What are the guideline sources, guidelines and references for Chronic pancreatitis ?
Guideline sources The following summarized guidelines for the evaluation and management of chronic pancreatitis are prepared by our editorial team based on guidelines from the Japanese Society of Gastroenterology (JSG 2022), the American College of Gastroenterology (ACG 2020), the European Society of Gastrointestinal Endoscopy (ESGE 2019), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2018), the Japan Pancreas Society (JPS/EPC/IAP/APA 2018; 2017), and the American Pancreatic Association (APA 2014). 1 2 3 4 5 6 7 9 9 9 10 11 Definition Chronic pancreatitis is a clinical syndrome involving inflammation, fibrosis, and loss of acinar and islet cells of the pancreas. 9 Epidemiology The pathogenesis of chronic pancreatitis typically involves multiple risk modifiers that interact to produce pancreatic disease, including bile duct obstruction (pancreatic tumors, chronic strictures), https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 1/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway exogenous toxins (alcohol, smoking), metabolic disturbances (hyperlipidemia, hypercalcemia), as well as autoimmune disease and genetic disease. 9 Pathophysiology The incidence of chronic pancreatitis ranges from 5 to 12 cases per 100,000 person-years, while its prevalence is estimated at 50 persons per 100,000 population. 10 Disease course Destruction of normal pancreatic tissue leads to the clinical manifestations of chronic abdominal pain, exocrine insufficiency (compromised digestion, absorption, and metabolism of nutrients), and endocrine insufficiency (pancreatogenic diabetes). 9 Prognosis and risk of recurrence Patients with chronic pancreatitis have increased mortality as compared with age and sex-matched controls (HR 5.0, 95% CI 4.8-5.2). 11 Guidelines 1. Screening and diagnosis Definitions: chronic pancreatitis is characterized by atrophy and fibrosis of the exocrine tissue, with or without chronic inflammation. Epidemiology: Data on population-based estimates of chronic pancreatitis are emerging. B A small fraction of patients progress from AP to CP. B Risk factors: alcohol and smoking are independent risk factors for chronic pancreatitis, and their risks are likely multiplicative. A Clinical presentation: recognize that abdominal pain is the most frequent symptom of chronic pancreatitis, and the severity, temporal nature, and natural history of pain is highly variable. B Differential diagnosis: As per ACG 2020 guidelines, identify underlying disorders of pancreatic inflammation to predict progression to chronic pancreatitis. B As per APA 2014 guidelines, autoimmune pancreatitis can mimic pancreatic carcinoma. 2. Diagnostic investigations Clinical assessment: As per ACG 2020 guidelines: https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 2/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway Obtain a comprehensive review of all risk factors in patients with clinical features of chronic pancreatitis to provide information on the underlying mechanisms, identify both fixed and modifiable risk factors, identify potential targets for therapies, and provide clinically relevant prognostic information. B Recognize that the development of diabetes mellitus in chronic pancreatitis is most likely related to the disease duration, although other etiologic factors such as BMI and smoking status may incur an increased risk. B As per IAP 2017 guidelines, obtain pain assessment in chronic pancreatitis following the guidelines for other types of chronic pain, taking into account the multidimensional nature of symptom presentation. B Cross-sectional imaging: As per ACG 2020 guidelines, obtain either CT or MRI as first-line imaging for the diagnosis of chronic pancreatitis. B As per APA 2014 guidelines, ultrasound and CT are the best tests to identify the late findings of chronic pancreatitis, but have limited utility for the diagnosis of early or mild pancreatitis. B Show 2 more Magnetic resonance cholangiopancreatography: As per JSG 2022 guidelines, consider obtaining abdominal MRI/MRCP for the diagnosis of chronic pancreatitis. C As per ACG 2020 guidelines, consider obtaining secretin-enhanced MRCP when the diagnosis of chronic pancreatitis after cross-sectional imaging or EUS is not confirmed and the clinical suspicion remains high. C Pancreatic function testing: As per ACG 2020 guidelines, obtain pancreatic function testing for the diagnosis of exocrine pancreatic insufficiency as a complementary means for the diagnosis of chronic pancreatitis. B As per APA 2014 guidelines: Direct pancreatic function tests are highly sensitive for detecting late chronic pancreatitis, but have lower sensitivity for early chronic pancreatitis (70-75%). B Indirect pancreatic function tests generally are sensitive for steatorrhea and useful to quantify the degree of exocrine insufficiency. B Genetic testing: As per JSG 2022 guidelines, consider obtaining genetic testing for PRSS1 and SPINK1 gene mutations in patients with juvenile pancreatitis or chronic pancreatitis of unknown origin and a family history. As per ACG 2020 guidelines, obtain genetic testing in patients with clinical evidence of a pancreatitis-associated disorder or possible chronic pancreatitis