Interventions for the management of abdominal pain in ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) is a chronic inflammation of the colon characterised by periods of relapse and remission. It starts in the rectum and can extend throughout the colon. UC and Crohn's disease (CD) are the most common inflammatory bowel diseases (IBDs). However, UC tends to be more common than CD. It has no known cure but can be managed with medication and surgery. However, studies have shown that abdominal pain persists in up to one-third of people with UC in remission. Abdominal pain could be a symptom of relapse of the disease due to adverse effects of medication, surgical complications and strictures or adhesions secondary to UC. OBJECTIVES: To assess the efficacy and safety of interventions for managing abdominal pain in people with ulcerative colitis. SEARCH METHODS: We searched CENTRAL, MEDLINE and five other databases and clinical trials registries on 28 April 2021. We contacted authors of relevant studies and ongoing or unpublished trials that may be relevant to the review. We also searched references of trials and systematic reviews for any additional trials. SELECTION CRITERIA: All published, unpublished and ongoing randomised trials that compared interventions for the management of abdominal pain with other active interventions or standard therapy, placebo or no therapy were included. People with both active and inactive disease were included. We excluded studies that did not report on any abdominal pain outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted data extraction and 'Risk of bias' assessments. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs), respectively, with 95% confidence intervals. We assessed the certainty of the evidence using the GRADE methodology. MAIN RESULTS: We included five studies (360 randomised participants). Studies considered mainly participants in an inactive state of the disease.   No conclusions could be drawn about the efficacy of any of the interventions on pain frequency, pain intensity, and treatment success. The certainty of the evidence was very low for all comparisons because of imprecision due to sparse data, and risk of bias. One study compared a low FODMAPs diet (n=13) to a sham diet (n=13). The evidence is very uncertain about the effect of this treatment on pain frequency (MD -4.00, 95% CI -20.61 to 12.61) and intensity (MD -9.00, 95% CI -20.07 to 2.07). Treatment success was not reported. One study compared relaxation training (n=20) to wait-list (n=20). The evidence is very uncertain about the effect of this treatment on pain frequency at end of intervention (MD 2.60, 95% CI 1.14 to 4.06) and 6-month follow-up (MD 3.30, 95% CI 1.64 to 4.96). Similarly, the evidence is very uncertain about the effect of this treatment on pain intensity at end of intervention (MD -1.70, 95% CI -2.92 to -0.48) and 6-month follow-up (MD -2.30, 95% CI -3.70 to -0.90). Treatment success was not reported. One study compared yoga (n=30) to no intervention (n=30). The study defined treatment success as the presence or absence of pain; however, the data they provided was unclear. Pain frequency and intensity were not reported. One study compared a kefir diet (Lactobacillus bacteria, n=15) to no intervention (n=15). The evidence is very uncertain about the effect of this treatment on pain intensity (MD -0.17, 95% CI -0.91 to 0.57). Pain frequency and treatment success were not reported. One study compared a stellate ganglion block treatment (n=90) to sulfasalazine treatment (n=30). The study defined treatment success as "stomachache"; however, the data they provided was unclear. Pain frequency and intensity were not reported. Two studies reported withdrawals due to adverse events. One study reported withdrawals due to adverse events as zero. Two studies did not report this outcome.  We cannot draw any conclusions about the effects of any of the interventions on withdrawals due to adverse events because of the very limited evidence. The reporting of secondary outcomes was inconsistent. Adverse events tended to be very low or zero. However, we can make no clear judgements about adverse events for any of the interventions, due to the low number of events. Anxiety was measured and reported at end of intervention in only one study (yoga versus no intervention), and depression was not measured in any of the studies. We can therefore draw no meaningful conclusions about these outcomes. AUTHORS' CONCLUSIONS: We found very low-certainty evidence on the efficacy and safety of interventions for the management of abdominal pain in ulcerative colitis. Pervasive issues with very serious imprecision from small samples size and high risk of bias have led to very low-certainty outcomes, precluding conclusions. While few adverse events and no serious adverse events were reported, the certainty of these findings was again very low for all comparisons, so no conclusions can be drawn. There is a need for further research. We have identified eight ongoing studies in this review, so an update will be warranted. It is key that future research addresses the issues leading to reduced certainty of outcomes, specifically sample size and reporting that leads to high risk of bias. It is also important that if researchers are considering pain as a critical outcome, they should report clearly if participants were pain-free at baseline; in that case, data would be best presented as separate subgroups throughout their research.

