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Gulisano HA, Eriksen E, Bjarkam CR, Drewes AM, Olesen SS. A sham-controlled, randomized trial of spinal cord stimulation for the treatment of pain in chronic pancreatitis. Eur J Pain 2024. [PMID: 38988274 DOI: 10.1002/ejp.2315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/30/2024] [Accepted: 06/30/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Spinal cord stimulation (SCS) has emerged as a treatment option for patients with chronic pancreatitis (CP) who experience pain that does not respond to standard interventions. However, there is a lack of sham-controlled trials to support its efficacy. METHODS This randomized, double-blinded, sham-controlled, cross-over trial enrolled 16 CP patients with insufficient pain relief from standard therapies. Patients underwent high-frequency (1000 Hz) paraesthesia-free SCS or sham for two 10-day stimulation periods, separated by a 3-day washout period. The primary outcome was daily pain intensity registered in a pain diary based on a numeric rating scale (NRS). Secondary outcomes included various questionnaires. Quantitative sensory testing was used to probe the pain system before and after interventions. RESULTS The average daily pain score on the NRS at baseline was 5.2 ± 1.9. After SCS, the pain score was 4.2 ± 2.1 compared to 4.3 ± 2.1 in the sham group (mean difference -0.1, 95% CI [-1.4 to 1.1]; P = 0.81). Similarly, no differences were observed between groups for the maximal daily pain score, secondary outcomes or quantitative sensory testing parameters. During an open-label, non-sham-controlled and non-blinded extension of the study, the average daily NRS was 5.2 ± 1.7 at baseline, 3.2 ± 1.8 at 3 months, 2.9 ± 1.9 at 6 months and 3.4 ± 2.2 at 12 months of follow-up (P = 0.001). CONCLUSION In this first sham-controlled trial of SCS in painful CP, we did not find evidence of short-term pain relief with paraesthesia-free high-frequency (1000 Hz) stimulation. However, evaluation of the long-term effect by larger sham-controlled trials with long-term follow-up is warranted. SIGNIFICANCE STATEMENT In this first sham-controlled trial to apply high-frequency (1000 Hz) spinal cord stimulation in patients with visceral pain due to chronic pancreatitis, we did not find evidence for clinically relevant pain relief. Taken together with potential procedure-related complications, adverse effects and costs associated with spinal cord stimulation, our findings question its use for management of visceral pain.
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Affiliation(s)
| | - Elin Eriksen
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Carsten Reidies Bjarkam
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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2
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Pallagi P, Tóth E, Görög M, Venglovecz V, Madácsy T, Varga Á, Molnár T, Papp N, Szabó V, Kúthy-Sutus E, Molnár R, Ördög A, Borka K, Schnúr A, Kéri A, Kajner G, Csekő K, Ritter E, Csupor D, Helyes Z, Galbács G, Szentesi A, Czakó L, Rakonczay Z, Takács T, Maléth J, Hegyi P. Heavy metals in cigarette smoke strongly inhibit pancreatic ductal function and promote development of chronic pancreatitis. Clin Transl Med 2024; 14:e1733. [PMID: 38877637 PMCID: PMC11178517 DOI: 10.1002/ctm2.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/30/2024] [Accepted: 05/21/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND AIMS Smoking is recognised as an independent risk factor in the development of chronic pancreatitis (CP). Cystic fibrosis transmembrane conductance regulator (CFTR) function and ductal fluid and bicarbonate secretion are also known to be impaired in CP, so it is crucial to understand the relationships between smoking, pancreatic ductal function and the development of CP. METHODS We measured sweat chloride (Cl-) concentrations in patients with and without CP, both smokers and non-smokers, to assess CFTR activity. Serum heavy metal levels and tissue cadmium concentrations were determined by mass spectrometry in smoking and non-smoking patients. Guinea pigs were exposed to cigarette smoke, and cigarette smoke extract (CSE) was prepared to characterise its effects on pancreatic HCO3 - and fluid secretion and CFTR function. We administered cerulein to both the smoking and non-smoking groups of mice to induce pancreatitis. RESULTS Sweat samples from smokers, both with and without CP, exhibited elevated Cl- concentrations compared to those from non-smokers, indicating a decrease in CFTR activity due to smoking. Pancreatic tissues from smokers, regardless of CP status, displayed lower CFTR expression than those from non-smokers. Serum levels of cadmium and mercury, as well as pancreatic tissue cadmium, were increased in smokers. Smoking, CSE, cadmium, mercury and nicotine all hindered fluid and HCO3 - secretion and CFTR activity in pancreatic ductal cells. These effects were mediated by sustained increases in intracellular calcium ([Ca2+]i), depletion of intracellular ATP (ATPi) and mitochondrial membrane depolarisation. CONCLUSION Smoking impairs pancreatic ductal function and contributes to the development of CP. Heavy metals, notably cadmium, play a significant role in the harmful effects of smoking. KEY POINTS Smoking and cigarette smoke extract diminish pancreatic ductal fluid and HCO3 - secretion as well as the expression and function of CFTR Cd and Hg concentrations are significantly higher in the serum samples of smokers Cd accumulates in the pancreatic tissue of smokers.
