The natural history of pain in alcoholic chronic pancreatitis

doi:10.1016/S0016-5085(99)70016-8

Gastroenterology

Volume 116, Issue 5, May 1999, Pages 1132-1140

https://doi.org/10.1016/S0016-5085(99)70016-8 Get rights and content

Abstract

Background & Aims: The pain pattern of chronic pancreatitis (CP) and its surgical implications are discussed. The aim of this study was to (1) define typical pain patterns, (2) correlate pain patterns with the presumptive causes of the pain, and (3) compare the natural history of patients treated conservatively or surgically with respect to pain relief, pancreatic dysfunction, and clinical outcome. Methods: A cohort in this prospective long-term study included 207 patients with alcoholic CP (91 without and 116 with surgery for pain relief). A clinically based staging system was applied to characterize pain in the evolution from onset to end-stage CP. Results: Average duration of CP was 17 years. In early-stage CP, episodes of recurrent (acute) pancreatitis predominated. Chronic pain was typically associated with local complications (mainly pseudocysts, 84 of 155; 54%), relieved definitely by a single (drainage) procedure in approximately two thirds of patients. Additional surgery was required for late pain recurrence in 39 patients (34%), primarily symptomatic cholestasis (18 of 39; 46%). All patients achieved complete pain relief in advanced CP. Conclusions: In our experience, relief of chronic pain regularly follows selective surgery tailored to the presumptive pain cause or occurs spontaneously in uncomplicated advanced CP.

GASTROENTEROLOGY 1999;116:1132-1140

Section snippets

Definitions

The diagnosis of ACP was based on a typical history of recurrent clinical acute pancreatitis; a daily alcohol intake of ≥80 g for at least 5 years; and one or more of the following: pancreatic calcifications, moderate to marked ductal lesions (Cambridge criteria), severe pancreatic exocrine insufficiency (pancreatic steatorrhea), and typical pancreatic histology.¹⁷

We defined duration of the disease as the time between onset of ACP (first documented episode of pancreatitis) and either the cutoff

Results

Clinical data of the 207 patients with ACP are shown in Table 1. The sex and age distribution were similar in the surgical and nonsurgical series with a high male predominance. The high rate of calcific ACP in the series (87%) is considered to be related to the long follow-up observation time and the frequent evaluations. The average duration of ACP was approximately 17 years in both groups. The postoperative follow-up of the surgical series was 12.7 years (Table 1).

Discussion

The clinical pain pattern of CP is generally characterized as chronic and usually requiring surgical intervention for relief.5, 6 Unfortunately, most reports provide insufficient descriptive data on the clinical pain pattern and its relation to the presumptive pain cause.13, 23 Therefore, data from different centers on pain characteristics and their therapeutic implications are difficult to compare.

This report summarizes our prospective long-term experience assessing the pain profile in a mixed

Acknowledgements

The authors thank Marion Meyer-Schoellkopf (CH-8804 Au Switzerland) and Walter P. Dyck, M.D. (Texas A&M University Health Science Center, Temple, Texas) for editorial support and J. Roiss for technical help.

