Pain management in chronic pancreatitis - Final - 1.pptx

1. Pain Management In Chronic
Pancreatitis
Dr Irum Rehman

2. Case No.1
• A 45 year old banker presented with severe epigastric pain
radiating to the back. He had a dinner party last night. There is
history of similar attacks in the past and he has lost about 12 kg of
weight. Patient also complains of passing large bulky stools, on
examination he is febrile and temperature is 99°F. There is
epigastric tenderness. Laboratory investigations showed Hb
11.5g/dl, TLC is 13500/µL with 80% neutrophils. Blood sugar is
280mg/dl. LFTs are normal.
• What is the diagnosis?
• What investigation you will carry out?
• What is the treatment?

3. Today’s agenda
• Mechanism of pain
• Management
Medical
Endotherapy
Surgical
Celiac Plexus Block
• Latest Guidelines

4. Defined as a progressive inflammatory response of the
pancreas that has lead to irreversible and permanent
changes.
Parenchyma Pancreatic Duct
Fibrosis
Loss of acini and islets of Langerhans
Formation of pancreatic stones
Stenosis
Pancreatic stones
Histologic evidence of chronic inflammation, fibrosis, and destruction of
exocrine (acinar cell) and endocrine (islets of Langerhans) tissue
Chronic Pancreatitis

5. PAIN
• Predominant symptom - 90% patients
• Epigastric, boring with radiation to the back, and is alleviated by leaning
forward. Typically, the pain is worse within 5 to 10 minutes of eating as a
result of stimulating the inflamed gland. Pain may initially be episodic
and tends to become more continuous over time
• Caused by
• Disease – active inflammation
• Altered nociception
• Hypertension – ductal or tissue via increased cholecystokinin
• Tissue ischemia
• Complications – inflammatory mass in the head; obstruction of bile duct
or duodenum, pseudocyst or cancer of pancreas

6. Mechanism of Pain
• Increased pressure with ischemia and inflammation.
• Alterations in peripherals and central nociceptive nerves.

7. Management Of Chronic Pancreatitis
• GOALS
• Pain management
• Correction of pancreatic insufficiency
• Management of complications
• ESTABLISH A SECURE DIAGNOSIS
• Other potential etiologies should be ruled out
• Peptic ulcer disease
• Duodenal or Biliary obstruction
• Pseudocysts
• Pancreatic carcinoma

8. Management of chronic pancreatitis pain
• BASICS
• Cessation of alcohol intake
• Cessation of smoking
• Small and low fat meals
• Hydration
• Supplementation with medium chain triglycerides (MCTs) and enteral
diet may be of benefit
• MCTs can be directly absorbed by the intestinal mucosa and are less of
a stimulant to pancreatic secretion
• An enteral therapy containing medium-chain triglycerides and
hydrolyzed peptides reduces postprandial pain associated with chronic
pancreatitis

9. ANALGESICS
• NSAIDS and Acetaminophen
• Tramadol (Low Potency opioid)
• adjunctive agents, tricyclic antidepressants, serotonin reuptake inhibitors
(SSRIs), and combined serotonin and norepinephrine reuptake inhibitors
(e.g. duloxetine) or gabapentoids (pregabalin or gabapentin)
• Consistent with The World Health Organization (WHO) analgesic ladder
• Pain control, rather than total absence of pain, is the realistic goal.

10. ANTIOXIDANT
• There is a significant reduction in antioxidant defense in patients
with CP
• Essential for protection against reactive oxygen species (ROS)
mediated electrophilic stress, a strong activator of pancreatic stellate
cells.
• Antioxidant supplementation, Organic selenium - 500 µg, Ascorbic acid -
500mg, Beta-Carotene - 5000 IU, Tocopherol - 200 IU, Methionine –
1000mg

11. Pancreatic Enzyme Supplements
• Rationale for this therapy is based upon suppression of feedback loops
in the duodenum that regulate the release of cholecystokinin
• CCK-release from the duodenum is regulated by CCK-releasing factors,
and these factors are destroyed by pancreatic digestive enzymes
• Increasing intraduodenal enzyme activity may reduce stimulation-
associated pancreatic pain

12. CHOLECYSTOKININ RELEASING FACTOR (CCK-RF) secreted into the proximal
intestine is inactivated by trypsin. Dietary protein competes for trypsin and
prevents it from inactivating CCK-RF. The resulting increase of CCK-RF in the
intestinal lumen releases CCK and stimulates pancreatic enzyme secretion.

14. • No statistically significant benefit of supplemental pancreatic enzyme
therapy to treat pain associated with chronic pancreatitis
• Enzyme supplementation is safe and thus is a reasonable initial
strategy in patients with severe pain who have not responded to other
conservative measures

15. ENDOSCOPIC THERAPY
• Limited to a subgroup of patients with amenable pancreatic ductal
anatomy
• Includes patients with:
• Dilated Pancreas. (Pancreatic duct > 5 mm) with a single or
dominant stricture, or
• An obstructing stone, in the head of the pancreas, with dilation of the
pancreatic duct upstream of the obstruction.
• Difficult to manage - PD strictures in the tail of the pancreas and
multiple strictures along the length of the main PD.

