Medical management of chronic pancreatitis

慢性胰腺炎的临床表现包括疼痛、脂肪泻和糖尿病。在西方国家，慢性胰腺炎最常见的病因是酗酒。70％以上的病人在就诊时有疼痛的临床表现，而且，这些患者中又有75％以上会在几年之后出现疼痛减轻或完全消失。对于所有的慢性胰腺炎的病人来说，均应排除非胰源性疼痛和胆道梗阻、胰腺假性囊肿等胰腺局部并发症。应建议所有慢性胰腺炎病人戒烟、戒酒。阿片类镇痛剂仅应用于治疗疼痛严重的病人。尽管有报道认为胰酶替代治疗有助于止痛，但是，对于已经确诊的慢性胰腺炎病人来说，该疗法无效。激素类药物进行腹腔神经丛阻滞术可能有助于病人度过剧烈疼痛期。顽固性疼痛是进行胰液引流或胰腺切除的适应证。建议应用适量胰酶替代联合(或不联合)制酸剂治疗营养不良。慢性胰腺炎导致的糖尿病与原发性糖尿病的治疗原则相似。     

慢性胰腺炎合并胰管结石的诊断和治疗

慢性胰腺炎是由于多种原因（酗酒、胆道系统疾病等）造成的胰腺组织结构和功能持续性损害,常合并胰管结石。疼痛是其最主要症状,同时常伴有消化不良、脂肪泻、糖尿病等并发症。结合多种影像学检查方法如B超、CT、ERCP和磁共振胰胆管造影（MRCP）等能明显提高慢性胰腺炎合并胰管结石的确诊率。慢性胰腺炎合并胰管结石应予以积极治疗,以控制症状、改善胰腺功能和治疗并发症为重点,强调以个体化治疗为原则的综合治疗。在体外震波碎石及内镜取石不彻底而症状不能控制或结石复发者应尽早手术治疗,根据结石分布范围选择相应的治疗方式,彻底去除病灶,取净结石,解除胰、胆管梗阻,充分引流胰液,同时注意尽量保存胰腺组织功能,可明显改善病人生存质量。     

慢性胰腺炎的外科治疗——我们的认识

慢性胰腺炎(chronic pancreatitis,CP)是各种不同病因所致的胰腺实质和胰管的不可逆性慢性持续炎症损害,其特征是反复发作的上腹部疼痛伴不同程度的胰腺内、外分泌功能减退或丧失,可并有胰腺实质钙化、胰管结石、假性囊肿形成.其主要的临床表现是腹痛,可有脂肪泻、体重下降、糖尿病等.内科治疗主要是戒烟、戒酒、低脂饮食、口服胰酶、控制胆道疾病,必要时口服抗氧化剂(维生素A、C、E)和补充中短链氨基酸等,疼痛症状明显还可加用非麻醉性或酌情使用麻醉性镇痛剂,但通常会在停药后复发.内科治疗能使31%患者缓解疼痛[1].内镜治疗的主要目的是胰管减压,主要用于CP伴胰管狭窄、胆总管狭窄、胆汁淤积、黄疸及胆管炎的患者.     

胰腺引流手术能延缓慢性胰腺炎病人胰腺功能的损害

慢性胰腺炎(CP)主要表现为腹痛以及胰腺内外分泌功能损害,后者常引起脂肪泻及糖尿病。当这些损害到最后阶段时是不可能依靠手术来恢复的。手术主要是解决不能忍受并会引起麻醉药戍瘾的腹痛。手术方式有胰腺部分或全郎切除以及减压两种方法,手术能缓解60～90％病人的疼痛。本文对手术及非手术治疗CP时胰腺功能的变化进行前瞻性研究。     

得每通用于胰腺外分泌功能不足133例临床观察

苏威制药生产的得每通是一种肠溶胰酶超微微粒胶囊,每粒胶囊含胰酶150 mg,其中脂肪酶10 000欧洲药典单位,用于补充胰酶分泌不足。各类胰腺疾病,如慢性胰腺炎、胰腺切除术、胰腺癌等均可导致胰腺外分泌功能不全,胰酶分泌障碍,从而不能有效地消化食物中的脂肪、碳水化合物和蛋白质。临床通常表现为腹痛、饱胀或恶心、胀气、腹泻等症状,严重的患有脂肪泻。此类病人需用胰酶替代疗法。     

