,外科治疗应采用个体化原则。     

A case of obstructive jaundice caused by incarceration of pancreatic stones in the ampulla of papilla Vater

A very rare case of obstructive jaundice caused by the incarceration of pancreatic stones in the ampulla of papilla Vater is reported. A forty-eight-year-old man, who had been taking alcohol daily for 10 years, was admitted to our hospital because of recurrent attacks of upper abdominal pain. Biochemical analysis demonstrated typical pattern of chronic pancreatitis. US, CT and ERCP showed a markedly dilated pancreatic duct and pancreatic calcifications. Cholecystolithiasis, or dilatation of the choledochus was not noted. Conservative treatment was performed under the diagnosis of chronic calcifying pancreatitis for one month. Then, obstructive jaundice, severe epigastralgia, and high fever occurred. Obstructive jaundice with sudden onset and existence of pancreatic stones suggested incarceration of pancreatic stones in the bile duct, and cephalic pancreaticoduodenectomy was performed. The largest pancreatic stone was incarcerated into the ampulla of papilla Vater. Histopathological analysis of the pancreas showed severe chronic pancreatitis. No report of the similar case can be found in the literature. Incarceration of pancreatic stones into biliary system might be very rare, however, should not be forgotten in differential diagnoses of obstructive jaundice in chronic pancreatitis patients.     

Chronic pancreatitis beginning in childhood and adolescence.

We identified 10 patients with symptoms beginning before the age of 20 years in a group of 69 patients with proven chronic pancreatitis. Six of the 10 patients were women. There was a family history of pancreatitis in three patients and alcohol exposure in seven patients. Three patients were dependent on narcotics at the time of presentation. Six of the 10 patients had pancreatic duct dilatation to 10 mm or more in diameter during observation. These six patients underwent pancreaticojejunostomy, with clinical improvement in five patients. The median time of follow-up was 19 years from presentation. No patient developed diabetes and one developed malabsorption. Only three patients were free of pain, but four other patients had only mild episodes that rarely required hospital admission. One patient died of metastatic abdominal carcinoma of unknown origin 51 years after developing familial pancreatitis. Chronic pancreatitis beginning at a young age is sufficiently common to merit special awareness. It is compatible with prolonged survival, and pancreaticojejunostomy may help if the pancreatic duct reaches sufficient size. The disease does not seem to burn out with time.     

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. Pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.     

Determination of patient quality of life following severe acute pancreatitis.

BACKGROUND: Severe acute pancreatitis results in significant morbidity and mortality. Clinical experience suggests a significantly reduced quality of life for patients, but few studies exist to confirm this experience. We sought to objectively demonstrate patient quality of life after severe acute pancreatitis. METHODS: Forty-two patients were assessed 24-36 months after an episode of severe acute pancreatitis. Patients completed the English Standard Short Form 36 survey (SF-36) and a questionnaire about pancreatic function to assess both their health-related quality of life and symptoms of pancreatic dysfunction. RESULTS: Compared with the general Canadian population, survivors of severe acute pancreatitis had significantly reduced SF-36 scores. There is also a significant correlation between the Ranson score at presentation and the SF-36 Physical Composite Score at time of follow-up (rho = -0.47, p = 0.03). Seventy-six percent of patients had ongoing symptoms suggestive of pancreatic dysfunction. These included abdominal pain, diarrhea, unintentional weight loss, new onset of diabetes mellitus and the need for regular pancreatic enzyme supplementation. CONCLUSIONS: Survivors of severe acute pancreatitis had a reduced quality of life compared with healthy controls. Higher Ranson scores at presentation may predict which patients are more likely to have poorer outcomes in the first few years of their recovery.     

Distant processing of pancreas islets for autotransplantation following total pancreatectomy.

