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Singh A, Bush N, Bhullar FA, Faghih M, Moreau C, Mittal R, Seo JH, Talukdar R, Lakhtakia S, Singh VK, Akshintala VS. Pancreatic duct pressure: A review of technical aspects and clinical significance. Pancreatology 2023; 23:858-867. [PMID: 37798192 DOI: 10.1016/j.pan.2023.09.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/12/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
Pancreatic duct pressure (PDP) dynamics comprise an intricately modulated system that helps maintain homeostasis of pancreatic function. It is affected by various factors, including the rate of pancreatic fluid secretion, patency of the ductal system, sphincter of Oddi function, and pancreatic fluid characteristics. Disease states such as acute and chronic pancreatitis can alter the normal PDP dynamics. Ductal hypertension or increased PDP is suspected to be involved in the pathogenesis of pancreatic pain, endocrine and exocrine pancreatic insufficiency, and recurrent pancreatitis. This review provides a comprehensive appraisal of the available literature on PDP, including the methods used in the measurement and clinical implications of elevated PDP.
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Affiliation(s)
- Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Nikhil Bush
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Mahya Faghih
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Chris Moreau
- Division of Gastroenterology, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Jung-Hee Seo
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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Rosendahl J. Understanding pain in chronic pancreatitis: not yet the end of the story? Gut 2022; 71:2378-2379. [PMID: 34887265 DOI: 10.1136/gutjnl-2021-326279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/08/2022]
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Olesen SS, Phillips AE, Faghih M, Kuhlmann L, Steinkohl E, Frøkjær JB, Bick BL, Ramsey ML, Hart PA, Garg PK, Singh VK, Yadav D, Drewes AM. Overlap and cumulative effects of pancreatic duct obstruction, abnormal pain processing and psychological distress on patient-reported outcomes in chronic pancreatitis. Gut 2022; 71:2518-2525. [PMID: 34675068 DOI: 10.1136/gutjnl-2021-325855] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/07/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Several factors have been suggested to mediate pain in patients with chronic pancreatitis. However, it is unknown whether these factors are overlapping and if they have cumulative effects on patient-reported outcomes (PROs). DESIGN We performed a multicentre cross-sectional study of 201 prospectively enrolled subjects with definitive chronic pancreatitis. All subjects underwent evaluation for pancreatic duct obstruction, abnormalities in pain processing using quantitative sensory testing, and screening for psychological distress (anxiety, depression and pain catastrophising) based on validated questionnaires. Abnormality was defined by normal reference values. PROs included pain symptom severity (Brief Pain Inventory short form) and quality of life (EORTC-QLQ-C30 questionnaire). Associations between pain-related factors and PROs were investigated by linear trend analyses, multiple regression models and mediation analyses. RESULTS Clinical evaluation suggestive of pancreatic duct obstruction was observed in 29%, abnormal pain processing in 23%, anxiety in 47%, depression in 39% and pain catastrophising in 28%; each of these factors was associated with severity of at least one PRO. Two or more factors were present in 51% of subjects. With an increasing number of factors, there was an increase in pain severity scores (p<0.001) and pain interference scores (p<0.001), and a reduction in quality of life (p<0.001). All factors had independent and direct effects on PROs, with the strongest effect size observed for psychological distress. CONCLUSION Pain-related factors in chronic pancreatitis are often present in an overlapping manner and have a cumulative detrimental effect on PROs. These findings support a multidisciplinary strategy for pain management. TRIAL REGISTRATION NUMBER The study was registered with ClinicalTrials.gov (NCT03434392).
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Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anna E Phillips
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Emily Steinkohl
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Faghih M, Phillips AE, Kuhlmann L, Afghani E, Drewes AM, Yadav D, Singh VK, Olesen SS. Pancreatic QST Differentiates Chronic Pancreatitis Patients into Distinct Pain Phenotypes Independent of Psychiatric Comorbidities. Clin Gastroenterol Hepatol 2022; 20:153-161.e2. [PMID: 34108130 PMCID: PMC8629107 DOI: 10.1016/j.cgh.2020.10.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quantitative sensory testing (QST) has been previously used to study pain in chronic pancreatitis (CP) but included methods that are not suitable for clinical purposes. The aims of this study were to determine if pancreatic QST (P-QST) can differentiate patients into distinct pain phenotypes and to determine the association of these with their clinical pain and psychiatric comorbidities. METHODS A multicenter cross-sectional study was conducted where patients completed validated questionnaires assessing quality of life (QoL), depression and anxiety scores as well as clinical pain symptoms followed by P-QST which included a cold pressor test, repetitive pinprick stimuli and pressure stimulation of the upper abdominal (T10) and control dermatomes. P-QST categorized patients into pain phenotypes based on a previously established nomogram. QoL, clinical pain and psychiatric assessment scores were compared across these groups. RESULTS A total of 179 patients were enrolled with a mean age of 54.1±13.6 years among whom 59% were males and 42% had an alcoholic etiology. P-QST showed no hyperalgesia in 91 (51%), segmental hyperalgesia in 50 (28%) and widespread hyperalgesia in 38 (21%) patients. Patients with widespread hyperalgesia had significantly higher pain intensity scores (P = .03) and rates of constant pain (P = .002) as well as decreased QoL (P < .001) and physical functioning (P =.03) in comparison with the other two pain phenotypes. In contrast, psychiatric comorbidities were similar across all groups. CONCLUSIONS P-QST may serve as a novel unbiased pain assessment tool in CP as it categorizes patients into distinct pain phenotypes independent of their psychiatric comorbidities.
