1
|
Phillips AE, Hughes SJ, Andersen DK, Bell A, Brand R, Coté GA, Cowdin A, Diazgranados N, Dudeja V, Duggan SN, Fogel E, Forsmark CE, Freeman AJ, Gittes G, Hart PA, Jeon C, Nealon W, Neoptolemos J, Palermo TM, Pandol S, Roberts KM, Rosenthal M, Singh VK, Yadav D, Whitcomb DC, Zyromski N. Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2024; 53:e368-e377. [PMID: 38518063 PMCID: PMC10963039 DOI: 10.1097/mpa.0000000000002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.
Collapse
Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven J Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Adam Bell
- Translational Medicine and Regulatory Affairs, Theraly Fibrosis, Gaithersburg, MD
| | - Randall Brand
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | | | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Evan Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - A Jay Freeman
- Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - George Gittes
- Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christie Jeon
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William Nealon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Stephen Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kristen M Roberts
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | | | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nicholas Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
2
|
Hines OJ, Pandol SJ. Management of chronic pancreatitis. BMJ 2024; 384:e070920. [PMID: 38408777 DOI: 10.1136/bmj-2023-070920] [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: 02/28/2024]
Abstract
Chronic pancreatitis results from repeated episodes of pancreatic inflammation and associated fibrosis leading to the loss of functional exocrine and endocrine pancreatic function. The disease is manifested by abdominal pain, deterioration in quality of life, food maldigestion and malabsorption, diabetes, and an increased risk for pancreatic adenocarcinoma. This review summarizes the latest evidence on the diagnosis and management of chronic pancreatitis and its manifestations. In particular, this review discusses advances in understanding of the role of genetic disorders in the mechanisms of the disease and surgical options for patients refractory to medical therapy. Furthermore, clinical trials are under way to develop medical therapeutics.
Collapse
Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Stephen J Pandol
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
3
|
Lewis DM, Rieke JG, Almusaylim K, Kanchibhatla A, Blanchette JE, Lewis C. Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types. Dig Dis Sci 2024; 69:615-633. [PMID: 38117426 DOI: 10.1007/s10620-023-08184-w] [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: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Pancreatic enzyme replacement therapy (PERT) is the standard treatment for exocrine pancreatic insufficiency (EPI). However, many individuals are inadequately treated, with gaps in clinical dosing, guidelines, and tools to aid individual titration. METHODS A systematic review identified research and guidelines on PERT dosing recommendations across conditions, systematically reviewing and synthesizing total PERT intake, meal/snack guidelines, and changes over time to provide an up-to-date look at the most common doses used in studies and guidelines. RESULTS This review of 257 articles found wide variability in PERT dosing guidelines within and across conditions. Many patients with EPI are underdosed, with guidelines differing globally and by disease type, and clinician prescribing may also play a role. The most common dosing guidelines focus on starting doses at 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies. Guidelines and studies typically focus only on fat digestion, and comparison by total daily dose shows underdosing is common. Most PERT studies are on safety and efficacy rather than optimal titration. CONCLUSION The current guidelines for PERT in EPI demonstrate substantial variability in dosing recommendations, both within and across disease types. This variation highlights the need for further research to optimize PERT dosing and improve patient outcomes. Healthcare providers should consider individualizing PERT dosing based on nutritional status and response to therapy, ensuring regular follow-up with patients for dose titrations with consideration that most guidelines are framed as initial doses rather than upper limits.
Collapse
Affiliation(s)
| | - Jorden G Rieke
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA.
