Chronic abdominal pain in chronic pancreatitis: pathogenesis, clinical phenotypes and modern concept of therapy

Close metadata

Recommended articles:

Patient-centered approach to assessing tolerability of antitumor treatment for oral cavity and oropharyngeal cancer. P.A. Herzen Journal of Oncology. 2024;(2):21-26

Infiltrating Endometriosis of the Distal Part of Round Uterine Ligament and It’s Association with Nuck’s Diverticulum (Literature Review and Case Report). Russian Journal of Human Reproduction. 2024;(2):112-121

Surgical technique for aspiration of soft lens nucleus with preoperative femtosecond laser-assisted fragmentation. Russian Annals of Ophthalmology. 2024;(2-2):109-115

Surgical treatment of a patient with syphilitic aortitis. Pirogov Russian Journal of Surgery. 2024;(5):123-128

Fixed combination of diclofenac and orphenadrine (Neodolpasse) for postoperative pain relief. Review of the results of international and Russian studies. Russian Journal of Anesthesiology and Reanimatology. 2024;(3):74-80

Surgical treatment of idiopathic pulmonary artery aneurysm. Russian Journal of Cardiology and Cardiovascular Surgery. 2024;(3):321-328

Thoracoscopic resection of recurrent atypically located parathyroid adenoma of anterior mediastinum in a patient with hyperparathyroidism undergoing renal replacement therapy. Pirogov Russian Journal of Surgery. 2024;(6):81-87

Surgical treatment of chondromyxoid fibroma of ribs via thoracoabdominal access. Pirogov Russian Journal of Surgery. 2024;(6):94-99

Patients with ischaemic heart disease and non-steroidal anti-inflammatory drugs dosing — recommendations and real-life clinical setting. Russian Journal of Preventive Medicine. 2024;(6):68-73

Predicting the risk of decreased ovarian reserve after surgical treatment of patients with deep infiltrative endometriosis using artificial intelligence. Russian Bulletin of Obstetrician-Gynecologist. 2024;(3):92-102

Chronic pancreatitis (CP) is a severe progressive disease, one of the main manifestations of which is chronic abdominal pain (CAP). The development of the CAP is complex. The central element of the CAP pathogenesis is peripheral sensitization associated with the direct activating effect of trypsin on nociceptors (PAR) and chronic inflammation. The cause of pain may be damage and inflammation of the pancreatic tissue, its compression by massive calcifications and pseudocysts, hypertension of the Virsung duct, etc. In addition, damage to the nerves — branches of the abdominal plexus that pass through the thickness of the pancreas, with the development of elements of neuropathic pain may occur. An important role also have the central sensitization and psychoemotional disorders. Control of the CAP should be include the rejection of bad habits (alcohol and smoking), enzyme replacement therapy, the use of analgesics (paracetamol, NSAIDs, opioids), as well as, if indicated, antidepressants and anticonvulsants.

Keywords:

chronic pancreatitis

chronic abdominal pain

peripheral sensitization

central sensitization

paracetamol

NSAIDs

opioids

enzyme replacement therapy

surgical treatment

Authors:

Moroz E.V.

GBOU VPO "Pervyĭ MGMU im. I.M. Sechenova", fakul'tetskaia terapevticheskaia klinika im. V.N. Vinogradova, universitetskaia klinicheskaia bol'nitsa #1, Moskva

Karateev A.E.

Nasonova Research Institute of Rheumatology, Moscow, Russia

Krukov E.V.

Main Military Clinical Hospital named after N.N. Burdenko, Moscow, Russia

Received:

16.04.2020

Accepted:

27.04.2020

List of references:

Maev IV, Bideeva TV, Kucheryavyj YuI, Andreev DN, Buyeverov AO. Pharmacotherapy of chronic pancreatitis from the perspective of modern clinical recommendations. Terapevticheskij arhiv. 2018;90(8):81-85. (In Russ.).
Rahman A, O’Connor DB, Gather F, Koscic S, Gilgan J, Mockler D, Bashir Y, Memba R, Duggan SN, Conlon KC. Clinical Classification and Severity Scoring Systems in Chronic Pancreatitis: A Systematic Review. Dig Surg. 2020;37(3):181-191. Epub 2019 Jul 3. https://doi.org/10.1159/000501429
Shimosegawa T. A New Insight into Chronic Pancreatitis. Tohoku Journal of Experimental Medicine. 2019;248(4):225-238. https://doi.org/10.1620/tjem.248.225
Barry K. Chronic Pancreatitis: Diagnosis and Treatment. American Family Physician. 2018;97(6):385-393.
Robinson SM, Rasch S, Beer S, Valantiene I, Mickevicius A, Schlaipfer E, Mann J, Maisonneuve P, Charnley RM, Rosendahl J. Systemic inflammation contributes to impairment of quality of life in chronic pancreatitis. Scientific Reports. 2019;9(1):7318. https://doi.org/10.1038/s41598-019-43846-8
Machicado JD, Amann ST, Anderson MA, Abberbock J, Sherman S, Conwell DL, Cote GA, Singh VK, Lewis MD, Alkaade S, Sandhu BS, Guda NM, Muniraj T, Tang G, Baillie J, Brand RE, Gardner TB, Gelrud A, Forsmark CE, Banks PA, Slivka A, Wilcox CM, Whitcomb DC, Yadav D. Quality of Life in Chronic Pancreatitis is Determined by Constant Pain, Disability/Unemployment, Current Smoking, and Associated Co-Morbidities. American Journal of Gastroenterology. 2017;112(4):633-642. https://doi.org/10.1038/ajg.2017.42
Machicado JD, Chari ST, Timmons L, Tang G, Yadav D. A population-based evaluation of the natural history of chronic pancreatitis. Pancreatology. 2018;18(1):39-45. https://doi.org/10.1016/j.pan.2017.11.012
Amann ST, Yadav D, Barmada MM, O’Connell M, Kennard ED, Anderson M, Baillie J, Sherman S, Romagnuolo J, Hawes RH, Alkaade S, Brand RE, Lewis MD, Gardner TB, Gelrud A, Money ME, Banks PA, Slivka A, Whitcomb DC. Physical and mental quality of life in chronic pancreatitis: a case-control study from the North American Pancreatitis Study 2 cohort. Pancreas. 2013;42(2):293-300. https://doi.org/10.1097/MPA.0b013e31826532e7
Shah R, Haydek C, Mulki R, Qayed E. Incidence and predictors of 30-day readmissions in patients hospitalized with chronic pancreatitis: A nationwide analysis. Pancreatology. 2018;18(4):386-393. https://doi.org/10.1016/j.pan.2018.04.006
Nechutova H, Dite P, Hermanova M, Novotny I, Martinek A, Klvana P, Kianicka B, Soucek M. Pancreatic pain. Wiener medizinische Wochenschrift (1946). 2014;164(3-4):63-72. https://doi.org/10.1007/s10354-014-0265-1
Balliet WE, Edwards-Hampton S, Borckardt JJ, Morgan K, Adams D, Owczarski S, Madan A, Galloway SK, Serber ER, Malcolm R. Depressive Symptoms, Pain, and Quality of Life among Patients with Nonalcohol-Related Chronic Pancreatitis. Pain Research and Treatment. 2012;978646. https://doi.org/10.1155/2012/978646
Han S, Patel B, Min M, Bocelli L, Kheder J, Wachholtz A, Wassef W. Quality of life comparison between smokers and non-smokers with chronic pancreatitis. Pancreatology. 2018;18(3):269-274. https://doi.org/10.1016/j.pan.2018.02.012
Poulsen JL, Olesen SS, Malver LP, Frøkjær JB, Drewes AM. Pain and chronic pancreatitis: a complex interplay of multiple mechanisms. World Journal of Gastroenterology. 2013;19(42):7282-7291. https://doi.org/10.3748/wjg.v19.i42.7282
Olesen SS, Krauss T, Demir IE, Wilder-Smith OH, Ceyhan GO, Pasricha PJ, Drewes AM. Towards a neurobiological understanding of pain in chronic pancreatitis: mechanisms and implications for treatment. Pain Reports. 2017;2(6):625. https://doi.org/10.1097/PR9.0000000000000625
Atsawarungruangkit A, Pongprasobchai S. Current understanding of the neuropathophysiology of pain in chronic pancreatitis. World Journal of Gastrointestinal Pathophysiology. 2015;6(4):193-202. https://doi.org/10.4291/wjgp.v6.i4.193
