First European Pain Consensus

Pain is the most common symptom of acute pancreatitis and one of the main indicators of its severity, but until now, no international document had specifically addressed how to manage it. This gap has been filled with the publication of the first European interdisciplinary guidelines on pain management in acute pancreatitis, developed within the methodological framework of United European Gastroenterology and endorsed by the European Pancreatic Club and six other European scientific societies, including those specializing in digestive surgery, endoscopy, abdominal radiology, digestive oncology, and pediatric gastroenterology.

The document, the result of nine working groups and a Delphi process involving up to three rounds among 31 international specialists, covers the entire patient journey: from the initial pain assessment to post-discharge follow-up and includes, for the first time, specific recommendations for the pediatric population and for pregnant women.

“The new European recommendations propose systematically measuring pain, not delaying the use of opioids when pain is severe, and, for the first time, incorporating epidural analgesia in acute pancreatitis, although its role as a disease-modifying strategy remains unproven,” Enrique Domínguez-Muñoz, MD, PhD, professor of medicine at the University of Santiago de Compostela and director of the Department of Gastroenterology and Hepatology at University Hospital of Santiago de Compostela in Santiago, Spain, told Univadis Spain, part of the Medscape Professional Network.

“What’s new about this consensus is not only that it recommends specific medications but that it structures pain management as a comprehensive clinical process: initial assessment, therapeutic escalation, monitoring, options for special situations, epidural analgesia, complementary therapies, and follow-up after discharge,” continued Domínguez-Muñoz.

Opioids Lead Severe Pain Care

For routine pain assessment, the experts recommend the numeric rating scale over the visual analog scale, as they have observed better adherence to this format, although both were considered equally valid. They also advise adopting a multidimensional assessment approach, given the proven benefits of this approach in conditions such as chronic pancreatitis. They also note that, in the absence of specific guidelines for acute pancreatitis, the general principles of acute postoperative pain management such as the use of the World Health Organization’s analgesic ladder for mild or moderate cases can be reasonably applied to patients with this condition. Pain assessment should be performed every 5-60 minutes, depending on the intensity of the pain. Adequate pain control can prevent relapses during enteral refeeding, reduce psychological stress, and lower the risk for organ dysfunction.

The most relevant point in the document is the role of opioids in severe pain. The panel concludes that drugs such as buprenorphine and pentazocine provide superior relief compared with nonsteroidal anti-inflammatory drugs (NSAIDs) and reduce the need for rescue analgesia. In response to traditional concerns about potential adverse effects of opioids on intestinal motility or the sphincter of Oddi, the authors emphasize that current evidence does not consistently demonstrate harm associated with their use, and that safety concerns should not delay their administration when pain is severe.

Regarding NSAIDs, the document clarifies that they do not appear to worsen disease severity and highlights the emerging role of selective COX-2 inhibitors, such as parecoxib, in combination with celecoxib or imrecoxib, which in recent trials have demonstrated the ability to reduce the risk for progression to severe forms of pancreatitis.

Epidural Analgesia Offers Relief

For the first time, specific recommendations are provided on epidural analgesia, noting its safety and efficacy profile in severe acute pancreatitis. Epidural analgesia receives one of the most nuanced assessments in the document: It is considered a safe and effective option for improving pain control when local expertise is available.

“Transient systemic hypotension was the most frequently reported adverse effect, usually controlled with fluid replacement and, in some cases, with inotropic support. It is important to note that no study reported serious neurologic, hemorrhagic, or infectious complications directly attributable to the technique,” said Karina Cárdenas-Jaén, Department of Gastroenterology, Dr. Balmis General University Hospital and Alicante Institute of Health and Biomedical Research, both in Alicante, Spain, and a member of the Pancreas and Biliary Tract working group of the Spanish Association of Gastroenterology.

The article indicates that epidural analgesia, combined with standard care, provides superior pain relief in acute pancreatitis compared with standard care alone, leading to improved patient-reported outcomes and a higher quality of life, particularly in patients with severe acute pancreatitis.

However, the experts find no solid evidence that it consistently reduces organ failure or mortality; therefore, they recommend against generalizing its use for that purpose until higher-quality studies are available.

Domínguez-Muñoz stated that “based on the available evidence, it cannot be asserted that epidural analgesia reduces pancreatic necrosis or reliably prevents local disease progression. Its use is best justified by pain relief, reduced opioid use, and the potential to facilitate deep breathing, mobility, and food intake — not by a proven effect on necrosis. If there is an impact on microcirculation and necrosis, it should currently be considered a pathophysiologic hypothesis supported by indirect evidence, not an independent clinical indication.”

Chinese Therapies Show Promise

In a novel approach, the panel also evaluates complementary therapies widely used in China, such as the herbal decoction Chaiqin Chengqi and acupuncture, which in clinical trials have demonstrated the ability to reduce abdominal pain and shorten the time to resumption of oral feeding, although with a low level of evidence and, in the case of the herbal decoction, an increased risk for hypernatremia. The authors caution that their application outside of China may be limited by a lack of regulatory approval.

Special Care for Children, Pregnancy

In children, the type of analgesic used is opioid or nonopioid; it does not appear to influence the length of hospital stay or the rate of admission to intensive care. Furthermore, early oral feeding does not significantly worsen children’s pain and may be considered.

In pregnant women with acute pancreatitis, although the evidence is very limited, it is suggested that epidural analgesia may provide better pain relief than intravenous opioid infusions such as fentanyl or tramadol, with similar maternal and fetal outcomes between the two groups.

Conclusions

The document noted that up to one fifth of patients experience persistent or recurrent pain after discharge, although there is insufficient data to recommend routine follow-up visits or imaging tests. The authors identify as research priorities the development of a pain assessment tool specific to acute pancreatitis (the CAPPOS project) and the conduct of larger clinical trials on the safety of opioids and nonpharmacologic therapies. The guidelines will be revised within a maximum of 5 years or sooner if new relevant evidence emerges.

“The new consensus shifts the framework: In acute pancreatitis, effective pain management is part of treating the disease. The epidural is the most notable development and a reasonable option for selected cases, but today it should be presented as a strategy for advanced analgesia and opioid reduction, not as a proven intervention to prevent pancreatic necrosis,” emphasized Domínguez-Muñoz.

“The guidelines are highly relevant, as they reinforce the need for early, structured, and individualized pain management in acute pancreatitis,” added Cárdenas-Jaén.

These international guidelines standardize criteria that will improve patient care and identify critical areas for future medical research.

Domínguez-Muñoz disclosed no relevant financial relationships.

This story was translated from Univadis Spain.