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Affiliation(s)
- Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anna E Phillips
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Louise Kuhlmann
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Yadav
- University of Pittsburgh School of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Pittsburgh, Pennsylvania
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; Pancreatitis Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Søren S Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Saleh M, Sharma K, Kalsi R, Fusco J, Sehrawat A, Saloman JL, Guo P, Zhang T, Mohamed N, Wang Y, Prasadan K, Gittes GK. Chemical pancreatectomy treats chronic pancreatitis while preserving endocrine function in preclinical models. J Clin Invest 2021; 131:143301. [PMID: 33351784 PMCID: PMC7843231 DOI: 10.1172/jci143301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/01/2020] [Indexed: 12/20/2022] Open
Abstract
Chronic pancreatitis affects over 250,000 people in the US and millions worldwide. It is associated with chronic debilitating pain, pancreatic exocrine failure, and high risk of pancreatic cancer and usually progresses to diabetes. Treatment options are limited and ineffective. We developed a new potential therapy, wherein a pancreatic ductal infusion of 1%-2% acetic acid in mice and nonhuman primates resulted in a nonregenerative, near-complete ablation of the exocrine pancreas, with complete preservation of the islets. Pancreatic ductal infusion of acetic acid in a mouse model of chronic pancreatitis led to resolution of chronic inflammation and pancreatitis-associated pain. Furthermore, acetic acid-treated animals showed improved glucose tolerance and insulin secretion. The loss of exocrine tissue in this procedure would not typically require further management in patients with chronic pancreatitis because they usually have pancreatic exocrine failure requiring dietary enzyme supplements. Thus, this procedure, which should be readily translatable to humans through an endoscopic retrograde cholangiopancreatography (ERCP), may offer a potential innovative nonsurgical therapy for chronic pancreatitis that relieves pain and prevents the progression of pancreatic diabetes.
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Affiliation(s)
- Mohamed Saleh
- Division of Pediatric Surgery
- Division of Pediatric Endocrinology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Jami L. Saloman
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Department of Neurobiology, Pittsburgh Center for Pain Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ping Guo
- Department of Clinical Science, Colorado State University, Fort Collins, Colorado, USA
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Demir E, Safak O, Friess H, Demir IE. Pain in chronic pancreatitis: mechanics or molecules? Pain Manag 2020; 10:205-208. [PMID: 32677878 DOI: 10.2217/pmt-2020-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Elke Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Okan Safak
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Germany.,CRC 1321 Modelling & Targeting Pancreatic Cance
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Germany.,CRC 1321 Modelling & Targeting Pancreatic Cance.,Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkeyr
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Cho NR, Kim YN, Kim JY, Ko YR, Hong TH, Moon HK, Park HJ. Celiac plexus block with botulinum toxin in severe chronic pancreatitis-A case report. J Clin Pharm Ther 2020; 45:848-851. [PMID: 32437035 DOI: 10.1111/jcpt.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The botulinum toxin (BoNT) has been widely used for various conditions associated with pain. CASE DESCRIPTION Here, we report a case where celiac plexus block (CPB) with BoNT relieved intractable chronic pancreatic pain without complications. CPB was performed at the L1 level under fluoroscopic guidance, and 50 IU BoNT was injected on each side. After 15 weeks, pain was decreased to 0/10 on a visual analogue scale, without opioids or tramadol. WHAT IS NEW AND CONCLUSION Our case demonstrates the efficacy of CPB with BoNT in intractable pain due to severe chronic pancreatitis.
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Affiliation(s)
- Noo Ree Cho
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Na Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Yeong Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Ri Ko
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of General Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Kyung Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Perito ER, Palermo TM, Pohl JF, Mascarenhas M, Abu-El-Haija M, Barth B, Bellin MD, Fishman DS, Freedman S, Gariepy C, Giefer M, Gonska T, Heyman MB, Himes RW, Husain SZ, Lin T, Liu Q, Maqbool A, McFerron B, Morinville VD, Nathan JD, Ooi CY, Rhee S, Schwarzenberg SJ, Shah U, Troendle DM, Werlin S, Wilschanski M, Zheng Y, Zimmerman MB, Lowe M, Uc A. Factors Associated With Frequent Opioid Use in Children With Acute Recurrent and Chronic Pancreatitis. J Pediatr Gastroenterol Nutr 2020; 70:106-114. [PMID: 31567889 PMCID: PMC6934913 DOI: 10.1097/mpg.0000000000002502] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The aim of the study was to understand the association of frequent opioid use with disease phenotype and pain pattern and burden in children and adolescents with acute recurrent (ARP) or chronic pancreatitis (CP). METHODS Cross-sectional study of children <19 years with ARP or CP, at enrollment into the INSPPIRE cohort. We categorized patients as opioid "frequent use" (daily/weekly) or "nonfrequent use" (monthly or less, or no opioids), based on patient and parent self-report. RESULTS Of 427 children with ARP or CP, 17% reported frequent opioid use. More children with CP (65%) reported frequent opioid use than with ARP (41%, P = 0.0002). In multivariate analysis, frequent opioid use was associated with older age at diagnosis (odds ratio [OR] 1.67 per 5 years, 95% confidence interval [CI] 1.13-2.47, P = 0.01), exocrine insufficiency (OR 2.44, 95% CI 1.13-5.24, P = 0.02), constant/severe pain (OR 4.14, 95% CI 2.06-8.34, P < 0.0001), and higher average pain impact score across all 6 functional domains (OR 1.62 per 1-point increase, 95% CI 1.28-2.06, P < 0.0001). Children with frequent opioid use also reported more missed school days, hospitalizations, and emergency room visits in the past year than children with no frequent use (P < 0.0002 for each). Participants in the US West and Midwest accounted for 83% of frequent opioid users but only 56% of the total cohort. CONCLUSIONS In children with CP or ARP, frequent opioid use is associated with constant pain, more healthcare use, and higher levels of pain interference with functioning. Longitudinal and prospective research is needed to identify risk factors for frequent opioid use and to evaluate nonopioid interventions for reducing pain and disability in these children.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - John F. Pohl
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Maria Mascarenhas
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Maisam Abu-El-Haija
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley Barth
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX
| | - Melena D. Bellin
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | | | - Cheryl Gariepy