| | - Khaleal Almusaylim
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Anuhya Kanchibhatla
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Julia E Blanchette
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Claudia Lewis
- Diabetes and Metabolic Care Center, University Hospitals Cleveland Medical Center, Cleveland, OH, 44106, USA
| |
Collapse
|
4
|
Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
Collapse
Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| |
Collapse
|
5
|
Pancreatic Function in Chronic Pancreatitis: A Cohort Study Comparing 3 Methods of Detecting Fat Malabsorption and the Impact of Short-term Pancreatic Enzyme Replacement Therapy. Pancreas 2019; 48:1068-1078. [PMID: 31404029 PMCID: PMC7243202 DOI: 10.1097/mpa.0000000000001381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Reliable pancreatic function tests in patients with chronic pancreatitis (CP) are needed. This cohort study identified malabsorption in people with CP compared with healthy people and then investigated short-term pancreatic enzyme replacement therapy (PERT) and fat malabsorption, nutritional status, and quality of life (QOL). METHODS Subjects with CP were evaluated before and after PERT and compared with the healthy cohort using coefficient of fat absorption (CFA), stool bomb calorimetry, and the malabsorption blood test (MBT). Anthropometrics, micronutrients, and QOL data were collected. Group means at baseline and after PERT were analyzed. RESULTS The 24 subjects with CP had greater stool energy loss (5668 cal/g [standard deviation {SD}, 753] vs 5152 cal/g [SD, 418], P < 0.01), reduced triglyceride absorption (MBT, 8.3 mg·h/dL [SD, 4.3] vs 17.7 mg·h/dL [SD, 10.3], P < 0.001), lower fat intake, and poorer QOL. Differences in CFA were not significant (90.9% [SD, 12.8] vs 95.4% [SD, 9.3]). After PERT, triglyceride absorption (Δ = 1.7 [SD, 3], P < 0.05) and QOL increased. CONCLUSIONS The MBT detected changes in triglyceride absorption in the absence of CFA changes. The MBT may be helpful in guiding PERT initiation in patients with CP before significant morbidity.
Collapse
|
6
|
Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. GASTROENTEROLOGY REVIEW 2018; 13:167-181. [PMID: 30302160 PMCID: PMC6173070 DOI: 10.5114/pg.2018.78067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/17/2018] [Indexed: 12/21/2022]
Abstract
This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).
Collapse
|
7
|
Abstract
Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.
Collapse
Affiliation(s)
- Abdulrahman Y Hammad
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Michael Ditillo
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Lourdes Castanon
- Department of Surgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA.
| |
Collapse
|
8
|
Abstract
Chronic pancreatitis is defined as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress. Potential causes can include toxic factors (such as alcohol or smoking), metabolic abnormalities, idiopathic mechanisms, genetics, autoimmune responses and obstructive mechanisms. The pathophysiology of chronic pancreatitis is fairly complex and includes acinar cell injury, acinar stress responses, duct dysfunction, persistent or altered inflammation, and/or neuro-immune crosstalk, but these mechanisms are not completely understood. Chronic pancreatitis is characterized by ongoing inflammation of the pancreas that results in progressive loss of the endocrine and exocrine compartment owing to atrophy and/or replacement with fibrotic tissue. Functional consequences include recurrent or constant abdominal pain, diabetes mellitus (endocrine insufficiency) and maldigestion (exocrine insufficiency). Diagnosing early-stage chronic pancreatitis is challenging as changes are subtle, ill-defined and overlap those of other disorders. Later stages are characterized by variable fibrosis and calcification of the pancreatic parenchyma; dilatation, distortion and stricturing of the pancreatic ducts; pseudocysts; intrapancreatic bile duct stricturing; narrowing of the duodenum; and superior mesenteric, portal and/or splenic vein thrombosis. Treatment options comprise medical, radiological, endoscopic and surgical interventions, but evidence-based approaches are limited. This Primer highlights the major progress that has been made in understanding the pathophysiology, presentation, prevalence and management of chronic pancreatitis and its complications.
Collapse
|
9
|
Hobbs PM, Johnson WG, Graham DY. Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World J Gastrointest Pharmacol Ther 2016; 7:370-386. [PMID: 27602238 PMCID: PMC4986390 DOI: 10.4292/wjgpt.v7.i3.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.
Collapse
|
10
|
Abstract
Chronic pancreatitis describes a wide spectrum of fibro-inflammatory disorders of the exocrine pancreas that includes calcifying, obstructive, and steroid-responsive forms. Use of the term chronic pancreatitis without qualification generally refers to calcifying chronic pancreatitis. Epidemiology is poorly defined, but incidence worldwide seems to be on the rise. Smoking, drinking alcohol, and genetic predisposition are the major risk factors for chronic calcifying pancreatitis. In this Seminar, we discuss the clinical features, diagnosis, and management of chronic calcifying pancreatitis, focusing on pain management, the role of endoscopic and surgical intervention, and the use of pancreatic enzyme-replacement therapy. Management of patients is often challenging and necessitates a multidisciplinary approach.
