Management of Pancreatitis: NICE Guidelines 2018
NICE has released its latest 2018 Guidelines on Pancreatitis.
Acute pancreatitis is acute inflammation of the pancreas and is a common cause of acute abdominal pain. The incidence in the UK is approximately 56 cases per 100,000 people per year. Around 50% of cases are caused by gallstones, 25% by alcohol and 25% by other factors.
Following are the major recommendations:
Information and support
Patient information
a)Give people with pancreatitis, and their family members or carers (as appropriate), written and verbal information on the following, where relevant, as soon as possible after diagnosis:
- pancreatitis and any proposed investigations and procedures, using diagrams
- hereditary pancreatitis, and pancreatitis in children, including specific information on genetic counselling, genetic testing, risk to other family members, and advice on the impact of their pancreatitis on life insurance and travel
- the long-term effects of pancreatitis, including effects on the person's quality of life
- the harm caused to the pancreas by smoking or alcohol.
b)Advise people with pancreatitis where they might find reliable high-quality information and support after consultations, from sources such as national and local support groups, regional pancreatitis networks and information services.
c) Give people with pancreatitis, and their family members or carers (as appropriate), written and verbal information on the following about the management of pancreatitis, when applicable:
- why a person may be going through a phase where no treatment is given
- that pancreatitis is managed by a multidisciplinary team
- the multidisciplinary treatment of pain, including how to access the local pain team and types of pain relief
- Nutrition advice, including advice on how to take pancreatic enzyme replacement therapy if needed
- follow-up and who to contact for relevant advice, including advice needed during episodes of acute illness
- psychological care if needed, where available (see the NICE guideline on depression in adults)
- pancreatitis services, including the role of specialist centers, and primary care services for people with acute, chronic or hereditary pancreatitis
- welfare benefits, education and employment support, and disability services.
d)For more guidance on giving information, including providing an individualised approach and helping people to actively participate in their care, see the NICE guideline on patient experience in adult NHS services.
e)Explain to people with severe acute pancreatitis, and their family members or carers (as appropriate), that:
- a hospital stay lasting several months is relatively common, including time in critical care
- for people who achieve full recovery, time to recover may take at least 3 times as long as their hospital stay
- local complications of acute pancreatitis may resolve spontaneously or may take weeks to progress before it is clear that intervention is needed
- it may be safer to delay intervention (for example, to allow a fluid collection to mature)
- people who have started to make a recovery may have a relapse
- although children rarely die from acute pancreatitis, approximately 15–20% of adults with severe acute pancreatitis die in hospital.
f) Tell adults with pancreatitis that NICE has published a guideline on patient experience in adult NHS services that will show them what they can expect about their care.
Passing information to GPs
g)Ensure that information passed to GPs includes all of the following, where applicable:
- detail on how the person should take their pancreatic enzyme replacement therapy (including dose escalation as necessary)
- that the person should be offered HbA1c testing at least every 6 months and bone mineral density assessments every 2 years.
Lifestyle interventions: alcohol
h)Advise people with pancreatitis caused by alcohol to stop drinking alcohol.
i) Advise people with recurrent acute or chronic pancreatitis that is not alcohol-related, that alcohol might exacerbate their pancreatitis.
j) For guidance on alcohol-use disorders, see the NICE guidelines on the diagnosis and management of physical complications of alcohol-use disorders and the diagnosis, assessment and management of harmful drinking and alcohol dependence.
Lifestyle interventions: smoking cessation
k) Be aware of the link between smoking and chronic pancreatitis and advise people with chronic pancreatitis to stop smoking in line with NICE's guidance on stop smoking interventions and services.
Acute pancreatitis
People with acute pancreatitis usually present with sudden-onset abdominal pain. Nausea and vomiting are often present and there may be a history of gallstones or excessive alcohol intake. Typical physical signs include epigastric tenderness, fever and tachycardia. Diagnosis of acute pancreatitis is confirmed by testing blood lipase or amylase levels, which are usually raised. If raised levels are not found, abdominal CT may confirm pancreatic inflammation.
Identifying the cause
A)Do not assume that a person's acute pancreatitis is alcohol-related just because they drink alcohol.
B)If gallstones and alcohol have been excluded as potential causes of a person's acute pancreatitis, investigate other possible causes such as:
- metabolic causes (such as hypercalcaemia or hyperlipidaemia)
- prescription drugs
- microlithiasis
- hereditary causes
- autoimmune pancreatitis
- ampullary or pancreatic tumours
- anatomical anomalies (pancreas divisum).
Preventing infection
C)Do not offer prophylactic antimicrobials to people with acute pancreatitis.
Fluid resuscitation
D)For guidance on fluid resuscitation, see the NICE guidelines on intravenous fluid therapy in adults in hospital and in children and young people in the hospital.
Nutrition support
E) Ensure that people with acute pancreatitis are not made 'nil‑by‑mouth' and do not have food withheld unless there is a clear reason for this (for example, vomiting).
