Pancreatitis pain control

There is evidence that, in humans, a luminal, protease-mediated, negative feedback system may be operative under certain circumstances (Slaff et al., 1984), but it is controversial whether (and rather unlikely that) this mechanism contributes to the pathogenesis of pain in patients with chronic pancreatitis. Several controlled therapeutic trials in patients with chronic pancreatitis have yielded conflicting results. Moreover, experimental data suggest that hormonally-induced inhibition of pancreatic secretion alone is ineffective in painful pancreatitis. It is more likely that amelioration of pain following enzyme administration originates from correction of disturbed motor function, such as ileal brake... 

The majority of patients with alcohol-related CP require pain control and pancreatic enzyme supplementation. " Avoidance... 

The severity and frequency of abdominal pain should be assessed periodically in order to determine the efficacy of the patient s pain control regimen. Most patients with abdominal pain can be adequately controlled with acetaminophen, NSAIDs, or selective COX-2 inhibitors. A trial of pancreatic enzymes and either an H2-receptor antagonist or proton pump inhibitor may relieve pain in patients with mild to moderate disease. Patients with severe pain will require narcotics. In these patients, pain should be monitored daily and medications adjusted accordingly. Some patients will require endoscopic therapy or pancreatic surgery. 

Therapentic ontcome depends in part on the ability of the patient to discontinne alcohol and tobacco nse and to maintain adeqnate nn-trition. Pain control and pancreatic enzyme snpplementation are important therapentic measures that contribute to the patient s quality of life. A small number of patients die from complications associated with an acute attack. 

Spigos et al. [112] adopted a strict protocol that resulted in a remarkably low number of complications. The protocol included broad-spectrum antibiotics started 8-12 hours before the procedure and continued for 1-2 weeks, local antibiotics (such as gentamicin) suspended in the solution used to deliver the particulate embolic agents and administered through the angiographic catheter, strict attention to sterility (whole-body povidone-iodine bath or wide surgical scrub at the site of catheter insertion), selective catheterization with the catheter tip beyond pancreatic branches, effective pain control with narcotics or epidural anesthesia for 48 hours (which prevents the splinting that may... 

Considering the lack of substantial impact on survival of any chemotherapy regimens, all patients with pancreatic cancer should be considered for enrollment in clinical trials. If this is not possible, gemcitabine appears to be emerging as the standard treatment due to its apparent favorable impact on disease-related symptoms, such as pain control and performance status.[105-108]... 

Only one study to date has been conducted on the treatment of acute pancreatitis with antioxidants. Clemens et al. (1991) were unable to show any difference in the incidence or severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in a prospective, randomized, double-blind, placebo-controlled trial of allopurinol. However, Salim (1991) performed a similar trial of the effect of allopurinol and DMSO in patients with pain from recurrent pancreatitis, and found significant benefit. On the basis that depletion of antioxidants is important in the pathogenesis of chronic pancreatitis, the administration of a cocktail of antioxidants was assessed for its effect on pain in this disease. Treatment with a combination of organic selenium, d-carotene, vitamins C and E, and methionine was of benefit in the initial pilot study, and in a placebo-controlled trial (San-dilands etal., 1990 Uden et al., 1990). 

Non-enteric-coated pancreatic enzyme supplements can be used for initial therapy. The relative dose of amylase, lipase, and protease may be increased until control of pain and fatty diarrhea is achieved or the patient experiences intolerable side effects. If pain and diarrhea control are achieved, the patient can be transitioned to an enteric-coated supplement to maximize compliance. A reasonable example starting regimen is Viokase-8, six tablets with each meal and at bedtime, given with famotidine 20 mg at bedtime. 

Make a plan for analgesia, in conjunction with a pain management service if possible, to control and prevent pain. Recommend an analgesic with ease of dosing and minimal side effects, realizing that patients with chronic pancreatitis may require large doses of opioids. 

The treatment of uncomplicated CP is aimed primarily at the control of chronic abdominal pain (see Fig. 39-4) and the correction of malabsorption with pancreatic enzymes (Fig. 39-5). Diabetes associated with CP may require exogenous insulin. 

Pancreas A 49-year-old man with poorly controlled type 2 diabetes mellitus with severe abdominal pain was delivered to hospital and was diagnosed to have pancreatitis three weeks after the use of vildagliptin. Patient s serum amylase was 2215 U/L at admission. Contrast enhanced computed tomography of the abdomen and pelvis... 

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