Stellate ganglion block and cardiac sympathetic denervation in patients with inappropriate sinus tachycardia.

BACKGROUND: Inappropriate sinus tachycardia (IST) remains a clinical challenge because patients often are highly symptomatic and not responsive to medical therapy. OBJECTIVE: To study the safety and efficacy of stellate ganglion (SG) block and cardiac sympathetic denervation (CSD) in patients with IST. METHODS: Twelve consecutive patients who had drug-refractory IST (10 women) were studied. According to a prospectively initiated protocol, five patients underwent an electrophysiologic study before and after SG block (electrophysiology study group). The subsequent seven patients had ambulatory Holter monitoring before and after SG block (ambulatory group). All patients underwent SG block on the right side first, and then on the left side. Selected patients who had heart rate reduction ≥15 beats per minute (bpm) were recommended to consider CSD. RESULTS: The mean (SD) baseline heart rate (HR) was 106 (21) bpm. The HR significantly decreased to 93 (20) bpm (P = .02) at 10 minutes after right SG block and remained significantly slower at 97(19) bpm at 60 minutes. Left SG block reduced HR from 99 (21) to 87(16) bpm (P = .02) at 60 minutes. SG block had no significant effect on blood pressure or HR response to isoproterenol or exercise (all P > .05). Five patients underwent right (n = 4) or bilateral (n = 1) CSD. The clinical outcomes were heterogeneous: one patient had complete and two had partial symptomatic relief, and two did not have improvement. CONCLUSION: SG blockade modestly reduces resting HR but has no significant effect on HR during exercise. Permanent CSD may have a modest role in alleviating symptoms in selected patients with IST.

Effects of oestrogen and Cimicifuga racemosa on the cardiac noradrenaline pathway of ovariectomized rats.

NEW FINDINGS: What is the central question of this study? We investigated the effects of oestrogen and Cimicifuga racemosa on the stellate ganglion, cardiac noradrenaline pathway and Ca2+ -calmodulin-dependent protein kinase II in ovariectomized rats. What is the main finding and its importance? The right stellate ganglion, but not the left, may be associated with decreased left ventricular noradrenaline content in ovariectomized rats. Oestrogen can reverse all changes caused by ovariectomy. Cimicifuga racemosa did not affect left ventricular noradrenaline, but decreased protein expression of ß1 -adrenergic receptor and Ca2+ -calmodulin-dependent protein kinase II. The results might explain potential effects of C. racemosa on the cardiovascular system and provide new insights into cardiovascular protection. The aim of this study was to investigate the effects of oestrogen and Cimicifuga racemosa on the stellate ganglion, cardiac noradrenaline (NA) pathway and Ca2+ -calmodulin-dependent protein kinase II (CaMK II). Forty adult female Sprague-Dawley rats were randomly divided into the following four groups: sham operated (SHAM); ovariectomized (OVX); ovariectomized with oestrogen treatment (E2); and ovariectomized with C. racemosa treatment (iCR). After 4 weeks of treatment, the NA content was determined by high-performance liquid chromatography, and dopamine ß-hydroxylase (DBH) and noradrenaline transporter (NET) expression were detected by immunohistochemistry. Western blotting was used to determine NET, ß1 -adrenergic receptor (ß1 -AR) and CaMK II expression. Compared with the SHAM group, body weights, DBH and NET expression in the right stellate ganglia, and NET, ß1 -AR and CaMK II expression in the left ventricles of the OVX group were increased, whereas left ventricular NA content was decreased; DBH and NET expression in the left stellate ganglion was not significantly different. The indexes of the E2 group were similar to those of the SHAM group. Moreover, in the iCR group, DBH, NET, ß1 -AR and CaMK II expression was decreased; NET expression and NA content of the left ventricle remained unchanged. Our conclusions are as follows. First, the right stellate ganglion, but not the left, may be associated with decreased left ventricular NA content in OVX rats. Second, oestrogen increases the left ventricular NA content and adjusts the expression of DBH and NET in the right stellate ganglion and restores ß1 -AR and CaMK II protein expression to normal levels. Third, C. racemosa does not affect left ventricular NA, but decreases the protein expression of ß1 -AR and CaMK II.

