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Pancreatic Cancer Pain Management

By Dr. Amod Manocha in Pain Management

Feb 15 , 2022 | 3 min read

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How common is pain in pancreatic cancer?

Pain in pancreatic cancer is a common problem affecting nearly 75% of patients at the time of diagnosis and over 90% in advanced stages. This is not surprising given the aggressive nature of the disease and pain is often the main reason for seeking medical attention.

Most patients describe having moderate to severe pain in the upper part of tummy just below the ribcage. Pain is often more towards the left side and commonly radiates towards the middle of the back. It may be squeezing, cramping, sharp, burning or aching, with oral intake often aggravating the pain making the patients fearful of eating and contributing to the associated weight loss.

What causes pain in pancreatic cancer?

The pain in pancreatic cancer may arise due to several reasons including

  • Cancer itself due to
    • Increased pressure or the blockage of pancreatic ducts
    • Inflammation of the pancreas and /or the nearby areas
  • Pressure and /or spread to the neighbouring structures including the
    • Nerves
    • Liver
    • Bowel or inner covering of the tummy (peritoneum)
    • Bone
    • Blockage of the first part of small intestine impeding the food flow
    • Irritation of diaphragm causing shoulder pain
  • Associated problems such as constipation and digestion problems, abdominal distension due to increased fluid (ascites) 
  • Treatment side effects such as those seen after chemotherapy, radiotherapy or surgery 
  • An unrelated coincidental problem such as arthritis of the joints in the spine

Which procedures can help to reduce pain in pancreatic cancer?

Pancreatic cancer pain can be severe and there is evidence supporting better outcomes with earlier treatment, so it’s better to seek help early. Procedures targeting coeliac plexus or splanchnic nerves can be helpful not only in pancreatic cancer but also in other upper abdominal cancers such as those of liver, gall bladder, stomach, some parts of intestine and non-cancer pains such as in chronic pancreatitis. These procedures have the potential to offer significant, lasting relief. Coeliac plexus is the name given to a network of nerves located deep in the upper part of tummy in front of spine and splanchnic nerves are one of the main nerves in this network, located on the either side of the spine. Both, splanchnic nerves and Coeliac plexus have an important role in sending messages including pain signals from the upper abdominal organs such as pancreas, liver, gall bladder to the brain.

The below mentioned procedures aim to reduce the pain signals being transmitted by these nerves and involve placing needles close to the target nerves using X Rays, Ultrasound, CT, Endoscopic guidance or a combination of these. Once the needles are in the correct place radiofrequency treatment or drugs are used to achieve prolonged inhibition of pain signals. Planning for these procedures often requires multidisciplinary review (such as reviewing the scans with radiologists) for deciding on the most suitable treatment option. The injection options include

  • Diagnostic Coeliac Plexus or Splanchnic Nerve blocks– These injections help to identify the source of pain and predict the response to other procedures. The procedure involves injecting local anaesthetic with or without steroids to interrupt the pain signals being transmitted to the brain thereby producing pain relief. 
  • Neurolytic Coeliac Plexus or Splanchnic Nerve blocks– these procedures involve use of drugs such as phenol or alcohol for prolonged inhibition or reduction in pain signals being transmitted to brain.
  • Radiofrequency ablation of splanchnic nerves– this procedure utilises radiofrequency energy to heat the needle tip to reduce the pain signals.
  • Refractory end of life pain may require delivering pain killers directly into the spine. 

What are the other options apart from injections?

Besides the cancer treatment options, other options include

Painkillers Medications

Combination of different pain killers is used based on the type of pain and individual co morbidities. Options include strong painkillers such as opioids, anti inflammatories, nerve type of pain killers, steroids etc. The combinations of medications selected, and doses of medications need to be regularly adjusted to parallel the disease. Not only that sometimes the route used for giving medications also needs to be changed.

Addressing Concomitant Issues

As discussed previously these can be important sources of discomfort and persisting pain. Addressing problems such as constipation and distended abdomen can go a long way in improving the quality of life. Dietary modification to supply adequate calories and at the same time not to trigger the pain is required in majority.

Psychological Support

Relationship between one’s emotional state such as mood /anxiety and pain is well known. Relaxation therapies such as meditation, mindfulness may help in managing thoughts, coping with feelings and produce a calming effect.