Collapse
Affiliation(s)
- Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
11
|
Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
Collapse
Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
12
|
Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part II: Diagnosis, complications, and management. Dis Mon 2015; 61:5-37. [PMID: 25681098 DOI: 10.1016/j.disamonth.2014.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
13
|
Kesseli SJ, Smith KA, Gardner TB. Total pancreatectomy with islet autologous transplantation: the cure for chronic pancreatitis? Clin Transl Gastroenterol 2015; 6:e73. [PMID: 25630865 PMCID: PMC4418411 DOI: 10.1038/ctg.2015.2] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/18/2014] [Accepted: 01/02/2015] [Indexed: 12/30/2022] Open
Abstract
Chronic pancreatitis (CP) is a debilitating disease that leads to varying degrees
of pancreatic endocrine and exocrine dysfunction. One of the most difficult
symptoms of CP is severe abdominal pain, which is often challenging to control
with available analgesics and therapies. In the last decade, total
pancreatectomy with autologous islet cell transplantation has emerged as a
promising treatment for the refractory pain of CP and is currently performed at
approximately a dozen centers in the United States. While total pancreatectomy
is not a new procedure, the endocrine function-preserving autologous islet cell
isolation and re-implantation have made the prospect of total pancreatectomy
more acceptable to patients and clinicians. This review will focus on the
current status of total pancreatectomy with autologous islet cell transplant
including patient selection, technical considerations, and outcomes. As the
procedure is performed at an increasing number of centers, this review will
highlight opportunities for quality improvement and outcome optimization.
Collapse
Affiliation(s)
- Samuel J Kesseli
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Kerrington A Smith
- Section of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| |
Collapse
|
14
|
D'Haese JG, Ceyhan GO, Demir IE, Tieftrunk E, Friess H. Treatment options in painful chronic pancreatitis: a systematic review. HPB (Oxford) 2014; 16:512-21. [PMID: 24033614 PMCID: PMC4048072 DOI: 10.1111/hpb.12173] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 07/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options. METHODS A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction. RESULTS A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed. CONCLUSIONS First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.
Collapse
Affiliation(s)
- Jan G D'Haese
- Department of Surgery, Rechts der Isar Clinic, Technical University of Munich, Munich, Germany
| | | | | | | | | |
Collapse
|
15
|
Nechutova H, Dite P, Hermanova M, Novotny I, Martinek A, Klvana P, Kianicka B, Soucek M. Pancreatic pain. Wien Med Wochenschr 2014; 164:63-72. [DOI: 10.1007/s10354-014-0265-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/27/2014] [Indexed: 12/16/2022]
|
16
|
Olesen SS, Juel J, Graversen C, Kolesnikov Y, Wilder-Smith OHG, Drewes AM. Pharmacological pain management in chronic pancreatitis. World J Gastroenterol 2013; 19:7292-7301. [PMID: 24259960 PMCID: PMC3831211 DOI: 10.3748/wjg.v19.i42.7292] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 08/05/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Intense abdominal pain is a prominent feature of chronic pancreatitis and its treatment remains a major clinical challenge. Basic studies of pancreatic nerves and experimental human pain research have provided evidence that pain processing is abnormal in these patients and in many cases resembles that seen in neuropathic and chronic pain disorders. An important ultimate outcome of such aberrant pain processing is that once the disease has advanced and the pathophysiological processes are firmly established, the generation of pain can become self-perpetuating and independent of the initial peripheral nociceptive drive. Consequently, the management of pain by traditional methods based on nociceptive deafferentation (e.g., surgery and visceral nerve blockade) becomes difficult and often ineffective. This novel and improved understanding of pain aetiology requires a paradigm shift in pain management of chronic pancreatitis. Modern mechanism based pain treatments taking into account altered pain processing are likely to increasingly replace invasive therapies targeting the nociceptive source, which should be reserved for special and carefully selected cases. In this review, we offer an overview of the current available pharmacological options for pain management in chronic pancreatitis. In addition, future options for pain management are discussed with special emphasis on personalized pain medicine and multidisciplinarity.