[Clinical observation of dysantonomia treated with transcutaneous electrical stimulation at Renying (ST 9) combined with stellate ganglion block].

OBJECTIVE: To compare the clinical efficacy difference in dysantonomia between transcutaneous electrical stimulation at Renying(ST 9) combined with stellate ganglion block(SGB) and simple SGB. METHODS: Sixty patients in accord with the diagnostic criteria of dysantonomia were randomly divided into two groups,30 cases in each group. In the observation group,transcutaneous electrical stimulation at Renying(ST 9) combined with SGB were adopted; in the control group,simple SGB was applied. In the two groups, treatment was used three times a week,and nine treatments were considered as one course. There was an interval of one week between courses,and two courses were treated. Total seven weeks were required. Scores were evaluated according to subjective symptoms before treatment,one month and three months after treatment in the two groups. RESULTS: The scores of subjective symptoms were not statistically different before treatment in the two groups(P>0. 05). The scores of subjective symptoms one month and three months after treatment were all lower than those before treatment(all P< 0. 01), and subjective symptoms scores in the observation group were lower than those in the control group(both P<0. 01). CONCLUSION: Transcutaneous electrical stimulation at Renying(ST 9) combined with SGB could obviously enhance the clinical effects for dysantonomia, and the control and improvement for clinical symptoms are apparently superior to simple SGB.

Stellate Ganglion Block, Compared With Xenon Light Irradiation, Is a More Effective Treatment of Neurosensory Deficits Resulting From Orthognathic Surgery, as Measured by Current Perception Threshold.

PURPOSE: The aim of this study was to evaluate the relative effectiveness of stellate ganglion blockade (SGB) versus xenon light irradiation (XLI) for the treatment of neurosensory deficits resulting from orthognathic surgery as determined by a comparison of prospective measurements of electrical current perception thresholds (CPTs) and ranged CPTs (R-CPTs). MATERIALS AND METHODS: CPT and R-CPT in the mental foramen area were measured during electrical stimulation at 98 different sites on the body in patients who had undergone orthognathic surgery. After surgery, patients were assigned to the SGB group or the XLI group. CPT and R-CPT of the 2 groups were measured at stimulation frequencies of 2,000, 250, and 5 Hz before surgery, 1 week after surgery, and after 10 treatment sessions. Furthermore, the influence of surgical factors, such as genioplasty and a surgically exposed inferior alveolar nerve (IAN), was examined in the 2 groups. RESULTS: Patients' CPT and R-CPT values indicated a considerable amount of sensory disturbance in most cases after surgery. The change in magnitude of all CPT and R-CPT values for the SGB group decreased considerably compared with that for the XLI group after treatment. There was no correlation between CPT or R-CPT values and surgical factors (eg, genioplasty and exposure of the IAN). CONCLUSION: SGB of the IAN could be an effective method for treating neurosensory deficits after orthognathic surgery on the IAN.

Effects of stellate ganglion block on sedation as assessed by bispectral index in normal healthy volunteers.

