Pain relief treatment for pancreatitis leads to Cushing’s in woman
Celiac plexus block with corticosteroid resulted in Cushing's-related symptoms
A young woman developed Cushing’s disease after she received pain relief treatment for her chronic pancreatitis — a long-lasting inflammation of the pancreas — via a celiac plexus block (CPB) with a corticosteroid called triamcinolone, a U.S. report says.
“Although her pain was relieved with CPB, she developed iatrogenic [or treatment-related] Cushing’s disease,” researchers wrote. When Cushing’s disease arises as a complication of treatment with a corticosteroid, it is called exogenous or iatrogenic.
“To our knowledge, this has not been previously reported in the current literature,” the researchers wrote, adding that doctors should consider which medications to use during a CPB “to avoid complications such as iatrogenic Cushing’s disease.”
The report, “Iatrogenic Cushing’s From Celiac Plexus Blocks for Chronic Pancreatitis: A Case Report,” was published in the journal Cureus.
Severe abdominal pain is major symptom of chronic pancreatitis
Severe abdominal pain is a major symptom in people with chronic pancreatitis or other pancreatic diseases, such as cancer. It is often difficult to treat.
When the pancreas becomes inflamed, it can put pressure on the celiac plexus, causing pain. The celiac plexus is a bundle of nerves in the upper abdomen that sits behind the pancreas.
A CPB can help relieve severe abdominal pain when other treatment options haven’t helped.
“Many studies have shown adequate pain control with CPB in chronic pancreatitis,” the researchers wrote.
The treatment involves injecting an anesthetic, alone or in combination with a corticosteroid, directly into the nerves of the celiac plexus to stop them from sending pain signals to the brain.
Although CPB carries some risks, and complications may occur, there has been no report of iatrogenic Cushing’s disease arising as a side effect.
“We report the first case of iatrogenic Cushing’s disease from CPB in the treatment of chronic pancreatitis,” the researchers wrote.
They described the case of a 27-year-old woman who had a history of chronic pancreatitis and irritable bowel syndrome, which causes gut discomfort. She also had gastroparesis, a condition that causes food to pass through the stomach slower than it should, and endometriosis, a disease where tissue similar to the lining of the womb grows outside the womb.
The patient had also been diagnosed and was currently being treated for bipolar disorder, a mental illness that affects mood, which can swing from one end of the spectrum to the other. For her, this meant going through periods of depression.
She entered the emergency department with complaints of severe abdominal pain, which she rated as a 10 out of 10 on a numerical rating scale. She also experienced nausea.
Pain reoccurred often and was due to her chronic pancreatitis, which was confirmed by endoscopic ultrasound — a procedure that allows doctors to examine the inside of the gut and nearby organs, such as the pancreas. The procedure revealed gastritis, an inflammation of the stomach, and moderate-to-severe chronic pancreatitis.
We report the first case of iatrogenic Cushing’s disease from CPB [celiac plexus block] in the treatment of chronic pancreatitis.
For her recurring pain, she was taking ibuprofen (an anti-inflammatory medication), famotidine (an antacid), and the pain killers acetaminophen and oxycodone, an opioid.
A pain management doctor added hydromorphone, another opioid, and methadone to her treatment regimen. Methadone is often used to lessen the effects of opioid withdrawal and reduce the harm linked to opioid use.
However, one month later, the patient again experienced severe abdominal pain, which she rated as an 8-10 out of 10. That’s when she went on to get a CPB.
During the procedure, she received an injection of bupivacaine, an anesthetic, and 80 mg of triamcinolone, a corticosteroid that’s used to ease inflammation. The procedure was repeated four months later for complete pain relief.
Then, two months later, another CPB was done. This time, doctors used bupivacaine and 200 mg of triamcinolone.
Within about one month, she was back at the emergency department with recurring pain, which she rated as a 10 out of 10. A new CPB was done using the same dosing as in the previous one. A hydromorphone pump was also placed that allowed her to control the amount of opioids she needed from time to time.
While this approach again provided complete pain relief, it didn’t last long. Two months later, she returned to the hospital with severe abdominal pain.
Patient’s symptoms lead doctors to suspect Cushing’s
This time around, she had gained 10 lbs and developed dark purple stretch marks around the abdomen. Her face looked round, and she had developed acne and facial hair. She also experienced insomnia and fatigue.
These symptoms led doctors to suspect the patient had iatrogenic Cushing’s disease. To confirm their suspicions, they ordered tests to check the levels of cortisol and adrenocorticotropic hormone (ACTH).
Cortisol and ACTH are two hormones that have a close relationship. ACTH is produced by the brain’s pituitary gland and signals the production and release of cortisol from the adrenal glands, which are located atop the kidneys. Cortisol then acts on different parts of the body. Too much cortisol, however, can cause Cushing’s disease.
Testing revealed she had low levels of both cortisol and ACTH, consistent with iatrogenic Cushing’s disease driven by excessive corticosteroid use.
It was recommended she stop using corticosteroids for “at least three to six months.” About five months later, her Cushing’s disease symptoms had resolved.
She continued to receive pain relief via CPB, and a referral for a pancreas transplant.