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Binetti M, Tonini V. Pain in chronic pancreatitis: What can we do today? World J Methodol 2024; 14:91169. [DOI: 10.5662/wjm.v14.i3.91169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/23/2024] [Accepted: 03/11/2024] [Indexed: 06/25/2024] Open
Abstract
The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient’s quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain’s management is challenging considering all these complex aspects and the lack of international protocols.
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Affiliation(s)
- Margherita Binetti
- Department of Medical and Surgical Science, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
| | - Valeria Tonini
- Department of Medical and Surgical Science, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
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2
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Knoph CS, Nedergaard RB, Olesen SS, Kuhlmann L, Drewes AM. Spinal Excitability in Patients with Painful Chronic Pancreatitis. J Pain Res 2023; 16:2287-2298. [PMID: 37431436 PMCID: PMC10329835 DOI: 10.2147/jpr.s408523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/10/2023] [Indexed: 07/12/2023] Open
Abstract
Purpose Abdominal pain is common in patients with chronic pancreatitis (CP), but management is challenging - possibly due to altered pain processing within the central nervous system rendering conventional treatments ineffective. We hypothesized that many patients with painful CP have generalized hyperalgesia correlating with central neuronal hyperexcitability. Patients and Methods Seventeen CP patients with pain and 20 matched healthy controls underwent experimental pain testing, including repeated pain stimuli (temporal summation), pressure algometry performed in dermatomes with same spinal innervation as the pancreatic gland (pancreatic areas) and remote dermatomes (control areas), a cold pressor test and a conditioned pain modulation paradigm. To probe central neuronal excitability, the nociceptive withdrawal reflex was elicited by electrical stimulation of the plantar skin, and electromyography was obtained from the ipsilateral anterior tibial muscle together with somatosensory evoked brain potentials. Results Compared to healthy controls, patients with painful CP had generalized hyperalgesia as evidenced by 45% lower pressure pain detection thresholds (P<0.05) and decreased cold pressor endurance time (120 vs 180 seconds, P<0.001). In patients, reflex thresholds were lower (14 vs 23 mA, P=0.02), and electromyographic responses were increased (16.4 vs 9.7, P=0.04) during the withdrawal reflex, reflecting predominantly spinal hyperexcitability. Evoked brain potentials did not differ between groups. A positive correlation was found between reflex thresholds and cold pressor endurance time (ρ=0.71, P=0.004). Conclusion We demonstrated somatic hyperalgesia in patients with painful CP associated with spinal hyperexcitability. This highlights that management should be directed at central mechanisms using, eg, gabapentinoids or serotonin-noradrenaline reuptake inhibitors.
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Affiliation(s)
- Cecilie Siggaard Knoph
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Louise Kuhlmann
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Characterizing mechanism-based pain phenotypes in patients with chronic pancreatitis: a cross-sectional analysis of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies. Pain 2023; 164:375-384. [PMID: 36149018 PMCID: PMC9726990 DOI: 10.1097/j.pain.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Pain is common in chronic pancreatitis (CP) and profoundly reduces quality of life (QoL). Multiple underlying mechanisms contribute to a heterogenous pain experience and reduce efficacy of pain management. This study was designed to characterize the distribution of mechanism-based pain phenotypes in painful CP. The data analyzed were collected as part of the PROspective Evaluation of Chronic Pancreatitis for EpidEmiologic and Translational StuDies, an NCI/NIDDK-funded longitudinal study of the natural history of CP. The PROspective Evaluation of Chronic pancreatitis for EpidEmiologic and translational stuDies includes patient-reported outcome (PRO) measures of pain, medication use, global health, and QoL. Of subjects (N = 681) with CP, 80% experienced abdominal pain within the year before enrollment. Subjects who experienced pain in the week before enrollment (N = 391) completed PROMIS Neuropathic and Nociceptive Pain Quality instruments which were then used to classify them by pain type: 40% had nociceptive, 5% had neuropathic-like, and 32% had both types of pain. The prevalence of having both types of pain was higher among women and subjects with diabetes mellitus, whereas nociceptive-only pain was more prevalent among men and those with pancreatic duct stricture. Other factors, including pain medication use and healthcare utilization, did not differ between groups based on pain type. Subjects in the Both group had significantly worse health and QoL scores relative to those with nociceptive-only pain, suggesting that using psychosocial pain surveys may be useful for understanding pain subtypes in patients with CP. Additional research is needed to identify biochemical and biophysical signatures that may associate with and predict responses to mechanism-specific interventions.
