The pain of chronic pancreatitis: a persistent clinical challenge

Abstract

The pain of chronic pancreatitis represents a major challenge to those working in the field, including pain specialists, gastroenterologists and surgeons. This article describes the different aetiologies of chronic pancreatitis and lists the models for the pathogenesis of pain, including novel ideas such as the role of the immune system in the modulation of pain. The patient profile in chronic pancreatitis is discussed along with the social impact of the disease in relation to alcohol misuse.

The range of treatment strategies including medical, endoscopic and surgical approaches are evaluated. Common analgesic regimes and their limitations are reviewed.

The pain of chronic pancreatitis remains refractory to effective treatment in many cases and further study and understanding of the underlying pathophysiology are required.

Keywords

Pancreatitis chronic pain neuropathic opioid

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References

Bornman

Beckingham

. ABC of diseases of liver, pancreas, and biliary system. Chronic pancreatitis. BMJ 2001; 322(7287): 660–663.

Sarner

Cotton

. Classification of pancreatitis. Gut 1984; 25: 756–759.

Sarles

. Pancreatitis Symposium, Marseille, April 25 and 26, 1963. Basel: Karger, 1965.

Sarles

. Proposal adopted unanimously by the participants of the Symposium, Marseilles 1963. Bibl Gastroenterol 1965; 7: 7–8.

Singer

Gyr

Sarles

. Revised classification of pancreatitis: report of the Second International Symposium on the Classification of Pancreatitis in Marseille, France, March 28–30, 1984. Gastroenterology 1985; 89: 683–685.

Sarles

Adler

Dani

. The classification of pancreatitis and definition of pancreatic diseases. Digestion 1989; 43: 234–236.

Sarles

Adler

Dani

. The pancreatitis classification of Marseilles, Rome 1988. Scand J Gastroenterol 1989; 24: 641– 642.

Jupp

Fine

Johnson

. The epidemiology and socioeconomic impact of chronic pancreatitis. Best Pract Res Clin Gastroenterol 2010; 24: 219–231.

Lawder

Grant

Storey

. Hanlon epidemiology of hospitalization due to alcohol-related harm: evidence from a Scottish cohort study. Public Health 2011; 125: 533–539.

10.

Stevens

Conwell

Zuccaro

. Pathogenesis of chronic pancreatitis: an evidence-based review of past theories and recent developments pathogenesis of chronic pancreatitis. Am J Gastroenterol 2004; 99: 2256–2270.

11.

Braganza

. Pancreatic disease: a casualty of hepatic ‘detoxification’? Lancet 1983; 2: 1000–1002.

12.

Bordalo

Goncalves

Noronha

. Newer concept for the pathogenesis of chronic alcoholic pancreatitis. Am J Gastroenterol 1977; 68: 278–285.

13.

Corrao

Bagnardi

Zambon

. Exploring the dose–response relationship between alcohol consumption and the risk of several alcohol-related conditions: A meta-analysis. Addiction 1999; 94: 1551–1673.

14.

Witt

Luck

Hennies

. Mutations in the gene encoding the serine protease inhibitor, Kazal type 1 are associated with chronic pancreatitis. Nat Genet 2000; 25: 213–216.

15.

Maisonneuve

Lowenfels

Müllhaupt

. Cigarette smoking accelerates progression of alcoholic chronic pancreatitis Gut 2005; 54:510–514.

16.

Alexakis

Connor

Ghaneh

. Influence of opioid use on surgical and long-term outcome after resection for chronic pancreatitis. Surgery 2004; 136: 600–608.

17.

Talamini

Bassi

Falconi

. Alcohol and smoking as risk factors in chronic pancreatitis and pancreatic cancer. Dig Dis Sci 1999; 44: 1303–1311.

18.

Sarles

. Pathogenesis of chronic pancreatitis. Gut 1990; 31: 629–632.

19.

Ammann

Muellhaupt

. Progression of alcoholic acute to chronic pancreatitis. Gut 1994; 35: 552–556.

20.

Whitcomb

Schneider

. Hereditary pancreatitis: a model for inflammatory disease of the pancreas. Best Pract Res Clin Gastroenterol 2002; 16: 347–363.

21.

Karanjia

Widdison

Leung

. Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct. Br J Surg 1994; 81: 259–264.

22.

Manes

Büchler

Pieramico

. Is increased pancreatic pressure related to pain in chronic pancreatitis? Int J Pancreatol 1994; 15: 113–117.

23.

Renou

Grandval

Ville

. Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up. Int J Pancreatol 2000; 27: 143–149.

24.

Bornman

Marks

Girdwood

. Pathogenesis of pain in chronic pancreatitis: ongoing enigma. World J Surg 2003; 27: 1175–1182.

25.

Anaparthy

Pasricha

. Pain and chronic pancreatitis: is it the plumbing or the wiring? Curr Gastroenterol Rep 2008; 10: 101–106.

26.

Winston

Shenoy

. Transient receptor potential vanilloid 1 mediates hyperalgesia and is up-regulated in rats with chronic pancreatitis. Gastroenterology 2007; 133: 1282–1292.

27.

Winston

Shenoy

. Enhanced excitability and suppression of A-type K⁺ current of pancreas-specific afferent neurons in a rat model of chronic pancreatitis. Am J Physiol Gastrointest Liver Physiol 2006; 291: G424–G431.