慢性胰腺炎内镜治疗的研究进展

消化内镜治疗慢性胰腺炎(chronic pancreatitis,CP)已有10多年的历史,常见方法有内镜下胰管括约肌切开术、内镜下胰管扩张和胰管支架植入术、超声内镜引导下腹腔干神经节的阻滞等。内镜治疗CP可以有效缓解疼痛,改善胰腺的功能,从一定程度上可替代外科治疗。多数CP伴有胰胆管的其他病变特征,包括胰管结石、胆总管狭窄、胰腺假性囊肿等,病情发展均可引起相应的症状并与CP互为因果。综合考虑治疗效果、并发症发生率及患者术后生活质量等,内镜下治疗可以作为CP及其伴发症的首选治疗方案     

肿块型慢性胰腺炎的治疗

慢性胰腺炎是一种进行性不可逆转地破坏胰腺并使胰腺组织被纤维组织替代的慢性炎症,而胰腺组织的破坏最终将导致腹泻、脂肪泻、糖尿病等胰腺外分泌、内分泌功能障碍和反复发作且难以控制的上腹部疼痛.慢性胰腺炎的病因较多,可分为:毒性代谢性因素(酗酒和吸烟是主要的原因)导致的慢性胰腺炎、特发性慢性胰腺炎、基因相关的慢性胰腺炎、自身免疫性慢性胰腺炎、复发性急性胰腺炎或梗阻因素导致的慢性胰腺炎.     

慢性胰腺炎诊治进展

慢性胰腺炎是一种复发性进行性腹痛及胰功能不全，最终导致胰内、外分泌功能丧失为特点的病变。临床以持续性疼痛、消瘦、脂肪泻三大顽症而与重症急性胰腺炎、胰性囊包纤维症统称为难治性胰腺疾患。随着人们饮食结构变化及饮酒习惯等原因其发病率与1974年相比增加3倍[1]。1诊断近年人们逐渐认识到统一慢性胰腺炎诊断标准和严重度分类的重要意义。美国华盛顿大学和德国UIM大学Freeny和Stanesca等在慢性胰腺炎分期研究中观察了病人的腹痛（临床指标）、胰腺内、外分泌异常（功能指标）以及CT和ERCP所观察到的胰管扩张情况（形态学指标）…     

胰头肿块型胰腺炎的诊断和治疗

慢性胰腺炎是一种胰腺组织破坏性的炎性病变,随着病程的发展,最终将导致胰腺内、外分泌功能的部分或全部丧失,其临床表现多样且不典型。一般表现为上腹痛、腹胀、恶心、食欲下降,脂肪泻和糖尿病。胰头肿块型胰腺炎是一种特殊类型的胰腺炎,其临床表现为梗阻性黄疸及胰头占位性病变,与胰     

慢性胰腺炎的内镜治疗

慢性胰腺炎（chronic pancreatitis，CP）是指由于不同病因引起胰腺局部或弥漫性组织损害，导致胰腺内、外分泌功能不全的疾病。病理特征为胰腺纤维化。临床以反复发作的上腹部疼痛，胰腺内、外分泌功能不全的各种表现为主要症状。在我国，CP的发病率较低，其病因主要是酒精性因素，胆道因素已降至第2位。随着人们的生活水平提高，饮食习惯改变，其发病率有上升趋势。近年来，内镜对胰腺疾病的治疗已经广泛开展．本文就CP的内镜治疗作一综述。     

Quality of Life Improvement after Videothoracoscopic Splanchnicectomy in Chronic Pancreatitis Patients: Case Control Study

The authors report on the effectiveness of videothoracoscopic splanchnicectomy (VSPL) as a method of pain treatment in patients with chronic pancreatitis (CP). A minimally invasive technique, VSPL is used in CP as an alternative method of pain treatment. The aim of the investigation was to evaluate by a prospective, semirandomized case-control study the influence of VSPL on the quality of life and the level of pain suffered by patients with CP. The study groups consisted of 32 patients who underwent VSPL between March 2000 and January 2001 and a control group of 32 CP patients who received conservative treatment. The effect of the therapy on subjective pain measures and multiparametric quality of life was measured before VSPL and throughout the first year thereafter. In the follow-up period there was a significant decrease in intensity of pain and an improvement in the quality of life of the patients—most significantly concerning emotional well-being and functioning in everyday life. We conclude that the VSPL is a safe, effective, and minimally invasive procedure and recommend that it be used in such cases.     