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Kuhlmann L, Olesen SS, Drewes AM. Assessment of visceral pain with special reference to chronic pancreatitis. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 3:1067103. [PMID: 36606031 PMCID: PMC9807876 DOI: 10.3389/fpain.2022.1067103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
A thorough pain assessment is of utmost importance when managing pain in clinical practice as it is the foundation for defining pain in need of treatment, either interventional or pharmacological. Pain characteristics can also guide interventional strategies and help evaluate the effect of treatment. In research settings, standardized pain assessment is crucial to improve comparability across studies and facilitate meta-analysis. Due to the importance of thorough visceral pain assessment, this manuscript describes the key elements of pain evaluation focusing on chronic pancreatitis. Most studies in pain assessment have focused on somatic pain, and although chronic pain often shares characteristics between etiologies, some differences must be addressed when assessing visceral pain. Especially differences between somatic and visceral pain are apparent, where visceral pain is diffuse and difficult to localize, with referred pain aspects and often autonomic symptoms dominating the clinical picture. These aspects need to be incorporated into the pain assessment instrument. The manuscript will discuss the different ways of assessing pain, including unidimensional measurement scales, multidimensional questionnaires, and quantitative sensory testing. The advantages and challenges linked to the different methods will be evaluated.
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Affiliation(s)
- Louise Kuhlmann
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark,Correspondence: Louise Kuhlmann
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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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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Hansen LEM, Fjelsted CA, Olesen SS, Phillips AE, Faghih M, Wegeberg AM, Drewes AM, Brock C. Simple Quantitative Sensory Testing Reveals Paradoxical Co-existence of Hypoesthesia and Hyperalgesia in Diabetes. FRONTIERS IN PAIN RESEARCH 2022; 2:701172. [PMID: 35295514 PMCID: PMC8915693 DOI: 10.3389/fpain.2021.701172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/04/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Diabetic neuropathy is characterized by the paradoxical co-existence of hypo- and hyperalgesia to sensory stimuli. The literature shows consistently sensory differences between healthy and participants with diabetes. We hypothesized that due to differences in pathophysiology, advanced quantitative sensory testing (QST) might reveal sensory discrepancies between type 1 (T1D) and type 2 diabetes (T2D). Furthermore, we investigated whether vibration detection thresholds (VDT) were associated with sensory response. Method: Fifty-six adults with T1D [43 years (28–58)], 99 adults with T2D [65 years (57–71)], and 122 healthy individuals [51 years (34–64)] were included. VDT, pressure pain detection thresholds (pPDT) and tolerance (pPTT), tonic cold pain (hand-immersion in iced water), and central pain mechanisms (temporal summation and conditioned pain modulation) were tested and compared between T1D and T2D. VDT was categorized into normal (< 18 V), intermediary (18–25 V), or high (> 25 V). Results: In comparison to healthy, analysis adjusted for age, BMI, and gender revealed hypoalgesia to tibial (pPDT): p = 0.01, hyperalgesia to tonic cold pain: p < 0.01, and diminished temporal summation (arm: p < 0.01; abdomen: p < 0.01). In comparison to participants with T2D, participants with T1D were hypoalgesic to tibial pPDT: p < 0.01 and pPTT: p < 0.01, and lower VDT: p = 0.02. VDT was not associated with QST responses. Conclusion: Participants with T1D were more hypoalgesic to bone pPDT and pPTT independent of lower VDT, indicating neuronal health toward normalization. Improved understanding of differentiated sensory profiles in T1D and T2D may identify improved clinical endpoints in future trials.
