Painful chronic pancreatitis - new approaches for evaluation and management

16. Pain in chronic pancreatitis

INTRODUCTION

Chronic pancreatitis is defined as a disease of the pancreas in which recurrent inflammatory episodes result in replacement of the pancreatic parenchyma by fibrous connective tissue in individuals with genetic, environmental, and other risk factors. Pain is one of the most important symptoms of chronic pancreatitis and, in many cases, has chronic visceral nociceptive, nociplastic, and even neuropathic components, with evidence of both central and peripheral sensitization, neuroplasticity, and neurogenic inflammation.

METHODS

The literature on the diagnosis and treatment of pain in chronic pancreatitis was reviewed and summarized.

RESULTS

Treatment of abdominal pain in chronic pancreatitis is guided by pancreatic morphology on imaging, although the correlation between pain symptoms and pathoanatomical changes is not always straightforward. Patients with pancreatic duct obstruction are initially offered endoscopic or surgical therapies, while non-obstructive disease is mostly managed medically. Lifestyle changes and psychological support are of particular importance for all chronic pancreatitis patients. Analgesic options range from non-opioid medications to opioids and adjuvant agents. Interventional pain management may consist of radiofrequency treatment of the splanchnic nerves and spinal cord stimulation. To date, there are no randomized trials supporting their efficacy in the treatment of chronic pancreatitis pain, and the recommendation to consider these treatment options is justified by evidence from observational studies. Possible opioid-sparing effects of interventional pain treatments are important to consider because opioid use and dependency are common in chronic pancreatitis patients and associated with worse outcomes. Celiac plexus block is not generally recommended for chronic pancreatitis due to the limited quality of evidence, overall short duration of effect, and invasiveness of the procedure. Central sensitization can impact the effectiveness of invasive treatments.

CONCLUSIONS

Managing pain in chronic pancreatitis is a complex task that requires a multidimensional and individualized approach. Due to the lack of randomized trials, treatment decisions are often guided by expert opinion. Integrating pharmacological and non-pharmacological interventions and collaborating with a multidisciplinary team are key components of effective chronic pancreatitis pain management.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Total pancreatectomy with islet autotransplantation outcomes in patients with pancreatitis of genetic etiology: A single-center experience with a large cohort of patients

PURPOSE

Total pancreatectomy with islet autotransplantation (TPIAT) is an effective treatment for patients with chronic pancreatitis (CP) when other interventions are unsuccessful. CP has many etiologies including heredity. Metabolic and pain relief outcomes after TPIAT are presented among patients with a genetic CP etiology compared with those with a nongenetic etiology in a large cohort of patients who underwent this procedure at our center.

METHODS

A retrospective analysis was performed of 237 patients undergoing TPIAT between 2006 and 2023. We analyzed the differences in patients with genetic (n = 56) vs nongenetic CP etiologies (n = 181) in terms of pre-TPIAT factors including patient characteristics and disease state, results from the isolation process, and outcomes such as long-term glycemic and pain control.

RESULTS

Patients with genetic CP underwent TPIAT at a significantly younger age (32.3 vs 41.3 years nongenetic; P < .0001) and endured symptoms for a significantly longer period (10 vs 6 years; P < .01). A significantly lower mass of islets was isolated from patients with genetic CP (P < .01), which increased with body mass index in both groups. Despite lower yields, patients with genetic CP maintained metabolic function similar to patients with nongenetic CP, as indicated by insulin independence and C-peptide, blood glucose, and hemoglobin A1C levels after TPIAT. Post-transplant narcotic usage and pain scores significantly decreased compared with those before TPIAT, and more patients with genetic CP were pain free and narcotic free after TPIAT.

CONCLUSION

Our data validate TPIAT as a beneficial procedure for patients enduring CP of genetic etiology. Pain that is inevitably recurrent after minor interventions owing to the nature of the disease and favorable TPIAT outcomes should be considered in the decision to perform early TPIAT in cases of genetic CP.

Pain management in chronic pancreatitis

Pain in chronic pancreatitis (CP) is difficult to manage. Many patients suffer from inadequate pain relief, completely incapacitating them in their daily activities. Historically, despite their well-known adverse effects, opioids have been the pillar of treatment regimens in painful CP. The management is now gradually evolving with a better understanding of the underlying pathophysiology of CP-related pain. Clinicians should follow a holistic approach to the management of CP-associated pain, which must involve lifestyle changes that are coupled with analgesic medications and other pain-relieving interventions. Furthermore, there is no easy cure for vanquishing CP-associated pain. Each patient must be evaluated on a case-by-case basis by a multidisciplinary team to decide which treatment option is best suited for that individual.

Recent advances in the understanding and management of chronic pancreatitis pain

Abdominal pain is the most common symptom of chronic pancreatitis (CP) and is often debilitating for patients and very difficult to treat. To date, there exists no cure for the disease. Treatment strategies focus on symptom management and on mitigation of disease progression by reducing toxin exposure and avoiding recurrent inflammatory events. Traditional treatment protocols start with medical management followed by consideration of procedural or surgical intervention on selected patients with severe and persistent pain. The incorporation of adjuvant therapies to treat comorbidities including psychiatric disorders, exocrine pancreatic insufficiency, mineral bone disease, frailty, and malnutrition, are in its early stages. Recent clinical studies and animal models have been designed to improve investigation into the pathophysiology of CP pain, as well as to improve pain management. Despite the array of tools available, many therapeutic options for the management of CP pain provide incomplete relief. There still remains much to discover about the neural regulation of pancreas-related pain. In this review, we will discuss research from the last 5 years that has provided new insights into novel methods of pain phenotyping and the pathophysiology of CP pain. These discoveries have led to improvements in patient selection for optimization of outcomes for both medical and procedural management, and identification of potential future therapies.

