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Talukdar R, Olesen SS, Unnisa M, Bedarkar A, Sarkar S, Tandan M, Jagtap N, Darisetty S, Kiran S, Koppoju V, Lakhtakia S, Ramchandani M, Kalapala R, Gupta R, Singh VK, Rao GV, Reddy DN, Drewes AM. Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis : A Sham-Controlled, Randomized Trial. Ann Intern Med 2024. [PMID: 38801774 DOI: 10.7326/m24-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. OBJECTIVE To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. DESIGN 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781). SETTING Asian Institute of Gastroenterology in India from February 2021 to July 2022. PARTICIPANTS 106 patients with chronic pancreatitis. INTERVENTION Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. MEASUREMENTS The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. RESULTS 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, -0.7 [95% CI, -1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, -5.4 days [CI, -9.9 to -0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. LIMITATION Single-center study and limited duration of follow-up. CONCLUSION In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. PRIMARY FUNDING SOURCE Asian Institute of Gastroenterology and Aalborg University Hospital.
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Affiliation(s)
- Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Søren S Olesen
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark (S.S.O., A.M.D.)
| | - Misbah Unnisa
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Akshay Bedarkar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Subhaleena Sarkar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Santosh Darisetty
- Department of Anesthesia, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.D.)
| | - Sekhramantri Kiran
- Lithotripsy Unit, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.K., V.K.)
| | - Vinod Koppoju
- Lithotripsy Unit, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.K., V.K.)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Rakesh Kalapala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (V.K.S.)
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (G.V.R.)
| | - Duvvur Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark (S.S.O., A.M.D.)
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Phillips AE, Hughes SJ, Andersen DK, Bell A, Brand R, Coté GA, Cowdin A, Diazgranados N, Dudeja V, Duggan SN, Fogel E, Forsmark CE, Freeman AJ, Gittes G, Hart PA, Jeon C, Nealon W, Neoptolemos J, Palermo TM, Pandol S, Roberts KM, Rosenthal M, Singh VK, Yadav D, Whitcomb DC, Zyromski N. Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2024; 53:e368-e377. [PMID: 38518063 PMCID: PMC10963039 DOI: 10.1097/mpa.0000000000002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven J Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Adam Bell
- Translational Medicine and Regulatory Affairs, Theraly Fibrosis, Gaithersburg, MD
| | - Randall Brand
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | | | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Evan Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - A Jay Freeman
- Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - George Gittes
- Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christie Jeon
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William Nealon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Stephen Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kristen M Roberts
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | | | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nicholas Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Walker J, Babyok OL, Saloman JL, Phillips AE. Recent advances in the understanding and management of chronic pancreatitis pain. JOURNAL OF PANCREATOLOGY 2024; 7:35-44. [PMID: 38524856 PMCID: PMC10959534 DOI: 10.1097/jp9.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/09/2023] [Indexed: 03/26/2024] Open
Abstract
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.
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Affiliation(s)
- Jessica Walker
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Olivia L. Babyok
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jami L. Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Pain Research, Center for Neuroscience, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Han C, Lv YW, Hu LH. Management of chronic pancreatitis: recent advances and future prospects. Therap Adv Gastroenterol 2024; 17:17562848241234480. [PMID: 38406795 PMCID: PMC10894541 DOI: 10.1177/17562848241234480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/30/2024] [Indexed: 02/27/2024] Open
Abstract
As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.