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Affiliation(s)
- Line Elise Møller Hansen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark
| | - Camilla Ann Fjelsted
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Steno Diabetes Center Nordjylland, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Steno Diabetes Center Nordjylland, 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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8
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Parasar K, Mohan S, John AG, Anand U. Pain in Chronic Pancreatitis During the COVID-19 Lockdown: Has It Given Us a New Dimension for Treatment? Cureus 2021; 13:e13423. [PMID: 33763317 PMCID: PMC7980778 DOI: 10.7759/cureus.13423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Prolonged lockdown in our country provided us with a unique opportunity to study the interplay of psychosocial impact on pain in surgically treated patients of chronic pancreatitis. Methods Forty-one patients who underwent surgery for chronic pancreatitis in the last 24 months were followed up, of which 27 were enrolled. The data were collected telephonically. Pain was assessed using the numeric pain rating (NPR) scale and depression using Patient Health Questionnaire (PHQ) 9. In patients having recent onset pain during the lockdown, oral tramadol 50 mg and amitryptiline 25 mg were prescribed and reassessed after two weeks. Results Of the 25 pain-free patients in February (pre-lockdown), 14 developed pain of varying intensity during the lockdown and were prescribed medications. Twelve out of 14 patients had very good resolution of pain after two weeks of medication. Conclusions Operated patients with chronic pancreatitis who developed new-onset depression and pain responded well to low-dose anti-depressants in addition to analgesics. This study gives indirect, objective evidence that covert depression leading to pain in chronic pancreatitis is often downplayed and interpreted as poor results of surgery.
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Affiliation(s)
- Kunal Parasar
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Shantam Mohan
- Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Aaron G John
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
| | - Utpal Anand
- Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, IND
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9
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Valente R, Waldthaler A, Scandavini CM, Vujasinovic M, Del Chiaro M, Arnelo U, Löhr JM. Conservative Treatment of Chronic Pancreatitis: A Practical Approach. Scand J Surg 2021; 109:59-68. [PMID: 32192418 DOI: 10.1177/1457496920905559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications. MATERIALS AND METHODS In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis. RESULTS Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers. CONCLUSIONS Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.
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Affiliation(s)
- R Valente
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A Waldthaler
- Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - C M Scandavini
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - M Vujasinovic
- CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - U Arnelo
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - J-M Löhr
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
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10
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Cruz-Monserrate Z, Gumpper K, Kaul S, Badi N, Terhorst S, Dubay K, Lesinski GB, Fisher W, McElhany A, Lara LF, Krishna S, Mace T, Higuita-Castro N, Ortega-Pineda L, Freitas MA, Hinton A, Yadav D, Hart PA, Pandol SJ, Ahmed S, Fatou B, Steen H, Conwell DL. Delayed Processing of Secretin-Induced Pancreas Fluid Influences the Quality and Integrity of Proteins and Nucleic Acids. Pancreas 2021; 50:17-28. [PMID: 33370019 PMCID: PMC7883383 DOI: 10.1097/mpa.0000000000001717] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Endoscopic pancreatic function tests are used to diagnose pancreatic diseases and are a viable source for the discovery of biomarkers to better characterize pancreatic disorders. However, pancreatic fluid (PF) contains active enzymes that degrade biomolecules. Therefore, we tested how preservation methods and time to storage influence the integrity and quality of proteins and nucleic acids. METHODS We obtained PF from 9 subjects who underwent an endoscopic pancreatic function test. Samples were snap frozen at the time of collection; after 1, 2, and 4 hours on ice; or after storage overnight at 4°C with or without RNase or protease inhibitors (PIs). Electrophoresis and mass spectrometry analysis determined protein abundance and quality, whereas nucleic acid integrity values determined DNA and RNA degradation. RESULTS Protein degradation increased after 4 hours on ice and DNA degradation after 2 hours on ice. Adding PIs delayed degradation. RNA was significantly degraded under all conditions compared with the snap frozen samples. Isolated RNA from PF-derived exosomes exhibited similar poor quality as RNA isolated from matched PF samples. CONCLUSIONS Adding PIs immediately after collecting PF and processing the fluid within 4 hours of collection maintains the protein and nucleic acid integrity for use in downstream molecular analyses.