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Affiliation(s)
- Petra Pallagi
- Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Emese Tóth
- Department of Medicine, University of Szeged, Szeged, Hungary
- Department of Theoretical and Integrative Health Sciences, University of Debrecen, Szeged, Hungary
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary
| | - Marietta Görög
- Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
| | - Viktória Venglovecz
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Tamara Madácsy
- Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Árpád Varga
- Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Tünde Molnár
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Noémi Papp
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Viktória Szabó
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Enikő Kúthy-Sutus
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Réka Molnár
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Attila Ördög
- Department of Plant Biology, University of Szeged, Szeged, Hungary
| | - Katalin Borka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Andrea Schnúr
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Albert Kéri
- Department of Molecular and Analytical Chemistry, University of Szeged, Szeged, Hungary
| | - Gyula Kajner
- Department of Molecular and Analytical Chemistry, University of Szeged, Szeged, Hungary
| | - Kata Csekő
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Pécs, Hungary
- National Laboratory of Drug Research and Development (Pharmalab), Budapest, Hungary
| | - Emese Ritter
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Pécs, Hungary
- National Laboratory of Drug Research and Development (Pharmalab), Budapest, Hungary
| | - Dezső Csupor
- Institute of Pharmacognosy, Faculty of Pharmacy, University of Szeged, Szeged, Hungary
- Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Pécs, Hungary
- National Laboratory of Drug Research and Development (Pharmalab), Budapest, Hungary
- Eötvös Loránd Research Network Chronic Pain Research Group, University of Pécs, Pécs, Hungary
| | - Gábor Galbács
- Department of Molecular and Analytical Chemistry, University of Szeged, Szeged, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - László Czakó
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Tamás Takács
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - József Maléth
- Department of Medicine, University of Szeged, Szeged, Hungary
- MTA-SZTE Momentum Epithelial Cell Signaling and Secretion Research Group, University of Szeged, Szeged, Hungary
- HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- Center of Translational Medicine and Institute of Pancreatic Disorders, Semmelweis University, Budapest, Hungary
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3
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Talukdar R, Olesen SS, Unnisa M, Bedarkar A, Sarkar S, Tandan M, Jagtap N, Darisetty S, Kiran S, Koppoju V, Lakhtakia S, Ramchandani M, Kalapala R, Gupta R, Singh VK, Rao GV, Reddy DN, Drewes AM. Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis : A Sham-Controlled, Randomized Trial. Ann Intern Med 2024; 177:749-758. [PMID: 38801774 DOI: 10.7326/m24-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. OBJECTIVE To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. DESIGN 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781). SETTING Asian Institute of Gastroenterology in India from February 2021 to July 2022. PARTICIPANTS 106 patients with chronic pancreatitis. INTERVENTION Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. MEASUREMENTS The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. RESULTS 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, -0.7 [95% CI, -1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, -5.4 days [CI, -9.9 to -0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. LIMITATION Single-center study and limited duration of follow-up. CONCLUSION In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. PRIMARY FUNDING SOURCE Asian Institute of Gastroenterology and Aalborg University Hospital.