BACKGROUND: The sympathetic nervous system plays an important role in the arousal response. Recently, the stellate ganglion block (SGB) was found to effectively treat anxiety and night awakening in humans and decrease electroencephalogram (EEG) indices of arousal responses in rat. But, the role of the sympathetic block in human arousal responses has not yet been studied. OBJECTIVE: We performed this prospective, double-blinded, controlled volunteer study to investigate the sedative effects and bispectral index (BIS) changes of SGB. STUDY DESIGN: A randomized, double-blind trial. SETTING: Single academic medical center. METHODS: This study was approved by the Ethics Committee of Kyungpook National University Hospital (ref: KNUH-10-1081) and registered with CRiS (Clinical Research Information Service, http://cris.cdc.go.kr, ref: KCT0000036, 2010. 9.24). Twenty healthy volunteers were enrolled in this study. The volunteers were randomly assigned to one of 2 groups: the SGB group (n = 10) and the sham group (n =10). Volunteers in SGB group received SGB and volunteers in the sham group received a sham procedure. BIS value, heart rate, and blood pressure were measured before and 5, 10, 20, and 30 minutes after the procedure. Observer's Assessment of Alertness/Sedation (OAA/S) scores were assessed before and 10 and 30 minutes after the intervention. RESULTS: In the SGB group, BIS values and OAA/S scores significantly decreased after the intervention as compared to baseline (P < 0.05). The values were also significantly decreased in the SGB group when compared to the values in sham group after the intervention (P < 0.05). There was a significant change of mean blood pressure 10 to 30 minutes after SGB (P < 0.05). There were no differences in heart rate during study period between groups. LIMITATIONS: This study is limited by a relatively small sample size. CONCLUSIONS: This study showed that SGB has a sedative effect in normal healthy volunteers, as evidenced by decreased OAA/S scores and BIS values.

Effect of combination of trigger point injection and stellate ganglion block on non-odontogenic mandibular molar pain referred from masseter muscle: a case report.

We report a case of myofascial pain syndrome (MPS), manifested as nonodontogenic mandibular molar pain referred from the masseter muscle, relieved by a combination of trigger point injection (TPI) and stellate ganglion block (SGB). The patient was a 32-year-old woman who had experienced cold hypersensitivity in the right third mandibular molar 2 months prior to visiting our department. Subsequently, she had visited a family dentist and undergone pulpectomy under local anesthesia. She eventually visited our clinic because there was no marked change in her symptoms. On the first visit, no tooth abnormality was found and the patient was neither anxious nor depressive. Tender points were found in the right masseter and temporal muscles during muscle palpation. Referred pain radiating to the right mandibular molars was observed when pressure was applied to the central portion of the right masseter muscle. As a result, we diagnosed MPS based on evidence of nonodontogenic tooth pain caused by referred pain from the masseter muscle. We performed TPI with 2% lidocaine hydrochloride to the tender point in the masseter muscle. Although the visual analog scale (VAS) pain score dropped from 97 to 36, complete pain relief was not achieved. The TPI was effective for approximately 7 hrs, after which severe throbbing pain returned. The sustained nature of the tooth pain suggested that it was sympathetic nerve-dependent. Subsequently, we performed SGB, resulting in a reduction in the VAS pain score from 90 to 32. Therefore, we performed another TPI and the VAS pain score dropped to 0. We continued SGB and TPI for the next 3 days and the symptoms disappeared. Thus, a combination of TPI and SGB controlled MPS manifested as masseter muscle-mediated nonodontogenic tooth pain.

Evaluation of effectiveness of stellate ganglion block (SGB) treatment of sudden hearing loss.

CONCLUSION: A stellate ganglion block (SGB) based on the goal of improving internal ear circulatory disturbance appears to be beneficial for the treatment of sudden hearing loss. OBJECTIVES: To evaluate the effectiveness of SGB for sudden hearing loss. METHODS: This retrospective study reviewed the medical records of 49 patients who received SGBs and 496 patients who received only conservative therapy, primarily with systemic steroids, for treatment of sudden hearing loss. Propensity scores were used in pairwise matching of these patients to avoid selection biases between the two treatment modalities. RESULTS: Propensity score matching yielded 48 pairs. The mean therapeutic effect of the SGB was calculated to be 0.40 ± 0.20 (mean ± standard error, p = 0.051).

