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INTERVENTIONAL MANAGMENT APPROACH FOR CHRONIC PANCREATIC PAIN
Author(s):
Kapural, L.*
Affiliations:
Carolinas Pain Institute, Anesthesiology, Winston-Salem, USA
ESRA Academy. Kapural L. Sep 13, 2017; 196176; esra7-0517
Leonardo Kapural
Leonardo Kapural
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Abstract
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Chronic pancreatitis is a progressive inflammatory disease of the pancreas that eventually leads to irreversible morphological changes of the pancreatic parenchyma and duct (1,2). 

Sympathetic innervation of the pancreas comes from splanchnic nerves, while parasympathetic fibers originate from vagus.  The acinar plexus within pancreas contains sympathetic and parasympathetic fibers.  While the parasympathetic system stimulates exocrine and endocrine secretion, sympathetics inhibits the same.  Sensory fibers are widespread within pancreas, especially dense around the acinar cells.(3,4) Pancreatic pain can be broadly categorized into three types: nociceptive pain, neuropathic pain, and neurogenic inflammation. 

           

            Patients with chronic pancreatitis may have co-existing conditions and potentially multiple pain generators, and/or overlying/co-existing psychological disturbances, substance abuse/misuse, or even a central pain component (1,2).  Accurate medical history, proper medical examination, endoscopic screening, diagnostic imaging, and laboratory tests should help to exclude other conditions causing abdominal pain, such as chronic abdominal wall pain (CAWP), intra-abdominal malignancy, and/or referred pain from other sources.

 

Transversus abdominis plane (TAP) block is a newer diagnostic and therapeutic block that may also help to treat abdominal wall pain, but also to distinguish somato-sensory from visceral and central origin of abdominal pain (5). Local anesthetic is injected under ultrasound guidance between internal oblique and transversus abdominis muscles, a potential space named transversus abdominis plane (TAP) (5).  This should relieve pain from most of the anterolateral abdominal wall from the costal margin down to the inguinal ligament (5).  The diagnostic role of a TAP block to determine the abdominal wall source of pain has not been established yet, however, both, single injection, or a continuous infusion has been used for treatment of CAWP.

While pain descriptors and locations can be helpful in delineating the source of pain, there is enormous variability in patients’ descriptions of pain related to chronic pancreatitis.  Even more, in patients where the exact source of pain is questioned, differentiating between referred visceral pain from somatosensory and centrally-mediated pain may require another interventional diagnostic procedure, the so called retrograde differential epidural nerve block. Until now, there are few reports documenting the valid diagnostic role of retrograde differential epidural block (6).

 

Managing and minimizing  chronic pain is often the objective of advanced pain management. Lifestyle changes such as abstinence from alcohol, smoking cessation, nutritional consultation, and regular physical excercise may help.  Acetaminophen is often given early, but also nonsteroidal anti-inflammatory drugs (NSAIDs).  Membrane stabilizers and antidepressants for chronic pain are used predominantly for neuropathic pain, but can also be used for chronic abdominal pain (1,2).  Calcium channel blockers such as pregabalin or gabapentin may be effective in some patients and may provide an opioid-sparing effect (7).  Good pain control and a decrease in opioid consumption over many months can be also achieved with repeated ketamine intravenous infusions  (2). Short- acting opioids may be used for moderate to severe breakthrough pain.  

             While conservative measures, including medication, do have a role in pain management of chronic pancreatitis, the increasing safety and effectiveness of interventional pain treatments provides a useful therapeutic alternative.  In addition, longevity of the pain relief and ability of such approaches not to conceal any acute abdominal co-morbidities, provides basis to execute such interventional treatments earlier in the algorithm of pain management of chronic pancreatitis (1,2).

 

            The celiac plexus block using local anesthetics is still the most frequently performed sympathetic block for control of pain from chronic pancreatitis and involves placement of the needle through the paraspinal area of the middle back to the anterior aspect of the mid L1 vertebral body (1,2).   Less utilized, mainly for the fear of pneumothorax, but more efficacious, is a T11 bilateral splanchnic block. Final position of the tip of the needle is within paravertebral compartment medial to the pleural cavity, and in close proximity to the greater and lesser splanchnic nerves (posterior third of T11 vertebral body; (8).   While both techniques can be employed for chronic pancreatitis-related pain, the T11 splanchnic approach seems to provide a longer time interval of pain relief than the bilateral celiac plexus block (8). 