28.

Hoogerwerf

Zou

Shenoy

. The proteinase-activated receptor 2 is involved in nociception. J Neurosci 2001; 21: 9036–9042.

29.

Dimcevski

Sami

Funch-Jensen

. Pain in chronic pancreatitis: the role of reorganization in the central nervous system. Gastroenterology 2007; 132: 1546–1556.

30.

Fregni

Pascual-Leone

Freedman

. Pain in chronic pancreatitis: a salutogenic mechanism or a maladaptive brain response Pancreatology 2007; 7: 411–422.

31.

Rattner

Fernandez-del Castillo

Warshaw

. Pitfalls of distal pancreatectomy for relief of pain in chronic pancreatitis. Am J Surg 1996; 171: 142–145; discussion 145–146.

32.

Fregni

DaSilva

Potvin

. Treatment of chronic visceral pain with brain stimulation. Ann Neurol 2005; 58: 971–997.

33.

Cervero

Laird

JMA

. Visceral pain. Lancet 1999; 353: 2145–2148.

34.

Wehler

Nichterlein

Fischer

. Factors associated with health-related quality of life in chronic pancreatitis. Am J Gastroenterol 2004; 99: 138–146.

35.

Pezzilli

Morselli Labate

Ceciliato

. Quality of life in patients with chronic pancreatitis. Dig Liver Dis 2005; 37: 181–189.

36.

Bhardwaj

Thareja

Prakash

. Micronutrient antioxidant intake in patients with chronic pancreatitis. Trop Gastroenterol 2004; 25: 69–72.

37.

World Health Organization. Analgesic ladder. Geneva: World Health Organization; 1986.

38.

Staahl

Christrup

Andersen

. A comparative study of oxycodone and morphine in a multi-modal, tissue-differentiated experimental pain model. Pain 2006; 123: 28–36.

39.

Staahl

Dimcevski

Andersen

. Differential effect of opioids in patients with chronic pancreatitis: an experimental pain study. Scand J Gastroenterol 2007; 42: 383–390.

40.

Angst

Clark

. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology 2006; 104: 570–587.

41.

Olesen

Bouwense

Wilder-Smith

. Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial. Gastroenterology 2011; 141: 536–543.

42.

Bouwense

Olesen

Drewes

. Effects of pregabalin on central sensitization in patients with chronic pancreatitis in a randomized, controlled trial. PLoS One 2012; 7: e42096.

43.

Bouwense

Buscher

van Goor

. S-ketamine modulates hyperalgesia in patients with chronic pancreatitis pain. Reg Anesth Pain Med 2011; 36: 303–307.

44.

Hocking

Cousins

. Ketamine in chronic pain management: an evidence-based review Anesth Analg 2003; 97: 1730–1739.

45.

Reinhoff

Baker

. Pancreolithiasis and chronic pancreatitis: preliminary report of a case of apparently successful treatment by trans-thoracic sympathectomy and vagotomy. JAMA 1947; 132: 20–30.

46.

Cuschieri

Shimi

Crosthwaite

. Bilateral endoscopic splanchnicectomy through posterior thoracoscopic approach. J R Coll Surg Edinb 1994; 39: 44–47.

47.

Baghdadi

Abbas

Albouz

. Systematic review of the role of thoracoscopic splanchnicectomy in palliating the pain of patients with chronic pancreatitis. Surg Endosc 2008; 22: 580–588.

48.

Maher

Johlin

Pearson

. Thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surgery 1996; 120: 603–609.

49.

Gress

Schmitt

Sherman

. Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience. Am J Gastroenterol 2001; 96: 409–416.

50.

Kaufman

Singh

Das

. Efficacy of endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis for managing abdominal pain associated with chronic pancreatitis and pancreatic cancer. J Clin Gastroenterol 2010; 44: 127–134.

51.

Puli

Reddy

Bechtold

. EUS-guided celiac plexus neurolysis for pain due to chronic pancreatitis or pancreatic cancer pain: a meta-analysis and systematic review. Dig Dis Sci 2009; 54: 2330–2337.

52.

Rösch

Daniel

Scholz

. Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up. Endoscopy 2002; 34: 765–771.

53.

Cahen

Gouma

Laramée

. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis. Gastroenterology 2011; 141: 1690–1695.

54.

Warshaw

Banks

Fernández-Del Castillo

. AGA technical review: treatment of pain in chronic pancreatitis. Gastroenterology 1998; 115: 765–776.

55.

Duffy

Reber

. Surgical treatment of chronic pancreatitis. J Hepatobiliary Pancreat Surg 2002; 9: 659–668.

56.

Strate

Taherpour

Bloechle

. Long-term follow-up of a randomized trial comparing the beger and frey procedures for patients suffering from chronic pancreatitis. Ann Surg 2005; 241: 591–598.

57.

Yin

Sun

Yin

. Surgical treatment strategies in chronic pancreatitis: a meta-analysis. Arch Surg 2012; 147: 961–968.

58.

Enhanced Recovery Partnership Programme, Department of Health. Delivering enhanced recovery: helping patients to get better sooner after surgery Available at: www.dh.gov.uk/publications (2010, accessed August 2012).