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Affiliation(s)
- Chao Han
- Department of Gastroenterology, The Hospital of 91876 Troops of Chinese People’s Liberation Army, Qinhuangdao, China
| | - Yan-Wei Lv
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433, China
- National Key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
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Hepatic Abscess After Pancreatic Extracorporeal Shock Wave Lithotripsy. ACG Case Rep J 2022; 9:e00896. [PMID: 36277738 PMCID: PMC9584177 DOI: 10.14309/crj.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
Abstract
We report the case of a 61-year-old woman with painful chronic pancreatitis related to proximal pancreatic duct pancreatolithiasis who underwent successful fragmentation with pancreatic extracorporeal shock wave lithotripsy (ESWL). Two weeks later, she developed abdominal pain, nausea, and vomiting and was found to have a new 4.6 × 2.3 cm hepatic abscess. She was treated with antibiotics but did not require additional intervention. Reported etiologies of post-ESWL abdominal pain include local irritation and bruising at the interface and pancreatitis, which has been reported in 4.2% of cases. We suggest that hepatic abscess ought to be considered in the differential diagnosis of post-ESWL abdominal pain.
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Clinical Course of Medically Managed Patients With Large and Small Duct Chronic Pancreatitis. Clin Transl Gastroenterol 2022; 14:e00537. [PMID: 36205696 PMCID: PMC9875973 DOI: 10.14309/ctg.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pancreatic duct obstruction is the primary indication for endoscopic and/or surgical therapy in patients with chronic pancreatitis (CP). However, the clinical course of medically managed patients in relation to pancreatic duct obstruction is largely unknown. METHODS This was a retrospective cohort study of medically managed patients with CP. We classified patients based on pancreatic duct obstruction from a stricture or stone using cross-sectional imaging (i.e., large vs small duct CP). We compared prevalence of diabetes and exocrine insufficiency (EPI) between subgroups at inclusion and investigated risk of new-onset diabetes, EPI, and all-cause mortality over a follow-up period of 5 years. Changes in pancreatic morphology were studied in patients who underwent follow-up imaging. RESULTS A total of 198 patients (mean age 58 ± 12 years, 70% male, 60% alcoholic etiology, 38% large duct CP) were evaluated. At inclusion, patients with large vs small duct CP had a higher prevalence of both diabetes (43% vs 24%, P = 0.004) and EPI (47% vs 28%, P = 0.007). There was an increased risk of new-onset EPI in patients with large duct CP (hazard ratio 1.72; 95% confidence interval [1.05-2.80], P = 0.031) and higher rates of pancreatic atrophy ( P < 0.001). No differences between groups were observed for new-onset diabetes and all-cause mortality. Conversion from small to large duct CP or vice versa during follow-up was observed in 14% of patients. DISCUSSION In a medically managed cohort of patients, large duct CP was associated with increased risk of EPI and pancreatic atrophy compared with small duct CP.
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Wang M, Yang D, Hu Z, Shi Y, Ma Y, Cao X, Guo T, Cai H, Cai H. Extracorporeal Cardiac Shock Waves Therapy Improves the Function of Endothelial Progenitor Cells After Hypoxia Injury via Activating PI3K/Akt/eNOS Signal Pathway. Front Cardiovasc Med 2021; 8:747497. [PMID: 34708093 PMCID: PMC8542843 DOI: 10.3389/fcvm.2021.747497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/13/2021] [Indexed: 01/05/2023] Open
Abstract
Background: Extracorporeal cardiac shock waves (ECSW) have great potential in the treatment of coronary heart disease. Endothelial progenitor cells (EPCs) are a class of pluripotent progenitor cells derived from bone marrow or peripheral blood, which have the capacity to migrate to ischemic myocardium and differentiate into mature endothelial cells and play an important role in neovascularization and endothelial repair. In this study, we investigated whether ECSW therapy can improve EPCs dysfunction and apoptosis induced by hypoxia and explored the underlying mechanisms. Methods: EPCs were separated from ApoE gene knockout rat bone marrow and identified using flow cytometry and fluorescence staining. EPCs were used to produce in vitro hypoxia-injury models which were then divided into six groups: Control, Hypoxia, Hypoxia + ECSW, Hypoxia + LY294002 + ECSW, Hypoxia + MK-2206 + ECSW, and Hypoxia + L-NAME + ECSW. EPCs from the Control, Hypoxia, and Hypoxia + ECSW groups were used in mRNA sequencing reactions. mRNA and protein expression levels were