Diagnosing Chronic Pancreatitis: Comparison and Evaluation of Different Diagnostic Tools

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.

Prodromal Signs and Symptoms of Chronic Pancreatitis: A Systematic Review

GOAL

We aimed to extract the percent of signs and symptoms at the time of diagnosis from published studies and to pool these using meta-analytic techniques.

BACKGROUND

Delayed or misdiagnosis of chronic pancreatitis may occur because the signs and symptoms are nonspecific and varied.

STUDY

We performed a systematic review of studies reporting the signs and symptoms of chronic pancreatitis at diagnosis. The percentage of patients with each sign and symptom was extracted and random-effects meta-analyses used to calculate pooled percentages.

RESULTS

In total, 22 observational studies were included. Across 14 studies, 55% of chronic pancreatitis patients were classified as having alcoholic etiology. Abdominal pain was the most common symptom (76%), and weight loss was reported in 22% of patients. Jaundice occurred in 11% of patients and steatorrhoea in 3%. Half of the patients had a history of acute pancreatitis, and 28% had diabetes mellitus at diagnosis. Heterogeneity between the studies was high for all signs and symptoms.

CONCLUSIONS

This research has identified some common features of patients with chronic pancreatitis, but the high heterogeneity makes it difficult to draw solid conclusions. Carefully designed studies to examine the signs and symptoms leading up to a diagnosis of chronic pancreatitis, and common combinations, are required. These would enable the development of a tool to aid in the early identification of chronic pancreatitis in the primary care setting, with potential for improved short-term and long-term outcomes for patients.

[Diagnosis and Treatment of Chronic Pancreatitis]

Chronic pancreatitis is a complex chronic inflammatory condition that results in pancreas fibrosis and calcification with subsequent exocrine and endocrine insufficiency. Alcohol and nicotine are the most prevalent risk factors, however, recent studies have increasingly discovered genetic associations that increase the risk to develop chronic pancreatitis. Here, we discuss different etiologies of the disease including autoimmune pancreatitis, and present evidence-based diagnostic and therapeutic approaches. In particular, we highlight the interdisciplinary and interventional management of local complications such as pseudocysts, pancreatic duct stones, biliary duct and pancreatic duct stenosis and persistent pain.

Classification of Early-Onset and Late-Onset Idiopathic Chronic Pancreatitis Needs Reconsideration

Bimodal classification of idiopathic chronic pancreatitis (ICP) into early-onset (<35 years) and late-onset (>35 years) ICP was proposed in 1994 based on a study of 66 patients. However, bimodal distribution wasn’t sufficiently demonstrated. Our objective was to examine the validity and relevance of the age-based bimodal classification of ICP. We analyzed the distribution of age at onset of ICP in our cohort of 1633 patients admitted to our center from January 2000 to December 2013. Classify ICP patients into early-onset ICP_(a) and late-onset ICP_(a) according to different cut-off values (cut-off value, a = 15, 25, 35, 45, 55, 65 years old) for age at onset. Compare clinical characteristics of early-onset ICP_(a) and late-onset ICP_(a). We found slightly right skewed distribution of age at onset for ICP in our cohort. There were differences between early-onset and late-onset ICP with respect to basic clinical characteristics and development of key clinical events regardless of the cut off age at onset i.e. 15, 25, 35, 45 or even higher. The validity of the bimodal classification of early-onset and late-onset ICP could not be established in our large patient cohort and therefore such a classification needs to be reconsidered.