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Matthew Giefer
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
| | - Tanja Gonska
- Department of Pediatrics, Sick Kids Hospital, University of Toronto, Toronto, ON, Canada
| | - Melvin B. Heyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Ryan W. Himes
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX
| | - Sohail Z. Husain
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Tom Lin
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Quin Liu
- Department of Pediatrics, Cedars-Sinai, Los Angeles, CA
| | - Asim Maqbool
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Brian McFerron
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Veronique D. Morinville
- Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, QC, Canada
| | - Jaime D. Nathan
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chee Y. Ooi
- School of Women’s and Children’s Health, Medicine, University of New South Wales, New South Wales, Sydney, Australia
| | - Sue Rhee
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | | | - Uzma Shah
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - David M. Troendle
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX
| | - Steven Werlin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | | | - Yuhua Zheng
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | | | - Mark Lowe
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Aliye Uc
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
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Abstract
PURPOSE OF REVIEW Pain is the most common symptom of chronic pancreatitis, having a profound effect on patients and a broad socioeconomic impact. Endoscopy is guideline recommended as first-line management for chronic pancreatitis pain in certain clinical scenarios. Herein, we provide an evidence-based review of the endoscopic treatment of pain due to chronic pancreatitis while highlighting some important confounders in the measurement of this outcome in clinical practice and research. RECENT FINDINGS Multiple recent studies have reported on the efficacy of current endoscopic therapies for chronic pancreatitis pain. Despite the high technical success rates of these procedures, pain outcomes remain disappointing. Complex mechanisms beyond ductal hypertension, such as central sensitization, visceral hypersensitivity and inflammatory neuritis account for some of the discordance observed between the rates of technical and clinical success. In addition, the sham effect is increasingly recognized as a confounder when interpreting the procedural benefit. Nevertheless, there are multiple promising innovations in the field of pancreatic endoscopy that are aimed to improve technical and clinical outcomes, but rigorous investigation is necessary to establish their role in clinical practice. SUMMARY Endoscopic therapy for chronic pancreatitis pain appears to be safe and effective in certain contexts and recent innovations in the field will hopefully further improve outcomes. In addition to evaluating the technical success of endotherapy in chronic pancreatitis, methodologically rigorous research focusing on patient-centered outcomes and accounting for the sham effect is necessary to advance this field.
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Steinritz D, Stenger B, Dietrich A, Gudermann T, Popp T. TRPs in Tox: Involvement of Transient Receptor Potential-Channels in Chemical-Induced Organ Toxicity-A Structured Review. Cells 2018; 7:cells7080098. [PMID: 30087301 PMCID: PMC6115949 DOI: 10.3390/cells7080098] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/24/2018] [Accepted: 07/31/2018] [Indexed: 12/28/2022] Open
Abstract
Chemicals can exhibit significant toxic properties. While for most compounds, unspecific cell damaging processes are assumed, a plethora of chemicals exhibit characteristic odors, suggesting a more specific interaction with the human body. During the last few years, G-protein-coupled receptors and especially chemosensory ion channels of the transient receptor potential family (TRP channels) were identified as defined targets for several chemicals. In some cases, TRP channels were suggested as being causal for toxicity. Therefore, these channels have moved into the spotlight of toxicological research. In this review, we screened available literature in PubMed that deals with the role of chemical-sensing TRP channels in specific organ systems. TRPA1, TRPM and TRPV channels were identified as essential chemosensors in the nervous system, the upper and lower airways, colon, pancreas, bladder, skin, the cardiovascular system, and the eyes. Regarding TRP channel subtypes, A1, M8, and V1 were found most frequently associated with toxicity. They are followed by V4, while other TRP channels (C1, C4, M5) are only less abundantly expressed in this context. Moreover, TRPA1, M8, V1 are co-expressed in most organs. This review summarizes organ-specific toxicological roles of TRP channels.
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Affiliation(s)
- Dirk Steinritz
- Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany.
- Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität Munich, 80336 Munich, Germany.
| | - Bernhard Stenger
- Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany.
| | - Alexander Dietrich
- Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität Munich, 80336 Munich, Germany.
| | - Thomas Gudermann
- Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität Munich, 80336 Munich, Germany.
| | - Tanja Popp
- Bundeswehr Institute of Pharmacology and Toxicology, 80937 Munich, Germany.
- Walther-Straub-Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität Munich, 80336 Munich, Germany.
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12
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Zhu C, Huang Q, Zhu J, Zhang X, Qin X. Groove resection of pancreatic head in groove pancreatitis: A case report. Exp Ther Med 2017; 14:1983-1988. [PMID: 28962113 PMCID: PMC5609124 DOI: 10.3892/etm.2017.4753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 04/20/2017] [Indexed: 12/14/2022] Open
Abstract
Groove pancreatitis (GP) is a rare type of chronic pancreatitis, which primarily affects the groove area of the pancreatic head. Surgery is considered as the ultimate method for GP if the symptoms are not improved by conservative or endoscopic treatments, and the Whipple technique is the common choice at present. The present study introduces a novel surgical procedure for GP, namely groove resection of pancreatic head (GRPH), in a 56-year-old male patient. To the best of our knowledge, this is the first report on GRPH for the surgical treatment of GP. This patient was diagnosed with typical GP without any evidence of malignancy, based on imaging studies and gastrointestinal endoscopy, and was treated with GRPH. Briefly, only the groove area of the pancreatic head was resected, while the duodenum, the main pancreatic duct and the majority of the pancreatic head were preserved. A complete relief of abdominal pain and a weight gain were achieved 2 months after surgery. Endoscopic examination indicated marked improvement of the duodenal lesions. In conclusion, GRPH is a less invasive surgical procedure for GP compared with other surgical procedures and may be an alternative for the surgical treatment of GP without severe lesions or stenosis of the duodenum.
