Acute Pancreatitis Pain Research Articles

No Effect of Methylnaltrexone on Acute Pancreatitis Severity: A Multicenter Randomized Controlled Trial.

Opioids used to manage severe pain in acute pancreatitis (AP) might exacerbate the disease through effects on gastrointestinal and immune functions. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, may counteract these effects without changing analgesia. This double-blind, randomized, placebo-controlled trial included adult patients with AP and systemic inflammatory response syndrome at 4 Danish centers. Patients were randomized to receive 5 days of continuous intravenous methylnaltrexone (0.15 mg/kg/d) or placebo added to the standard of care. The primary end point was the Pancreatitis Activity Scoring System score after 48 hours of treatment. Main secondary outcomes included pain scores, opioid use, disease severity, and mortality. In total, 105 patients (54% men) were randomized to methylnaltrexone (n = 51) or placebo (n = 54). After 48 hours, the Pancreatitis Activity Scoring System score was 134.3 points in the methylnaltrexone group and 130.5 points in the placebo group (difference 3.8, 95% confidence interval [CI] -40.1 to 47.6; P = 0.87). At 48 hours, we found no differences between the groups in pain severity (0.0, 95% CI -0.8 to 0.9; P = 0.94), pain interference (-0.3, 95% CI -1.4 to 0.8; P = 0.55), and morphine equivalent doses (6.5 mg, 95% CI -2.1 to 15.2; P = 0.14). Methylnaltrexone also did not affect the risk of severe disease (8%, 95% CI -11 to 28; P = 0.38) and mortality (6%, 95% CI -1 to 12; P = 0.11). The medication was well tolerated. Methylnaltrexone treatment did not achieve superiority over placebo for reducing the severity of AP.

Erector spinae plane block as a component of intensive care for acute pancreatitis: a prospective randomized pilot study

BACKGROUND: Analgesia is crucial in the treatment of patients with acute pancreatitis, which includes the increased use of regional analgesia. In recent years, less-invasive and safer methods of pain relief, particularly erector spinae plane block (ESP-block), has drawn attention from the anesthesiological community. However, studies on its use in acute pancreatitis are rare. OBJECTIVE: Our aim was to make a clinical evaluation of bilateral erector spinae plane block in patients with acute pancreatitis. MATERIALS AND METHODS: A pilot prospective randomized study was conducted. The patients were divided into two groups: group 1 (n=7), ESP blockade was used, and group 2 (n=12), epidural analgesia (EA) was used. The primary points were considered to be an assessment of pain syndrome intensity and the need for analgesics. Additional results were liver and kidney function, acid-base condition, inflammatory response level, and the time of onset of peristalsis. RESULTS: The decrease in pain intensity in both groups was unidirectional: after 8 h, it was 3.57±1.98 points to the NRS in group 1 and 2.91±1.97 points to the NRS in group 2, and after 24 h, it was 1.42±1.27 and 1.75±2.3 points to the NRS, respectively. No significant difference was found in pain intensity between the groups (р 0,05). The average consumption of ketorolac was 78.2±16.3 mg in group 2 — 63.28±17.23 mg for 1 patient. The average need for narcotic analgesics, that is, morphine, per patient was 22±8 mg in group 1 and 36.3±17.2 mg in group 2 (р 0,05). During the therapy, blood α-amylase, diuresis rate, creatinine level, and glomerular filtration rate did not have a significant difference between the groups, as well as pH, BE, and blood lactate levels (р 0,05). Peristalsis was noted after 12.49±19.73 h in the ESP-block group and after 16.9±21.3 h in the 2nd group (р 0,05). The ICU length of stay between the groups did not differ and was 62±3 and 62±7 h, respectively (р 0,05). CONCLUSION: Bilateral erector spinae plane block is a simple and safe method that induces analgesic effect and effect on homeostasis in acute pancreatitis, similar to epidural blockade. Further study of the role and location of erector spinae plane block in treating pain in acute pancreatitis is required.

Molecular mechanisms of pain in acute pancreatitis: recent basic research advances and therapeutic implications.