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Affiliation(s)
- Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kristyn Gumpper
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Sabrina Kaul
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Niharika Badi
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Samantha Terhorst
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kelly Dubay
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Gregory B. Lesinski
- Winship Cancer Institute, Department of Hematology and Medical Oncology, Emory University, Atlanta, GA
| | - William Fisher
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Amy McElhany
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Luis F. Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Somashekar Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Thomas Mace
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Natalia Higuita-Castro
- Department of Biomedical Engineering and Department of Surgery, The Ohio State University, Columbus, OH
| | | | - Michael A. Freitas
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
- Department of Cancer Biology and Genetics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH
| | - Dhiraj Yadav
- University of Pittsburgh, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Pittsburgh, PA
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Stephen J. Pandol
- Digestive Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Saima Ahmed
- Departments of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Benoit Fatou
- Departments of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Hanno Steen
- Departments of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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Patient and Disease Characteristics Associate With Sensory Testing Results in Chronic Pancreatitis. Clin J Pain 2020; 35:786-793. [PMID: 31268890 PMCID: PMC6693925 DOI: 10.1097/ajp.0000000000000740] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abdominal pain is the most common symptom in chronic pancreatitis (CP) and has an extensive impact on patients' lives. Quantitative sensory testing (QST) provides information on sensitivity to pain and mechanisms that can help quantify pain and guide treatment. The aims of this study were (1) to explore sensitivity to pain in patients with CP using QST and (2) to associate patient and disease characteristics with QST results. METHODS Ninety-one patients with painful CP and 28 healthy control participants completed a QST paradigm using static tests (muscle pressure stimulation and electrical skin stimulations) to unravel segmental and widespread hyperalgesia as a consequence of visceral pain. A dynamic conditioned pain modulation (CPM) paradigm was used as a proxy of pain modulation from the brainstem to inhibit incoming nociceptive barrage, and questionnaires were used to gather information on pain experience and quality of life. RESULTS Patients had impaired CPM compared with controls (18.0±29.3% vs. 30.9±29.3%, P=0.04) and were hypersensitive to pressure stimulation, specifically in the pancreatic (Th10) dermatome (P<0.001). The capacity of CPM was associated with clinical pain intensity (P=0.01) and (in the univariate analysis only) the use of opioids was associated with hyperalgesia to pressure stimulation (P<0.05). CONCLUSIONS Sensitivity to pain in CP patients can be characterized by a simple bedside QST. Severe clinical pain in CP was associated with reduced CPM function and should be targeted in management.
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Olesen SS, Drewes AM, Gaud R, Tandan M, Lakhtakia S, Ramchandani M, Rao GV, Reddy DN, Talukdar R. Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE trial): study protocol for a randomized, sham-controlled trial. Trials 2020; 21:338. [PMID: 32299454 PMCID: PMC7164272 DOI: 10.1186/s13063-020-04296-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/30/2020] [Indexed: 02/08/2023] Open
Abstract
Background Pain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge. In patients with obstruction of the pancreatic duct, including stones and strictures, endoscopic treatment with or without preceding extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct decompression. The rationale for these procedures is based on the assumption that obstruction of the pancreatic duct leads to ductal hypertension and pain. However, clinical pain symptoms correlate poorly with pancreatic duct morphology, and the evidence for pancreatic duct decompression as an effective treatment for pain is based on case series and comparison between different procedures. No randomized, prospective, sham-controlled trials are currently available. The SCHOKE (Extracorporeal Shock Wave Lithotripsy and Endotherapy for Pain in Chronic Pancreatitis) trial is a randomized, sham-controlled trial designed to determine if pancreatic duct decompression is an effective treatment for pain in patients with CP. Methods The SCHOKE trial is a randomized, single-blind, parallel-group, sham-controlled trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in patients with CP. In total, 106 adult patients with painful CP and pancreatic duct obstruction will be randomized to combined ESWL and subsequent endoscopic treatment or corresponding sham procedures. The primary outcome is pain relief during the 3-month postrandomization period as documented in a pain diary. Secondary outcomes include quality of life and functional scores, patient global impression of change, change in use of analgesics, frequency of hospitalization, and complications. Standard follow-up is at 3 and 6 months after randomization. In an experimental substudy, quantitative sensory testing obtained before and after intervention will be used to obtain information on central pain processing and to develop models for prediction of treatment outcome. Discussion The SCHOKE trial investigates if pancreatic duct decompression, obtained by combined ESWL and endoscopic treatment, is effective for pain treatment in patients with CP. Trial registration ClinicalTrials.gov, NCT03966781. Registered on May 25, 2019. Protocol date and version identifier: March 1, 2020; version 3.0. Sponsor: Rupjyoti Talukdar, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.
