Clinical Endoscopy

  • 제42권5호
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  • Pages.323-326
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  • 2011
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  • 2234-2400(pISSN)
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  • 2234-2443(eISSN)
대한소화기내시경학회 (The Korean Society of Gastrointestinal Endoscopy)
권호 표지

내시경초음파 유도하 복강신경얼기 박리술 시행 후 마약금단증상을 보인 췌장암 1예

A Case of Pancreatic Cancer and Opioid Withdrawal after Endoscopic Ultrasound-guided Celiac Plexus Neurolysis

  • 설수환 (대구파티마병원 소화기내과) ;
  • 김현수 (대구파티마병원 소화기내과) ;
  • 황병식 (대구파티마병원 소화기내과) ;
  • 오대명 (대구파티마병원 소화기내과) ;
  • 백인엽 (대구파티마병원 소화기내과) ;
  • 박민규 (대구파티마병원 소화기내과) ;
  • 류현욱 (대구파티마병원 소화기내과) ;
  • 권종규 (대구파티마병원 소화기내과)
  • 발행 : 2011.05.30
⟨ 이전 논문 다음 논문 ⟩

초록

췌장암은 진단 시 수술이 불가능한 경우가 흔해 통증조절과 같은 대증요법이 주 치료다. 특히 말기로 갈수록 마약성 진통제를 증량해도 통증이 조절이 되는 않는 경우가 있어 복강신경얼기 박리술과 같은 비약물성 치료를 내시경초음파 유도하에 시도하고 있다. EUS-CPN은 천자침의 위치를 실시간으로 확인하여 시행하므로 안전하며 통증경감의 효과도 좋다. 저자들은 수술이 불가능한 췌장암 환자에서 마약성 진통제로 통증조절 중 진통제로 인한 부작용으로 인해 대체시술로 EUS-CPN을 시행하였고, 이후 암성통증이 조절되어 마약을 중단한 후 마약금단증상을 경험하였다. EUS-CPN은 마약성 진통제의 부작용 및 용량을 줄일 수 있는 효과가 있으며 통증경감의 효과도 좋지만 통증조절이 잘 되더라도 마약성 진통제를 바로 중단하게 되면 금단 증상이 나타날 수 있어 수일에 걸쳐 용량을 감량하는 것이 필요하다.

Pancreatic cancer is usually unresectable upon diagnosis, and treatment aims to optimize the quality of the patient's life by managing symptoms, and, particularly, by providing adequate pain control. When the pain is refractory to opioids, interventions such as celiac plexus neurolysis (CPN) can be considered. Endoscopic ultrasound (EUS)-guided CPN has been introduced for pancreatic cancer. Reported herein is a case of a 75 year-old man with pancreatic cancer who was treated with opioids due to severe abdominal pain. EUS-guided CPN was performed for pain control, and the opioid administration was discontinued as the pain improved dramatically. However, the patient experienced opioid withdrawal symptoms, including anxiety, insomnia, nausea, and vomiting. Thus, although EUS-guided CPN successfully reduced pain in a patient undergoing such treatment and to whom opioid was administered, opioid administration should not be abruptly discontinued. Rather, the opioid dose should be reduced gradually to avoid drug withdrawal.

키워드

참고문헌

  1. Ventafridda GV, Caraceni AT, Sbanotto AM, Barletta L, De Conno F. Pain treatment in cancer of the pancreas. Eur J Surg Oncol 1990;16:1-6.
  2. Dumas EO, Pollack GM. Opioid tolerance development: a pharmacokinetic/pharmacodynamic perspective. AAPS J 2008;10:537-551. https://doi.org/10.1208/s12248-008-9056-1
  3. Collett BJ. Opioid tolerance: the clinical perspective. Br J Anaesth 1998;81:58-68. https://doi.org/10.1093/bja/81.1.58
  4. Chak A. What is the evidence for EUS-guided celiac plexus block/neurolysis? Gastrointest Endosc 2009;69(suppl 2):172S-173S. https://doi.org/10.1016/j.gie.2008.12.022
  5. Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996;44:656-662. https://doi.org/10.1016/S0016-5107(96)70047-0
  6. el-Kamar FG, Grossbard ML, Kozuch PS. Metastatic pancreatic cancer: emerging strategies in chemotherapy and palliative care. Oncologist 2003;8:18-34.
  7. Molinari M, Helton WS, Espat NJ. Palliative strategies for locally advanced unresectable and metastatic pancreatic cancer. Surg Clin North Am 2001;81:651-666. https://doi.org/10.1016/S0039-6109(05)70151-1
  8. Brescia FJ. Palliative care in pancreatic cancer. Cancer Control 2004;11:39-45. https://doi.org/10.1177/107327480401100106
  9. Carr DB, Goudas LC, Balk EM, Bloch R, Ioannidis JP, Lau J. Evidence report on the treatment of pain in cancer patients. J Natl Cancer Inst Monogr 2004;32:23-31.
  10. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995;63:65-76. https://doi.org/10.1016/0304-3959(95)00017-M
  11. Levy MJ, Wiersema MJ. EUS-guided celiac plexus neurolysis and celiac plexus block. Gastrointest Endosc 2003;57:923-930. https://doi.org/10.1016/S0016-5107(03)70036-4
  12. Patt R. Outcomes, efficacy, complications and sequelae of visceral pain management. In: Raj PR, ed. Practical management of pain. 3rd ed. St. Louis: Mosby, 2000:904.
  13. Gunaratnam NT, Sarma AV, Norton ID, Wiersema MJ. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. Gastrointest Endosc 2001;54:316-324. https://doi.org/10.1067/mge.2001.117515
  14. Davies DD. Incidence of major complications of neurolytic coeliac plexus block. J R Soc Med 1993;86:264-266.
  15. O'Toole TM, Schmulewitz N. Complication rates of EUS-guided celiac plexus blockade and neurolysis: results of a large case series. Endoscopy 2009;41:593-597. https://doi.org/10.1055/s-0029-1214868
  16. Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. Pain 2007;129:235-255. https://doi.org/10.1016/j.pain.2007.03.028
  17. Gowing LR, Farrell M, Ali RL, White JM. Alpha2-adrenergic agonists in opioid withdrawal. Addiction 2002;97:49-58. https://doi.org/10.1046/j.1360-0443.2002.00037.x
  18. Gowing LR, Ali RL. The place of detoxification in treatment of opioid dependence. Curr Opin Psychiatry 2006;19:266-270. https://doi.org/10.1097/01.yco.0000218596.54054.a1