Although severe abdominal pain is the main symptom of acute pancreatitis, its mechanisms are poorly understood. An emerging body of literature evidence indicates that neurogenic inflammation might play a major role in modulating the perception of pain from the pancreas. Neurogenic inflammation is the result of a crosstalk between injured pancreatic tissue and activated neurons, which leads to an auto-amplification loop between inflammation and pain during the progression of acute pancreatitis. In this review, we summarize recent findings on the role of neuropeptides, ion channels, and the endocannabinoid system in acute pancreatitis-related pain. We also highlight potential therapeutic strategies that could be applied for managing severe pain in this disease.

Comprehensive Review of Acute Pancreatitis Pain Syndrome

Pancreatitis is a condition that causes inflammation in the pancreas, an organ located behind the stomach. This condition often presents as neuropathic, inflammatory, and/or visceral pain. Acute pancreatitis is typically characterized by sudden and severe abdominal pain, often in the upper right part of the abdomen. The pain from pancreatitis can be caused by different mechanisms, such as abnormal activation of pancreatic zymogens or NF-κB mediated inflammation in the pancreas. The treatment of pancreatitis depends on its type, severity, and underlying cause. Hospitalization and medications are typically necessary, while in others, surgery may be required. Proper management of pancreatitis is essential, as it can help reduce the risk of complications and improve the patient’s quality of life. The literature on pancreatitis pain management evaluates systematic approaches and the effectiveness of various treatments, such as lidocaine, opioid agonists, ketamine, magnesium, endoscopic methods, spinal cord stimulation, and other novel treatments present opportunities for exploration in pancreatitis pain management.

Dysregulated B7H4/JAK2/STAT3 Pathway Involves in Hypertriglyceridemia Acute Pancreatitis and Is Attenuated by Baicalin.

Patients with hypertriglyceridemia (HTG) are prone to develop more severe acute pancreatitis (AP). However, the specific molecular mechanism still has not been elaborated clearly, and effective drugs for treating HTG-AP are not yet readily available. Baicalin is an ingredient isolated from a natural product that with potential to attenuate inflammation and pain in AP. The aim of the present study was to explore the effect of baicalin on HTG-AP and the possible mechanism involved. A mouse model of HTG-AP was successfully established by administering Poloxamer 407 and L-arginine intraperitoneally. We analyzed pathological changes, and performed TUNEL staining, DHE staining, and western blot to detect apoptosis, inflammation, oxidative stress, and B7H4/JAK2/STAT3 signaling in the pancreas. Treatment with baicalin decreased serum triglyceride, cholesterol, lipase, amylase levels, and attenuated pancreatic edema. After intervention with baicalin, apoptosis and inflammation in HTG-AP mice were alleviated, as indicated by the decrease of Bax, cleaved-caspase-3, IL-6, TNF-α, and IL-1β. Baicalin also alleviated oxidative stress by decreasing NOX2, increasing SOD2 protein expression, and regulating Nrf2/Keap1 signaling in HTG-AP mice. Furthermore, baicalin decreased the upregulated B7H4/JAK2/STAT3 pathway in HTG-AP. In conclusion, our data suggested that baicalin could attenuate HTG-AP, possibly through regulating B7H4/JAK2/STAT3 signaling.

The characteristics and prognostic role of acute abdominal on-admission pain in acute pancreatitis: A prospective cohort analysis of 1432 cases.

IntroductionPain is the most common symptom in acute pancreatitis (AP) and is among the diagnostic criteria. Therefore, we aimed to characterize acute abdominal pain in AP.MethodsThe Hungarian Pancreatic Study Group prospectively collected multicentre clinical data on 1435 adult AP patients between 2012 and 2017. Pain was characterized by its intensity (mild or intense), duration prior to admission (hours), localization (nine regions of the abdomen) and type (sharp, dull or cramping).Results97.3% of patients (n = 1394) had pain on admission. Of the initial population with acute abdominal pain, 727 patients answered questions about pain intensity, 1148 about pain type, 1134 about pain localization and 1202 about pain duration. Pain was mostly intense (70%, n = 511/727), characterized by cramping (61%, n = 705/1148), mostly starting less than 24 h prior to admission (56.7%, n = 682/1202). Interestingly, 50.9% of the patients (n = 577/1134) had atypical pain, which means pain other than epigastric or belt‐like upper abdominal pain. We observed a higher proportion of peripancreatic fluid collection (19.5% vs. 11.0%; p = 0.009) and oedematous pancreas (8.4% vs. 3.1%; p = 0.016) with intense pain. Sharp pain was associated with AP severity (OR = 2.481 95% CI: 1.550–3.969) and increased mortality (OR = 2.263, 95% CI: 1.199–4.059) compared to other types. Longstanding pain (>72 h) on admission was not associated with outcomes. Pain characteristics showed little association with the patient's baseline characteristics.ConclusionA comprehensive patient interview should include questions about pain characteristics, including pain type. Patients with sharp and intense pain might need special monitoring and tailored pain management.SignificanceAcute abdominal pain is the leading presenting symptom in acute pancreatitis; however, we currently lack specific guidelines for pain assessment and management. In our cohort analysis, intense and sharp pain on admission was associated with higher odds for severe AP and several systemic and local complications. Therefore, a comprehensive patient interview should include questions about pain characteristics and patients with intense and sharp pain might need closer monitoring.