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Affiliation(s)
- Søren S Olesen
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.
| | - Asbjørn M Drewes
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Rajesh Gaud
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - G V Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rupjyoti Talukdar
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.,Pancreas Research Group, Wellcome DBT Labs, Asian Healthcare Foundation, Hyderabad, Telangana, India
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Ramakrishnan P, Loh WM, Gopinath SC, Bonam SR, Fareez IM, Mac Guad R, Sim MS, Wu YS. Selective phytochemicals targeting pancreatic stellate cells as new anti-fibrotic agents for chronic pancreatitis and pancreatic cancer. Acta Pharm Sin B 2020; 10:399-413. [PMID: 32140388 PMCID: PMC7049637 DOI: 10.1016/j.apsb.2019.11.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/23/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022] Open
Abstract
Activated pancreatic stellate cells (PSCs) have been widely accepted as a key precursor of excessive pancreatic fibrosis, which is a crucial hallmark of chronic pancreatitis (CP) and its formidable associated disease, pancreatic cancer (PC). Hence, anti-fibrotic therapy has been identified as a novel therapeutic strategy for treating CP and PC by targeting PSCs. Most of the anti-fibrotic agents have been limited to phase I/II clinical trials involving vitamin analogs, which are abundant in medicinal plants and have proved to be promising for clinical application. The use of phytomedicines, as new anti-fibrotic agents, has been applied to a variety of complementary and alternative approaches. The aim of this review was to present a focused update on the selective new potential anti-fibrotic agents, including curcumin, resveratrol, rhein, emodin, green tea catechin derivatives, metformin, eruberin A, and ellagic acid, in combating PSC in CP and PC models. It aimed to describe the mechanism(s) of the phytochemicals used, either alone or in combination, and the associated molecular targets. Most of them were tested in PC models with similar mechanism of actions, and curcumin was tested intensively. Future research may explore the issues of bioavailability, drug design, and nano-formulation, in order to achieve successful clinical outcomes with promising activity and tolerability.
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Affiliation(s)
- Puvanesswaray Ramakrishnan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Wei Mee Loh
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Subash C.B. Gopinath
- School of Bioprocess Engineering, Universiti Malaysia Perlis, Arau 02600, Malaysia
- Institute of Nano Electronic Engineering, Universiti Malaysia Perlis, Kangar 01000, Malaysia
| | - Srinivasa Reddy Bonam
- UMR 7242, CNRS-University of Strasbourg, Biotechnology and Cell Signaling/Laboratory of Excellence Medalis, Illkirch 67400, France
| | - Ismail M. Fareez
- Department of Oral Biology and Biomedical Sciences, Faculty of Dentistry, MAHSA University, Selangor 42610, Malaysia
| | - Rhanye Mac Guad
- Department of Biomedical Science and Therapeutics, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
| | - Maw Shin Sim
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, University of Malaya, Kuala Lumpur 50603, Malaysia
- Corresponding authors. Tel./fax: +60 3 51022709 (Yuan Seng Wu); +60 3 79675749 (Maw Shin Sim).
| | - Yuan Seng Wu
- Department of Biochemistry, Faculty of Medicine, Bioscience and Nursing, MAHSA University, Selangor 42610, Malaysia
- Corresponding authors. Tel./fax: +60 3 51022709 (Yuan Seng Wu); +60 3 79675749 (Maw Shin Sim).