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Affiliation(s)
- Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Søren S Olesen
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark (S.S.O., A.M.D.)
| | - Misbah Unnisa
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Akshay Bedarkar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Subhaleena Sarkar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Santosh Darisetty
- Department of Anesthesia, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.D.)
| | - Sekhramantri Kiran
- Lithotripsy Unit, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.K., V.K.)
| | - Vinod Koppoju
- Lithotripsy Unit, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (S.K., V.K.)
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Rakesh Kalapala
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (V.K.S.)
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (G.V.R.)
| | - Duvvur Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India (R.T., M.U., A.B., S.S., M.T., N.J., S.L., M.R., R.K., R.G., D.N.R.)
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark (S.S.O., A.M.D.)
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4
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Hart PA, Osypchuk Y, Hovbakh I, Shah RJ, Nieto J, Cote GA, Avgaitis S, Kremzer O, Buxbaum J, Inamdar S, Fass R, Phillips RW, Yadav D, Ladd AM, Al-Assi MT, Gardner T, Conwell DL, Irani S, Sheikh A, Nuttall J. A Randomized Controlled Phase 2 Dose-Finding Trial to Evaluate the Efficacy and Safety of Camostat in the Treatment of Painful Chronic Pancreatitis: The TACTIC Study. Gastroenterology 2024; 166:658-666.e6. [PMID: 38103842 DOI: 10.1053/j.gastro.2023.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS Chronic pancreatitis (CP) causes an abdominal pain syndrome associated with poor quality of life. We conducted a clinical trial to further investigate the efficacy and safety of camostat, an oral serine protease inhibitor that has been used to alleviate pain in CP. METHODS This was a double-blind randomized controlled trial that enrolled adults with CP with a baseline average daily worst pain score ≥4 on a numeric rating system. Participants were randomized (1:1:1:1) to receive camostat at 100, 200, or 300 mg 3 times daily or placebo. The primary end point was a 4-week change from baseline in the mean daily worst pain intensity score (0-10 on a numeric rating system) using a mixed model repeated measure analysis. Secondary end points included changes in alternate pain end points, quality of life, and safety. RESULTS A total of 264 participants with CP were randomized. Changes in pain from baseline were similar between the camostat groups and placebo, with differences of least squares means of -0.11 (95% CI, -0.90 to 0.68), -0.04 (95% CI, -0.85 to 0.78), and -0.11 (95% CI, -0.94 to 0.73) for the 100 mg, 200 mg, and 300 mg groups, respectively. Multiple subgroup analyses were similar for the primary end point, and no differences were observed in any of the secondary end points. Treatment-emergent adverse events attributed to the study drug were identified in 42 participants (16.0%). CONCLUSION We were not able to reject the null hypothesis of no difference in improvements in pain or quality of life outcomes in participants with painful CP who received camostat compared with placebo. Studies are needed to further define mechanisms of pain in CP to guide future clinical trials, including minimizing placebo responses and selecting targeted therapies. CLINICALTRIALS gov, Number: NCT02693093.