The characteristics and prognostic role of acute abdominal on-admission pain in acute pancreatitis: A prospective cohort-analysis of 1432 cases

The characteristics and prognostic role of acute abdominal on-admission pain in acute pancreatitis: A prospective cohort-analysis of 1432 cases

Fever and Abdominal Pain in Acute Pancreatitis

Question: A 44-year-old man with diabetes and a history of severe acute pancreatitis with encapsulated pancreatic necrosis in the context of hyperlipemia requiring admission to the intensive care unit. He was admitted for a second episode of acute pancreatitis. He initially presented renal failure and metabolic acidosis requiring admission to the intensive care unit with the need for vasopressors and the initiation of broad-spectrum antibiotic coverage. Despite antibiotic treatment, on day 7 of admission a high fever occurred, requiring antibiotic escalation with no microbiological findings.

Transversus abdominis plane block in acute pancreatitis pain management

Transversus abdominis plane block in acute pancreatitis pain management

Intravenous paracetamol vs tramadol for pain management in patients with acute pancreatitis

Introduction: Acute Pancreatitis causes severe and persistent pain, and thus, necessitates effective treatment. Opioids are widely used to relieve pain in acute pancreatitis due to their efficacy and effectiveness. Intravenous paracetamol has been documented to have comparable effectiveness as that of opioids, with lesser side effects. In this study, the analgesic efficacy of tramadol, an opioid was compared with paracetamol in acute pancreatitis.
 Method: This was an open label comparative study conducted in a tertiary referral hospital of Nepal. Patients with Acute Pancreatitis were randomly assigned to receive 1 g of paracetamol or 50 mg of tramadol with 100 mL normal saline within 4-5 minute. Pain measurements of the patients were conducted at baseline and 24 hours after the treatment intervention. Changes in pain scores were calculated by subtracting the mean scores at baseline and 24 hours as pairs.
 Result: In this study, 80 patients were enrolled and included in the final analysis. The study subjects had a mean age of 39.33 +/- 13.3 years and 62(77.5%) of them were male. Alcohol was the etiology for pancreatitis in 67.5% (n=54) of patients. Mean pain scores at baseline and 24 hours were similar in the two groups. Similarly, change of scores from baseline to 24 hours did not differ between the groups. Comparison of pain improvements failed to reveal any differences between groups.
 Conclusion: Intravenous paracetamol is an effective alternative to tramadol in pain management of acute pancreatitis.

Nitric Oxide Stimulates Acute Pancreatitis Pain via Activating the NF-κB Signaling Pathway and Inhibiting the Kappa Opioid Receptor.

Pain is the most important clinical feature of acute pancreatitis (AP); however, its specific mechanism is currently unclear. In this study, we showed that AP caused an increase in nitric oxide (NO) secretion, activated the NF-κB pathway in the dorsal root ganglia (DRGs), and caused pain. We established an AP model in vivo and tested the expression of NO, the kappa opioid receptor (KOR), and pain factors. We showed that NO in AP was significantly elevated and increased the expression of pain factors. Next, by treating DRGs in vitro, it was found that NO activated the NF-κB pathway; conversely, NF-κB had no effect on NO. Moreover, inhibition of NF-κB promoted the KOR, whereas NF-κB did not change after KOR activation. Finally, behavioral experiments showed that a NO donor increased the pain behavior of mice, while a NO scavenger, NF-κB inhibitor, or KOR agonist attenuated the pain response in mice. These results suggest that iNOS/NO/NF-κB/KOR may be a key mechanism of pain in AP, providing a theoretical basis for the use of peripheral-restricted KOR agonists for pain treatment in AP.