What can be done about hot flushes after treatment for breast cancer?

Breast cancer survivors frequently experience severe hot flushes as a result of their treatment. This can adversely affect their quality of life, compliance with treatment and overall survival. To relieve vasomotor symptoms, a variety of drugs have been used including clonidine, gabapentin, selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. Stellate ganglion block (SGB) has recently emerged as a new technique against hot flushes and preliminary studies report encouraging efficacy with minimal complications. Other approaches include various alternative treatments and, in a few cases, hormone replacement therapy (HRT). All randomized, controlled studies of drugs, hormone treatments and alternative therapies for vasomotor symptoms have been reviewed and efficacy and safety noted. Side-effects of current medical treatments frequently outweigh the benefits--leading many patients to discontinue the medications. Statistically significant differences between placebo and test agent may not translate into a meaningful subjective benefit. Desvenlafaxine looks promising as does SGB, despite its invasive nature. The favorable safety profile of SGB is confirmed through the long experience of SGB performed for other medical purposes. The majority of non-HRT treatments for hot flushes are little better than placebo but early results from randomized trials of desvenlafaxine and pilot studies of SGB suggest that it is worthwhile to test their efficacy specifically in breast cancer survivors.

Prostaglandin E1 in combination with hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss.

CONCLUSIONS: Prostaglandin E1 (PGE1) is less effective than stellate ganglion block (SGB) in the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) patients with severe hearing losses when used together with hyperbaric oxygen (HBO) therapy. In contrast with the systemic action of intravenous PGE1, SGB's localized vasodilating action may explain its advantage over intravenous PGE1. OBJECTIVES: To investigate the effect of PGE1 plus HBO therapy on ISSNHL in comparison with that of SGB plus HBO therapy. PATIENTS AND METHODS: We retrospectively analyzed 205 consecutive patients with ISSNHL (hearing levels > or = 40 dB; time from the onset of hearing loss to the start of treatment < or = 30 days). Ninety-five patients underwent intravenous PGE1 plus HBO therapy (PG group) and 110 underwent SGB plus HBO therapy (SGB group). Hearing recovery was evaluated by grade assessment and by hearing improvement compared to that in the unaffected contralateral ear. RESULTS: The overall hearing outcome was not statistically different between the two groups. For patients with initial hearing levels <80 dB, the groups had roughly equivalent hearing outcomes, whereas in patients with initial hearing levels > or = 80 dB, the hearing improvement rate was significantly higher in the SGB group than in the PG group (53.0 +/- 5.0% vs 35.3 +/- 6.8%; p <0.05).

Stellate ganglion blockade provides relief from menopausal hot flashes: a case report series.

OBJECTIVE: To investigate whether standard C6 stellate ganglion blockade (SGB) might provide relief from hot flashes associated with menopause. METHODS: Six women were referred for severe menopausal hot flashes and elected to undergo standard SGB (5 ml 0.375% Marcaine, Abbott Labs, Abbott Park, IL) to evaluate a novel intervention for hot flash relief. Hot flashes were assessed by self-reporting before and after stellate ganglion block. RESULTS: Initial SGB (SGB1) was successful in all 6 subjects, as evidenced by a positive Horner's syndrome and anhydrosis. Successful SGB caused complete alleviation of hot flashes for times ranging from 2 to 5 weeks. Patients returned for follow-up SGB after mild hot flashes returned. A second SGB produced additional asymptomatic periods of relief ranging from 4 to 18 weeks. In each case, repeated block provided hot flash relief equal to or greater than that of the initial block. Two patients who submitted for a third SGB reported 15 and 48 weeks of relief. CONCLUSION: Successful SGB appears to be related to relief of hot flashes. Repeat SGB results in efficacious multiple week relief of severe hot flashes associated with menopause.