analyzed using qRT-PCR and western blot analysis, respectively. Proliferation, apoptosis, adhesion, migration, and angiogenesis were measured using CCK-8, flow cytometry, gelatin, transwell, and tube formation, respectively. Nitric oxide (NO) levels were measured using an NO assay kit. Results: Kyoto encyclopedia of genes and genomes (KEGG) enrichment analysis showed that differentially expressed genes were enriched in cancer signaling, PI3K-Akt signaling, and Rap1 signaling pathways. We selected differentially expressed genes in the PI3K-Akt signaling pathway and verified them using a series of experiments. The results showed that ECSW therapy (500 shots at 0.09 mJ/mm2) significantly improved proliferation, adhesion, migration, and tube formation abilities of EPCs following hypoxic injury, accompanied by upregulation of p-PI3K, p-Akt, p-eNOS, Bcl-2 protein and NO, PI3K, and Akt mRNA expression, and downregulation of Bax and Caspase3 protein expression. All these effects of ECSW were eliminated using inhibitors specific to PI3K (LY294002), Akt (MK-2206), and eNOS (L-NAME). Conclusion: ECSW exerted a strong repaired effect on EPCs suffering inhibited hypoxia injury by inhibiting cell apoptosis and promoting angiogenesis, mainly through activating the PI3K/Akt/eNOS signaling pathway, which provide new evidence for ECSW therapy in CHD.
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Affiliation(s)
- Mingqiang Wang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Dan Yang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhao Hu
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunke Shi
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yiming Ma
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xingyu Cao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Tao Guo
- Department of Cardiology, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Hongbo Cai
- Department of Vascular Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hongyan Cai
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
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Issa Y, Boermeester MA. Management of chronic pancreatitis: more pain than gain? Br J Surg 2021; 108:1397-1399. [PMID: 34648624 DOI: 10.1093/bjs/znab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Yama Issa
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Phillips AE, Faghih M, Singh VK, Olesen SS, Kuhlmann L, Novovic S, Bick B, Hart PA, Ramsey ML, Talukdar R, Garg PK, Yadav D, Drewes AM. Rationale for and Development of the Pancreatic Quantitative Sensory Testing Consortium to Study Pain in Chronic Pancreatitis. Pancreas 2021; 50:1298-1304. [PMID: 34860815 DOI: 10.1097/mpa.0000000000001912] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Abdominal pain is the primary symptom of chronic pancreatitis (CP), but pain is difficult to assess, and objective methods for pain assessment are lacking. The characterization of the sensory component of pain as a surrogate for nociception can be achieved by sensory testing using standardized stimuli. Herein, we describe the rationale for and development of an international consortium to better understand and characterize CP pain. METHODS A collaboration was initially formed between the University of Aalborg, Johns Hopkins University, and the University of Pittsburgh. This group refined the protocol for pancreatic quantitative sensory testing (P-QST) and then expanded the collaboration with plans for incorporating P-QST into prospective studies. RESULTS The collaboration has successfully developed a P-QST nomogram. Chronic pancreatitis patients identified with P-QST as having widespread hyperalgesia had higher pain intensity scores, higher prevalence of constant pain, and decreased quality of life. Psychiatric comorbidities were independent of pain phenotypes. Multiple studies are underway to validate these findings and evaluate their utility in clinical trials. CONCLUSIONS Development of the P-QST Consortium will facilitate collaborative efforts to use P-QST as a means for evaluation and characterization of pain in CP patients, and optimize methods to guide individualized pain management approaches.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Srdan Novovic
- Pancreatitis Centre Copenhagen, Gastrounit, Hvidovre Hospital, Copenhagen, Denmark
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Philip A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Assessment of pain associated with chronic pancreatitis: An international consensus guideline. Pancreatology 2021; 21:1256-1284. [PMID: 34391675 DOI: 10.1016/j.pan.2021.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022]
Abstract
Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.
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