Søren Schou Olesen, MD, on Pain and Chronic Pancreatitis

Søren Schou Olesen, MD, PhD, is an associate professor and chief physician with the Centre for Pancreatic Diseases with the Department of Gastroenterology and Hepatology at the Clinical Institute of Aalborg University Hospital in Aalborg, Denmark.

Acute and chronic pancreatitis constitute a continuum of inflammatory diseases of the pancreas with an increasing incidence in most high-income countries¹. Chronic pancreatitis represents the end stage of this continuum and is typically complicated by loss of exocrine and endocrine function leading to diabetes mellitus, exocrine pancreatic insufficiency, maldigestion and weight loss². In the majority of patients these metabolic complications are accompanied by a chronic abdominal pain syndrome, which can be very difficult and challenging to manage³. As such, chronic pain is the most difficult symptom to manage from both the patient’s and the provider’s perspective and has been associated with significantly reduced quality of life and frequent hospitalizations⁴. Pain-induced anorexia may also impact on the metabolic sequelae of pancreatitis and thus place the patient in a vicious cycle.

Pain in the context of chronic pancreatitis is multifactorial and often accompanied by psychiatric distress, which can further aggravate the condition⁵. Therefore, a systematic approach aimed at identifying and treating individual sources of pain and comorbidities is
recommended³. The patient should be advised to discontinue use of alcohol and smoking to decelerate disease progression. The presence of pancreatic and extrapancreatic complications, including pseudocysts, malignancy, peptic ulcer, etc., should be thoroughly
evaluated using cross-sectional imaging and upper gastrointestinal endoscopy in newly diagnosed patients and in patients with changing symptoms. In the presence of pancreatic duct obstruction due to strictures, stones, or both, endoscopic or surgical decompression may provide pain relief, although this has never been formally validated in randomized controlled trials⁶. Nonopioid analgesics and medications directed at central neural pathways, such as gabapentoids, are useful in a subset of patients and can be combined with invasive therapy⁷. Pancreatic enzyme replacement therapy has no documented effects on pain but are useful to normalize digestion in the presence of exocrine pancreatic insufficiency². Opioid-based pain medications should be used with caution and preferable in collaboration with pain experts.

Screening for psychiatric comorbidities is advised and can be performed using simple questionaries such as the Hospital Anxiety and Depression Scale⁵. In the presence of symptoms indicative of anxiety or depression, patients should be referred for psychiatric evaluation. Due to the complexity and multimodality of treatment, management in multidisciplinary teams are recommended for complex cases³. 

References

1.        Olesen SS, Mortensen LH, Zinck E, et al. Time trends in incidence and prevalence of chronic pancreatitis: A 25‐year population‐based nationwide study. United Eur Gastroenterol J. 2021;9(1):82-90. doi:10.1177/2050640620966513

2.        Singh VK, Yadav D, Garg PK. Diagnosis and management of chronic pancreatitis: a review. JAMA. 2019;322(24):2422-2434. doi:10.1001/jama.2019.19411

3.        Drewes AM, Bouwense SAW, Campbell CM, et al. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology. 2017;17(5):720-731. doi:10.1016/j.pan.2017.07.006

4.        Olesen SS, Nøjgaard C, Novovic S, et al. Pain and aetiological risk factors determine quality of life in patients with chronic pancreatitis, but a brick in the puzzle is missing. Pancreatology. 2020;20(7):1347-1353. doi:10.1016/j.pan.2020.09.004

5.        Phillips AE, Faghih M, Drewes AM, Singh VK, Yadav D, Olesen SS. Psychiatric Comorbidity in Patients With Chronic Pancreatitis Associates With Pain and Reduced Quality of Life. Am J Gastroenterol. 2020;115(12):2077-2085. doi:10.14309/ajg.0000000000000782

6.        Drewes AM, Kempeneers MA, Andersen DK, et al. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut. 2019;68(8):1343-1351. doi:10.1136/gutjnl-2019-318742

7.        Olesen SS, Bouwense S a W, Wilder-Smith OHG, van Goor H, Drewes AM. Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial. Gastroenterology. 2011;141(2):536-543. doi:10.1053/j.gastro.2011.04.003