In chronic pancreatitis with calcifications and pancreatic duct obstruction on MRCP, no masses are seen. What is the most appropriate initial management?

• A. Chemotherapy
• B. Immediate pancreatic resection
• C. Antibiotics
• D. Pancreatic enzyme supplementation

Answer: (D)

Chronic pancreatitis often damages the pancreas’s ability to produce digestive enzymes, leading to exocrine insufficiency with malabsorption and weight loss. The first-line management is pancreatic enzyme replacement therapy, which provides the lipase, amylase, and protease the pancreas can’t adequately deliver. By supplementing these enzymes, fat digestion improves, steatorrhea decreases, and nutritional status and absorption of fat-soluble vitamins improve. This approach addresses the functional consequence of pancreatic damage even when imaging shows calcifications and duct obstruction but no mass.

Antibiotics aren’t indicated here unless there’s an infection, and chemotherapy isn’t appropriate without a tumor. Resection or decompression procedures are considered only after medical management fails or if there are specific complications or intractable pain, not as the initial step. So starting with pancreatic enzyme supplementation aligns with treating the underlying exocrine failure and optimizing digestion in chronic pancreatitis, especially when there’s ductal changes but no mass.