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Affiliation(s)
- Chunfu Zhu
- Department of Hepato-biliary-pancreatic Surgery, Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Qin Huang
- Department of Pathology and Laboratory Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, West Roxbury, MA 02132, USA
| | - Jianfei Zhu
- Department of Hepato-biliary-pancreatic Surgery, Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Xudong Zhang
- Department of Hepato-biliary-pancreatic Surgery, Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Xihu Qin
- Department of Hepato-biliary-pancreatic Surgery, Changzhou No. 2 People's Hospital, Nanjing Medical University, Changzhou, Jiangsu 213000, P.R. China
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Han L, Ma J, Duan W, Zhang L, Yu S, Xu Q, Lei J, Li X, Wang Z, Wu Z, Huang JH, Wu E, Ma Q, Ma Z. Pancreatic stellate cells contribute pancreatic cancer pain via activation of sHH signaling pathway. Oncotarget 2017; 7:18146-58. [PMID: 26934446 PMCID: PMC4951278 DOI: 10.18632/oncotarget.7776] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/05/2016] [Indexed: 12/29/2022] Open
Abstract
Abdominal pain is a critical clinical symptom in pancreatic cancer (PC) that affects the quality of life for PC patients. However, the pathogenesis of PC pain is largely unknown. In this study, we show that PC pain is initiated by the sonic hedgehog (sHH) signaling pathway in pancreatic stellate cells (PSCs), which is activated by sHH secreted from PC cells, and then, neurotrophic factors derived from PSCs mediate the pain. The different culture systems were established in vitro, and the expression of sHH pathway molecules, neurotrophic factors, TRPV1, and pain factors were examined. Capsaicin-evoked TRPV1 currents in dorsal root ganglion (DRG) neurons were examined by the patch-clamp technique. Pain-related behavior was observed in an orthotopic tumor model. sHH and PSCs increased the expression and secretion of TRPV1, SP, and CGRP by inducing NGF and BDNF in a co-culture system, also increasing TRPV1 current. But, suppressing sHH pathway or NGF reduced the expression of TRPV1, SP, and CGRP. In vivo, PSCs and PC cells that expressed high levels of sHH could enhance pain behavior. Furthermore, the blockade of NGF or TRPV1 significantly attenuated the pain response to mechanical stimulation compared with the control. Our results demonstrate that sHH signaling pathway is involved in PC pain, and PSCs play an essential role in the process greatly by inducing NGF.
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Affiliation(s)
- Liang Han
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jiguang Ma
- Department of Anesthesiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Wanxing Duan
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Lun Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Shuo Yu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Qinhong Xu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jianjun Lei
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Xuqi Li
- Department of General Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott and White Health Care, Temple, TX, 76508, USA.,Department of Surgery, Texas A & M College of Medicine, Temple, TX, 76504, USA
| | - Erxi Wu
- Department of Neurosurgery, Baylor Scott and White Health Care, Temple, TX, 76508, USA.,Department of Pharmaceutical Sciences, Texas A & M Health Science Center, College Station, TX, 77843, USA
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Zhenhua Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
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Chronic Pancreatitis in the 21st Century - Research Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2016; 45:1365-1375. [PMID: 27748719 PMCID: PMC5117429 DOI: 10.1097/mpa.0000000000000713] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to focus on research gaps and opportunities in chronic pancreatitis (CP) and its sequelae. This conference marked the 20th year anniversary of the discovery of the cationic trypsinogen (PRSS1) gene mutation for hereditary pancreatitis. The event was held on July 27, 2016, and structured into 4 sessions: (1) pathophysiology, (2) exocrine complications, (3) endocrine complications, and (4) pain. The current state of knowledge was reviewed; many knowledge gaps and research needs were identified that require further investigation. Common themes included the need to design better tools to diagnose CP and its sequelae early and reliably, identify predisposing risk factors for disease progression, develop standardized protocols to distinguish type 3c diabetes mellitus from other types of diabetes, and design effective therapeutic strategies through novel cell culture technologies, animal models mimicking human disease, and pain management tools. Gene therapy and cystic fibrosis conductance regulator potentiators as possible treatments of CP were discussed. Importantly, the need for CP end points and intermediate targets for future drug trials was emphasized.
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15
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Tanhehco YC, Weisberg S, Schwartz J. Pancreatic islet autotransplantation for nonmalignant and malignant indications. Transfusion 2015; 56:761-70. [DOI: 10.1111/trf.13417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 10/02/2015] [Accepted: 10/08/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Yvette C. Tanhehco
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Stuart Weisberg
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
| | - Joseph Schwartz
- Department of Pathology and Cell Biology; Columbia University Medical Center; New York New York
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16
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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.
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17
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Abstract
Sensory nerves are a kind of nerve that conduct afferent impulses from the periphery receptors to the central nervous system (CNS) and are able to release neuromediators from the activated peripheral endings. Sensory nerves are particularly important for microcirculatory response, and stimulation of pancreatic sensory nerves releases a variety of neuropeptides such as substance P (SP), calcitonin gene-related peptide (CGRP), etc., leading to neurogenic inflammation characterized as the local vasodilatation and plasma extravasation. Deactivation of sensory nerves often leads to the disturbances of pancreatic microcirculation. Pancreatitis is a common digestive disease that can lead to severe complications and even death if it goes untreated. Experimental studies in animals and tissue analysis in patients with pancreatitis have shown significant changes in sensory nerves supplying the pancreatic gland. Thus making clear the whole mechanism of pancreatitis is essential to treat and cure it. Sensory nerves may have a close correlation with the development of pancreatitis, and knowing more about the role of sensory nerve in pancreatitis is important for the treatment for pancreatitis. This review is aimed to summarize the relationship between sensory nerves and pancreatitis.
