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Kundra A, Strand DS, Shami VM. Endoscopic Management of Pain due to Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:433-448. [PMID: 38796291 DOI: 10.1016/j.giec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.
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Affiliation(s)
- Arjun Kundra
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Department of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
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2
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Han S, Li R, Palermo TM. Daily Pain Experiences in Chronic Pancreatitis: Identifying Pain Phenotypes. Pancreas 2024; 53:e34-e41. [PMID: 37922366 PMCID: PMC10842615 DOI: 10.1097/mpa.0000000000002271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
OBJECTIVES Pain, the hallmark symptom of chronic pancreatitis (CP), remains difficult to assess. To capture the variability of pain that patients can experience day to day, this study used pain diaries to describe daily pain experiences and identify pain phenotypes. METHODS This study is a secondary data analysis from a pilot trial examining cognitive behavioral therapy for pain treatment in CP. Before treatment, patients completed an online daily pain diary using the Brief Pain Inventory for 7 days. Using indicators of pain magnitude, pain variability, pain synchrony along with least, worst, and average pain intensity levels, we identified pain patterns using K-means clustering. RESULTS Of 30 patients in the pilot trial, a total of 27 patients (mean age of 49.8 years, 80% women) had complete data to include in this report. Four clusters were identified: cluster 1, lowest pain magnitude (n = 3); cluster 2, moderate pain magnitude and high pain variability (n = 4); cluster 3, moderate pain magnitude and low pain variability (n = 9); and cluster 4, highest pain magnitude and lowest pain variability (n = 11). CONCLUSIONS Daily pain diaries offer a novel way of evaluating the dynamic pain experiences in CP. Although 4 distinct pain patterns were identified, further studies are needed to validate these findings.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rui Li
- Center for Child Health, Behavior & Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Tonya M. Palermo
- Center for Child Health, Behavior & Development, Seattle Children’s Research Institute, Seattle, Washington
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington
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3
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Saloman JL, Li Y, Stello K, Li W, Li S, Phillips AE, Hall K, Fogel EL, Vege SS, Li L, Andersen DK, Fisher WE, Forsmark CE, Hart PA, Pandol SJ, Park WG, Topazian MD, Van Den Eeden SK, Serrano J, Conwell DL, Yadav D. Serum Biomarkers of Nociceptive and Neuropathic Pain in Chronic Pancreatitis. THE JOURNAL OF PAIN 2023; 24:2199-2210. [PMID: 37451493 PMCID: PMC10787046 DOI: 10.1016/j.jpain.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Debilitating abdominal pain is a common symptom affecting most patients with chronic pancreatitis (CP). There are multiple underlying mechanisms that contribute to CP-related pain, which makes successful treatment difficult. The identification of biomarkers for subtypes of pain could provide viable targets for nonopioid interventions and the development of mechanistic approaches to pain management in CP. Nineteen inflammation- and nociception-associated proteins were measured in serum collected from 358 subjects with definite CP enrolled in PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies, a prospective observational study of pancreatitis in US adult subjects. First, serum levels of putative biomarkers were compared between CP subjects with and without pain. Only platelet-derived growth factor B (PDGF-B) stood out, with levels significantly higher in the CP pain group as compared to subjects with no pain. Subjects with pain were then stratified into 4 pain subtypes (Neuropathic, Nociceptive, Mixed, and Unclassified). A comparison of putative biomarker concentration among 5 groups (no pain and 4 pain subtypes) identified unique proteins that were correlated with pain subtypes. Serum transforming growth factor beta 1 (TGFβ1) level was significantly higher in the Nociceptive pain group compared to the No pain group, suggesting that TGFβ1 may be a biomarker for nociceptive pain. The Neuropathic pain only group was too small to detect statistical differences. However, glycoprotein 130 (GP130), a coreceptor for interleukin 6, was significantly higher in the Mixed pain group compared to the groups lacking a neuropathic pain component. These data suggest that GP130 may be a biomarker for neuropathic pain in CP. PERSPECTIVE: Serum TGFβ1 and GP130 may be biomarkers for nociceptive and neuropathic CP pain, respectively. Preclinical data suggest inhibiting TGFβ1 or GP130 reduces CP pain in rodent models, indicating that additional translational and clinical studies may be warranted to develop a precision medicine approach to the management of pain in CP.