BACKGROUND: Small duct chronic pancreatitis is associated with intractable pain and failure to thrive, usually unresponsive to conventional management approaches. Total pancreatectomy is considered after failure of medical intervention. The major morbidity following total pancreatectomy is diabetes mellitus with its associated complications. This adverse outcome can be mitigated through autotransplantation of islets recovered from the pancreatectomy specimen. This approach has been limited historically owing to the absence of an on-site islet processing facility. We present the results from 5 pancreatectomized patients whose islets were prepared 1,500 miles away. METHODS: Five patients (4 women, 1 man, average age 42 years) who failed medical therapy and were not candidates for longitudinal pancreaticojejunostomy underwent total/completion pancreatectomy (4 total, 1 completion) for intractable symptoms from idiopathic small duct chronic pancreatitis. The resected pancreata were preserved in ViaSpan solution and were transferred to an islet processing laboratory by commercial airliner and returned. The dispersed pancreatic islet tissue was infused into a portal vein tributary through an operatively placed catheter after systemic heparinization. RESULTS: All 5 patients experienced complete relief from pancreatic pain; 2 had significant residual discomfort from underlying Crohn's disease. Three of the 5 patients had minimal or no insulin requirement after autotransplantation (median follow-up of 23 months); 1 patient continued with glycemic control difficulties related to Crohn's disease. One patient died 17 months following autotransplantation from an unrelated pneumonia. CONCLUSION: Total pancreatectomy with autologous islet transplantation can offer patients with idiopathic small duct chronic pancreatitis pain relief without the sequelae of diabetes mellitus and can be performed without an on-site islet processing facility. All patients undergoing total/ completion pancreatectomy should be considered candidates for this procedure.     

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??Diagnosis treatment of chronic pancreatitis combinded with pancreatic duct stones MIAO Yi,JIANG Kui-rong. Department of Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
Corresponding author:MIAO Yi,E-mail: miaoyi@njmu.edu.cn
Abstract Chronic pancreatitis is a progressive fibroinflammatory disease with sustained damage of structure and function of pancreatic tissue, which results from a complex mix of causes (eg, alcohol, Biliary diseases), and often exists with intraductal calculi. Pain in the form of recurrent attacks of pancreatitis or constant and disabling pain is usually the main symptom. Steatorrhoea, diabetes, local complications associated with the disease are additional therapeutic challenges. Combined with a variety of imaging methods such as BUS, CT, ERCP and MRCP, etc. can significantly improve the diagnosis of chronic pancreatitis with pancreatic duct stone. Chronic pancreatitis with pancreatic duct stones should be actively treated, of which the focus is to control symptoms, improve function and treatment of complications with individual therapy. The appropriate surgery should be performed as soon as possible according to distribution of stone when the stone removal is not complete or recrudescent after extracorporeal shock wave lithotripsy and endoscopic. completely removing the lesion, taking out all the stones, removing the pancreas and bile duct obstruction, fully drainage of pancreatic juice and trying to save the pancreatic tissues are the goal of the surgery, which can significantly improve quality of life of patients.     

Segmental pancreatic autotransplantation with pancreatic ductal occlusion after near total or total pancreatic resection for chronic pancreatitis. Results at 5- to 54-month follow-up evaluation.

Reported are eight patients with idiopathic chronic pancreatitis and two patients with alcoholic pancreatitis who had near total distal pancreatectomy for disabling pain and underwent simultaneous segmental pancreatic autotransplantation of the body and tail of the gland to the femoral area in an attempt to prevent or delay the onset of diabetes. The median follow-up period was 31 months, and follow-up study in nine patients ranged from 24 to 54 months. Patency of the grafts was determined by angiography and selected percutaneous venous assays for insulin. Islet cell function was determined by oral glucose tolerance tests, intravenous (I.V.) glucose tolerance tests, and I.V. glucagon stimulation studies. Segmental autotransplantation was technically successful in eight patients, only one of whom required insulin (at 2 years after grafting). The other seven patients with technically successful grafts have remained insulin independent, including two patients who later underwent pyloric preserving pancreatoduodenectomy for completion pancreatectomy. Variable pain relief was observed in patients who underwent near total pancreatectomy, but pain was unrelieved in those patients who underwent limited distal resection. Patients with idiopathic pancreatitis appear to have better pain relief and preservation of endocrine function than alcoholic patients. Segmental pancreatic autotransplantation prevents or delays the onset of diabetes mellitus and should be considered as an alternative for those patients who require extensive pancreatic resection for chronic pancreatitis.     