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Affiliation(s)
- Qingfu Li
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jie Peng
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China
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18
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Cattaruzza F, Johnson C, Leggit A, Grady E, Schenk AK, Cevikbas F, Cedron W, Bondada S, Kirkwood R, Malone B, Steinhoff M, Bunnett N, Kirkwood KS. Transient receptor potential ankyrin 1 mediates chronic pancreatitis pain in mice. Am J Physiol Gastrointest Liver Physiol 2013; 304:G1002-12. [PMID: 23558009 PMCID: PMC3680686 DOI: 10.1152/ajpgi.00005.2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic pancreatitis (CP) is a devastating disease characterized by persistent and uncontrolled abdominal pain. Our lack of understanding is partially due to the lack of experimental models that mimic the human disease and also to the lack of validated behavioral measures of visceral pain. The ligand-gated cation channel transient receptor potential ankyrin 1 (TRPA1) mediates inflammation and pain in early experimental pancreatitis. It is unknown if TRPA1 causes fibrosis and sustained pancreatic pain. We induced CP by injecting the chemical agent trinitrobenzene sulfonic acid (TNBS), which causes severe acute pancreatitis, into the pancreatic duct of C57BL/6 trpa1(+/+) and trpa1(-/-) mice. Chronic inflammatory changes and pain behaviors were assessed after 2-3 wk. TNBS injection caused marked pancreatic fibrosis with increased collagen-staining intensity, atrophy, fatty replacement, monocyte infiltration, and pancreatic stellate cell activation, and these changes were reflected by increased histological damage scores. TNBS-injected animals showed mechanical hypersensitivity during von Frey filament probing of the abdomen, decreased daily voluntary wheel-running activity, and increased immobility scores during open-field testing. Pancreatic TNBS also reduced the threshold to hindpaw withdrawal to von Frey filament probing, suggesting central sensitization. Inflammatory changes and pain indexes were significantly reduced in trpa1(-/-) mice. In conclusion, we have characterized in mice a model of CP that resembles the human condition, with marked histological changes and behavioral measures of pain. We have demonstrated, using novel and objective pain measurements, that TRPA1 mediates inflammation and visceral hypersensitivity in CP and could be a therapeutic target for the treatment of sustained inflammatory abdominal pain.
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Affiliation(s)
- Fiore Cattaruzza
- 1Department of Surgery, University of California, San Francisco, California;
| | - Cali Johnson
- 1Department of Surgery, University of California, San Francisco, California;
| | - Alan Leggit
- 2Department of Neuroscience, University of California, San Francisco, California;
| | - Eileen Grady
- 1Department of Surgery, University of California, San Francisco, California;
| | - A. Katrin Schenk
- 5Department of Physics, Randolph College, Lynchburg, Virginia; and
| | - Ferda Cevikbas
- 3Department of Dermatology, University of California, San Francisco, California;
| | - Wendy Cedron
- 3Department of Dermatology, University of California, San Francisco, California;
| | - Sandhya Bondada
- 1Department of Surgery, University of California, San Francisco, California;
| | - Rebekah Kirkwood
- 1Department of Surgery, University of California, San Francisco, California;
| | - Brian Malone
- 4Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California;
| | - Martin Steinhoff
- 1Department of Surgery, University of California, San Francisco, California; ,3Department of Dermatology, University of California, San Francisco, California;
| | - Nigel Bunnett
- 6Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
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TRPV1 and TRPA1 antagonists prevent the transition of acute to chronic inflammation and pain in chronic pancreatitis. J Neurosci 2013; 33:5603-11. [PMID: 23536075 DOI: 10.1523/jneurosci.1806-12.2013] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Visceral afferents expressing transient receptor potential (TRP) channels TRPV1 and TRPA1 are thought to be required for neurogenic inflammation and development of inflammatory hyperalgesia. Using a mouse model of chronic pancreatitis (CP) produced by repeated episodes (twice weekly) of caerulein-induced AP (AP), we studied the involvement of these TRP channels in pancreatic inflammation and pain-related behaviors. Antagonists of the two TRP channels were administered at different times to block the neurogenic component of AP. Six bouts of AP (over 3 wks) increased pancreatic inflammation and pain-related behaviors, produced fibrosis and sprouting of pancreatic nerve fibers, and increased TRPV1 and TRPA1 gene transcripts and a nociceptive marker, pERK, in pancreas afferent somata. Treatment with TRP antagonists, when initiated before week 3, decreased pancreatic inflammation and pain-related behaviors and also blocked the development of histopathological changes in the pancreas and upregulation of TRPV1, TRPA1, and pERK in pancreatic afferents. Continued treatment with TRP antagonists blocked the development of CP and pain behaviors even when mice were challenged with seven more weeks of twice weekly caerulein. When started after week 3, however, treatment with TRP antagonists was ineffective in blocking the transition from AP to CP and the emergence of pain behaviors. These results suggest: (1) an important role for neurogenic inflammation in pancreatitis and pain-related behaviors, (2) that there is a transition from AP to CP, after which TRP channel antagonism is ineffective, and thus (3) that early intervention with TRP channel antagonists may attenuate the transition to and development of CP effectively.