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Endoscopic Management of Pain due to Chronic Pancreatitis
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Comment on Study of the Comprehensive Pain Assessment Tool Short Form for Chronic Pancreatitis
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The Impacts of Genetic and Environmental Factors on the Progression of Chronic Pancreatitis
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Both environmental factors, such as alcohol consumption and smoking, and genetic factors are strongly associated with the risk of developing chronic pancreatitis (CP). However, comprehensive understanding of their impacts on the progression of CP remains elusive.
A prospective cohort study was performed on a large cohort of CP patients with known genetic backgrounds. The cumulative incidence of pancreatic insufficiency after the onset of CP was analyzed using Kaplan–Meier survival curves. Multivariate Cox proportional hazards regression analysis also was performed.
A total of 798 patients were enrolled in the study and followed up for 10.5 years. Rare pathogenic genotypes in the SPINK1, PRSS1, CTRC, or CFTR genes were identified in 410 (51.4%) patients. The development of pancreatic insufficiency was significantly earlier in patients with a history of smoking and/or alcohol consumption in both the positive (P < .001) and negative (P = .001) gene mutation groups. However, the development of pancreatic insufficiency did not differ significantly between patients with and without gene mutations despite alcohol and/or smoking status, with P values of .064 and .115, respectively. Multivariate Cox regression analysis showed that age at onset of CP (hazard ratio, [HR], 1.02; P < .001) and alcohol consumption (HR, 1.86; P < .001) were independent risk factors for the development of diabetes, while male sex (HR, 1.84; P = .022) and smoking (HR, 1.56; P = .028) were predictors of steatorrhea.
Although rare pathogenic mutations in the 4 major susceptibility genes for CP were not correlated significantly with the development of pancreatic insufficiency, environmental factors (either alcohol consumption or smoking) significantly accelerated disease progression (ClinicalTrials.gov: NCT04574297).
Pancreatic QST Differentiates Chronic Pancreatitis Patients into Distinct Pain Phenotypes Independent of Psychiatric Comorbidities
2022, Clinical Gastroenterology and Hepatology
Quantitative sensory testing (QST) has been previously used to study pain in chronic pancreatitis (CP) but included methods that are not suitable for clinical purposes. The aims of this study were to determine if pancreatic QST (P-QST) can differentiate patients into distinct pain phenotypes and to determine the association of these with their clinical pain and psychiatric comorbidities.
A multicenter cross-sectional study was conducted where patients completed validated questionnaires assessing quality of life (QoL), depression and anxiety scores as well as clinical pain symptoms followed by P-QST which included a cold pressor test, repetitive pinprick stimuli and pressure stimulation of the upper abdominal (T10) and control dermatomes. P-QST categorized patients into pain phenotypes based on a previously established nomogram. QoL, clinical pain and psychiatric assessment scores were compared across these groups.
A total of 179 patients were enrolled with a mean age of 54.1±13.6 years among whom 59% were males and 42% had an alcoholic etiology. P-QST showed no hyperalgesia in 91 (51%), segmental hyperalgesia in 50 (28%) and widespread hyperalgesia in 38 (21%) patients. Patients with widespread hyperalgesia had significantly higher pain intensity scores (P = .03) and rates of constant pain (P = .002) as well as decreased QoL (P < .001) and physical functioning (P =.03) in comparison with the other two pain phenotypes. In contrast, psychiatric comorbidities were similar across all groups.
P-QST may serve as a novel unbiased pain assessment tool in CP as it categorizes patients into distinct pain phenotypes independent of their psychiatric comorbidities.
Assessment of pain associated with chronic pancreatitis: An international consensus guideline
2021, Pancreatology
Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.

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^☆: Address requests for reprints to: Rudolf W. Ammann, M.D., Division of Gastroenterology, Department of Medicine, University Hospital, CH-8091 Zurich, Switzerland. Fax: (41) 1-255-4503.

^☆☆: Supported in part by the Amélie Waring Foundation, Zurich, Switzerland.

^★: The participants of the Zurich Pancreatitis Study Group are as follows: Arik Akovbiantz, Philipp Bertschinger, Werner Brühlmann, Peter Buchmann, Hugo Buehler, Marco Decurtins, Andreas U. Freiburghaus, Michael Fried, Philipp U. Heitz, Felix Largiadêr, Borut Marincek, Urs Metzger, Christa Meyenberger, Rainer Muench, Rolf Schlumpf, Bernhard Stamm, Wilhelm Vetter, Hans-Peter Wirth, and a large number of residents of the Gastrointestinal Unit and the Medical Policlinic, University Hospital of Zurich, engaged in the regular control studies of patients.

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Liver, Pancreas, and Biliary TractThe natural history of pain in alcoholic chronic pancreatitis☆,☆☆,★

Abstract

Section snippets

Definitions

Results

Discussion

Acknowledgements

Gastroenterology

Gastroenterology

Clin Gastroenterol

Gastroenterology

Am J Surg

Gastroenterology

Gastroenterology

Am J Surg

Chronic relapsing pancreatitis: a study of 29 cases without associated disease of the biliary or gastrointestinal tract

Gastroenterology

Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients

Gastroenterology

Differences in the natural history of idiopathic (nonalcoholic) and alcoholic chronic pancreatitis

Pancreas

Immune cell infiltration and growth-associated protein 43 expression correlate with pain in chronic pancreatitis

Gastroenterology

Histoire naturelle de la pancréatite chronique: étude de 120 cas

Gastroenterol Clin Biol

Pancréatite chronique alcoolique; relation de la douleur avec le sevrage et la chirurgie pancréatique

Gastroenterol Clin Biol

Evaluation of pain in chronic relapsing pancreatitis: a study of operated and nonoperated patients

Am J Gastroenterol

Natürlicher Verlauf der chronischen Pankreatitis-Schmerz, exokrine und endokrine Pankreas-insuffizienz und Progenose der Erkrankung

Zentralbl Chir

Surgical options in chronic pancreatitis

Int J Pancreatol

Pain in chronic pancreatitis: patients, patience and the impatient surgeon

Gastroenterology

Liver, Pancreas, and Biliary Tract
The natural history of pain in alcoholic chronic pancreatitis☆,☆☆,★