F)Offer enteral nutrition to anyone with severe or moderately severe acute pancreatitis. Start within 72 hours of presentation and aim to meet their nutritional requirements as soon as possible.
G)Offer anyone with severe or moderately severe acute pancreatitis parenteral nutrition only if enteral nutrition has failed or is contraindicated.
Managing complications
Infected necrosis
H)Offer people with acute pancreatitis an endoscopic approach for managing infected or suspected infected pancreatic necrosis when anatomically possible.
I) Offer a percutaneous approach when an endoscopic approach is not anatomically possible.
J)When deciding on how to manage infected pancreatic necrosis, balance the need to debride promptly against the advantages of delaying intervention.
Pseudocysts
K)For guidance on managing pseudocysts, see recommendations 1.3.10–1.3.12.
Pancreatic ascites and pleural effusion
L)For guidance on managing pancreatic ascites and pleural effusion secondary to pancreatitis, see recommendation 1.3.14.
Type 3c diabetes
M)For guidance on managing type 3c diabetes secondary to pancreatitis, see recommendations 1.3.15–1.3.19.
Referral for specialist treatment
N)If a person develops necrotic, infective, haemorrhagic or systemic complications of acute pancreatitis:
- seek advice from a specialist pancreatic centre within the referral network and
- discuss whether to move the person to the specialist centre for the treatment of the complications.
O) When managing acute pancreatitis in children:
- seek advice from a paediatric gastroenterology or hepatology unit and a specialist pancreatic centre and
- discuss whether to move the child to the specialist centre.
Chronic pancreatitis
People with chronic pancreatitis usually present with chronic or recurrent abdominal pain. This guideline assumes that people with chronic abdominal pain will already have been investigated using CT scan, ultrasound scan or upper gastrointestinal endoscopy to determine a cause for their symptoms.
Investigating upper abdominal pain
1)Think about chronic pancreatitis as a possible diagnosis for people presenting with chronic or recurrent episodes of upper abdominal pain and refer accordingly.
Identifying the cause
2)Do not assume that a person's chronic pancreatitis is alcohol-related just because they drink alcohol. Other causes include:
- genetic factors
- autoimmune disease, in particular IgG4 disease
- metabolic causes
- structural or anatomical factors.
Nutrition support
3) Be aware that all people with chronic pancreatitis are at high risk of malabsorption, malnutrition and a deterioration in their quality of life.
4)Use protocols agreed with the specialist pancreatic centre to identify when advice from a specialist dietitian is needed, including advice on food, supplements and long-term pancreatic enzyme replacement therapy, and when to start these interventions.
5) Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis.
6) For guidance on nutrition support for people with chronic alcohol-related pancreatitis, see alcohol-related pancreatitis in the NICE guideline on alcohol-use disorders.
7) For guidance on nutrition support, see the NICE guideline on nutrition support for adults.
Managing complications
Pancreatic duct obstruction
8) Consider surgery (open or minimally invasive) as first-line treatment in adults with painful chronic pancreatitis that is causing obstruction of the main pancreatic duct.
9)Consider extracorporeal shockwave lithotripsy for adults with pancreatic duct obstruction caused by a dominant stone if surgery is unsuitable.
Pseudocysts
10) Offer endoscopic ultrasound (EUS)-guided drainage, or endoscopic transpapillary drainage for pancreatic head pseudocysts, to people with symptomatic pseudocysts (for example, those with pain, vomiting or weight loss).
11) Consider EUS-guided drainage, or endoscopic transpapillary drainage for pancreatic head pseudocysts, for people with non-symptomatic pseudocysts that meet 1 or more of the following criteria:
- they are associated with pancreatic duct disruption
- they are creating pressure on large vessels or the diaphragm
- they are at risk of rupture
- there is suspicion of infection.
12)Consider surgical (laparoscopic or open) drainage of pseudocysts that need intervention if endoscopic therapy is unsuitable or has failed.
Neuropathic pain
13) For adults with neuropathic pain related to chronic pancreatitis, follow the recommendations in the NICE guideline on neuropathic pain in adults.
Pancreatic ascites and pleural effusion
14) Consider referring a person with pancreatic ascites and pleural effusion for management in a specialist pancreatic centre.
Type 3c diabetes
15) Assess people with type 3c diabetes every 6 months for potential benefit of insulin therapy.
16) For guidance on managing type 3c diabetes for people who are not using insulin therapy, see the NICE guidelines on type 2 diabetes in adults and diagnosing and managing diabetes in children and young people.
17) For guidance on managing type 3c diabetes for people who need insulin, see:
- the recommendations on insulin therapy and insulin delivery in the NICE guideline on type 1 diabetes in adults
- the recommendations on insulin therapy in the NICE guideline on diagnosing and managing diabetes in children and young people
- NICE's technology appraisal guidance on continuous subcutaneous insulin infusion for the treatment of diabetes mellitus.
To read the complete guidelines, click on the following link:
https://www.nice.org.uk/guidance/ng104/chapter/Recommendations
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