16. ENDOSCOPIC THERAPIES
• Pancreatic sphincterotomy
• Stricture dilation with a graduated dilating catheter or balloon dilators
• Stone extraction sometimes coupled with lithotripsy
• PD stent (Timing of pancreatic stent exchange is variable in practice:
routine every 8 -12 weeks prior to stent occlusion versus on-demand
exchange based on recurrence of symptoms)

17. Pancreatic Sphincterotomy
• Required for larger-caliber pancreatic stent placement and for
pancreatic duct stone extraction
• Pull-type sphincterotome or needle-knife sphincterotome over a small-
caliber pancreatic duct stent
• Major papilla pancreatic sphincterotomy done in patients in whom
long-standing cicatricial stenosis of the sphincter has produced
obstructive chronic pancreatitis.
• Minor papilla sphincterotomy done in patients with pancreas divisum

18. • Performed to dilate and bypass an obstructing stricture
• A number of retrospective case series show pain improvement in
about one half to two thirds of patients.
• Complications are clogging of stents (producing recurrent pain,
attacks of acute pancreatitis, or pancreatic sepsis), inward stent
migration (which may require surgical extraction), and ductal
perforation.
Stent Placement

19. Pancreatic Duct Stone Removal
• Pancreatic duct stones are found in approximately 22 to 60 percent of patients
with chronic pancreatitis
• Causes increased intraductal pressure
• 1. Extracorporeal shock wave lithotripsy (ESWL) creates millimetric fragmentation
of pancreatic stones, which has improved the results of endoscopic therapy
• 2. intraductal lithotripsy devices
• Short term pain relief following ESWL

22. • There is no close correlation between the presence of pancreatic
ductal stones and pain. Many patients with pancreatic ductal
stones have no pain.
• Guidelines recommend ESWL alone as an appropriate therapy for
pancreatic ductal stones greater than 5mm.

23. SURGERY
• When the initial medical and endoscopic treatments fail to
relieve intractable abdominal pain.
• Complications involving adjacent organs or structures
(duodenal, splenic venous, or biliary complications)
• First line therapy if there is suspicion of pancreatic cancer.

24. Indications for Surgery in
Chronic Pancreatitis
• Biliary or pancreatic stricture
• Duodenal stenosis
• Fistulas (peritoneal or pleural effusion)
• Hemorrhage
• Intractable chronic abdominal pain
• Pseudocysts
• Suspected pancreatic neoplasm
• Vascular complications

25. PROCEDURES
• Decompression/drainage operations
• Pancreatic resections
• Denervation procedures

26. Ductal Drainage Procedures
• Done in patients with a dilated pancreatic duct but without an
inflammatory mass in the head of the pancreas.
• Lateral pancreaticojejunostomy is commonly performed and
yields pain relief in 60 to 91 percent of patients.
• Decline in effectiveness over the period of time.
• Exocrine and endocrine functions are generally unaffected.

28. • Surgical drainage as the preferred treatment
• In cases of less extensive disease and surgical risk
patient, endoscopic treatment may still be a valuable
alternative

29. RESECTION
• Considered in patients with pancreatic mass or small duct
disease.
• Resective procedures include
• Whipple procedure
• Pylorus-preserving pancreaticoduodenectomy
• Distal pancreatectomy
• Duodenum-preserving resection of pancreatic head
• Total pancreatectomy

30. • Whipple procedure - Most widely performed surgery in patients with chronic
pancreatitis. Pain relief in 85 percent of patients.
• Distal pancreatectomy - Increased risk of early-onset diabetes.
• Indicated if the disease is confined to the tail of the pancreas
• Total pancreatectomy - is a last-resort procedure associated with a high rate
of brittle diabetes and inadequate pain relief and should be accompanied by
autologous islet cell transplantation.

32. DENERVATION PROCEDURES
• Most afferent nerves emanating from the pancreas pass through the celiac
ganglion and splanchnic nerves.
• Interruption of these nerve fibers has the potential to alleviate pain originating
from the pancreas
• Accomplishedusing an open surgical approach and using thoracoscopic surgery

33. CELIAC PLEXUS NEUROLYSIS
AND CELIAC PLEXUS BLOCK
• Anterior approach under the guidance of transcutaneous ultrasound,
computed tomography, laparoscopy or EUS
• EUS allows for real-time imaging of the celiac space for CPB and
CPN as well as fine needle aspiration (FNA) for diagnostic purposes
and tumor staging

34. EUS-guided celiac plexus block
(basic anatomy)
• The celiac plexus is composed of a right and left ganglion, located anterolateral
to the aorta at the level of the celiac trunk.
• The crura of the diaphragm and the L1 vertebral body are located posterior to
the celiac plexus.
• Kidneys, adrenals and the inferior vena cava are present laterally
• Pancreas covers the celiac plexus anteriorly

35. • Location of the celiac plexus in relation to the celiac trunk is the most
reliable landmark
• Celiac ganglia are not easily identified by EUS
• On average, the left and the right ganglion are located 0.9 cm and 0.6
cm inferior to the celiac artery respectively

37. CELIAC PLEXUS BLOCK
• First described by Kappis in 1914
• Corticosteroidinjection in patients with benign pancreatic diseases like chronic
pancreatitis
• Bupivacaine is often used in combination with the steroid injection to provide a
more prolonged analgesic effect compared to the local anesthetic alone

38. Celiac plexus neurolysis
• Ablation of the plexus, often achieved with alcohol or phenol administered
• Bupivicaine is injected first to prevent pain associated with the alcohol injection.
• CPN with alcohol is not routinely used in benign diseases given the risk of
retroperitoneal fibrosis, which would render any subsequent pancreatic surgery
more difficult

39. Celiac plexus intervention

40. Celiac ganglia intervention

43. THANKS