Radiofrequency denervation of bilateral splanchnic nerves provides prolonged relief of chronic pain from chronic pancreatitis. In a few larger case-series, substantial pain relief, decreased analgesic use, and improved quality of life were achieved for many months (1,2).

            While spinal cord stimulation (SCS) has been utilized for decades to treat various pain syndromes, only recently has chronic visceral abdominal pain become a target for electrical stimulation (9,10).  For long-standing chronic abdominal pain of visceral origin, spinal cord stimulation of the dorsal columns has surfaced as an interesting therapeutic option to provide long-term, non-pharmacologic control of severe chronic visceral pain, and improve quality of life (1,2,9,10).   It is not clear how spinal cord stimulation controls chronic abdominal pain and visceral hyperalgesia. Pain relief may be achieved by the activation of supraspinal pain modulatory pathways by SCS, release of inhibitory neuromodulators such as GABA, or blockade of nerve conduction by antidromic activation.  Antidromic activation of peripheral sensory fibers may suppress the afferent input that is related to visceral hyperalgesia. Sympathetic system may be affected down-regulation of segmental or supraspinal sympathetic outflow (9,10) . It seems that SCS in particular provides the most promising long-term treatment option to date for ongoing pain when it is utilized in patients with the stable chronic form of chronic pancreatitis. 

 

REFERENCES:

 

1 Puylaert,M,  Kapural L, van Zundert J, Peek D, Lataster A, Mekhail N, van Kleef M, Keulemans Y. Pain in chronic pancreatitis (Chapter 26)  Evidence-based Interventional Pain Practice: According to Clinical Diagnoses. Eds: van Zundert J, Patjin J, Hartrick C, Lataster A, Huygen F, Mekhail N, van Kleff M. Wiley Blackwell, 2012; pp 202-212. 

 

2. L Kapural, Puyalert M, Walsh M, Sweiss G.  Interdisciplinary treatement of the pain from chronic pancreatitis.  In Pain Medicine, An Interdisciplinary Case-Based Approach, eds. Hayek S, Shah BJ, Desai MJ, Chelimsky TC, Oxford Univeristy Press, New York,2015, pp 289-297.

 

3. Bockman D. Nerves in the pancreas: what are they for? The Am J Surg. 2007;1997:S61-S64.

 

4. Salvioli B, Bovara M, Barbara G, De Ponti F, Stanghellini V, Tonini M, et al. Neurology and neuropathology of the pancreatic innervation. Jop. 2002;3:26-33.

 

 

5. Narouze S. Chronic Abdominal Wall Pain: Diagnosis and Interventional Treatment. in L. Kapural (ed.), Chronic Abdominal Pain: An Evidence-Based, Comprehensive Guide to Clinical Management, Springer, New York, 2015;189-195.

6. Rizk MK, Tolba R, Kapural L, Mitchell J, Lopez R, Mahboobi R, Vrooman B, Mekhail N. Differential epidural block predicts the success of visceral block in patients with chronic visceral abdominal pain. Pain Pract. 2012;12:595–601.

 

  1. 011;141:536–543. This is a first trial documenting succesful use of membrane stabilizers for chronic pain from pancreatitis.

 

8. Badhey HS, Jolly S, Kapural L. Bilateral splanchnic block T11 provides longer pain relief than celiac plexus block from non-malignant abdominal pain. Abstracts from the American Society of Regional Anesthesia and Pain Medicine 14 Annual Pain medicine Meeting . Miami, FL 11/21/2015; Abs 140.

 

9. Kapural L. Spinal cord stimulation for Gastrointestinal painful disorders. In Textbook of Neuromodulation Eds. Krames E, Peckham H and Rezai A.  2009; pp 873-879.

 

10. Kapural L,Yelle M. Chapter 65: Clinical applications of neuromodulation: Spinal cord stimulation for abdominal pain. In Comprehensive treatment of Chronic Pain by Medical, Interventional and Integrative Approaches,the AAPM Textbook on Patient Management Eds Deer et al, Springer, New York, 2013, pp 689-696.

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