Outcome of surgical treatment of chronic pancreatitis associated with sphincter of Oddi dysfunction

The clinical management of patients with chronic pancreatitis (CP) associated with sphincter of Oddi dysfunction (SOD) presents many challenges. The aim of this study was to evaluate patient outcome after surgical management of CP associated with SOD intractable to medical management. The records of patients with CP and SOD who underwent surgical treatment between 1994 and 1998 were retrospectively reviewed and analyzed. Manometry of biliary and pancreatic ducts was performed. Basal pressures were considered abnormal if > or = 40 mm Hg for at least 30 seconds. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and clinical criteria were utilized in the diagnosis of CP. Quality-of-life issues were assessed. Twenty-nine patients were identified (21 women and eight men) with a mean age of 43.3 years (range 24-54). Mean basal biliary and pancreatic sphincter pressures were 155.1 and 90.4 mm Hg respectively. Chronic pancreatitis was graded as mild in nine patients, moderate in six, severe in two, and normal or equivocal in 12 patients according to the Cambridge classification. A Whipple procedure was performed in 17 (59%) patients, lateral pancreaticojejunostomy in nine (31%), and distal resections or a combination of procedures in three (10%). The morbidity and mortality rates were 21 and 0 per cent respectively. Mean follow-up was 30 months (range 3-48). Pain relief ranging from fair to excellent was seen in 83 per cent of patients with pain scores decreasing from an average of 9 (scale 1-10) before surgery to 3 postoperatively. Seventy per cent maintained their weight, 45 per cent continued to require pancreatic enzyme supplementation, and there were no changes in the status of diabetes. Rehospitalizations for recurrent pancreatitis or persistent pain were necessary in 24 per cent of patients. Surgical management of patients with CP and SOD who fail medical management is safe and effective in most patients. Operative morbidity and mortality are low, and the majority of patients have improvement in pain, although some require rehospitalization for recurrent pancreatitis and chronic pain.     

Duodenum- and spleen-preserving total pancreatectomy for end-stage chronic pancreatitis

BACKGROUND: Total pancreatectomy may be warranted in patients with advanced chronic pancreatitis in whom partial resection has failed and in those with end-stage pancreatic function. A new operation, duodenum- and spleen-preserving total pancreatectomy, is described. METHODS: Nineteen consecutive patients with chronic pancreatitis who had duodenum- and spleen-preserving total pancreatectomy were studied. RESULTS: There were 15 men and four women with a median age of 40 (range 29-64) years. The aetiology was alcohol misuse in nine, hereditary pancreatitis in five and idiopathic in five patients. All patients had chronic intractable abdominal pain. Six had undergone pancreatic surgery previously and one had had multiple coeliac plexus blocks. There were ten postoperative complications in five patients, and one hospital death. The median hospital stay was 25 (range 10-84) days. There was a reduction in pain (P < 0.001) and analgesic use (P < 0.001) after surgery, and weight gain was noted at 12 and 24 months (P < 0.001). Nine patients required readmission to hospital, four because of surgical complications: adhesional obstruction in one, biliary stricture in two and duodenal obstruction in one. In the other five patients (four of whom had long-standing pre-existing diabetes mellitus) readmission was for better control of pain (three patients), diabetes mellitus (two), and diabetes-associated diarrhoea (two) or gastropathy (one). CONCLUSION: Duodenum- and spleen-preserving total pancreatectomy has a role in selected patients with medically intractable pain from chronic pancreatitis.     

Early and late onset in idiopathic and alcoholic chronic pancreatitis. Different clinical courses.