Management of pain in small duct chronic pancreatitis

Small duct chronic pancreatitis (CP) is defined by a nondilated main pancreatic duct, and the morphological and clinical features of chronic pancreatitis with pain are the most prominent symptoms. Current treatment strategies are based on pain history and the location and extent of disease. Traditionally, radical pancreatic resectional procedures have been carried out for small duct CP, especially with an associated head mass of uncertain aetiology. Based on the information from five randomized trials, the duodenum-preserving pancreatic head resection and its modifications have proven to provide excellent long-term pain relief and to be superior to more radical operations. Therefore, these procedures can be considered the standard for small duct CP with head dominant disease. The longitudinal V-shaped excision of the ventral pancreas combines extensive drainage and a limited resection and offers good pain relief in diffuse small duct CP. However, long-term results and larger series are awaited for definite conclusions. Thoracoscopic splanchnicectomy and endosonography-guided celiac plexus blocks require controlled trials before their routine use. This article provides an overview about the current and evidence-based pain management in small duct CP. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

Role of alpha1-blockers in chronic prostatitis syndromes

Category III chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most commonly diagnosed prostatitis syndrome. CP/CPPS is characterized by lower urinary tract symptoms (LUTS) of which pain (particularly perineal pain and pain on ejaculation) and dysfunctional voiding cause the greatest morbidity and poor quality of life. There is no standard treatment for CP/CPPS. Patients report only transient relief of symptoms from currently available therapies and are frequently required to change treatments. The origin of LUTS and possibly the pelvic pain (e.g. on ejaculation) is thought to be prolonged smooth muscle contraction in the bladder and prostate, caused by alpha(1)-adrenoceptor activation. alpha(1)-Blockers are not indicated in the treatment of CP/CPPS but clinical experience suggests that they might be of benefit, possibly by promoting smooth muscle relaxation. Encouraging results of three phase II, randomized, placebo-controlled trials evaluating (using a validated instrument) the efficacy of alfuzosin, tamsulosin and terazosin in alpha(1)-blocker-na?ve patients with CP/CPPS, support this hypothesis. The National Institute of Health and the National Institute of Diabetes and Digestive and Kidney Diseases are currently conducting a large phase III trial in 272 newly diagnosed and alpha(1)-blocker-na?ve CP/CPPS patients randomized to received alfuzosin 10 mg once daily or placebo for 12 weeks.     

Economic impact of chronic prostatitis

There are four types of prostatitis, including type I (acute bacterial prostatitis), type II (chronic bacterial prostatitis), type III (chronic prostatitis/chronic pelvic pain syndrome, or CP/CPPS), and type IV (asymptomatic inflammatory prostatitis). These prostatitis conditions account for approximately 2 million office visits each year to primary care physicians and urologists. The annual cost to treat prostatitis is approximately $84 million. Compared with control subjects, men with prostatitis incur significantly greater costs, predominantly due to increased outpatient visits and pharmacy expenses. CP/CPPS is the most common type of prostatitis. The condition is characterized by chronic, idiopathic pelviperineal pain. Due to the lack of effective treatments for CP/CPPS, the per-person costs associated with the condition are substantial and are similar to those reported for peripheral neuropathy, low back pain, fibromyalgia, and rheumatoid arthritis. Costs appear to be higher in men with more severe symptoms. Indirect costs (eg, work and productivity loss) are incurred by many patients with CP/CPPS. Identification of effective treatments for CP/CPPS would be expected to substantially reduce the costs associated with the condition.     

