Introduction:
Pain is a common problem for people with chronic pancreatitis or pancreatic carcinoma. Sometimes pain is the first sign that leads to finding out that they have pancreas cancer or pancreatitis. About 3 out of 4 people with pancreatic cancer have pain when they are diagnosed.
Type of pain:
The pain can be mild or very bad and can affect how they live, work, and feel. Many people say they have severe pain that comes and goes but a dull pain stays all the time in the upper part of their belly just under the chest. The pain can feel like squeezing, cramping, stabbing, burning, or hurting. Pain is often more on the left side and can spread to the back. Eating or drinking can make the pain worse while leaning forward gives some relief.
Cause of Pain
'Pain in pancreatic cancer can be caused by
The cancer itself [because of too much pressure or blockage in the ducts of the pancreas]. Inflammation of the pancreas or nearby areas can also be responsible.
Swelling of the pancreas puts a pressure to the nearby structures such as Nerves (in about 7 to 9 out of 10 cases). Blockage of the first part of the small bowel that stops food from moving can be another cause of pain.
Peritonitis, ascites (Bloating of the belly because of too much fluid retention), constipation can be the other causes.
Due to irritation of the diaphragm, some patients experience shoulder pain.
· Side effect of treatments such as drugs, radiation, chemotherapy, or surgery.
Why Splanchnic nerves and Coeliac plexus are important here?
Coeliac plexuses contain a group of nerves (which include splanchnic nerves) in the upper part of the abdomen that is behind the pancreas. This group of nerves send signals from the pancreas to our brain, then only we perceive the pain. So, treatment is targeted at the coeliac plexus or splanchnic nerve to treat the pancreatic pain.
What are the pain procedures performed to reduce pain in pancreatic cancer or chronic pancreatitis?
The procedures we talk about here are used not only for pancreatic pain, but also for other cancers in the upper abdomen, like liver, gall bladder, stomach.
These procedures do not cure cancer, but by relieving the pain, improves patient’s quality of life. These procedures are quite effective, and one daycare intervention can make the patient pain-free for 6-8 months. Pain relief period may be less if cancer spreads very quickly despite chemotherapy or radiotherapy or other forms of cancer treatment.
These procedures fall into three categories:
1.Diagnostic blocks– These are done by injecting local anesthetic with or without steroids around the coeliac plexus or the splanchnic nerves. This procedure if successful is followed by Neurolysis.
2.Chemical Neurolysis: These are done by using chemicals such as alcohol / phenol to destroy the coeliac plexus nerves.
3.Radiofrequency procedures for splanchnic nerves: These are done by using radiofrequency energy to heat up the needle tip that touches the nerves. This reduces the pain signals that the nerves send to the brain.
The best intervention and approach for a patient will vary based on individual factors such as how severe the disease is, other issues like breathing problems or fluid retention in abdomen, ability to lie on the stomach/ back etc. While taking decision, CT scan or MRI picture of the abdomen are considered.
The procedure may need the patient to lie on their back or stomach for about 45 min to an hour, depending on the approach chosen. A guiding device (X-ray or Ultrasound) is always used to precisely put the needles on the target nerves.
What are the associated risks?
Every intervention has some risk. The decision to do or not do an intervention is based on weighing the risk/benefit ratio. The risks will change depending on the intervention selected and the patient’s medical conditions. When doing these procedures, steps are taken to lower the risks as much as possible such as doing the procedure with guidance (x-ray, ultrasound, CT etc), using contrast (dye) to check the spread of medications and using electrical stimulation in radiofrequency procedures etc.
These procedures can have common side effects like local pain, drop in blood pressure and loose stools. Luckily most of the common side effects are temporary.
Some of the risks can be severe. Studies have shown the risk of serious adverse events as around 2%. It is good to discuss about these with the pain physician before the intervention as the list of these can be long and change with the intervention selected.
What other options do we have to reduce pain?
Painkillers Medicines
'The type of pain and other medical conditions determine the kind of pain killers that can be used. The painkillers dose may have to be adjusted or new ones may have to be added as the disease progresses.
Opioids are some of the strongest pain killers. These painkillers can be given in different ways such as by mouth, through the veins, under the skin or as patches. Oral medications also have a slow-release form that gives more steady pain relief throughout the day. These drugs have often been in the spotlight for the wrong reasons such as addiction/ abuse risk and the social stigma attached to their use. Patients may harm themselves by having preconceived ideas and creating obstacles. It is vital that you talk openly about any such issues with your Pain Specialist.
Different types of pain may need different kinds of pain killers such as anti-inflammatories for pain from inflammation, gabapentin and pregabalin for nerve related pain.
Like any other medication, these medications have side effects, and these can be managed in most cases by patient education, preventive measures, modification of the use of medications and lifestyle changes.
Pain control in cancer is not only about medications or injections, but there is also more to it. To get a good control, it often needs addressing the accompanying factors that can increase the pain felt. For example:
The link between one’s emotional state such as sadness /worry and pain is well established. These factors can amplify the pain felt and hence dealing with them is essential. Relaxation therapies such as meditation, mindfulness may help in handling thoughts, coping with emotions, and creating a soothing effect.
Abdominal pain get worse with other problems like constipation and abdominal swelling and hence the need to address these separately.
About the Author:
Dr. Chinmoy Roy is a respected pain expert and author of multiple medical books who is available at Rajarhat Pain Clinic, Newtown, Kolkata. He is an expert of using radiofrequency, CRYO, chemical neurolytics and other modalities related to the pain procedures.
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