Фармакоэпидемиологическое изучение эффективности прокаина (новокаина) в комбинации с другими лекарственными средствами в лечении болевого синдрома при остром панкреатите

The purpose of the study : on the base of statistical and pharmacoepidemiological researches to study the effectiveness of procaine (novocaine) and to develop optimal combinations of pharmacological agents in the treatment of pain in acute pancreatitis. Materials and methods . In a cohort retrospective research, we studied case histories of 131 patients with acute pancreatitis who were treated at Surgery Department of Archbishop Luka City Clinical Hospital of Tambov. Among them, 71 men (54.2 %) and 60 women (45.8 %), whose average age was 52.5, including 46 years old men and 59 years old women. We studied the number of medicines used to treat the pain syndrome, the time of its relief, and made a pharmacoepidemiological assessment of the effectiveness of treatment with novocaine in combination with various drugs. Procaine was injected intravenously in the form of a 0.25-0.5 % solution. Results . We found out that combination of procaine with non-steroidal anti-inflammatory medicines and gastric secretion blockers have an effective analgesic effect. Treatment of pain by intravenous injection of a solution of novocaine and its combination with anticholinergic and myotrop antispasmodics was ineffective.

Comparison of efficacy of diclofenac and tramadol in relieving pain in patients of acute pancreatitis: A randomized parallel group double blind active controlled pilot study.

Opioids and non steroidal anti inflammatory drugs (NSAIDs) are commonly used for pain relief in acute pancreatitis (AP). Opioids carry risk of sphincter of oddi constriction. Although diclofenac prevents post endoscopic retrograde cholangio-pancreatography (ERCP) pancreatitis, few reports of diclofenac associated AP are also present. Although, both tramadol and diclofenac are commonly used for pain relief in AP, no study has evaluated their comparative efficacy and safety. Forty-six eligible participants were randomized to either diclofenac or tramadol. Primary objectives ofour study were improvement in pain intensity onvisual analogue scale (VAS pain score after 1hr of drug administration)and number of patients requiring supplementary analgesia. The secondary objectives were total number of times of supplementary analgesia requirement, time to significant decrease (33%) in VAS pain score from baseline, number of painful days (VAS pain score>5), VAS pain score on 7th day, side effects, all cause death and complications of pancreatitis between the two groups. Although 46 patients were randomized, the final analysis included 41 participants. Five patients were withdrawn from the study (intubation=3, altered sensorium=2). No significant difference was seen in terms of VAS score after 1hr of drug administration, number of patients requiring supplementary analgesic and number of painful days. However, time taken to significant reduction of pain was lower in the diclofenac group (p=.028). Both the agents were comparable in terms of safety. Although complications were less in the diclofenac group, the difference was not statistically significant. Both diclofenac and tramadol are equally effective in controlling pain in AP with similar safety profile. There are no studies that have compared the safety and efficacy of two commonly used analgesics for pain relief in patients with AP. We found that both diclofenac and tramadol are equally effective in decreasing the pain associated with AP. There is also no significant difference in the incidence of side effects between both the groups. Hence both diclofenac and tramadol can be used safely and effectively for pain control in AP. The trial was registered with clinical trials registry India (Number- CTRI/2018/05/014309).