Defining numerical cut points for mild,moderate, and severe pain in adult burn survivors: A northwest regional burn model system investigation

IntroductionPain is a common and often debilitating sequela of burn injury. Burn pain develops following damage to peripheral sensory nerves and the release of inflammatory mediators from injury. Burn pain is complex and can include background and procedural pain that result from the injury itself, wound care, stretching, and surgery. Clinicians and researchers need valid and reliable pain measures to guide screening, treatment, and research protocols. Unlike other conditions, visual analog, or numeric pain rating scale (VAS/NRS) scores that represent mild, moderate, and severe pain among people with burn injury have not been established. The aim of this study was to identify the most suitable average pain intensity rating scores for mild, moderate, and severe pain in adult burn survivors using a PROMIS Pain Interference (PROMIS-PI) short form.MethodsAn average pain intensity VAS/NRS score (0?10) and customized PROMIS-PI short form were administered to adults with burn injury treated at a regional burn center at hospital discharge (baseline) and at 6, 12, and 24-months after injury. To identify pain intensity scores that represent mild, moderate, and severe pain, we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; 3,7; 4,6; 4,7; 2,5; and 3,5. Optimal cut points were considered those with the highest ANOVA F statistics. Models with similar F statistics were also compared with BIC.ResultsData from a sample of 253 participants (83% white, 66% male, mean age 47 years) with VAS/NRS pain intensity and PROMIS-PI scores at one or more timepoints were analyzed. The optimal classification for mild, moderate, and severe pain was CP 2,5 at baseline and 12-months. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was only 2.2.ConclusionsVAS/NRS scores for pain among adults with burn injury can be categorized as mild (0?2), moderate (3?5), and severe (6?10). These findings advance our understanding regarding the meaning of pain intensity ratings after burn injury, and provide an objective definition for clinical management, quality improvement, and pain research.     

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??Medical treatment of chronic pancreatitis LAI Ya-min,QIAN Jia-ming. Department of Gastroenterology, Chinese Academy of Medical Sciences, China Peking Union Medical College,Peking Union Medical College Hospital, Beijing100730,China
Corresponding author??QIAN Jia-ming, E-mail qjiaming57@gmail.com
Abstract Chronic pancreatitis (CP) is an ongoing in?amatory disorder characterized by irreversible destruction of the pancreas associated with disabling chronic pain and permanent loss of exocrine and endocrine function. The treatment of patients with CP revolves around control of pain, diabetes and steatorrhea. Pain relief is the most common and most difficult problem. The initial approach should consist of non-opioid analgesics and supplementation with pancreatic enzymes containing high amounts of proteases. Enzymes significantly reduce fat excretion and stool frequency and improve fat absorption. Dosing and timing are important. Although the medical treatment of CP is frustrating in most cases and the role of pancreatic enzyme replacement therapy and anti-oxidants is uncertain,the benefit of pancreatic endotherapy for CP is encouraging. The modalities include pancreatic sphincterotomy, stenting and ESWL to break large calculi. With growing expertise in endoscopic techniques, refinements in equipment and promising results from uncontrolled studies, patients should be offered opportunities of endoscopic therapy before subjecting them to surgical treatment. Both alcohol and smoking cessation are likely to be beneficial to CP patient. A low-fat diet may contribute to development of fat-soluble vitamin deficiencies and is an unnecessary intervention for treatment of steatorrhoea.     

Herbal nutraceutical treatment of chronic prostatitis–chronic pelvic pain syndrome: a literature review

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most frequent form of prostatitis, and has a serious impact on patients’ quality of life, and causes severe symptoms. The pain in the pelvic, perineal and penile areas, lower abdominal pain, and pain during urination or ejaculation are the main complaints of CP/CPPS. The underlying complex and unknown pathophysiology of this syndrome have made the management of CP/CPPS and the availability of monotherapy challenging. To identify an effective monotherapy, a plethora of clinical trials failed due to its puzzling etiology. Antibiotics, anti-inflammatory, and a-blockers have been commonly used for the treatment of CP/CPPS, but the desired and complete effects have not been gotten yet. The patients and clinicians are attracted to alternative therapies because of their multi-targeted effects. Attention toward natural compounds effectiveness and safety, supporting the development of a new nutraceutical science. In the alternative remedies for the treatment of prostatic diseases, medicinal herbs, in the form of herb parts or extracts, are getting attention due to their positive effects on prostatic diseases. At present, there is no available detailed literature review about the efficacy of medicinal herbs in the treatment of CP/CPPS. This review aimed to explore the useful medicinal herbs in the treatment of CP/CPPS from different perspectives and their possible mechanism of action in managing CP/CPPS.