Collapse
|
17
|
Recomendaciones del Club Español Pancreático para el diagnóstico y tratamiento de la pancreatitis crónica: parte 2 (tratamiento). GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:422-36. [DOI: 10.1016/j.gastrohep.2012.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 02/08/2023]
|
18
|
Forsmark CE. Management of chronic pancreatitis. Gastroenterology 2013; 144:1282-91.e3. [PMID: 23622138 DOI: 10.1053/j.gastro.2013.02.008] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/27/2013] [Accepted: 02/05/2013] [Indexed: 02/08/2023]
Abstract
Advances in our understanding of chronic pancreatitis have improved our care of patients with this disease. Although our therapies are imperfect and many patients remain symptomatic, appropriate medical care improves the quality of life in these patients. Proper management requires an accurate diagnosis, recognition of the modifiable causes of disease, assessment of symptoms and complications, treatment of these symptoms and complications utilizing a multidisciplinary team, and ongoing monitoring for the effect of therapy and the occurrence of complications.
Collapse
Affiliation(s)
- Christopher E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida 32610-0214, USA.
| |
Collapse
|
19
|
de-Madaria E, Abad-González A, Aparicio JR, Aparisi L, Boadas J, Boix E, de-Las-Heras G, Domínguez-Muñoz E, Farré A, Fernández-Cruz L, Gómez L, Iglesias-García J, García-Malpartida K, Guarner L, Lariño-Noia J, Lluís F, López A, Molero X, Moreno-Pérez O, Navarro S, Palazón JM, Pérez-Mateo M, Sabater L, Sastre Y, Vaquero EC, Martínez J. The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment). Pancreatology 2012; 13:18-28. [PMID: 23395565 DOI: 10.1016/j.pan.2012.11.310] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 11/11/2012] [Accepted: 11/20/2012] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.
Collapse
Affiliation(s)
- E de-Madaria
- Pancreatic Unit, University General Hospital of Alicante, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Pancreatic islet autotransplantation with total pancreatectomy for chronic pancreatitis. Surg Today 2012; 43:715-9. [DOI: 10.1007/s00595-012-0382-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 07/26/2012] [Indexed: 12/11/2022]
|
21
|
Quinlan J, Carter K. Acute pain management in patients with persistent pain. Curr Opin Support Palliat Care 2012; 6:188-93. [DOI: 10.1097/spc.0b013e3283520fb6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
22
|
Abstract
Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges.
Collapse
MESH Headings
- Abdominal Pain/etiology
- Abdominal Pain/therapy
- Algorithms
- Animals
- Anti-Inflammatory Agents/therapeutic use
- Autoimmunity
- Biomarkers/blood
- Cholangiopancreatography, Endoscopic Retrograde
- Diabetes Mellitus/etiology
- Diabetes Mellitus/therapy
- Disease Models, Animal
- Disease Progression
- Drainage
- Endoscopy, Digestive System
- Fibrosis
- Genetic Predisposition to Disease
- Humans
- Ischemia/complications
- Magnetic Resonance Imaging
- Micronutrients/therapeutic use
- Mutation
- Pancreas/blood supply
- Pancreas/metabolism
- Pancreas/pathology
- Pancreatectomy
- Pancreaticojejunostomy
- Pancreatitis, Acute Necrotizing
- Pancreatitis, Alcoholic
- Pancreatitis, Chronic/classification
- Pancreatitis, Chronic/complications
- Pancreatitis, Chronic/diagnosis
- Pancreatitis, Chronic/etiology
- Pancreatitis, Chronic/metabolism
- Pancreatitis, Chronic/pathology
- Pancreatitis, Chronic/therapy
- Prednisolone/therapeutic use
- Risk Factors
- Smoking/adverse effects
- Steatorrhea/etiology
- Steatorrhea/therapy
Collapse
Affiliation(s)
- Joan M Braganza
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK.
| | | | | | | |
Collapse
|
23
|
Chauhan S, Forsmark CE. Pain management in chronic pancreatitis: A treatment algorithm. Best Pract Res Clin Gastroenterol 2010; 24:323-35. [PMID: 20510832 DOI: 10.1016/j.bpg.2010.03.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/07/2010] [Accepted: 03/16/2010] [Indexed: 01/31/2023]
Abstract
Abdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.
Collapse
|