[Interventional radiological and endoscopic technologies in diagnosis and treatment of chronic pancreatitis]

This review is devoted to internationally accepted diagnostic algorithms for complicated chronic pancreatitis (CP). In addition, the authors discuss interventional radiological and endoscopic diagnostic and therapeutic procedures, as well as their role in surgical approaches for this disease. Chronic pancreatitis is often diagnosed with severe symptoms following severe course of disease and complications. Imaging techniques, such as ultrasound, endoscopic ultrasound, CT, MRI/MR cholangiocreatography (MRCP), secretin-stimulated MRCP, are valuable to assess the pancreas in patients with initial manifestations of CP. Modern treatment of complicated CP includes transpapillary or transmural drainage of false cysts, shock wave lithotripsy and stenting for pancreatic duct strictures and/or stones, stenting for biliary hypertension, endovascular interventions for vascular complications and radical surgical treatment. Endoscopic methods are preferable regarding better short-term quality of life. Early surgical intervention (within 3 years after clinical manifestation) is effective to eliminate or significantly reduce pain and pancreatic insufficiency. Multidisciplinary team including surgeons, endoscopists and interventional radiologists should determine the most optimal diagnostic and treatment approach individually for each patient.

Assessing the Impact of Medication and Stenting on the Quality of Life of Patients With Chronic Pancreatitis: A Prospective Study

This research aimed to assess the effect of pharmacotherapy alone versus the combination of pharmacotherapy and endoscopic stenting on the quality of life (QoL) outcomes of chronic pancreatitis patients. Chronic pancreatitis, an inflammatory disease, often presents with persistent pain, affecting patients' quality of life. Thirty patients treated either with pharmacotherapy alone or with the addition of endoscopic stenting were analyzed. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) was used to gather data on the patients' QoL. Results showed that both treatment groups experienced improvements in global health, role functioning, fatigue, and abdominal pain scores over follow-ups. Specifically, the stenting group saw notable enhancements in global health and role functioning. The study's conclusions provide valuable insights into the potential benefits of both treatments, with stenting offering significant improvements in certain QoL parameters. However, the sample size and source limit generalizability, suggesting the need for more extensive research across diverse settings.

Prevalence of depression among patients with Chronic Pancreatitis: A systematic review and meta-analysis

INTRODUCTION

Chronic Pancreatitis (CP) is a fibroinflammatory condition with debilitating symptoms. Quality of life is severely affected in patients with CP and they are likely to suffer from mental health disorders, including depression. We conducted a systematic review and meta-analysis assessing the prevalence of depressive symptoms and depression in patients with CP.

METHODS

MEDLINE (OVID), PsycINFO, Cochrane Library, Embase, CINAHL Complete, Scopus and Web of Science were searched until July 2022 to identify manuscripts reporting the prevalence of depressive symptoms and depression (diagnosed clinically or with a validated scale without language restriction) in patients with Chronic Pancreatitis. The pooled prevalence was calculated using a random effects model. Heterogeneity was assessed by the inconsistency index (I2).

RESULTS

Among 3647 articles identified, 58 studies were identified for full text review, and ultimately nine studies were included. A total of 87136 patients were included in the studies. Depression was diagnosed clinically or symptoms were identified using validated scales including Center for Epidemiological Studies 10-item Depression Scale (CESD), Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS). The overall prevalence of depression in patients with chronic pancreatitis was 36.2% (95%CI: 18.8-55.7). In the stratified analysis, depression prevalence according to the clinical diagnosis, BDI and HADS was 30.10%, 48.17% and 36.61%, respectively.

CONCLUSION

The high prevalence of depression among patients with CP deserves a call-to-action due to its medical implications and worsening quality of life. Our findings raise awareness of the importance of screening patients with CP for mental health disorders. Further well-designed studies are needed to further characterize these findings.

Advances in acute and chronic pancreatitis

Acute pancreatitis (AP) and chronic pancreatitis are the third leading gastrointestinal causes for admissions and readmissions to hospitals in the United States. This review of articles published between 2019-2022 (December) from international sources identified four categories of crucial new findings: The report includes (1) New genetic pathogenic mutations (TRPV6); expected genetic outcomes in a Northern European population; (2) a new serum diagnostic marker for AP-fatty acid ethyl esters-distinguishing acute pancreatitis associated with alcohol; explanations of the impact of monocytes/macrophages on the inflammatory process that defines their future in diagnosis, staging, and treatment; (3) innovations in timing of per os low-fat, solid food intake immediately on admission; resolution of concepts of aggressive parenteral fluid intake; dramatic shifts to non-operative from operative treatment of infected pancreatic necrosis. Each modification reduced interventions, complications, and lengths-of-stay; and (4) authoritarian recommendations for medical treatment of chronic pain. These advances offer opportunities to initiate newly proven treatments to enhance outcomes, alter the natural history, and envision the future of two diseases that have no known cure.

Pain patterns in chronic pancreatitis and chronic primary pain

BACKGROUND

Abdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator.

AIMS

This cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes.

METHODS

Patients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics.

RESULTS

Compared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent.

CONCLUSIONS

Within CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.