Bouwense SA, Olesen SS, Drewes AM, Frøkjær JB, van Goor H, Wilder-Smith OH. Is altered central pain processing related to disease stage in chronic pancreatitis patients with pain? An exploratory study. PLoS One. 2013;8(2):55460. https://doi.org/10.1371/journal.pone.0055460
Liu L, Shenoy M, Pasricha PJ. Substance P and calcitonin gene related peptide mediate pain in chronic pancreatitis and their expression is driven by nerve growth factor. Journal of the Pancreas. 2011;12(4):389-394.
Teo K, Johnson MH, Truter S, Pandanaboyana S, Windsor JA. Pain assessment in chronic pancreatitis: A comparative review of methods. Pancreatology. 2016;16(6):931-939. https://doi.org/10.1016/j.pan.2016.09.006
Frøkjær JB, Olesen SS, Gram M, Yavarian Y, Bouwense SA, Wilder-Smith OH, Drewes AM. Altered brain microstructure assessed by diffusion tensor imaging in patients with chronic pancreatitis. Gut. 2011;60(11):1554-1562. https://doi.org/10.1136/gut.2010.236620
Hansen TM, Muthulingam JA, Drewes AM, Olesen SS, Frøkjær JB. Cingulate glutamate levels associate with pain in chronic pancreatitis patients. Neuroimage Clinical. 2019;23:101925. https://doi.org/10.1016/j.nicl.2019.101925
Kuhlmann L, Olesen SS, Olesen AE, Arendt-Nielsen L, Drewes AM. Mechanism-based pain management in chronic pancreatitis — is it time for a paradigm shift? Expert Review of Clinical Pharmacology. 2019;12(3):249-258. https://doi.org/10.1080/17512433.2019.1571409
Singh VK, Drewes AM. Medical Management of Pain in Chronic Pancreatitis. Digestive Diseases and Sciences. 2017;62(7):1721-1728. https://doi.org/10.1007/s10620-017-4605-z
Majumder S, Chari ST. Chronic pancreatitis. The Lancet. 2016;387(10031):1957-1966. https://doi.org/10.1016/S0140-6736(16)00097-0
Dominguez-Munoz JE, Drewes AM, Lindkvist B, Lindkvist B, Ewald N, Czakó L, Rosendahl J, Löhr JM. Recommendations from the United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis. Pancreatology. 2018;18(8):847-854. https://doi.org/10.1016/j.pan.2018.09.016
Moroz EV, Sokolov AA, Artemkin EN. Use of non-steroidal anti-inflammatory drugs for the prevention of acute pancreatitis after endoscopic cholangiopancreatography (literature review). Byulleten’ Vostochno-Sibirskogo nauchnogo centra Sibirskogo otdeleniya Rossijskoj Akademii medicinskih nauk. 2015;2(102):115-120. (In Russ.).
Baxter KA, Pucher PH, Berry DP, Elberm H, Abu-Hilal M, Marangoni G, Hamady Z. The effect of non-steroidal anti-inflammatory drugs on severity of acute pancreatitis and pancreatic necrosis. Annals of the Royal College of Surgeons of England. 2018;100(3):199-202. https://doi.org/10.1308/rcsann.2017.0205
Gülen B, Dur A, Serinken M, Karcıoğlu Ö, Sönmez E. Pain treatment in patients with acute pancreatitis: A randomized controlled trial. Turkish Journal of Gastroenterology. 2016;27(2):192-196. https://doi.org/10.5152/tjg.2015.150398
Kumar NS, Muktesh G, Samra T, Samanta J, Sinha SK, Dhaka N, Yadav TD, Gupta V, Kochhar R. Comparison of efficacy of diclofenac and tramadol in relieving pain in patients of acute pancreatitis: A randomized parallel group double blind active controlled pilot study. European Journal of Pain. 2020;24(3):639-648. https://doi.org/10.1002/ejp.1515
Mahapatra SJ, Jain S, Bopanna S, Gupta S, Singh P, Trikha A, Sreenivas V, Shalimar, Garg PK. Pentazocine, a Kappa-Opioid Agonist, Is Better Than Diclofenac for Analgesia in Acute Pancreatitis: A Randomized Controlled Trial. American Journal of Gastroenterology. 2019;114(5):813-821. https://doi.org/10.14309/ajg.0000000000000224
Lai SW, Lin CL, Liao KF. Association of Meloxicam Use with the Risk of Acute Pancreatitis: A Case-Control Study. Clinical Drug Investigation. 2015;35(10):653-657. https://doi.org/10.1007/s40261-015-0326-2
Hung SC, Liao KF, Hung HC, Lin CL, Lai SW, Lin CH. Nabumetone use and risk of acute pancreatitis in a case-control study. Pancreatology. 2016;16(3):353-357. https://doi.org/10.1016/j.pan.2016.03.003