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20
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Pancreatic islet autotransplantation with total pancreatectomy for chronic pancreatitis. Surg Today 2012; 43:715-9. [DOI: 10.1007/s00595-012-0382-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 07/26/2012] [Indexed: 12/11/2022]
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21
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Watson P. Chronic pancreatitis in dogs. Top Companion Anim Med 2012; 27:133-9. [PMID: 23148854 DOI: 10.1053/j.tcam.2012.04.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 04/30/2012] [Indexed: 12/14/2022]
Abstract
Chronic pancreatitis used to be considered uncommon in dogs, but recent pathological and clinical studies have confirmed that it is in fact a common and clinically significant disease. Clinical signs can vary from low-grade recurrent gastrointestinal signs to acute exacerbations that are indistinguishable from classical acute pancreatitis. Chronic pancreatitis is a significant cause of chronic pain in dogs, which must not be underestimated. It also results in progressive impairment of endocrine and exocrine function and the eventual development of diabetes mellitus or exocrine pancreatic insufficiency or both in some affected dogs at end stage. The etiology is unknown in most cases. Chronic pancreatitis shows an increased prevalence in certain breeds, and recent work in English Cocker Spaniels suggests it is part of a polysystemic immune-mediated disease in this breed. The histological and clinical appearance is different in different breeds, suggesting that etiologies may also be different. Diagnosis is challenging because the sensitivities of the available noninvasive tests are relatively low. However, with an increased index of suspicion, clinicians will recognize more cases that will allow them to institute supportive treatment to improve the quality of life of the patient.
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Affiliation(s)
- Penny Watson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom.
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22
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Pancreatic nociception--revisiting the physiology and pathophysiology. Pancreatology 2012; 12:104-12. [PMID: 22487519 DOI: 10.1016/j.pan.2012.02.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/23/2012] [Accepted: 02/19/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas. OBJECTIVES This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings. METHODS A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC). RESULTS Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms. CONCLUSIONS Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.
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23
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Abstract
Chronic pancreatitis is typically a painful condition and it can be associated with a severe burden of disease. The pathogenesis of pain in this disorder is poorly understood and its treatment has been largely empirical, often consisting of surgical or other invasive methods, with an outcome that is variable and frequently unsatisfactory. Human and experimental studies have indicated a critical role for neuronal mechanisms that result in peripheral and central sensitization. The pancreatic nociceptor seems to be significantly affected in this condition, with increased excitability associated with downregulation of potassium currents. Some of the specific molecules implicated in this process include the vanilloid receptor, TRPV1, nerve growth factor, the protease activated receptor 2 and a variety of others that are discussed in this Review. Studies have also indicated novel therapeutic targets for this condition.
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Affiliation(s)
- Pankaj Jay Pasricha
- Stanford University School of Medicine, 300 Pasteur Drive, M211 Alway Building, Stanford, CA 94305, USA.
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24
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Zhu Y, Mehta K, Li C, Xu GY, Liu L, Colak T, Shenoy M, Pasricha PJ. Systemic administration of anti-NGF increases A-type potassium currents and decreases pancreatic nociceptor excitability in a rat model of chronic pancreatitis. Am J Physiol Gastrointest Liver Physiol 2012; 302:G176-81. [PMID: 22038828 PMCID: PMC3345962 DOI: 10.1152/ajpgi.00053.2011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We have previously shown that pancreatic sensory neurons in rats with chronic pancreatitis (CP) display increased excitability associated with a decrease in transient inactivating potassium currents (I(A)), thus accounting in part for the hyperalgesia associated with this condition. Because of its well known role in somatic hyperalgesia, we hypothesized a role for the nerve growth factor (NGF) in driving these changes. CP was induced by intraductal injection of trinitrobenzene sulfonic acid (TNBS) in rats. After 3 wk, anti-NGF antibody or control serum was injected intra-peritoneally daily for 1 wk. This protocol was repeated in another set of experiments in control rats (receiving intraductal PBS instead of TNBS). Pancreatic nociceptors labeled with the dye Dil were identified, and patch-clamp recordings were made from acutely dissociated DRG neurons. Sensory neurons from anti-NGF-treated rats displayed a lower resting membrane potential, increased rheobase, decreased burst discharges in response to stimulatory current, and decreased input resistance compared with those treated with control serum. Under voltage-clamp condition, neuronal I(A) density was increased in anti-NGF-treated rats compared with rats treated with control serum. However, anti-NGF treatment had no effect on electrophysiological parameters in neurons from control rats. The expression of Kv-associated channel or ancillary genes Kv1.4, 4.1, 4.2, 4.3, and DPP6, DPP10, and KCHIPs 1-4 in pancreas-specific nociceptors was examined by laser-capture microdissection and real-time PCR quantification of mRNA levels. No significant differences were seen among those. These findings emphasize a key role for NGF in maintaining neuronal excitability in CP specifically via downregulation of I(A) by as yet unknown mechanisms.
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Affiliation(s)
- Yaohui Zhu
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Kshama Mehta
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Cuiping Li
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Guang-Yin Xu
- 2Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Liansheng Liu
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Tugba Colak
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Mohan Shenoy
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
| | - Pankaj Jay Pasricha
- 1Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California; and
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25
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ZHU YAOHUI, COLAK TUGBA, SHENOY MOHAN, LIU LIANSHENG, PAI REETESH, LI CUIPING, MEHTA KSHAMA, PASRICHA PANKAJJAY. Nerve growth factor modulates TRPV1 expression and function and mediates pain in chronic pancreatitis. Gastroenterology 2011; 141:370-7. [PMID: 21473865 PMCID: PMC7522725 DOI: 10.1053/j.gastro.2011.03.046] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 02/09/2011] [Accepted: 03/07/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The pathogenesis of pain in chronic pancreatitis (CP) is poorly understood and treatment remains difficult. We hypothesized that nerve growth factor (NGF) plays a key role in this process via its effects on the transient receptor potential vanilloid 1, TRPV1. METHODS CP was induced by intraductal injection of trinitrobenzene sulfonic acid in rats. After 3 weeks, anti-NGF antibody or control serum was administered daily for 1 week. Pancreatic hyperalgesia was assessed by nocifensive behavioral response to electrical stimulation of the pancreas as well as by referred somatic pain assessed by von Frey filament testing. TRPV1 currents in pancreatic sensory neurons were examined by patch-clamp. The expression and function of TRPV1 in pancreas-specific nociceptors was examined by immunostaining and quantification of messenger RNA levels. RESULTS Blockade of NGF significantly attenuated pancreatic hyperalgesia and referred somatic pain compared with controls. It also decreased TRPV1 current density and open probability and reduced the proportion of pancreatic sensory neurons that expressed TRPV1 as well as levels of TRPV1 in these neurons. CONCLUSIONS These findings emphasize a key role for NGF in pancreatic pain and highlight the role it plays in the modulation of TRPV1 expression and activity in CP.