Treatment of post-herpetic neuralgia. A review of 77 consecutive cases.

The treatment of 77 consecutive cases of post-herpetic neuralgia is reviewed. Stellate blockade proved helpful in 75% of patients with pain of less than 1 year's duration; 40% became virtually pain free. Drug treatment and electrical counterirritation methods gave improvement in 60% of cases but only 15% became pain free. Stellate block carried out after 1 year of pain proved helpful in only 44% of patients, and only 22% became pain free. Stellate blockade carried out within 1 year of the onset of symptoms would appear to be one of the treatments of choice for post-herpetic neuralgia. It would be of interest to see the results of a controlled randomised trial.

Reversible blockade of cardiac efferents with procaine instilled into the pericardium of cats.

The blocking of afferent signals from the heart by the instillation of local anaesthetics into the pericardium has frequently been used for studying cardiac reflexes. Yet no attempts have been made to define what effects this has on efferent cardiac drive. Therefore, in nine chloralosed cats with open chests and catheters sewn into the pericardium the procaine concentrations were determined which would block the heart rate responses to electrostimulation of the vagi nerves or the stellate ganglia. The procaine effects on arterial pressure and left ventricular peak positive dP/dt were also evaluated and in 11 cats the vagolytic effects of atropine (0.25 mg . kg-1, intravenous) and intrapericardial procaine (0.1%) were compared. As little as 0.05% procaine attenuated the bradycardia associated with stimulation of the stellate ganglia by only about 30%. Virtual elimination of both sympathetic and vagal drive was achieved with 0.5% procaine having only mild effects on blood pressure and left ventricular dP/dt. Atropine (0.25 mg . kg-1, intravenously) and procaine (0.1% intrapericardially) affected heart rate equally. With procaine in the pericardium it is possible to reversibly and selectively block cardiac efferents and to separate vagal and sympathetic drive by choosing the appropriate concentration of the local anaesthetic.

[Temporary amaurosis in endonasal microsurgery of the ethmoid and lacrimal sac in local anaesthesia (author's transl)]. / Temporäre Amaurose bei mikrochirurgischer endonasaler Ethmoid- und Saccus-lacrimalis-Operation in Lokalanästhesie.

After injection of 1-2 cc. Scandicain and Suprarenin into the ethmoidalis vessels a female patient developed 1972 protrusio bulbi combined with amaurosis. After endonasal lacrimal sac operation with decompression of the orbita the protrusio bulbi disappeared without change of the amaurosis. Under the operating microscope no haematoma was found neither in the ethmoid nor in the orbita. Finally after 35-40 min. under an injection for blockage of the ganglion stellatum, the patient cried: "I can see light". Under further treatment, as known for acute hearing loss, the patient recovered a normal vision. In 1979 we have operated on 96 lacrimal sacs and all together 225 endonasal microsurgical ethmoid resections. After performing more than 8000 ethmoid operative procedures in the years before, a similar complication was observed in 1936 only. No persistent amaurosis was noticed. As amaurosis is extremely rare in our statistics on endonasal microsurgical ethmoid resections under reduction of blood pressure, there is no reason why the patient should be informed preoperatively about this rare complication.

Sympathetically induced atrial tachycardia. Successful treatment by left stellate ganglion block.

An unusual type of atrial tachycardia was observed in a 52-year-old woman. The tachycardia occurred only when the patient kept the left upper limb in the lateral and horizontal position. Propranolol, atropine sulfate, carotid sinus massage and ocular compression were not effective in terminating or preventing the arrhythmia. Left stellate ganglion block has stopped the tachycardia for at least two years. The atrial tachycardia in this patient was thought to be caused by mechanical stimulation of the left stellate ganglion resulting in pacemaker shifting, as has been demonstrated in the canine heart.