Guidelines for the understanding and management of pain in chronic pancreatitis

Abstract

Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.

Association of multiple patient and disease characteristics with the presence and type of pain in chronic pancreatitis

“…10 Pain prevalence and pain patterns. Sixty percent of patients had pain, and intermittent pain was the most frequently reported pain pattern.…”

“…These include patients' age at diagnosis, 8 etiology and duration of CP, 8,9 morphological features of the pancreas including pancreatic duct pathology, 10 and the presence (or absence) of exocrine pancreatic insufficiency (EPI) and diabetes. These include patients' age at diagnosis, 8 etiology and duration of CP, 8,9 morphological features of the pancreas including pancreatic duct pathology, 10 and the presence (or absence) of exocrine pancreatic insufficiency (EPI) and diabetes.…”

Surgery in Chronic Pancreatitis: Indication, Timing and Procedures

“…Long-term beneficial effects of opioids on chronic pancreatitis pain are not proven; still, 50% of chronic pancreatitis patients use opioids on a daily basis [19]. Interestingly, pain relief can be achieved in a large proportion of these patients by treating their morphological abnormalities by interventional endoscopy or surgery [3, 20-23]. Bearing in mind that the longer patients are treated with opioids, the greater the risk of opioid dependence and opioid-induced hyperalgesia, it seems better to use opioids as a bridge to invasive treatment when morphological abnormalities are present instead of definitive treatment [3, 24].…”

“…In the current literature and guidelines for painful obstructive chronic pancreatitis, inconsistency is found regarding the timing and choice for surgery or endoscopy first [3, 23, 25]. Recently, multiple studies have suggested that early surgery is superior in providing pain relief and improvement of quality of life, compared to the step-up approach in which medical therapy is followed by endoscopy and finally surgery [4-6].…”

“…A plausible explanation for these failures can be due to changes in pain processing [13, 23, 59]. Nociceptive input from the pancreas to the central nervous system can be altered by structural changes of the nerves innervating the pancreas resulting in hyperalgesia.…”