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Affiliation(s)
- YAOHUI ZHU
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - TUGBA COLAK
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - MOHAN SHENOY
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - LIANSHENG LIU
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - REETESH PAI
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - CUIPING LI
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - KSHAMA MEHTA
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - PANKAJ JAY PASRICHA
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Abstract
OBJECTIVES We examined the role of brain-derived neurotrophic factor (BDNF) in the pathogenesis of pain in an experimental model of chronic pancreatitis (CP). METHODS Pancreatitis was induced by retrograde infusion of trinitrobenzene sulfonic acid into the pancreatic duct of adult rats. Twenty-one days after injection, BDNF expression was examined in pancreas-specific dorsal root ganglia (DRGs) by immunohistochemistry, and protein levels were quantified from DRGs and spinal cord extracts. The effects of intrathecal infusion of a neutralizing antibody to BDNF on pancreatic hyperalgesia were assessed by the sensitivity of the abdominal wall to filament probing as well as the nocifensive behavior to electrical stimulation of the pancreas. RESULTS Levels of BDNF in DRGs and spinal cords (T9-13) were significantly higher in trinitrobenzene sulfonic acid rats compared with controls, accompanied by an increase in the number of pancreas-specific neurons expressing BDNF immunoreactivity. Brain-derived neurotrophic factor antagonism suppressed phospho-tropomyosin-related kinase B receptor levels in the spinal cord and significantly reduced behavioral responses in rats with CP. CONCLUSIONS Brain-derived neurotrophic factor is upregulated in pancreas-specific primary afferent neurons in rats with CP, and BDNF antagonism is associated with a reduction of pain-related behavior in these animals, suggesting an important role for this neurotransmitter in the nociception of CP.
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27
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Ceppa E, Cattaruzza F, Lyo V, Amadesi S, Pelayo JC, Poole DP, Vaksman N, Liedtke W, Cohen DM, Grady EF, Bunnett NW, Kirkwood KS. Transient receptor potential ion channels V4 and A1 contribute to pancreatitis pain in mice. Am J Physiol Gastrointest Liver Physiol 2010; 299:G556-71. [PMID: 20539005 PMCID: PMC2950679 DOI: 10.1152/ajpgi.00433.2009] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The mechanisms of pancreatic pain, a cardinal symptom of pancreatitis, are unknown. Proinflammatory agents that activate transient receptor potential (TRP) channels in nociceptive neurons can cause neurogenic inflammation and pain. We report a major role for TRPV4, which detects osmotic pressure and arachidonic acid metabolites, and TRPA1, which responds to 4-hydroxynonenal and cyclopentenone prostaglandins, in pancreatic inflammation and pain in mice. Immunoreactive TRPV4 and TRPA1 were detected in pancreatic nerve fibers and in dorsal root ganglia neurons innervating the pancreas, which were identified by retrograde tracing. Agonists of TRPV4 and TRPA1 increased intracellular Ca(2+) concentration ([Ca(2+)](i)) in these neurons in culture, and neurons also responded to the TRPV1 agonist capsaicin and are thus nociceptors. Intraductal injection of TRPV4 and TRPA1 agonists increased c-Fos expression in spinal neurons, indicative of nociceptor activation, and intraductal TRPA1 agonists also caused pancreatic inflammation. The effects of TRPV4 and TRPA1 agonists on [Ca(2+)](i), pain and inflammation were markedly diminished or abolished in trpv4 and trpa1 knockout mice. The secretagogue cerulein induced pancreatitis, c-Fos expression in spinal neurons, and pain behavior in wild-type mice. Deletion of trpv4 or trpa1 suppressed c-Fos expression and pain behavior, and deletion of trpa1 attenuated pancreatitis. Thus TRPV4 and TRPA1 contribute to pancreatic pain, and TRPA1 also mediates pancreatic inflammation. Our results provide new information about the contributions of TRPV4 and TRPA1 to inflammatory pain and suggest that channel antagonists are an effective therapy for pancreatitis, when multiple proinflammatory agents are generated that can activate and sensitize these channels.
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Affiliation(s)
| | | | | | | | | | | | | | - Wolfgang Liedtke
- 3Department of Medicine and Neurobiology, Duke University Medical Center, Durham, North Carolina; and
| | - David M. Cohen
- 4Portland Veterans Affairs Medical Center, Portland, Oregon
| | | | - Nigel W. Bunnett
- Departments of 1Surgery and ,2Physiology, University of California, San Francisco, San Francisco, California;
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28
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Chauhan S, Forsmark CE. Pain management in chronic pancreatitis: A treatment algorithm. Best Pract Res Clin Gastroenterol 2010; 24:323-35. [PMID: 20510832 DOI: 10.1016/j.bpg.2010.03.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/07/2010] [Accepted: 03/16/2010] [Indexed: 01/31/2023]
Abstract
Abdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.