     

Sexual dysfunction in the patient with prostatitis

Prostatitis (chronic prostatitis/chronic pelvic pain syndrome [CP/CPPS]) is a common condition in men that accounts for a significant number of visits to a medical doctor or urologist. It is one of the most widely diagnosed conditions in men who attend urologic clinics. Erectile dysfunction, defined as the consistent inability to obtain and/or maintain a penile erection sufficient for adequate sexual relations, also is a common problem. This review explores the links between sexual dysfunction and prostatitis. Most of the data linking lower urinary tract symptoms and erectile dysfunction suggest that lower urinary tract symptoms impair the overall quality of life and that a low quality of life contributes to or causes erectile dysfunction. Prostatitis-like symptoms such as perineal, penile, and suprapubic discomfort or pain during or after ejaculation and voiding complaints such as irritative and obstructive voiding symptoms (urinary frequency, urgency, and dysuria) may affect the global emotional well-being of a man. Erectile dysfunction also is strongly associated with a negative impact on the quality of life. The available literature demonstrating the influence of CP/CPPS on the incidence of erectile dysfunction is scant. From the literature, it is known that lower urinary tract symptoms and benign prostatic hyperplasia are definitely related to erectile dysfunction. Any kind of pain is likely to be the most significant symptom in men with CP/CPPS as it relates to sexual dysfunction. Sexual dysfunction such as ejaculation discomfort is described as a symptom of CP/CPPS. Most of the data linking the two suggest that CP/CPPS impairs the overall quality of life and it is this that contributes to or causes erectile dysfunction.     

Sexual dysfunction in the patient with prostatitis

PURPOSE OF REVIEW: Prostatitis [chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)] is a common condition in men that accounts for a significant number of visits to a medical doctor or urologist. It is one of the most widely diagnosed conditions in men attending urologic clinics. Erectile dysfunction, defined as the consistent inability to obtain and/or maintain a penile erection sufficient for adequate sexual relations, is also a common problem. This review explores the links between sexual dysfunction and prostatitis. RECENT FINDINGS: Most of the data linking lower urinary tract symptoms and erectile dysfunction suggest that lower urinary tract symptoms impair the overall quality of life and that a low quality of life contributes to or causes erectile dysfunction. Prostatitis-like symptoms such as perineal, penile, and suprapubic discomfort or pain during or after ejaculation and voiding complaints such as irritative and obstructive voiding symptoms: urinary frequency, urgency, and dysuria may affect the global emotional well-being of a man. Erectile dysfunction is also strongly associated with a negative impact on the quality of life. SUMMARY: The available literature demonstrating the influence of CP/CPPS on the incidence of erectile dysfunction is scant. From the literature, it is known that lower urinary tract symptoms and benign prostatic hyperplasia are definitely related to erectile dysfunction. Any kind of pain is likely to be the most significant symptom in men with CP/CPPS as it relates to sexual dysfunction. Sexual dysfunction like ejaculation discomfort is described as a symptom of CP/CPPS. Indeed, most of the data linking the two suggest that CP/CPPS impairs the overall quality of life and it is this that contributes to or causes erectile dysfunction.     

Chronic pancreatitis

Chronic pancreatitis (CP) is a complex progressive fibro-inflammatory disease of the pancreas with a variable clinical course often progressing to a permanent loss of exocrine and endocrine function. Over the last 20 years the incidence has continued to increase. CP has multifactorial aetiological risk factors with chronic alcoholism being the most common. The updated TIGAR-O_V2 classification identifies the pertinent risk factors and aetiology. The most susceptible patients to develop CP have a sentinel acute pancreatitis event which initiates the chronic progressive inflammation, scarring and fibrosis of the pancreas. Symptomatically CP presents as intractable abdominal pain, with weight loss and functional loss (steatorrhoea and type 3c diabetes mellitus) being late manifestations of the disease. Diagnosis is made by a combination of clinical history, examination and cross sectional imaging, combined with pancreatic function tests (only in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms, venous thrombosis and an increased risk of developing pancreatic adenocarcinoma. Management includes: diagnosis and identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, GI physician and pancreatic surgeon) in patients with on-going symptoms or when there is doubt in the diagnosis.