Treatment Of Pain In Chronic Pancreatitis Research Articles

Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification.

Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.

Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons!

Pain is the dominating symptom of chronic pancreatitis (CP) causing impairment of quality of life, decreased activity, unemployment and major healthcare costs.1 Opinions differ on the best strategy to treat...

Management of Chronic Pancreatitis

Chronic pancreatitis (CP) is a syndrome that is characterized by inflammation, irreversible fibrosis, and loss of acinar and islet cells. It has also been described as an “enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment.” This review describes the epidemiology, diagnosis, diagnostic challenges, differential diagnosis, treatment, complications, and clinical course and prognosis of CP, as well as future challenges. Figures show a computed tomographic (CT) scan of calcific CP, a secretin-enhanced magnetic resonance cholangiopancreatogram showing a dilated and tortuous main pancreatic duct, a CT scan of a large chronic pseudocyst compressing the stomach and pancreas, an endoscopic ultrasound (EUS) image of CP, a retrograde pancreatogram showing a dilated main pancreatic duct with stones and “blunted” side branches, sources of pain in CP, neuropathic pain mechanisms in CP, and an algorithm summarizing treatment of pain in CP. Tables list the TIGAR-O etiologic classification of CP, standard criteria for diagnosis of CP by EUS, Cambridge endoscopic retrograde cholangiopancreatography grading for CP, and a stepwise radiographic and endoscopic diagnostic approach to patients with suspected CP. Key words: bile duct obstruction, chronic pancreatitis, pancreatic calcifications, TIGAR-O system This review contains 8 highly rendered figures, 4 tables, and 54 references.

Cochrane Corner: Antioxidants to reduce pain in chronic pancreatitis

The common symptoms of chronic pancreatitis (CP) include frequent or constant pain in the upper abdomen radiating to the back, and weight loss resulting from by malabsorption of food. Diabetes may also develop if the insulin-producing cells of the pancreas are damaged. It is a difficult to treat condition, usually involving a low-fat diet, medications for the pain and sometimes patients require pancreatic enzymes, insulin or surgery. CP occurs more frequently inmen than inwomen, often developing in people aged 30–40. Oxidative stress has been implicated in the pathophysiology of CP and there is evidence that the pain of CPmay be in part be due to oxygen free radical induced pancreatic damage [1]. Peoplewith the condition may also have a reduced intake of antioxidants as a result of eating less because of pain, and also as a result of malabsorption, and lower levels of antioxidants are often observed in patients with the disease [2]. It is thought that improving the status of antioxidants might be effective in slowing the disease process and reducing pain. This Cochrane review included 12 RCTs, with a total of 585 participants, which evaluated antioxidants for the treatment of pain in CP [3]. Six trials were double-blind, placebo-controlled studies, and the other six were of less robust methodology. The antioxidant treatments used in the studies varied widely, but in general consisted of a combination of several commonly used antioxidants, in particular, selenium, ascorbic acid, b-carotene, atocopherol, and methionine. As studies used different types, numbers of preparations and doses of antioxidants, and as there Cochrane review Pancreatitis Antioxidants

Antioxidants for pain in chronic pancreatitis.

Reduced intake and absorption of antioxidants due to pain and malabsorption are probable causes of the lower levels of antioxidants observed in patients with chronic pancreatitis (CP). Improving the status of antioxidants might be effective in slowing the disease process and reducing pain in CP. To assess the benefits and harms of antioxidants for the treatment of pain in patients with CP. We searchedthe Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Conference Proceedings Citation Index from inception to October 2012. Two review authors performed the selection of trials independently. We included all randomised controlled trials (RCTs) evaluating antioxidants for treatment of pain in CP. All trials were included irrespective of blinding, numbers of participants randomly assigned and language of the article. Two review authors extracted data independently. The risk of bias of included trials was assessed. Study authors were asked for additional information in the case of missing data. Twelve RCTs with a total of 585 participants were included. Six trials were double-blinded, placebo-controlled studies, and the other six trials were of less adequate methodology. Most trials were small and had high rates of dropout. Eleven of the 12 included trials described the effects of antioxidants on chronic abdominal pain in chronic pancreatitis. Pain as measured on a visual analogue scale (VAS, scale range 0 to 10) after one to six months was less in the antioxidant group than in the control group (mean difference (MD) -0.33, 95% confidence interval (CI) -0.64 to -0.02, P value 0.04, moderate-quality evidence). The number of pain-free participants was not statistically significantly different (risk ratio (RR) 1.73, 95% CI 0.95 to 3.15, P value 0.07, low-quality evidence). More adverse events were observed in the antioxidant group, both in the parallel trials (RR 4.43, 95% CI 1.60 to 12.29, P value 0.0004, moderate-quality evidence) and in the cross-over trials (RR 5.80, 95% CI 1.56 to 21.53, P value 0.0009, moderate-quality evidence). Adverse events occurred in 16% of participants and were mostly mild (e.g. headache, gastrointestinal complaints), but were sufficient to make participants stop antioxidant use. Other important outcomes such as use of analgesics, exacerbation of pancreatitis and quality of life were rarely reported. One trial from 1991 evaluated the effects of antioxidants on acute pain during exacerbation of chronic pancreatitis and found that a significantly higher proportion of participants in the antioxidant group experienced pain relief. This trial was conducted more than 25 years ago and has not been reproduced since that time. Therefore, additional trials are needed before reliable conclusions can be drawn. Current evidence shows that antioxidants can reduce pain slightly in patients with chronic pancreatitis. The clinical relevance of this small reduction is uncertain, and more evidence is needed. Adverse events in one of six patients may prevent the use of antioxidants. Effects of antioxidants on other outcome measures, such as use of analgesics, exacerbation of pancreatitis and quality of life remain uncertain because reliable data are not available.