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Affiliation(s)
- Jami L. Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, PA, USA
- Pittsburgh Center for Pain Research, School of Medicine, University of Pittsburgh, PA, USA
- Department of Neurobiology, School of Medicine, University of Pittsburgh, PA, USA
| | - Yan Li
- Department of Biostatistics, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Kimberly Stello
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, PA, USA
| | - Wenhao Li
- Department of Biostatistics, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Shuang Li
- Department of Biostatistics, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, PA, USA
| | - Kristen Hall
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, PA, USA
| | - Evan L. Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | | | - Liang Li
- Department of Biostatistics, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - William E. Fisher
- Division of General Surgery, Baylor College of Medicine, Houston, TX
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition. University of Florida, Gainesville, FL
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephen J. Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Walter G. Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Mark D. Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Darwin L. Conwell
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, PA, USA
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Parhiala M, Nøjgaard C, Bartholdy A, Waage A, Ignatavičius P, Engjom T, Dimcevski G, Nordaas IK, Kalaitzakis E, Drewes AM, Hadi A, Olesen SS, Poulsen JL, Laukkarinen J. Quality of life after endoscopic procedures for chronic pancreatitis: A multicentre study. United European Gastroenterol J 2023; 11:884-893. [PMID: 37812591 PMCID: PMC10637126 DOI: 10.1002/ueg2.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/14/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Chronic Pancreatitis (CP) causes morphological changes in the pancreatic tissue, leading to complications and pain, which may require endoscopic interventions. OBJECTIVE Our aim was to determine the frequency of endoscopic procedures (EP) in CP patients and to analyse pain and quality of life (QoL) in these patients after their EP. METHODS This study included 1327 CP patients from the Scandinavian Baltic Pancreatic Club (SBPC) database including four countries and eight centres. We analysed patients undergoing EPs and gathered information on the EP, pancreatic function, pain, disease and duration. The EORTC C-30 QoL questionnaire was gathered prospectively and multivariable analysis was conducted on independent parameters between the groups. The reference population had no interventions (n = 870). RESULTS 260 CP patients (22%) underwent EPs, median one year (range 0-39 years) after CP diagnosis. 68% were males. The median age was 59 (20-90) years. Most common aetiological factors were alcohol in 65% and smoking in 71%. Extracorporeal shock wave lithotripsy (ESWL) was used in 6% of the CP population and in 21% of the EP group. Biliary duct stenting was performed on 37% and pancreatic stenting was performed on 56% of the patients. There was no difference in pain patterns between patients who had pancreatic stenting and the reference population. The EP group had slightly better QoL (p = 0.047), functioning and fewer symptoms than the reference population, in the multivariable analysis there was no interaction effect analysis between the groups. The pancreatic stent group had better QoL and the same amount of pain than the reference group. The patients who needed later surgery (23%) had more pain (p = 0.043) and fatigue (p = 0.021). CONCLUSIONS One in five of the CP patients underwent EP. These patients scored higher on QoL responses and had better symptom scores. CP patients who had pancreatic stenting performed had the same pain patterns as the reference population. Randomised prospective trials are needed to determine the effect of endoscopy procedures on CP patients.
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Affiliation(s)
- Mikael Parhiala
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Gastroenterology and Alimentary Tract SurgeryTampere University HospitalTampereFinland
| | - Camilla Nøjgaard
- Pancreatitis Centre East (PACE)Copenhagen University Hospital HvidovreCopenhagenDenmark
| | - Andreas Bartholdy
- Pancreatitis Centre East (PACE)Copenhagen University Hospital HvidovreCopenhagenDenmark
| | - Anne Waage
- Department of SurgeryOslo University HospitalOsloNorway
| | | | - Trond Engjom
- Department of GastroenterologyHaukeland University HospitalBergenNorway
| | - Georg Dimcevski
- Department of GastroenterologyHaukeland University HospitalBergenNorway
| | | | - Evangelos Kalaitzakis
- Division of GastroenterologyDigestive Disease Center KBispebjerg University HospitalCopenhagenDenmark
| | - Asbjørn M. Drewes
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Amer Hadi
- Division of GastroenterologyDigestive Disease Center KBispebjerg University HospitalCopenhagenDenmark
| | - Søren S. Olesen
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Jakob L. Poulsen
- Department of Gastroenterology and HepatologyCentre for Pancreatic DiseasesAalborg University HospitalAalborgDenmark
| | - Johanna Laukkarinen
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of Gastroenterology and Alimentary Tract SurgeryTampere University HospitalTampereFinland
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5