Hung SC, Hung SR, Lin CL, Lai SW, Hung HC. Use of celecoxib correlates with increased relative risk of acute pancreatitis: a case-control study in Taiwan. American Journal of Gastroenterology. 2015;110(10):1490-1496. https://doi.org/10.1038/ajg.2015.259
García Rodríguez LA, Hernández-Díaz S. Relative risk of upper gastrointestinal complications among users of acetaminophen and nonsteroidal anti-inflammatory drugs. Epidemiology. 2001;12(5):570-576.
He YH, Lu L, Wang YF, Huang JS, Zhu WQ, Guo Y, Li CX, Li HM. Acetaminophen-induced acute pancreatitis: A case report and literature review. World Journal of Clinical Cases. 2018;6(9):291-295. https://doi.org/10.12998/wjcc.v6.i9.291
Chen SJ, Lin CS, Hsu CW, Lin CL, Kao CH. Acetaminophen Poisoning and Risk of Acute Pancreatitis: A Population-Based Cohort Study. Medicine (Baltimore). 2015;94(29):1195. https://doi.org/10.1097/MD.0000000000001195
Hobbs PM, Johnson WG, Graham DY. Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World Journal of Gastrointestinal Pharmacology and Therapeutics. 2016;7(3):370-386. https://doi.org/10.4292/wjgpt.v7.i3.370
de la Iglesia-García D, Huang W, Szatmary P, Baston-Rey I, Gonzalez-Lopez J, Prada-Ramallal G, Mukherjee R, Nunes QM, Domínguez-Muñoz JE, Sutton R; NIHR Pancreas Biomedical Research Unit Patient Advisory Group. Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut. 2017;66(8):1354-1355. https://doi.org/10.1136/gutjnl-2016-312529
D’Haese JG, Ceyhan GO, Demir IE, Layer P, Uhl W, Löhr M, Rychlik R, Pirilis K, Zöllner Y, Gradl B, Foerster D, Möbius J, Henniges F, Friess H. Pancreatic enzyme replacement therapy in patients with exocrine pancreatic insufficiency due to chronic pancreatitis: a 1-year disease management study on symptom control and quality of life. Pancreas. 2014;43(6):834-841. https://doi.org/10.1097/MPA.0000000000000131
Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D; Working group for the International (IAP — APA — JPS — EPC) Consensus Guidelines for Chronic Pancreatitis. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology. 2017;17(5):720-731. https://doi.org/10.1016/j.pan.2017.07.006
Talukdar R, Lakhtakia S, Nageshwar Reddy D, Rao GV, Pradeep R, Banerjee R, Gupta R, Ramchandani M, Tandan M, Murthy HV. Ameliorating effect of antioxidants and pregabalin combination in pain recurrence after ductal clearance in chronic pancreatitis: Results of a randomized, double blind, placebo-controlled trial. Journal of Gastroenterology and Hepatology. 2016;31(9):1654-1662. https://doi.org/10.1111/jgh.13332
Ahmed Ali U, Jens S, Busch OR, Keus F, van Goor H, Gooszen HG, Boermeester MA. Antioxidants for pain in chronic pancreatitis. The Cochrane Database of Systematic Reviews. 2014;8:CD008945. https://doi.org/10.1002/14651858
Gurusamy KS, Lusuku C, Davidson BR. Pregabalin for decreasing pancreatic pain in chronic pancreatitis. The Cochrane Database of Systematic Reviews. 2016;2:CD011522. https://doi.org/10.1002/14651858
Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM. Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial. Gastroenterology. 2011;141(2):536-543. https://doi.org/10.1053/j.gastro.2011.04.003
Ratnayake CB, Bunn A, Pandanaboyana S, Windsor JA. Spinal Cord Stimulation for Management of Pain in Chronic Pancreatitis: A Systematic Review of Efficacy and Complications. Neuromodulation. 2020;23(1):19-25. https://doi.org/10.1111/ner.13051
Fregni F, Potvin K, Dasilva D, Wang X, Lenkinski RE, Freedman SD, Pascual-Leone A. Clinical effects and brain metabolic correlates in non-invasive cortical neuromodulation for visceral pain. European Journal of Pain. 2011;15(1):53-60. https://doi.org/10.1016/j.ejpain.2010.08.002
Mancerov MP, Moroz EV. Reactive pancreatitis after endoscopic manipulations on the large duodenal papilla. Rossijskij zhurnal gastroenterologii, gepatologii, koloproktologii. 2007;3(17):14-23. (In Russ.).

Close metadata