ERCP Bootcamp (On-Demand) | July 2026-Agrawal_Pancreatic Endotherapy for Chronic Pancreatitis

Agrawal_Pancreatic Endotherapy for Chronic Pancreatitis

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This presentation reviewed the role of endotherapy in chronic pancreatitis, focusing on pain management, patient selection, and when to choose endoscopic therapy versus surgery.<br /><br />Chronic pancreatitis is a fibroinflammatory disease with multifactorial causes, commonly related to alcohol, smoking, genetic factors, recurrent acute pancreatitis, or ductal obstruction. Typical symptoms include chronic or recurrent abdominal pain, steatorrhea, weight loss, and diabetes. Diagnosis relies on clinical features plus imaging such as CT, MRI/MRCP, and EUS, though early or small-duct disease can be missed.<br /><br />Management is stepwise and multidisciplinary: lifestyle changes, nutrition, enzyme replacement, pain medications, endoscopic therapy, and surgery. Pain may reflect a mechanical “plumbing” problem from duct obstruction by stones or strictures, a neuropathic “wiring” problem, or both. Endoscopic or surgical duct decompression helps mainly when obstruction is present; neuropathic pain may respond better to other approaches such as celiac plexus block.<br /><br />Evidence from randomized trials, including ESCAPE, Díte, and Cahen, generally favors surgery over endoscopy for durable pain relief in patients with obstructive large-duct disease who are good surgical candidates. ASGE guidance recommends surgical evaluation first in such patients; endoscopy is reasonable when surgery is contraindicated or declined.<br /><br />Endoscopic strategies depend on the lesion:<br />- Stones: ERCP for small or radiolucent stones; ESWL for larger radiopaque stones; pancreatoscopy-guided lithotripsy (EHL or laser) can reduce procedures.<br />- Pancreatic strictures: a single large-diameter plastic stent is usually first line; fully covered metal stents may be used for persistent strictures.<br />- Biliary strictures: fully covered metal stents are preferred over multiple plastic stents because they achieve similar outcomes with fewer procedures.<br /><br />Overall, the key message is to match therapy to the pain mechanism and anatomy, set realistic expectations, and involve surgery early when appropriate.

Keywords

chronic pancreatitis

endotherapy

pain management

patient selection

endoscopic therapy

surgery

ERCP

pancreatic duct obstruction

pancreatic stones

pancreatic strictures