90 Factors Associated With Increased Opioid Use in a Retrospective Cohort of 14,140 Acute Pancreatitis Patients

INTRODUCTION: Pain management is a critical component of treating acute pancreatitis (AP). No guidelines exist on optimal pain management strategies. Opioids have become a mainstay in the treatment of pain in AP, but there are uncertainties regarding their effectiveness and concerns about their safety. The risk of subsequent opioid dependence (OD) after developing AP has not been well-studied. Our aim is to 1) Investigate the risk of developing OD after having AP, and 2) Evaluate whether patient factors such as age, gender, race, and insurance status affect the risk of developing OD after AP. METHODS: We performed a retrospective analysis in the IBM Explorys database (1999–2019), a pooled, de-identified clinical database of over 63 million unique patients across the United States. At the time of analysis there were 63,566,840 patients. Patient populations were identified using SNOMED and ICD codes. Odds ratios were calculated to determine the relationship between AP and OD for the population subgroups outlined above. RESULTS: 316,450 patients had AP from 1999–2019. 14,140 of these patients also were OD. The odds of being OD after AP was 11.06 (95% CI 10.87, 11.25). Patients under the age of 65 years had the highest risk of developing OD. Patients with Medicaid had the highest risk of any type of medical insurance. Females were more likely to develop OD than males. Caucasian and African American patients had a similar risk of becoming OD. Asian patients were least likely to develop OD. Full results are listed in Table 1. Corresponding Forrest plots of this data are illustrated in Figure 1. CONCLUSION: Our results are consistent with what has been observed previously, as an evaluation of opioid use among inpatients with AP also found a significant variation in opioid use among hospitalized patients. High doses of opioids have been shown to result in longer hospitalizations and more adverse outcomes. Prospective trials and systematic reviews have not found that any particular analgesic is superior for pain control in AP patients. There is currently a lack of clinical guidance on the utility and efficacy of using opioids in managing pain from AP. We hope that our results can inform clinicians of different patient factors that may increase the risk of OD after having AP. Future use of drug monitoring systems and electronic health record utilization may help further analyze factors associated with persistent opioid use.

109 Persistent Hemoconcentration After Initial Resuscitation Is Associated With Increased Need for Opiates in the ED in Patients Presenting With Acute Pancreatitis

INTRODUCTION: Opiates are commonly used in the management of abdominal pain in acute pancreatitis (AP). The factors associated with increased need for opiates during the initial management are unknown. METHODS: Medical records of adults presenting to the ED from 9/1/2013 to 8/31/2016 with AP were identified retrospectively. AP was diagnosed, and severity stratified using the revised Atlanta Classification (2012). Total quantity of opiates required during ED phase of care was converted to morphine equivalents (ME) and divided by number of hours in the ED to get mean ME per hour in the ED (MME). Log-linear multivariable regression analysis was performed to identify factors associated with MME. Hemoconcentration was defined as hematocrit ≥44%. RESULTS: 318 AP patients were identified. 248 received opiates in the ED. Baseline characteristics are shown in Table 1. At ED presentation, 75 (30.65%) had at least 2 SIRS criteria and 46 (18.55%) had hemoconcentration. On the second set of labs (still within 24 hours of ED arrival), 11/46 (23.9%) remained hemoconcentrated and 2 developed hemoconcentration despite resuscitation. The distribution of mean ME per hour in the ED (MME) ranged from 0.12 mg to 24.81 mg. Mean MME was 2.15 mg (SD = 2.54). Simple linear and multivariable regression analyses are shown in Table 2. Age and first episode of AP were independently associated with less MME. After exponentiation, for every 1-year increase in age, a 1% decrease in MME was observed. Patients with the first episode of AP required 34.9% less MME compared to those with prior AP. On subgroup analysis of patients who were opiate naïve at presentation (N = 193), first episode of AP was still associated with less MME (b-coefficient −0.4024, P = 0.0025); they required 33.1% less MME compared to those with prior AP. Hemoconcentration after initial resuscitation (but within 24 hours of presentation) was associated with increased MME. Patients with hemoconcentration on the second set of labs required 95% higher MME compared to those without hemoconcentration. Increasing number of SIRS criteria was also associated with increased MME; one additional SIRS criteria was associated with a 15% increase in MME. CONCLUSION: Persistent or new hemoconcentration within 24 hours of presentation is associated with increased opiate requirement in the ED in patients with AP. This suggests that inadequacy of initial fluid resuscitation to correct intravascular fluid losses may lead to increased pain and need for opiate medications.

Factors Associated With Opioid Use in Patients Hospitalized for Acute Pancreatitis