with unclear etiology, especially in younger patients. B 3. Diagnostic procedures https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 3/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway Endoscopic retrograde cholangiopancreatography: recognize that ERCP is seldom used for diagnostic purposes. B Endoscopic ultrasound: As per JSG 2022 guidelines, consider obtaining EUS for the diagnosis of chronic pancreatitis/early chronic pancreatitis due to its allowance for detailed observation of the pancreatic parenchyma and the morphology of the pancreatic duct. C As per ACG 2020 guidelines, obtain EUS only if the diagnosis is in question after cross-sectional imaging. B As per APA 2014 guidelines, the ideal threshold number of EUS criteria necessary to diagnose chronic pancreatitis has not been firmly determined. The presence of 5 or more criteria strongly suggests the diagnosis, while the presence of 2 criteria rules out the diagnosis of chronic pancreatitis. B Histology: As per ACG 2020 guidelines, consider performing histological examination as the gold standard for the diagnosis of chronic pancreatitis in high-risk patients when the clinical and functional evidence of chronic pancreatitis is strong, but imaging modalities are inconclusive. C As per APA 2014 guidelines, exocrine function declines as structural severity worsens in chronic pancreatitis. B 4. Medical management General principles: Refer all patients with presumed or established diagnosis of chronic pancreatitis to specialist pancreatic centers for investigation and treatment. B Follow the principles of the "pain relief ladder" provided by the WHO for analgesic therapy, adjusted to the pain characteristics of chronic pancreatitis. B Opioids: As per JSG 2022 guidelines, administer weak opioids if NSAIDs are ineffective. B As per ACG 2020 guidelines, consider administering opioids for the treatment of patients with painful chronic pancreatitis only if all other reasonable therapeutic options have been exhausted. C Antioxidants: As per ACG 2020 guidelines, consider initiating antioxidant therapy for the treatment of pain in patients with chronic pancreatitis. C As per IAP 2017 guidelines, consider including a combination of antioxidants in sufficient dosages in the pain treatments of patients with chronic pancreatitis. C Pancreatic enzyme replacement therapy: As per JSG 2022 guidelines, consider initiating pancreatic enzyme replacement therapy for abdominal symptoms, such as abdominal distention and flatulence, associated with pancreatic https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 4/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway exocrine dysfunction, but not for pain relief in patients with chronic pancreatitis. C Show 2 more As per ACG 2020 guidelines: Consider initiating pancreatic enzyme replacement therapy to improve the complications of malnutrition in patients with chronic pancreatitis and exocrine pancreatic insufficiency. C Avoid using pancreatic enzyme supplements to improve pain in patients with chronic pancreatitis. D As per IAP 2017 guidelines, consider initiating pancreatic enzyme therapy with high protease content as an initial treatment for pain in patients with chronic pancreatitis. C Protease inhibitors: consider initiating proteolytic enzyme inhibitors for the treatment of pain in patients with chronic pancreatitis. C Management of pancreatogenic diabetes: Initiate oral hypoglycemic agents for the management of pancreatogenic diabetes whether the patient has insulin resistance or normal insulin secretory capacity. B Initiate insulin therapy in patients with insulin-dependent diabetes mellitus. B Experimental treatment: offer experimental treatment modalities only in the context of a clinical research trial. B 5. Nonpharmacologic interventions Dietary modifications: Do not advise a uniform fat-restricted diet in the decompensated stage of chronic pancreatitis with exocrine pancreatic insufficiency. D Do not advise uniform calorie restriction in patients with pancreatogenic diabetes in view of the risk of poor nutrition and hypoglycemia. Ensure glycemic control in combination with treatment for pancreatic exocrine insufficiency with an appropriate energy intake. D Alcohol cessation: As per ACG 2020 guidelines, advise alcohol cessation in patients with chronic pancreatitis. B As per IAP 2017 guidelines, advise abstinence from alcohol, in addition to adequate treatment, in patients with chronic pancreatitis. B Smoking cessation: As per JSG 2022 guidelines, offer smoking cessation guidance in patients with chronic pancreatitis. B As per ACG 2020 guidelines, advise smoking cessation in patients with chronic pancreatitis. B As per IAP 2017 guidelines, advise abstinence from smoking, in addition to adequate treatment, in patients with chronic pancreatitis. B Behavioral interventions: offer behavioral interventions as part of the multidisciplinary approach in the management of pain in patients with chronic pancreatitis, particularly when patients https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 5/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway experience psychological impact of pain and quality of life has decreased. B 6. Therapeutic procedures General principles: be cautious when performing