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Nerve growth factor and artemin are paracrine mediators of pancreatic neuropathy in pancreatic adenocarcinoma. Ann Surg 2010; 251:923-31. [PMID: 20395845 DOI: 10.1097/sla.0b013e3181d974d4] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To further characterize the neurotrophic attributes of pancreatic cancer (PCa). SUMMARY BACKGROUND DATA PCa is characterized by neuropathic alterations which are resulting in pancreatic pain. To further characterize pancreatic neuropathy, we aimed: to analyze whether neuropathic alterations in PCa are only limited to the tumor-core or whether they are similarly encountered in neural structures in the noncancerous pancreas, to demonstrate whether PCa features neurotrophic attributes and finally to identify responsible neurotrophic molecules. METHODS Nerve density and area were quantified in normal pancreas (NP, n=45), histologically "normal" pancreas next to pancreatic cancer (NNPCa, n=61) and PCa (n=97). Growth-associated protein-43, nerve growth factor (NGF), and Artemin expressions were assessed by Immunohistochemistry, Western-Blot, and quantitative real time polymerase chain reaction-analyses. Isolated myenteric plexus of newborn rats were exposed to NP, NNPCa, and PCa tissue extracts and supernatants of Panc1 and T3M4 cancer cells with or without Artemin and NGF depletion, followed by neurite density analysis. RESULTS Dense neural networks and enlarged nerves were not only detected in PCa but were also present in NNPCa. Growth-associated protein-43, NGF, and Artemin expressions were absent/weak in NP, but increased in both NNPCa and PCa and were closely associated with intrapancreatic neuropathy. PCa and NNPCa tissue extracts and Panc1/T3M4 supernatants noticeably increased neurite density in myenteric plexus-cultures, which were attenuated by depletion of NGF and Artemin. CONCLUSIONS The neurotrophic effects of PCa extend into the peritumoral "normal" pancreatic areas without neuro-cancer interactions. The neurotrophic characteristics of PCa can be mimicked by in vitro analyses and reveal NGF and Artemin as potential key players in the generation of pancreatic neuropathy in PCa.
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Affiliation(s)
- Christopher E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville, FL 32610-0214, USA. .edu
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Abstract
BACKGROUND Pain in chronic pancreatitis chronic pancreatitis is a frustrating and challenging symptom for both the patient and clinician. It is the most frequent and most significant symptom. Many patients fail the currently available conservative options and require opiates or endoscopic/surgical therapy. Aim To highlight the pathophysiology and management of chronic pancreatitis pain, with an emphasis on recent developments and future directions. METHODS Expert review, utilizing in addition a comprehensive search of PubMed utilizing the search terms chronic pancreatitis and pain, treatment or management and a manual search of recent conference abstracts for articles describing pain and chronic pancreatitis. RESULTS Pancreatic pain is heterogenous in its manifestations and pathophysiology. First-line medical options include abstinence from alcohol and tobacco, pancreatic enzymes, adjunctive agents, antioxidants, and non-opiate or low potency opiate analgesics. Failure of these options is not unusual. More potent opiates, neurolysis and endoscopic and surgical options can be considered in selected patients, but this requires appropriate expertise. New and better options are needed. Future options could include new types of pancreatic enzymes, novel antinociceptive agents nerve growth factors, mast cell-directed therapy, treatments to limit fibrinogenesis and therapies directed at the central component of pain. CONCLUSIONS Chronic pancreatitis pain remains difficult to treat. An approach utilizing conservative medical therapies is appropriate, with more invasive therapies reserved for failure of this conservative approach. Treatment options will continue to improve with new and novel therapies on the horizon.
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Affiliation(s)
- J G Lieb
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
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Ceyhan GO, Bergmann F, Kadihasanoglu M, Altintas B, Demir IE, Hinz U, Müller MW, Giese T, Büchler MW, Giese NA, Friess H. Pancreatic neuropathy and neuropathic pain--a comprehensive pathomorphological study of 546 cases. Gastroenterology 2009; 136:177-186.e1. [PMID: 18992743 DOI: 10.1053/j.gastro.2008.09.029] [Citation(s) in RCA: 252] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 08/14/2008] [Accepted: 09/16/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Chronic pancreatitis (CP) and pancreatic adenocarcinoma (PCa) are characterized by intrapancreatic neural alterations and pain. Our aims were to: (a) Investigate whether neuropathic changes like pancreatic neuritis, increased neural density, and hypertrophy are phenomena only in CP or whether they are also evident in other pancreatic disorders as well, (b) study possible variations in neural cancer cell invasion among malignant pancreatic tumors, and (c) explore whether these neuropathic changes contribute to pain sensation. METHODS Neuropathic changes were studied in PCa (n=149), in CP (n=141), in pancreatic tumors (PTm) including serous/mucinous cystadenomas, invasive/noninvasive intraductal papillary mucinous neoplasias, benign/malignant neuroendocrine tumors, ampullary cancers (n=196), and in normal pancreas (n=60). The results were correlated with GAP-43 expression, tissue inflammation, pancreatic neuritis, neural invasion, fibrosis, desmoplasia, pain, and patient survival. RESULTS Increased neural density and hypertrophy were only detected in PCa and CP and were strongly associated with GAP-43 over expression and abdominal pain. The severity of pancreatic neuritis was strongest in PCa and was closely linked to changes in neural density and hypertrophy. The aggressiveness of neural cancer cell invasion was most prominent in PCa and was related to neuropathic changes, desmoplasia, and pain. Severe and enduring pain were strongly associated with poor prognosis in PCa patients. CONCLUSIONS Enhanced neural density and hypertrophy are only typical features of CP and PCa among all investigated pancreatic disorders. Such neuropathic changes, including damage to nerves by inflammatory and/or cancer cells, seem to enhance and generate pancreatic neuropathic pain.
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Affiliation(s)
- Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
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