Crohn's Disease Forum » General IBD Discussion » Pain options: splanchnic nerve block? Ketamine?

10-02-2017, 12:24 AM   #1
Join Date: Aug 2016
Location: Victoria, Australia
Pain options: splanchnic nerve block? Ketamine?

Hi everyone! Apologies if this is an unnecessary new thread, but I haven't been able to find much on the forums on this issue.

The pain management story is all special and fun. My wonderful pain specialist has me on Lyrica (pregabalin) which I have found pretty effective (although not perfect). At high doses, a side effect presented which drove me bonkers and felt like a deal-breaker - so we tried gabapentin, which not only had the same side effect, but was less effective at managing my pain.

Then my lovely pain specialist - seriously, wonderful doc, very warm and approachable, also explains things very well, listens well and is never dismissive - went on maternity leave. Congratulations!

...and I'm referred to a colleague in the meantime to provide continuity of care. He seems nice enough, but when I said I wanted to try something else, he suggested the following:

1) splanchnic nerve block

2) ketamine infusion (which he doesn't do, because he doesn't think the effect lasts beyond the time in hospital)

I admit I was a bit flabbergasted. The thing is, compared to a lot of people on here and by any objective clinical measure, my Crohn's is mild. I'm in pain all the time, but I don't have obstructions, scarring (I think - I do have a few ulcers, maybe they'll become scars?), adhesions, stoma, diarrhoea, etc. So I feel bad for complaining about it and making a fuss, even though my pain is bad enough that I can't concentrate or get stuff done - it's just there in the background. All. The. Time. And my pain processing is messed up enough that I often don't realise until I'm clenching my fists and breathing through it, and then my brain lets me know and it's like "Oh! I'm in pain. Huh."

so this guy I've just met - and had to tell about my TMI side effect (erm, more on that below) - is proposing I get steroids injected into my splanchnic nerve, or will offer to refer me to his colleague who does ketamine. And I just am in shock. I don't know what to think.

He's working up a quote for the nerve block.

Me, being a scientist by trade and training, immediately hits the primary literature, and folks, I am not seeing much that is encouraging.

I can find no articles on the use of nerve blocks in IBD. None. The celiac plexus looks really good for chronic pancreatitis, but that's a different kind of pain. I even found an article on clinical management of pain in IBD that specifically mentioned that they thought a nerve block would be ineffective, given that the pain of IBD is complex.

Thing is, they're right. It is complex, I can name and describe three or four different types of pain off the top of my head, some of which are upper abdominal, some lower abdominal, some near-constant, some intermittent, some dependent on other activity (i.e., the stabbing bouncing pain happens if I go for a run when other pain is present - hence why I take codeine before running. I would like to stop doing this?).

Meanwhile, I found one (1) article that looked at the effects of ketamine infusion in the management of chronic pain in patients <17. I'm 36. The pool of inflammatory patients was not bad - n= 79 - but IBD and pancreatitis were pooled together. It was noted that Crohn's patients responded particularly well to ketamine in terms of pain improvement.

But there was no information on how long this effect lasted after the infusion stopped.

If the nerve block works, it lasts up to 6 months (but it's really different for different people - I process drugs VERY quickly, so I'd be lucky to get that. I mean, on the upside, I sober up quickly, hey? ).

If the ketamine works, I might get 3 months, or in some cases a much longer term effect.

This is all based on the fact that my visceral pain is mostly hyperalgesia, *not* being constantly made worse by active Crohn's - I'm not in remission yet. I've only been on methotrexate for a few months (azathioprine and 6MP both turned toxic for me - damn). I could get my hypersensitivity system completely reset by one of these procedures (best case scenario).

And then the Crohn's could just set the system up again.

I'm just not sure what to do. I've got an appointment with the ketamine guy to get some of these questions answered, but does anyone have any more info on this sort of pain management intervention?

I'd just like to move on from codeine. It's not super awesome for IBD, and I'm tired of it, to be honest.

Hope you're all well, sorry for being so wordy, and I hope you're all doing well.

(PS the side effect is quite TMI, and apologies, but in the interests of people being aware - and it's quite common for pregabalin and gabapentin - it's anorgasmia. Which will be more awful for some people than others. For me, it's really bad, like anxiety-causing bad! ...I'm just going to go sit in the corner blushing now)
10-02-2017, 09:42 AM   #2
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Join Date: Oct 2016
Location: Massachusetts

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My GP has me on a Butrans patch for the intense pain I get. Itís actually pretty effective. In tiny doses buprenorphine is used for moderate to severe pain relief. They arenít sure why I am in so much pain, but the thought is itís due to a narrowing in my terminal ileum. It might be worth checking out. I took both lyrica and gabapentin for migraines and not only did they not help but I felt like my brain didnít work. With Butrans I donít have any side effects.

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