In summary, a prerequisite for the development of alcoholic pancreatitis would be the specific individual predisposition present in patients with late-onset idiopathic chronic pancreatitis. Furthermore, because the reported prevalence of chronic pancreatitis in patients with heavy alcohol consumption is markedly higher than the prevalence of late-onset idiopathic pancreatitis in the general population, the authors conclude that, in predisposed patients, alcohol consumption promotes the development of pancreatitis and accelerates the manifestation of symptoms and complications. This concept explains the observation that only a minority of severe alcoholics develop chronic pancreatitis. Conversely, in postmortem studies, a substantial proportion of older individuals without premortem evidence of pancreatic disease and no excessive alcohol history have pancreatic morphologic alterations resembling chronic pancreatitis. Thus, in the general population, a considerable number of asymptomatic "carriers," together with an undetected high prevalence of late-onset idiopathic chronic pancreatitis, may exist. In these persons, alcohol consumption might amplify and accelerate preexisting asymptomatic idiopathic pancreatic damage. As a consequence, in a dose-dependent manner, alcohol may lead to an earlier onset of or induce clinically apparent pancreatitis in persons who otherwise might never have had symptoms during their lives.     

Chronic pancreatitis

Chronic pancreatitis (CP) is a complex progressive fibro-inflammatory disease of the pancreas with a variable clinical course often progressing to a permanent loss of exocrine and endocrine function. Over the last 20 years the incidence has continued to increase. CP has multifactorial aetiological risk factors with chronic alcoholism being the most common. The updated TIGAR-O_V2 classification identifies the pertinent risk factors and aetiology. The most susceptible patients to develop CP have a sentinel acute pancreatitis event which initiates the chronic progressive inflammation, scarring and fibrosis of the pancreas. Symptomatically CP presents as intractable abdominal pain, with weight loss and functional loss (steatorrhoea and type 3c diabetes mellitus) being late manifestations of the disease. Diagnosis is made by a combination of clinical history, examination and cross sectional imaging, combined with pancreatic function tests (only in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms, venous thrombosis and an increased risk of developing pancreatic adenocarcinoma. Management includes: diagnosis and identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, GI physician and pancreatic surgeon) in patients with on-going symptoms or when there is doubt in the diagnosis.     

Organ-preserving surgery in chronic pancreatitis: the duodenum-preserving pancreatic head resection

Chronic pancreatitis is a inhomogeneous disease of multifactorial genesis and a variable clinical course. Upper abdominal pain is the leading clinical symptom of the majority of the patients. The primary treatment of these patients is conservative, but if the treatment fails in pain relief or organ complications occur surgical treatment is indicated. The most common organ complications due to chronic pancreatitis are stenosis of the common bile duct and the pancreatic duct, duodenal stenosis, stenosis of the portal vein with portal hypertension, pancreatic pseudocysts and the development of pancreatic fistula. Due to the pathophysiological concept of an elevated duct pressure as a source of pain, duct decompression by drainage procedures is the favored surgical procedure by many surgeons. Nevertheless, even in patients with a dilated pancreatic main duct, only half of the patients will benefit from drainage operations. Long-term severe upper abdominal pain and complications of the neighboring organs due to an inflammatory mass in the head of the pancreas should be indicative for resective procedures which should be organ-preserving as much as possible and take into account the endocrine function of the pancreatic gland. Simultaneous multiple organ resections like pylorus-preserving partial duodenopancreatectomy or total pancreatectomy are not necessary for a benign disease and should be only performed in patients with proven malignancy. The aim of the surgical procedure is to reduce pain and frequency of relapsing pancreatitis without impairing the endocrine function of the pancreatic gland.     

Pancreas divisum: endoscopic therapy

Pancreas divisum is a common congenital variation that can be associated with pancreatic disease. Symptomatic patients with divisum must be classified according to clinical presentation and morphologic findings. Response to endoscopic therapy is best in patients with ARP, of whom 75% benefit. Results in patients with chronic pancreatitis and pain but without objective pancreatitis are mixed, and patients should be carefully selected.