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Affiliation(s)
- Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Yurii Osypchuk
- Department of General Surgery, Odesa Regional Hospital, Odesa, Ukraine
| | - Iryna Hovbakh
- Department of General Practice-Family Medicine, Kharkov Medical Academy of Postgraduate Education, Kharkiv, Ukraine
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jose Nieto
- Advanced Therapeutic Endoscopy Center, Borland Groover Clinic, Jacksonville, Florida
| | - Gregory A Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | | | | | - James Buxbaum
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, Ohio
| | | | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Antonio Mendoza Ladd
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas
| | | | - Timothy Gardner
- Division of Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shayna Irani
- Division of Gastroenterology, Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Aasim Sheikh
- Gastrointestinal Specialists of Georgia, Marietta, Georgia
| | - Janet Nuttall
- Kangen Pharmaceuticals, America LLC, Kansas City, Kansas
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5
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Zhou Y, Huang RQ, Xu JJ, Yi JH, Wang F, Zhou XY, Zhang J, Wang T, Liu Y, Chen C, Chen WW, Lu GT, Li ZS, Wang D, Hu LH. Prevalence and risk factors of fatigue and its association with quality of life among patients with chronic pancreatitis: A cross-sectional study. Pancreatology 2024; 24:211-219. [PMID: 38302312 DOI: 10.1016/j.pan.2024.01.010] [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: 07/02/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Fatigue is a debilitating symptom found in various chronic diseases and is associated with more severe symptoms and worse quality of life (QoL). However, this symptom has not been adequately addressed in chronic pancreatitis (CP), and there have been no studies on fatigue in patients with CP. METHODS This cross-sectional study was conducted at the Changhai Hospital in Shanghai, China. Data on the patients' sociodemographic, disease, and therapeutic characteristics were collected. Fatigue was assessed using the Multidimensional Fatigue Inventory-20. QoL was assessed utilizing the European Organization for the Research and Treatment of Cancer of QoL questionnaire (EORTC-QLQ-C30). Sleep quality, anxiety and depression, and pain was assessed using Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, and the Brief Pain Inventory, respectively. RESULTS The prevalence of fatigue among Chinese patients with CP was 35.51 % (87/245). Multivariate analysis showed that steatorrhea (OR = 2.638, 95 % CI: 1.117-6.234), history of smoking (OR = 4.627, 95 % CI: 1.202-17.802), history of endoscopic treatment (OR = 0.419, 95 % CI: 0.185-0.950), depression (OR = 5.924, 95 % CI: 2.462-14.255), and sleep disorder (OR = 6.184, 95 % CI: 2.543-15.034) were influencing factors for the presence of fatigue. The scores for global health and all functional dimensions in the EORTC-QLQ-C30 significantly decreased, whereas the scores for all symptom dimensions significantly increased in patients with fatigue. CONCLUSIONS This study indicated that Fatigue is a common symptom and has a negative impact on the QoL of patients with CP. Steatorrhea, smoking history, endoscopic treatment, depression, and sleep disorders were associated with fatigue.
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Affiliation(s)
- You Zhou
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China; Pancreatic Center, Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Ren-Qian Huang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jin-Jie Xu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jin-Hui Yi
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Fan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiao-Yu Zhou
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Liu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Cui Chen
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei-Wei Chen
- Department of Gastroenterology, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Guo-Tao Lu
- Pancreatic Center, Department of Gastroenterology, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China.
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6
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Walker J, Babyok OL, Saloman JL, Phillips AE. Recent advances in the understanding and management of chronic pancreatitis pain. JOURNAL OF PANCREATOLOGY 2024; 7:35-44. [PMID: 38524856 PMCID: PMC10959534 DOI: 10.1097/jp9.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/09/2023] [Indexed: 03/26/2024] Open
Abstract
Abdominal pain is the most common symptom of chronic pancreatitis (CP) and is often debilitating for patients and very difficult to treat. To date, there exists no cure for the disease. Treatment strategies focus on symptom management and on mitigation of disease progression by reducing toxin exposure and avoiding recurrent inflammatory events. Traditional treatment protocols start with medical management followed by consideration of procedural or surgical intervention on selected patients with severe and persistent pain. The incorporation of adjuvant therapies to treat comorbidities including psychiatric disorders, exocrine pancreatic insufficiency, mineral bone disease, frailty, and malnutrition, are in its early stages. Recent clinical studies and animal models have been designed to improve investigation into the pathophysiology of CP pain, as well as to improve pain management. Despite the array of tools available, many therapeutic options for the management of CP pain provide incomplete relief. There still remains much to discover about the neural regulation of pancreas-related pain. In this review, we will discuss research from the last 5 years that has provided new insights into novel methods of pain phenotyping and the pathophysiology of CP pain. These discoveries have led to improvements in patient selection for optimization of outcomes for both medical and procedural management, and identification of potential future therapies.