elective interventional procedures in patients actively using alcohol. Ensure separate considerations for interventional procedures in patients requiring urgent or emergent procedures for complications of chronic pancreatitis. B Endoscopic therapy: As per JSG 2022 guidelines, consider offering endoscopic treatment if adequate doses of NSAIDs or weak opioids are ineffective for pain relief. Show 5 more As per ESGE 2019 guidelines, consider performing endoscopic therapy and/or extracorporeal shockwave lithotripsy as first-line therapy in patients with painful uncomplicated chronic pancreatitis with an obstructed main pancreatic duct in the head/body of the pancreas. Evaluate the clinical response at 6-8 weeks. Arrange a multidisciplinary team discussion if the clinical response appears unsatisfactory, and consider offering surgical options. C Show 8 more As per IAP 2017 guidelines: Perform endoscopic therapy as first-line therapy in patients with painful chronic pancreatitis with distal obstruction of the main pancreatic duct (single stone and/or single stricture in the head of the pancreas) and in the early stage of the disease. Consider combining endoscopic therapy with extracorporeal shock wave lithotripsy in the presence of large (> 4 mm) obstructive stone(s) located in the pancreatic head, and with ductal stenting in the presence of a dominant main pancreatic duct stricture inducing a markedly dilated duct. B Perform extracorporeal shock wave lithotripsy alone in patients with uncomplicated painful calcified chronic pancreatitis. Perform extracorporeal shock wave lithotripsy as first-line therapy in patients with obstructive calcifications, > 4 mm confined to the head of pancreas. Recognize that combining systematic endoscopical therapy with extracorporeal shock wave lithotripsy adds to the cost of patient care, at the same time not probably improving the outcome of pancreatic pain. B Neurolysis: As per ACG 2020 guidelines, consider performing celiac plexus block for the treatment of pain in patients with chronic pancreatitis. C As per IAP 2017 guidelines, consider performing neurolytical interventions in selected patients with painful chronic pancreatitis failed endoscopic and surgical treatment. Prefer thoracoscopic splanchnic denervation for long-term pain relief in patients not receiving chronic opioid treatment. B 7. Surgical interventions Indications for surgery: https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 6/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway As per JSG 2022 guidelines: Decide on surgical indications and procedures after a thorough evaluation of symptoms and complications given that early surgery after the onset of chronic pancreatitis can delay progression. B Consider offering surgery if adequate doses of NSAIDs or weak opioids are ineffective for pain relief. Offer surgical treatment if endoscopic treatment has been ineffective for pain relief. B As per ACG 2020 guidelines: Perform surgical intervention over endoscopic therapy in patients with obstructive chronic pancreatitis for long-term relief of pain if first-line endoscopic approaches to pancreatic drainage have been exhausted or unsuccessful. B Reserve total pancreatectomy with islet autotransplant for highly selected patients with refractory chronic pain if all other symptom control measures have failed. B As per IAP 2017 guidelines: Consider performing decompression of the pancreatic duct or combined interventions, depending on the morphological changes of the pancreas and pain processing status a (partially) resection, to reduce pain. B Offer early surgery for painful chronic pancreatitis: within the first 2-3 years after diagnosis or symptom onset in patients undergone 5 endoscopic procedures in patients not yet required opioid analgesics for medical pain management. B 8. Specific circumstances Pediatric patients: advise maintaining a regular diet in pediatric patients with chronic pancreatitis, with or without exocrine pancreatic insufficiency. B Show 10 more 9. Follow-up and surveillance Surveillance for malnutrition: obtain periodic evaluation for malnutrition, including fat-soluble vitamin deficiency and osteoporosis, in patients with chronic pancreatitis. B Surveillance for malignancy: insufficient evidence to recommend screening for pancreatic malignancy in patients with chronic pancreatitis. I Management of relapse: exclude obstructing stones or strictured anastomosis via imaging as the first step for the management of pain relapse, followed by a limited number endoscopic interventions, and early consideration of re-surgery to achieve pain control. B https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 7/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway References 1. Kyoko Shimizu, Tetsuhide Ito, Atsushi Irisawa et al. 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J Pediatr Gastroenterol Nutr. 2017 Jan;64 1 95 103. Open https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 8/9 6/23/23, 3:26 AM Chronic pancreatitis Pathway 16. Jean-Marc Dumonceau, Andrea Tringali, Ioannis S Papanikolaou et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy ESGE Clinical Guideline Updated October 2017. Endoscopy. 2018 Sep;50 9 910 930. Open https://web.pathway.md/diseases/recGfbh0HwYYgFzCL 9/9