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慢性胰腺炎疼痛管理指南推荐

已有 2173 次阅读 2017-7-28 06:28 |个人分类:临床指南和病例解析|系统分类:观点评述

慢性胰腺炎疼痛管理指南推荐

慢性胰腺炎疼痛管理指南推荐

Q1. What is the natural history and burden of pain in chronic pancreatitis?
Abdominal pain is the most frequent symptom of CP. However, the severity, temporal nature, and natural history of pain is highly variable (Quality assessment: moderate; Recommendation: strong; Agreement: strong)

Q2. Are there different types of pain in CP and what does it mean for treatment?
Pain in CP remains poorly understood and inadequately correlated with neurobiological mechanisms. By definition, CP is characterized by inflammation but unlike other inflammatory disorders, there is a paucity of therapeutic attempts targeting this particular aspect of pathophysiology. On the other hand, there are striking changes in structure and function in both the peripheral and central nervous system in this condition, lending plausibility to a maladaptive state that includes both neuropathic and dysfunctional pain. In the absence of effective anti-inflammatory approaches, it is clearly important to focus on the alteration of function that accompanies these changes in the nociceptive system as a potential therapeutic target. (Quality assessment: low; Recommendation: strong; Agreement: strong)

Q3. Which methods are available to assess pancreatic pain and its response to treatment?
Assessment of pain in CP follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Only a few instruments have been validated for subjective pain assessment in CP; however, several appropriate measures exist despite not being rigorously validated in this population. (Quality assessment: moderate; Recommendation: strong; Agreement: strong)

Q4. What is the role of smoking and alcohol on pain treatment in CP
Abstinence from alcohol and smoking, in addition to adequate treatment, should be strongly advised in patients with CP (Quality assessment: moderate (alcohol) to weak (smoking); recommendation: strong; Agreement: strong)

Q5.Do enzymes and antioxidants influence pain in CP?
Pancreatic enzyme therapy with high protease content may be tried as an initial treatment for pain relief in patients with CP. Furthermore; combination of antioxidants in sufficient dosages should be included in the armamentarium of pain treatments (Quality assessment: moderate; Recommendation: strong; Agreement: weak)

Q6. Which analgesics are recommended for pain in chronic pancreatitis?
Currently the standard guideline for analgesic therapy in CP follows the principles of the “pain relief ladder” provided by the World Health Organization (WHO) adjusted to the pain characteristics of this condition (Quality assessment: moderate; Recommendation: strong; Agreement: strong)

Q7. Is endoscopic therapy effective for pain treatment in CP?
The best candidates for successful treatment of painful CP with first-line endoscopic therapy are patients with distal obstruction of the main pancreatic duct (single stone and/or single stricture in the head of the pancreas) and in the early stage of the disease. Endoscopic therapy can be combined with Extracorporeal Shock Wave Lithotripsy (ESWL) in the presence of large (>4 mm) obstructive stone(s) located in the pancreatic head, and with ductal stenting in the presence of a dominant main pancreatic duct stricture that induces a markedly dilated duct. (Quality assessment: moderate; Recommendation: strong; Agreement: conditional)

Q8. Is ESWL effective for pain treatment in CP?
In patients with uncomplicated painful calcified CP, ESWL alone is a safe and effective treatment. Best candidates for benefiting from initial first-line ESWL are patients with obstructive calcifications, > 4 mm confined to the head of pancreas. Combining systematic endoscopical therapy with ESWL adds to the cost of patient care, at the same time not probably improving the outcome of pancreatic pain (Quality assessment: moderate, Recommendation strong; Agreement: conditional).

Q9. Are other treatments (neurolytical, psychological, etc.) effective for pain management in CP?
Neurolytical interventions can be used in selected patients with painful CP who have failed endoscopic and surgical treatment. Thoracoscopic splanchnic denervation is more effective regarding long-term pain relief in patients who are not on chronic opioid treatment. Behavioral interventions should be part of the multidisciplinary approach in CP pain particularly when patients experience psychological impact of pain and quality of life has decreased. Early intervention in children may be particularly important. (Quality assessment: low; Recommendation: strong; Agreement: conditional)

Q10. What is the optimal surgical approach to relieve pain in CP?
Depending on the morphological changes of the pancreas and pain processing status a (partially) resection, decompression of the pancreatic duct or combined interventions can be performed to reduce pain. Long-term effects are variable, but success rates up to 80% have been reported. The emerging role of total pancreatectomy as initial surgical treatment looks promising but needs further investigation (Quality assessment: moderate; Recommendation: strong; Agreement: conditional)

Q11. When is the optimal time for surgery in painful CP?
Current evidence on the timing of surgery for painful CP suggests a beneficial role for early surgery, i.e. 1) within the first 2e3 years after diagnosis or symptom onset, 2) for patients who had equal to or fewer than 5 endoscopic procedures, and 3) for patients who have not yet required opioid analgesics for medical pain treatment (Quality assessment: low; Recommendation: weak; Agreement: strong).

Q 12. How to manage pain "relapse" after surgery or endoscopy for painful CP?
Current evidence suggests that the first step for the management of pain relapse should be exclusion of obstructing stones or strictured anastomosis via imaging, followed by a limited number endoscopic interventions, and early consideration of re-surgery to achieve pain control (Quality assessment: weak; Recommendation: strong; Agreement: weak).

Q13. What are the indications for referral to a specialist center
for further investigation of pain?
All patients with presumed or established diagnosis of CP should be routinely referred to specialist pancreatic centers for investigation and treatment of their disease (Quality assessment: moderate; Recommendation: strong; Agreement: strong).