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Affiliation(s)
- Jessica Walker
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Olivia L. Babyok
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jami L. Saloman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Pain Research, Center for Neuroscience, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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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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Petrov MS. Fatty change of the pancreas: the Pandora's box of pancreatology. Lancet Gastroenterol Hepatol 2023:S2468-1253(23)00064-X. [PMID: 37094599 DOI: 10.1016/s2468-1253(23)00064-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/12/2023] [Accepted: 02/14/2023] [Indexed: 04/26/2023]
Abstract
Prevention of common diseases of the pancreas or interception of their progression is as attractive in theory as it is elusive in practice. The fundamental challenge has been an incomplete understanding of targets coupled with a multitude of intertwined factors that are associated with the development of pancreatic diseases. Evidence over the past decade has shown unique morphological features, distinctive biomarkers, and complex relationships of intrapancreatic fat deposition. Fatty change of the pancreas has also been shown to affect at least 16% of the global population. This knowledge has solidified the pivotal role of fatty change of the pancreas in acute pancreatitis, chronic pancreatitis, pancreatic cancer, and diabetes. The pancreatic diseases originating from intrapancreatic fat (PANDORA) hypothesis advanced in this Personal View cuts across traditional disciplinary boundaries with a view to tackling these diseases. New holistic understanding of pancreatic diseases is well positioned to propel pancreatology through lasting research breakthroughs and clinical advances.
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Affiliation(s)
- Maxim S Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand.
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Phillips AE, Faghih M, Singh VK, Bick B, Yadav D, Drewes AM, Olesen SS. Widespread Hyperalgesia by Pancreatic Quantitative Sensory Testing Is Associated With Reduced Pain Response in Chronic Pancreatitis. Pancreas 2023; 52:e257-e258. [PMID: 37967828 DOI: 10.1097/mpa.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
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Chen C, Zhou Y, Wang D, Li G, Yin K, Tao H, Wang CY, Li ZS, Wei C, Hu LH. Anxiety, depression, and coping styles among patients with chronic pancreatitis in East China. BMC Psychiatry 2023; 23:212. [PMID: 36991480 PMCID: PMC10061863 DOI: 10.1186/s12888-023-04691-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Anxiety and depression are common psychological comorbidities in patients with chronic pancreatitis (CP). There is still a lack of epidemiological studies on anxiety and depression in Chinese CP patients. This study aimed to identify the incidence and related factor of anxiety and depression among East Chinese CP patients and explore the relationship between anxiety, depression, and coping styles. METHODS This prospective observational study was conducted from June 1, 2019 to March 31, 2021 in Shanghai, China. Patient diagnosed with CP were interviewed using the sociodemographic and clinical characteristics questionnaire, Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), and Coping Style Questionnaire (CSQ). Multivariate logistic regression analysis was conducted to identify the related factors of anxiety and depression. Correlation test was preformed to analyze the correlation between anxiety, depression, and coping styles. RESULTS The incidence of anxiety and depression in East Chinese CP patients was 22.64% and 38.61%, respectively. Patients' previous health status, level of disease coping, frequency of abdominal pain episodes, and pain severity were significantly associated with anxiety and depression. Mature coping styles (Problem solving, Seeking for help) had a positive impact on anxiety and depression, while immature coping styles (Self-blame, Fantasy, Repression, Rationalization) had negative effects on anxiety and depression. CONCLUSION Anxiety and depression were common in patients with CP in China. The factors identified in this study may provide references for the management of anxiety and depression in CP patients.
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Affiliation(s)
- Cui Chen
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - You Zhou
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
- Department of Nursing, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Dan Wang
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Ge Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Kun Yin
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Hong Tao
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Chun-Yan Wang
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China.
| | - Cun Wei
- Department of Naval Psychology, Faculty of Psychology, Naval Medical University, No. 800 Xiangyin Road, Yangpu District, Shanghai, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, China.
