Box 153 Pain treatment options chronic pancreatitis [3745

Treatments with Grade B evidence

Abstinence from alcohol (Level III) Antioxidants and micronutrients (Level II) Cholecystokinin receptor antagonists (Level II)

Treatments with Grade C evidence

Opioids (including K-ORAs; Level II and III) Anti-inflammatory drugs (Level III) Endoscopic management (stents, sphincterotomy, stone removal) (Level III evidence - inferior to surgical intervention) [44, 45] Oral pancreatic enzyme treatment (Level II) Octreotide (prevents complications of pancreatic procedures - Level II) Neurolysis (Level IV)

Intraceliac local anesthetic and/or steroid injections (Level IV)

Surgical diversion or resection (Level III) Pseudocystic drainage (percutaneous, endoscopic, surgical) (Level IV) Shock-wave lithotripsy of pancreatic stones (Level III)

alcohol despite the diagnosis of chronic pancreatitis has a 50% mortality rate at 5-year follow-up. If they abstain from drinking, it takes more than 25 years to have a similar mortality rate. It has been commonly reported that total abstinence from alcohol achieves pain relief in up to 50% of patients, particularly those with mild to moderate disease [39].

Celiac plexus blocks with local anesthetics have been used for diagnostic purposes as well as a primary therapy for pain in association with chronic pancreatitis. Although widely used, there have been relatively few formally reported experiences with nerve blocks for the long-term treatment of chronic pancreatitis. Leung et al. [40] studied the use of celiac plexus blocks in 23 patients with chronic pancreatitis. Twelve of the 23 had complete analgesia, whereas six had partial relief. There was no effect in five patients. The mean pain-free period was 2 months. There was less of an effect in patients with previous pancreatic surgery, and repeat blocks were unhelpful. Because of concerns about potential irreversible nerve injury, the injection of steroids as opposed to alcohol has been recommended when using celiac plexus blocks for the treatment of chronic pancreatitis. In one study, steroid injections provided pain relief in 4/16 patients [41]. However, 11 of the 12 patients who did not obtain relief were narcotic dependent, whereas none of the four who obtained relief were narcotic dependent. This finding emphasizes the complexity of treating pain in a population of patients with chemical dependencies and other abnormal psychologic and psychosomatic behaviors.

In another report [42] which investigated the mode of delivering the nerve blocks, 25% of patients with CT-guided celiac plexus blocks experienced pain relief compared to 43% of patients who were treated by endoscopic ultrasound-guided celiac plexus blocks. The benefit from endoscopic ultrasound-guided celiac plexus also persisted for longer than that of the CT-guided blocks. More importantly, paraplegia has not been described after endoscopic ultrasound-guided celiac plexus block. The same group of investigators more recently published their prospective experience with endoscopic ultrasound-guided celiac plexus blocks with steroids in 90 patients with pain resulting from chronic pancreatitis [43]. A significant improvement in pain scores occurred in 55% of these patients. The benefit persisted beyond 12 weeks in 26% of the patients and beyond 24 weeks in 10%. Younger patients (<45 years) and patients with previous pancreatic surgery for chronic pancreatitis did not appear to benefit from the blocks.

The current evidence indicates that endoscopic ultrasound-guided celiac plexus blocks are safe and well tolerated with excellent temporary results in some patients. Unfortunately, reliable predictors of success are lacking. In the absence of long-term studies in patients with chronic pancreatitis, the role of endo-scopic ultrasound-guided celiac plexus blocks should be limited to treating flares of chronic pain in patients with otherwise limited therapeutic options.

Surgical diversion or resection is often viewed as the definitive treatment of chronic pancreatitis despite the absence of prospective randomized studies. The endo-scopic placement of stents, sphincterotomy, dilation and/or stone removal are well-established alternatives to surgery in the treatment of biliary tract diseases, and similar techniques for the relief of chronic pancreatic pain have been developed. However, recent randomized comparisons of endoscopic versus surgical management of ductal obstruction have suggested the superiority of surgical interventions. In one study [44], patients with chronic pancreatitis and a distal obstruction of the pancreatic duct without an inflammatory mass were randomized to undergo endoscopic transampullary drainage of the pancreatic duct (n = 19) or operative pancrea-ticojejunostomy (n = 20). At 24 months of follow-up, patients treated surgically had lower pain scores and required fewer procedures. Complete or partial pain relief was achieved in 32% of patients who underwent endoscopic drainage as compared with 75% of patients assigned to surgical drainage. Another study of 72 patients found surgery superior to endoscopic sphinc-terotomy with stenting and/or stone removal [45].

Opioids are the primary pharmacologic analgesic therapy for advanced chronic pancreatitis, although some have suggested the use of "adjuvants" such as antidepressants. There is the unfortunate but common experience of clinicians that patients who have alcoholic pancreatitis may exchange their alcohol addiction for an opioid addiction. Patients with substance abuse histories develop painful diseases and ethically require treatment, but clinicians still experience significant angst in association with symptom-based treatment rather than etiology-based treatment.

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