Limited guidance exists regarding the optimal approach to management of pain in acute pancreatitis (AP). To investigate sources of variability in opioid use for treatment of acute pain in patients hospitalized for AP and to explore a potential association of opioid prescribing patterns with length of stay. This retrospective cohort study included 4307 patients 18 years and older hospitalized for AP in a community-based integrated health care system, from January 1, 2008, to June 30, 2015. Analysis began in November 2017. Opioid use was quantified by morphine equivalent dose (MED). Three analyses were performed: (1) factors associated with increased opioid administration during the initial 12 hours of hospitalization (baseline), (2) association of baseline opioid use with length of stay, and (3) frequency of opioid use 90 days after hospital discharge (persistent use). The cohort included 4307 patients (median [interquartile range] age, 57.4 [44.0-70.2] years; 2241 women [52.0%]) with AP. At baseline, 3443 patients (79.9%) received opioids, and 388 patients (9.6%) had persistent opioid use after discharge. After adjusting for pain and other clinical factors, women received less MED than men (adjusted event ratio, 0.83; 95% CI, 0.79-0.86; P < .001). Hispanic and Asian patients received less MED than non-Hispanic white patients (adjusted event ratio, 0.85; 95% CI, 0.81-0.90; P < .001; and adjusted event ratio, 0.79; 95% CI, 0.72-0.86; P < .001, respectively). Alcohol-related AP etiology was associated with increased MED vs gallstone disorders (adjusted event ratio, 1.11; 95% CI, 1.05-1.18; P < .001). Two of 13 hospitals administered significantly less opioids compared with the others. Median (interquartile range) length of stay was independently associated with MED at baseline, with 3.0 (2.1-4.5) days among patients not receiving opioids vs 5.0 (3.2-8.7) days among patients in the highest quintile of MED (P < .001). In addition to pain and disease severity, opioid use varied by etiology of AP, sex, race/ethnicity, and institution of treatment. Increased opioid use at baseline was associated with longer hospitalization. These findings suggest opportunities for improved approaches to pain control for patients with AP.

Radiofrequency ablation of bilateral splanchnic nerve in acute pancreatitis pain: Interventional approach.

Sir, Radiofrequency ablation (RFA) of the bilateral splanchnic nerve has been used in patients with chronic pancreatitis pain refractory to medical management.[1] We describe the management of pain in acute pancreatitis using RFA ablation of bilateral splanchnic nerve. A 37-year-old male presented with chief complaints of severe pain abdomen radiating to back and vomiting since 6-months. The pain aggravated following meals and was not relieved with analgesics. The verbal numeric rating scale (VNRS)[2] was 9/10. Patient was chronic alcoholic since 25 years. Blood investigations were within acceptable range. Computed tomography (CT) of the abdomen showed bulky and heterogeneous pancreas with necrosis (>50%) in body and tail of pancreas sparing the head region [Figure 1a] with modified CT severity index of 10. A large collection 9 cm × 6 cm was present in the lesser sac, which was managed with the ultrasound-guided aspiration of a pseudocyst. The patient showed clinical improvement, but the VNRS continued to be 8/10 in spite of analgesics. Patient had received several trials of the combination of analgesics including; paracetamol, tramadol, paracetamol-codeine phosphate combination, tapentadol, flupirtine, and adjuvant medications like pancreatic enzyme supplementation, with no relief in symptoms. A CT scan done after 4 weeks revealed a bulky pancreas with heterogeneous density with modified CT severity index of 6 for which no surgical intervention was required. Patient was referred to a pain clinic. After explaining the procedure to the patient and written informed consent, RFA of bilateral splanchnic nerve was planned. An intravenous access (IV) was placed and 1 L normal saline was administered. Monitoring (Aestiva 5™, GE healthcare, Datex-Ohmeda division, Helsinki, Finland) was started and IV fentanyl 50 μg and diclofenac 50 mg were administered to reduce pain related to the prone position. Under strict asepsis and fluoroscopic guidance a 20G, 10 cm RF needle with 10 mm curved active tip (Cosman cannula RFK™ Cosman Medical, Inc., Burlington, MA, USA) was placed at the junction of anterior one-thirds and posterior two-thirds of T11 vertebral body [Figure 1b] and after confirmation with nonionic radio-opaque contrast, sensory stimulation was confirmed at 50-Hz frequency and at 0.5 V [Figure 1c]. Following no motor stimulation, RFA was done at 60°C, and four cycles of 120 s each were applied. A mixture of 5 ml of 0.2% ropivacaine and 20 mg of triamcinolone was injected before removing the RF needle. A similar procedure was done on the other side. The patient's VNRS reduced to 0/10. At 1-year, VNRS remained 2/10 with improvement in quality of life and occasional requirement of mild analgesics.Figure 1: (a) Computed tomography of the abdomen, the white arrow showing necrosis of body and black arrow showing necrosis in the tail of pancreas (b) fluoroscopic image of radio frequency needle placed at the junction of anterior one-thirds and posterior two-thirds of T11 vertebral body (c) splanchnic nerve block with radio frequency needle and stimulating electrode in situPain in acute pancreatitis is transmitted via afferent splanchnic nerves of the celiac plexus.[34] Percutaneous splanchnic nerve block was performed in the present case as compared to celiac plexus block due to its predictable anatomy, accurate needle placement, and theoretically reduced the risk of complications. Under fluoroscopy, RFA is a minimally invasive target-selective technique, which heats the tissues at 65-75°C to produces thermal lesion. This interrupts the conduction of nociceptive signals and blocks the pain transmission. The duration of pain relief depends on the duration of time taken by coagulated nerves to regenerate.[5] Earlier authors had also reported a reduction in the pain after RFA in patients with chronic pancreatitis.[67] Pain during acute pancreatitis offers more challenges, as patients are clinically less stable than in chronic pancreatitis. Prone position may require additional analgesics due to discomfort and pain during RFA procedure.[5] Application of bilateral splanchnic nerve RFA may be considered for pain relief in moderately severe acute pancreatitis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