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Beas R, Riva-Moscoso A, Ribaudo I, Chambergo-Michilot D, Norwood DA, Karkash A, Izquierdo-Veraza D, Montrose J, Ramirez-Rojas M, Montalvan-Sanchez E. Prevalence of depression among patients with Chronic Pancreatitis: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2023; 47:102115. [PMID: 36977457 DOI: 10.1016/j.clinre.2023.102115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Chronic Pancreatitis (CP) is a fibroinflammatory condition with debilitating symptoms. Quality of life is severely affected in patients with CP and they are likely to suffer from mental health disorders, including depression. We conducted a systematic review and meta-analysis assessing the prevalence of depressive symptoms and depression in patients with CP. METHODS MEDLINE (OVID), PsycINFO, Cochrane Library, Embase, CINAHL Complete, Scopus and Web of Science were searched until July 2022 to identify manuscripts reporting the prevalence of depressive symptoms and depression (diagnosed clinically or with a validated scale without language restriction) in patients with Chronic Pancreatitis. The pooled prevalence was calculated using a random effects model. Heterogeneity was assessed by the inconsistency index (I2). RESULTS Among 3647 articles identified, 58 studies were identified for full text review, and ultimately nine studies were included. A total of 87136 patients were included in the studies. Depression was diagnosed clinically or symptoms were identified using validated scales including Center for Epidemiological Studies 10-item Depression Scale (CESD), Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS). The overall prevalence of depression in patients with chronic pancreatitis was 36.2% (95%CI: 18.8-55.7). In the stratified analysis, depression prevalence according to the clinical diagnosis, BDI and HADS was 30.10%, 48.17% and 36.61%, respectively. CONCLUSION The high prevalence of depression among patients with CP deserves a call-to-action due to its medical implications and worsening quality of life. Our findings raise awareness of the importance of screening patients with CP for mental health disorders. Further well-designed studies are needed to further characterize these findings.
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Affiliation(s)
- Renato Beas
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA..
| | - Adrian Riva-Moscoso
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Unidad de Investigación y Docencia, Clínica Internacional, Lima, Peru
| | - Isabella Ribaudo
- Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | | | - Dalton Argean Norwood
- Division of Preventive Medicine, Department of Medicine, The University of Alabama at Birmingham
| | - Ahmad Karkash
- Oncology Department, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Diego Izquierdo-Veraza
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan Montrose
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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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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Clinical Course of Medically Managed Patients With Large and Small Duct Chronic Pancreatitis. Clin Transl Gastroenterol 2022; 14:e00537. [PMID: 36205696 PMCID: PMC9875973 DOI: 10.14309/ctg.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/21/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pancreatic duct obstruction is the primary indication for endoscopic and/or surgical therapy in patients with chronic pancreatitis (CP). However, the clinical course of medically managed patients in relation to pancreatic duct obstruction is largely unknown. METHODS This was a retrospective cohort study of medically managed patients with CP. We classified patients based on pancreatic duct obstruction from a stricture or stone using cross-sectional imaging (i.e., large vs small duct CP). We compared prevalence of diabetes and exocrine insufficiency (EPI) between subgroups at inclusion and investigated risk of new-onset diabetes, EPI, and all-cause mortality over a follow-up period of 5 years. Changes in pancreatic morphology were studied in patients who underwent follow-up imaging. RESULTS A total of 198 patients (mean age 58 ± 12 years, 70% male, 60% alcoholic etiology, 38% large duct CP) were evaluated. At inclusion, patients with large vs small duct CP had a higher prevalence of both diabetes (43% vs 24%, P = 0.004) and EPI (47% vs 28%, P = 0.007). There was an increased risk of new-onset EPI in patients with large duct CP (hazard ratio 1.72; 95% confidence interval [1.05-2.80], P = 0.031) and higher rates of pancreatic atrophy ( P < 0.001). No differences between groups were observed for new-onset diabetes and all-cause mortality. Conversion from small to large duct CP or vice versa during follow-up was observed in 14% of patients. DISCUSSION In a medically managed cohort of patients, large duct CP was associated with increased risk of EPI and pancreatic atrophy compared with small duct CP.
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Strand DS, Law RJ, Yang D, Elmunzer BJ. AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review. Gastroenterology 2022; 163:1107-1114. [PMID: 36008176 DOI: 10.1053/j.gastro.2022.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.
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Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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