Stent-related complications of endotherapy in the treatment of chronic pancreatitis pain and their relationship to the duration of stent placement

Stent-related complications of endotherapy in the treatment of chronic pancreatitis pain and their relationship to the duration of stent placement

Meta-analysis

Treatment of the pain caused by chronic pancreatitis (CP) is not standardized. Knowledge of the response to placebo in this setting may aid the design of future trials. We aimed at investigating the placebo effect on abdominal pain remission rates in patients with CP. MEDLINE, EMBASE, and Scopus were searched, and randomized placebo-controlled trials in CP providing data on abdominal pain remission rates in placebo arms were included. Pooled estimates of the placebo rate were calculated using random-effects logistic regression analysis. Stratum-specific rates for different patients and study-level covariates were calculated to account for heterogeneity. Seven randomized controlled trials (202 placebo-treated patients) met the predefined criteria. The pooled estimate of the placebo rate for pain remission was 19.9% (95% confidence interval, 9%-36%). There was a statistically significant heterogeneity among the studies (I(2) = 76%; P < 0.001). A multicenter design, a run-in period of less than 2 weeks, and absence of a washout in crossover trials were all significant sources of heterogeneity associated with higher placebo responses. This meta-analysis identifies for the first time the efficacy of placebo for pain in CP and variables determining it. These data provide a sound basis for designing future placebo-controlled randomized clinical trials for the treatment of pain in CP.

Su1389 Stent-Related Complications of Endotherapy in the Treatment of Chronic Pancreatitis Pain and Their Relationship to the Duration of Stent Placement

Su1389 Stent-Related Complications of Endotherapy in the Treatment of Chronic Pancreatitis Pain and Their Relationship to the Duration of Stent Placement

Long-term Results of Extracorporeal Shockwave Lithotripsy and Endoscopic Therapy for Pancreatic Stones

The aim of this study was to evaluate the short- and long-term results of extracorporeal shockwave lithotripsy (ESWL) and endoscopic therapy for pancreatic stones. A total of 117 patients with pancreatic stones underwent ESWL and endoscopic treatment in our institute. Seventy patients who were followed-up for over 3 years after treatment were evaluated retrospectively. Immediate pain relief was achieved in 97% and complete removal of stones was achieved in 56%. During the long-term follow-up evaluation, 49 of 70 patients continued to be asymptomatic. Pain recurred more frequently in patients with incomplete removal than in those with complete removal (P < .05). Twenty-one patients who became symptomatic during the follow-up period underwent additional therapy, and pain relief was attained without surgery in all of them. Both endocrine and exocrine function deteriorated after the long-term follow-up period (P < .05). ESWL and endoscopic treatment of pancreatic stones proved to be effective for long-term pain relief, especially in patients in whom stones were removed completely at initial therapy.

Successful treatment of chronic pancreatitis pain with interpleural analgesia.

Interpleural analgesia has recently been shown to be effective in the management of various chronic pain syndromes. We have used interpleural analgesia successfully in 11 patients with severe chronic pancreatitis of 24-38 months' duration. Daily injections of 30 ml of 0.5 per cent bupivacaine with epinephrine 5 mu.ml-1, were given through a percutaneously inserted pleural catheter over a five- to ten-day period. Patients have remained pain-free during follow up which ranges from 24 to 40 weeks. This method of providing analgesia for the patient suffering from the pain of chronic pancreatitis is simple, safe, effective and can be provided on an outpatient basis.