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Abstract
Gastrointestinal (GI) pain - a form of visceral pain - is common in some disorders, such as irritable bowel syndrome, Crohn's disease and pancreatitis. However, identifying the cause of GI pain frequently represents a diagnostic challenge as the clinical presentation is often blurred by concomitant autonomic and somatic symptoms. In addition, GI pain can be nociceptive, neuropathic and associated with cancer, but in many cases multiple aetiologies coexist in an individual patient. Mechanisms of GI pain are complex and include both peripheral and central sensitization and the involvement of the autonomic nervous system, which has a role in generating the symptoms that frequently accompany pain. Treatment of GI pain depends on the precise type of pain and the primary disorder in the patient but can include, for example, pharmacological therapy, cognitive behavioural therapies, invasive surgical procedures, endoscopic procedures and lifestyle alterations. Owing to the major differences between organ involvement, disease mechanisms and individual factors, treatment always needs to be personalized and some data suggest that phenotyping and subsequent individual management of GI pain might be options in the future.
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A clinically feasible method for the assessment and characterization of pain in patients with chronic pancreatitis. Pancreatology 2020; 20:25-34. [PMID: 31787527 DOI: 10.1016/j.pan.2019.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pain is the primary symptom of chronic pancreatitis (CP), but methods for sensory testing and pain characterization have not previously been validated for clinical use. We present a clinically feasible method for the assessment and characterization of pain mechanisms in patients with CP based on quantitative sensory testing (QST). METHODS This was a cross-sectional, multicenter study of 122 control subjects without pancreatic disease and another 60 patients with painful CP. All subjects underwent standardized QST assessments including a cold pressor test, a conditioned pain modulation paradigm, repetitive pin-prick stimuli (temporal summation) and pressure stimulation of the upper abdominal (pancreatic) and control dermatomes. The effects of age and gender on QST assessment parameters were investigated and normative reference values based on quartile regression were derived and implemented in algorithms to categorize patients according to their patterns of central pain processing (normal vs. segmental sensitization vs. widespread sensitization). RESULTS Absolute pressure thresholds were subject to clinically relevant gender effects (all p < 0.001), while the remainder of QST parameters were unaffected by age and gender. The algorithm with the best discriminatory capacity showed good separation between patients and controls (p < 0.001); 50% of patients had normal central pain processing, 23% had evidence of segmental sensitization and 27% had evidence of widespread sensitization. CONCLUSION We show normative reference values for a clinically feasible method for assessment and characterization of pain mechanisms in patients with CP. Application of this method streamlines the evaluation of pancreatic pain and may be used to inform treatment. CLINICALTRIALS. GOV ID NCT03434392.
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Drewes AM, Kempeneers MA, Andersen DK, Arendt-Nielsen L, Besselink MG, Boermeester MA, Bouwense S, Bruno M, Freeman M, Gress TM, van Hooft JE, Morlion B, Olesen SS, van Santvoort H, Singh V, Windsor J. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343-1351. [PMID: 31129569 PMCID: PMC6691929 DOI: 10.1136/gutjnl-2019-318742] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnessota Medical School, Minneapolis, Minnesota, USA
| | - Thomas M Gress
- Department of Gastroenterology, Philipps University & University Hospital of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Olesen SS, Drewes AM, Novovic S, Nøjgaard C. The sentinel acute pancreatitis event hypothesis revisited. Pancreatology 2019; 19:614-615. [PMID: 30962131 DOI: 10.1016/j.pan.2019.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/31/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
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Abstract
CGRP has long been suspected as a mediator of arthritis pain, although evidence that CGRP directly mediates human musculoskeletal pain remains circumstantial. This chapter describes in depth the evidence surrounding CGRP's association with pain in musculoskeletal disorders and also summarises evidence for CGRP being a direct cause of pain in other conditions. CGRP-immunoreactive nerves are present in musculoskeletal tissues, and CGRP expression is altered in musculoskeletal pain. CGRP modulates musculoskeletal pain through actions both in the periphery and central nervous system. Human observational studies, research on animal arthritis models and the few reported randomised controlled trials in humans of treatments that target CGRP provide the context of CGRP as a possible pain biomarker or mediator in conditions other than migraine.
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Affiliation(s)
- David A Walsh
- Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre and Division of ROD, University of Nottingham, Nottingham, UK.
- Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire, UK.
| | - Daniel F McWilliams
- Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre and Division of ROD, University of Nottingham, Nottingham, UK
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