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Yadav D, Askew RL, Palermo T, Li L, Andersen DK, Chen M, Fisher WE, Fogel EL, Forsmark CE, Hart PA, Othman MO, Pandol SJ, Park WG, Topazian MD, Van Den Eeden SK, Vege SS, Yang Y, Serrano J, Conwell DL. Association of Chronic Pancreatitis Pain Features With Physical, Mental, and Social Health. Clin Gastroenterol Hepatol 2023; 21:1781-1791.e4. [PMID: 36191836 PMCID: PMC10065964 DOI: 10.1016/j.cgh.2022.09.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/30/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Pain is a cardinal symptom of chronic pancreatitis (CP). Using Patient-Reported Outcomes Measurement Information System (PROMIS) measures, we characterized physical and mental health and symptom profiles of a well-defined cohort of individuals with CP and compared them with control subjects. Among patients with CP, we also examined associations between pain (intensity, temporal nature) and PROMIS symptom profiles and the prevalence of clinically significant psychological comorbidities. METHODS We analyzed baseline data in 488 CP patients and 254 control subjects enrolled in PROCEED (Prospective Evaluation of Chronic Pancreatitis for Epidemiologic and Translational Studies), an ongoing longitudinal cohort study. Participants completed the PROMIS-Global Health, which captures global physical and mental health, and the PROMIS-29 profile, which captures 7 symptom domains. Self-reported pain was categorized by severity (none, mild-moderate, severe) and temporal nature (none, intermittent, constant). Demographic and clinical data were obtained from the PROCEED database. RESULTS Pain was significantly associated with impairments in physical and mental health. Compared with participants with no pain, CP participants with severe pain (but not mild-moderate pain) had more decrements in each PROMIS domain in multivariable models (effect sizes, 2.54-7.03) and had a higher prevalence of clinically significant depression, anxiety, sleep disturbance, and physical disability (odds ratios, 2.11-4.74). Similar results were noted for constant pain (but not intermittent pain) for PROMIS domains (effect sizes, 4.08-10.37) and clinically significant depression, anxiety, sleep disturbance and physical disability (odds ratios, 2.80-5.38). CONCLUSIONS Severe and constant pain are major drivers for poor psychological and physical health in CP. Systematic evaluation and management of psychiatric comorbidities and sleep disturbance should be incorporated into routine management of patients with CP. (ClinicalTrials.gov, Number: NCT03099850).
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Robert L Askew
- Department of Psychology, Stetson University, DeLand, Florida
| | - Tonya Palermo
- Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Liang Li
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Minxing Chen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William E Fisher
- Division of General Surgery, Baylor College of Medicine, Houston, Texas
| | - Evan L Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Christopher E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas
| | - Stephen J Pandol
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California
| | - Walter G Park
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yunlong Yang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jose Serrano
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
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6
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Ertem FU, Eubanks J, Saul M, Kang CR, Emerick T, Yadav D. Ketamine infusion for pain management in hospitalized patients with Chronic Pancreatitis: A case series. Pancreatology 2023:S1424-3903(23)00097-2. [PMID: 37085380 DOI: 10.1016/j.pan.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/17/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Furkan U Ertem
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James Eubanks
- Department Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chae-Ryon Kang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Trent Emerick
- Department of Anesthesiology and Perioperative Medicine University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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7
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Lu M, Sun Y, Feldman R, Saul M, Althouse A, Arteel G, Yadav D. Coexistent alcohol-related cirrhosis and chronic pancreatitis have a comparable phenotype to either disease alone: A comparative retrospective analysis. World J Hepatol 2023; 15:431-440. [PMID: 37034239 PMCID: PMC10075006 DOI: 10.4254/wjh.v15.i3.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/03/2023] [Accepted: 03/09/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Alcohol use disorder is a prevalent disease in the United States. It is a well-demonstrated cause of recurrent and long-standing liver and pancreatic injury which can lead to alcohol-related liver cirrhosis (ALC) and chronic pancreatitis (ACP). ALC and ACP are associated with significant healthcare utilization, cost burden, and mortality. The prevalence of coexistent disease (CD) ranges widely in the literature and the intersection between ALC and ACP is inconsistently characterized. As such, the clinical profile of coexistent ALC and ACP remains poorly understood. We hypothesized that patients with CD have a worse phenotype when compared to single organ disease.
AIM To compare the clinical profile and outcomes of patients with CD from those with ALC or ACP Only.
METHODS In this retrospective comparative analysis, we reviewed international classification of disease 9/10 codes and electronic health records of adult patients with verified ALC Only (n = 135), ACP Only (n = 87), and CD (n = 133) who received care at UPMC Presbyterian-Shadyside Hospital. ALC was defined by histology, imaging or clinical evidence of cirrhosis or hepatic decompensation. ACP was defined by imaging findings of pancreatic calcifications, moderate-severe pancreatic duct dilatation, irregularity or atrophy. We compared demographics, pertinent clinical variables, healthcare utilization, and mortality for patients with CD with those who had single organ disease.
RESULTS Compared to CD or ACP Only, patients with ALC Only were more likely to be older, Caucasian, have higher body mass index, and Hepatitis B or C infection. CD patients (vs ALC Only) were less likely to have imaging evidence of cirrhosis and portal hypertension despite possessing similar MELD-Na and Child C scores at the most recent contact. CD patients (vs ACP Only) were less likely to have acute or recurrent acute pancreatitis, diabetes mellitus, insulin use, oral pancreatic enzyme therapy, and need for endoscopic therapy or pancreatic surgery. The number of hospitalizations in patients with CD were similar to ACP Only but significantly higher than ALC Only. The overall mortality in patients with CD was similar to ALC Only but trended to be higher than ACP Only (P = 0.10).
