Bio-sketch
Dr. Mellar P. Davis, MD, FCCP FAAHPM is a member of the Solid Tumor Division of the Taussig Cancer Institute, Cleveland Clinic. He is Director of the Fellowship Palliative Medicine Program at the Cleveland Clinic. He has been chair of the Palliative Care Study Group of the Multinational Association of Supportive Care (MASCC) since 2007 and a board member of MASCC since 2010. He has been a Professor of Medicine in The Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, since 2009. He was elected as a fellow to the American Academy of Hospice and Palliative Medicine in 2010 and has been Editor in Chief of Progress on Palliative Care since 2008.His present duties within the AAHPM consist of Associate Editor in Chief of PC FACS (Fast Article Critical Summary for Clinicians in Palliative Care).
Symposium: Cancer pain management ‒ Up To Date
Mechanisms and Management of Cancer-related Visceral Pain Syndromes
Abstract
Visceral pain is experienced by 40% of those with advanced cancer from intra-abdominal cancers and 28% of all advanced cancer patients. Visceral cancer pain syndromes include hepatic metastases with capsular invasion, celiac nodal invasion, lumbar plexopathy from retroperitoneal nodes, and mesenteric traction from peritoneal implants, bowel obstruction and intussusception. The unique neuroanatomy of visceral afferent innervation predicts unique clinical presentations. Somatic referral is due to the convergence synapse of visceral and somatic primary afferents in the dorsal horn. The highly emotive nature of visceral pain is due to a significant representation in insular cortex. Management is based on the WHO 3 step ladder guideline. Despite the unique nature of visceral nociceptive processing, choice of analgesics and adjuvants by guidelines are similar to those used for somatic pain. There is some suggestion though that oxycodone is superior to morphine when treating pancreatitis. This may be due to the high representation of kappa opioid receptors in visceral. There are few analgesic trials exclusively designed for visceral pain. Celiac and hypogastric blocks relieve pain as do spinal analgesics. Commissural myelotomy rather than lateral cordotomy uniquely relieves visceral pain. Gastrointestinal stenting relieves obstruction and reduces pain but also may cause pain. Treatment related toxicity from radiation and chemotherapy may result in long term visceral hypersensitivity syndrome and pain in cancer survivors.
Within this lecture participants will be able to understand the differences in nociceptive processing between visceral and somatic pain, visceral pain pathophysiology, potential treatment options and gaps in knowledge particularly related to cancer visceral pain.