How do opioids compare with non-opioid analgesics for the management of acute pancreatitis pain?

How do opioids compare with non-opioid analgesics for the management of acute pancreatitis pain?

Opioids for acute pancreatitis pain

Acute pancreatitis is an acute inflammatory process of the pancreas that may also involve adjacent tissues and/or remote organ systems. Abdominal pain is the main symptom and is usually accompanied by nausea, vomiting and fever. Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety. To assess the effectiveness and safety of opioids for treating acute pancreatitis pain. The search strategy included the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE (from 1950 to June 2013) and EMBASE (from 1980 to June 2013). There were no restrictions by language or publication status. We considered randomised clinical trials (RCTs) assessing the effectiveness of any opioid drug used for treating acute pancreatitis pain. Two review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RRs) for dichotomous data and calculated a 95% confidence interval (CI) for each RR. We performed an intention-to-treat (ITT) analysis. We undertook meta-analysis for some outcomes. We included five RCTs with a total of 227 participants (age range 23 to 76 years; 65% men) with acute pancreatitis pain. The opioids assessed were intravenous and intramuscular buprenorphine, intramuscular pethidine, intravenous pentazocine, transdermal fentanyl and subcutaneous morphine.One RCT, comparing subcutaneous morphine with intravenous metamizole reported non-significant reduction in the number of participants with improvements in pain intensity (primary outcome) (RR 0.50, 95% CI 0.19 to 1.33). Three studies compared analgesia using opioids with non-opioid treatments. After excluding one study that used opioids through continuous intravenous infusion, there was a decrease in the number of patients requiring supplementary analgesia (RR 0.53, 95% CI 0.30 to 0.93). In a single study, there were no differences in the number of patients requiring supplementary analgesia between buprenorphine and pethidine (RR 0.82, 95% CI 0.61 to 1.10).Pancreatitis complications were not associated with a significant difference between the drugs tested. No clinically serious or life-threatening adverse events occurred related to treatment. No differences for this outcome were found between opioid and non-opioid treatments, or for type of adverse event (nausea-vomiting and somnolence-sedation). One death in the procaine group was reported across all the trials.One RCT comparing pethidine with intramuscular buprenorphine reported non-significant differences of supplementary analgesic, adverse events or deaths. One RCT comparing fentanyl with placebo found no difference in adverse events.The findings of this review are limited by the lack of information to allow full appraisal of the risk of bias, the measurement of relevant outcomes and the small numbers of participants and events covered by the trials. Opioids may be an appropriate choice in the treatment of acute pancreatitis pain. Compared with other analgesic options, opioids may decrease the need for supplementary analgesia. There is currently no difference in the risk of pancreatitis complications or clinically serious adverse events between opioids and other analgesia options.Future research should focus on the design of trials with larger samples and the measurement of relevant outcomes for decision-making, such as the number of participants showing reductions in pain intensity. The reporting of these RCTs should also be improved to allow users of the medical literature to appraise their results accurately. Large longitudinal studies are also needed to establish the risk of pancreatitis complications and adverse events related to drugs.

Pain in acute pancreatitis and its relation with prognosis: A prospective and descriptive study

Pain in acute pancreatitis and its relation with prognosis: A prospective and descriptive study