Pain mechanisms in chronic pancreatitis: of a master and his fire

Chronic pancreatitis (CP) is a syndrome that is characterized by inflammation, irreversible fibrosis, and loss of acinar and islet cells. It has also been described as an “enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment.” This review describes the epidemiology, diagnosis, diagnostic challenges, differential diagnosis, treatment, complications, and clinical course and prognosis of CP, as well as future challenges. Figures show a computed tomographic (CT) scan of calcific CP, a secretin-enhanced magnetic resonance cholangiopancreatogram showing a dilated and tortuous main pancreatic duct, a CT scan of a large chronic pseudocyst compressing the stomach and pancreas, an endoscopic ultrasound (EUS) image of CP, a retrograde pancreatogram showing a dilated main pancreatic duct with stones and “blunted” side branches, sources of pain in CP, neuropathic pain mechanisms in CP, and an algorithm summarizing treatment of pain in CP. Tables list the TIGAR-O etiologic classification of CP, standard criteria for diagnosis of CP by EUS, Cambridge endoscopic retrograde cholangiopancreatography grading for CP, and a stepwise radiographic and endoscopic diagnostic approach to patients with suspected CP. Key words: bile duct obstruction, chronic pancreatitis, pancreatic calcifications, TIGAR-O system This review contains 8 highly rendered figures, 4 tables, and 54 references.

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Pain Mechanisms in Chronic Pancreatitis

The Pancreas ◽

10.1002/9781119188421.ch41 ◽

2018 ◽

pp. 349-354

Author(s):

Pierluigi di Sebastiano ◽

Tommaso Grottola ◽

Francesco F. di Mola

Keyword(s):

Chronic Pancreatitis ◽

Pain Mechanisms

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Study protocol for a randomised double-blinded, sham-controlled, prospective, cross-over clinical trial of vagal neuromodulation for pain treatment in patients with chronic pancreatitis

BMJ Open ◽

10.1136/bmjopen-2019-029546 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029546 ◽

Cited By ~ 3

Author(s):

Janusiya Anajan Muthulingam ◽

Søren Schou Olesen ◽

Tine Maria Hansen ◽

Christina Brock ◽

Asbjørn Mohr Drewes ◽

...

Keyword(s):

Chronic Pancreatitis ◽

Pain Treatment ◽

Day Treatment ◽

Pain Modulation ◽

Central Pain ◽

Pain Mechanisms ◽

Analgesic Effects ◽

Intention To Treat ◽

The Individual ◽

Double Blinded

IntroductionThe management of chronic pancreatitis (CP) is challenging and requires a personalised approach focused on the individual patient’s main symptoms. Abdominal pain is the most prominent symptom in CP, where central pain mechanisms, including sensitisation and impaired pain modulation, often are involved. Recent clinical studies suggest that vagal nerve stimulation (VNS) induces analgesic effects through the modulation of central pain pathways. This study aims to investigate the effect of 2 weeks transcutaneous VNS (t-VNS) on clinical pain in patients with CP, in comparison to the effect of sham treatment.Methods and analysisTwenty-one patients with CP will be enrolled in this randomised, double-blinded, single-centre, sham-controlled, cross-over study. The study has two treatment periods: A 2-week active t-VNS using GammaCore device and a 2-week treatment with a sham device. During both treatment periods, the patients are instructed to self-administer VNS bilaterally to the cervical vagal area, three times per day. Treatment periods will be separated by 2 weeks. During the study period, patients will record their daily pain experience in a diary (primary clinical endpoint). In addition, all subjects will undergo testing which will include MRI, quantitative sensory testing, cardiac vagal tone assessment and collecting blood samples, before and after the two treatments to investigate mechanisms underlying VNS effects. The data will be analysed using the principle of intention to treat.Ethics and disseminationThe regional ethics committee has approved the study: N-20170023. Results of the trial will be submitted for publication in peer-reviewed journals.Trial registration numberThe study is registered at www.clinicaltrials.gov:NCT03357029.

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