CONCLUSION CD does not have a worse phenotype compared with single organ disease. The dominant phenotype in CD is similar to ALC Only which should be the focus in longitudinal follow-up.
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Affiliation(s)
- Michael Lu
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Yujie Sun
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Robert Feldman
- Department of Medicine, Center for Research on Health Care Data, Pittsburgh, PA 15213, United States
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Andrew Althouse
- Department of Medicine, Center for Research on Health Care Data, Pittsburgh, PA 15213, United States
| | - Gavin Arteel
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
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Characterizing mechanism-based pain phenotypes in patients with chronic pancreatitis: a cross-sectional analysis of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies. Pain 2023; 164:375-384. [PMID: 36149018 PMCID: PMC9726990 DOI: 10.1097/j.pain.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Pain is common in chronic pancreatitis (CP) and profoundly reduces quality of life (QoL). Multiple underlying mechanisms contribute to a heterogenous pain experience and reduce efficacy of pain management. This study was designed to characterize the distribution of mechanism-based pain phenotypes in painful CP. The data analyzed were collected as part of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies, an NCI/NIDDK-funded longitudinal study of the natural history of CP. The PROspective Evaluation of Chronic pancreatitis for EpidEmiologic and translational stuDies includes patient-reported outcome (PRO) measures of pain, medication use, global health, and QoL. Of subjects (N = 681) with CP, 80% experienced abdominal pain within the year before enrollment. Subjects who experienced pain in the week before enrollment (N = 391) completed PROMIS Neuropathic and Nociceptive Pain Quality instruments which were then used to classify them by pain type: 40% had nociceptive, 5% had neuropathic-like, and 32% had both types of pain. The prevalence of having both types of pain was higher among women and subjects with diabetes mellitus, whereas nociceptive-only pain was more prevalent among men and those with pancreatic duct stricture. Other factors, including pain medication use and healthcare utilization, did not differ between groups based on pain type. Subjects in the Both group had significantly worse health and QoL scores relative to those with nociceptive-only pain, suggesting that using psychosocial pain surveys may be useful for understanding pain subtypes in patients with CP. Additional research is needed to identify biochemical and biophysical signatures that may associate with and predict responses to mechanism-specific interventions.
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9
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Bhullar FA, Faghih M, Akshintala VS, Ahmed AI, Lobner K, Afghani E, Phillips AE, Hart PA, Ramsey ML, Bick BL, Kuhlmann L, Drewes AM, Yadav D, Olesen SS, Singh VK. Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:20-29. [PMID: 34840065 PMCID: PMC8785146 DOI: 10.1016/j.pan.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/OBJECTIVES While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP. METHODS MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI). RESULTS Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively. CONCLUSION Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.
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Affiliation(s)
- Furqan A. Bhullar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Venkata S. Akshintala
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmed I. Ahmed
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Katie Lobner
- William H. Welch Medical Library, Johns Hopkins University, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mitchell L. Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Benjamin L. Bick
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indiana, USA
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn M. Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Søren S. Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Vikesh K. Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA,Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Yadav D, Palermo TM, Phillips AE, Bellin MD, Conwell DL. Painful chronic pancreatitis - new approaches for evaluation and management. Curr Opin Gastroenterol 2021; 37:504-511. [PMID: 34172622 PMCID: PMC8826115 DOI: 10.1097/mog.0000000000000769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Management of abdominal pain in patients with chronic pancreatitis is often suboptimal. We review recent data on the epidemiology and new approaches for managing pain in chronic pancreatitis. RECENT FINDINGS Chronic pancreatitis duration does not appear to affect the pain experience. Pain pattern in chronic pancreatitis patients frequently changes and is not related to traditional patient and disease-related factors. Psychologic comorbidities, i.e. anxiety and depression, are frequent in patients with chronic pancreatitis, and are associated with more severe pain and pain interference. Adjunctive treatments, such as cognitive behavioral therapy, may positively influence pain management in chronic pancreatitis. Total pancreatectomy with islet autotransplantation (TPIAT) is an increasingly adopted treatment option in painful chronic pancreatitis. Ongoing multicenter studies will help define optimal candidates, predictors of successful pain remission and diabetes outcomes after TPIAT. Pancreatic quantitative sensory testing, a promising technique to interrogate nociception and sensory response, holds promise to identify patients with central sensitization. Initial studies show feasibility to stratify patients into defined pain profiles, and future studies will explore if these can help in prognostication of pain therapy. SUMMARY Several lines of investigations currently under evaluation are likely to have a positive impact on the management of pain in chronic pancreatitis.
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Affiliation(s)
- Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Anna E. Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melena D. Bellin
- Division of Endocrinology and Metabolism, University of Minnesota Medical Center, Minneapolis, MN
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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