Pancreatitis: a summary of recommendations from NICE

Guideline name: Pancreatitis [NG104]

Update type: New guideline

Published: September 2018

Takehome

• Clinicians should not assume alcohol to be the cause of pancreatitis just because a person drinks alcohol. It is important to investigate other possible causes.
• Many complications can result from pancreatitis. Of note, chronic pancreatitis patients have an 80% chance of developing diabetes.

Acute pancreatitis

Investigation and Diagnosis

• Suspect acute pancreatitis in patients presenting with sudden-onset abdominal pain.
• Other signs and symptoms include nausea, vomiting, epigastric tenderness, fever and tachycardia.
• Assess for a history of gallstones or excessive alcohol intake.
• Acute pancreatitis is typically confirmed by presence of elevated blood lipase or amylase levels. In absence of elevations, abdominal CT may confirm pancreatic inflammation.
• Alcohol is not always the cause of acute pancreatitis. Other possible causes include
  • metabolic causes
  • prescription drugs
  • microlithiasis
  • hereditary causes
  • autoimmune pancreatitis
  • ampullary or pancreatic tumours
  • anatomical anomalies

Complications:

• Infected Necrosis
• Pseudocysts
• Pancreatic ascites and pleural effusion
• Type 3c (Pancreatogenic) Diabetes

Chronic Pancreatitis

Investigation and Diagnosis

• Chronic pancreatitis should be suspected in patients presenting with chronic or recurrent upper abdominal pain; refer appropriately.
• Alcohol is not always the cause of chronic pancreatitis. Other possible causes include:
  •  genetic factors
  • autoimmune disease (particularly IgG4 disease)
  • metabolic causes
  •  structural or anatomical factors

Complications:

• Pancreatic duct obstruction
• Pseudocysts
• Neuropathic pain
• Pancreatic ascites and pleural effusion
• Type 3c (Pancreatogenic) Diabetes

Nutrition support

• All chronic pancreatitis patients are at high risk of malabsorption, malnutrition and a deterioration in their quality of life.
• 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.
• Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis.

Follow-up

Pancreatic exocrine function

• Offer clinical and biochemical assessment, to be agreed with the specialist centre, for pancreatic exocrine insufficiency and malnutrition at least every 12 months (every 6 months in under 16s). Adjust the treatment of vitamin and mineral deficiencies accordingly.
• Offer adults with chronic pancreatitis a bone density assessment every 2 years.

Identify pancreatic cancer

• Be aware that people with chronic pancreatitis have an increased risk of developing pancreatic cancer. The lifetime risk is highest, around 40%, in those with hereditary pancreatitis.
• Consider annual monitoring for pancreatic cancer in people with hereditary pancreatitis.

Identify diabetes

• People with chronic pancreatitis have a greatly increased risk of developing diabetes, with a lifetime risk as high as 80%. The risk increases with duration of pancreatitis and presence of calcific pancreatitis.
• Offer monitoring of HbA1c for diabetes at least every 6 months.