Recommendations from the United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis
Introduction
The Harmonizing diagnosis and treatment of chronic pancreatitis across Europe (HaPanEU) initiative of United European Gastroenterology (UEG) aims to provide the community with evidence-based, state-of-the-art clinical guidelines to help in the management of patients with chronic pancreatitis (CP) [1]. The statements are based on the recent guidelines and recommendations published by the Australian [2], Belgian [3], German [4], Hungarian [5], Italian [6], Romanian [7], and Spanish [8,9] Societies of Gastroenterology and Pancreatology, as well as pertinent new literature.
The recommendations format comprised the question, the statement, its level of evidence and strength of recommendation, and the percentage agreement of the global consensus group with the final version. With this aim, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was applied: strength of recommendation (1 = strong, 2 = weak) and quality of the evidence (A = high, B = moderate, C = low) [10,11]. Recommendations with ≥90%, 70–89%, 61–69% or ≤60% consensus were defined as strong agreement, moderate agreement, agreement and weak agreement, respectively.
The full document of the HaPanEU guidelines was published elsewhere [1]. This article summarises the recommendations and statements for a rapid overview and quick reference. New papers published after the HaPanEU guidelines do not contradict these recommendations.
Section snippets
Definition of CP (regardless of the aetiology)
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CP is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of the pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganisation of the pancreas leads to progressive exocrine and endocrine pancreatic insufficiency. (Strong agreement).
What needs to be done to define the aetiology of CP patients?
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It is recommended that a comprehensive medical history (including alcohol abuse, smoking and family history), laboratory evaluation (including Ca2+ and triglyceride levels) and imaging studies (including
Diagnosis
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Endoscopic ultrasound (EUS), magnetic resonance imaging (MRI), and CT are the best imaging methods for establishing a diagnosis of CP. EUS outperforms MRI and CT. Abdominal ultrasound is the least accurate imaging technique for CP, whereas endoscopic retrograde cholangiopancreatography (ERCP) is not considered a diagnostic procedure due to its invasiveness. (GRADE 1C, strong agreement).
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CT examination is the most appropriate method for identifying pancreatic calcifications, while for very small
Diagnosis of pancreatic exocrine insufficiency (PEI)
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PEI refers to an insufficient secretion of pancreatic enzymes (acinar function) and/or sodium bicarbonate (ductal function) to maintain a normal digestion. (GRADE 1A, strong agreement).
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Due to the large reserve capacity of the pancreas, ‘mild’ to ‘moderate’ exocrine insufficiency can be compensated, and overt steatorrhoea is not expected unless the secretion of pancreatic lipase is reduced to <10% of normal (‘severe’/‘decompensated’ insufficiency). However, patients with ‘compensated’ PEI also
Surgical treatment of CP
Surgical treatment has no role in asymptomatic and uncomplicated CP. This section deals with the technical aspects of surgical treatment; the treatment for pain is detailed in section 8.
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Surgery is superior to endoscopy in terms of mid-term and long-term pain relief in patients with painful CP. (GRADE 2B, agreement).
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Early surgery is favoured over surgery at a more advanced stage of the disease in terms of optimal long-term pain relief, long-term improved QoL, and risk of postoperative PEI (GRADE
Medical therapy for exocrine pancreatic insufficiency
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PERT is indicated for patients with CP and PEI in the presence of clinical symptoms or laboratory signs of malabsorption (nutritional deficiencies). An appropriate nutritional evaluation is recommended to detect signs of malabsorption. (GRADE 1A, strong agreement).
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Enteric-coated microspheres or mini-microspheres of <2 mm in size are the preparations of choice for PEI. Micro- or mini-tablets of 2.2–2.5 mm in size may be also effective, although scientific evidence in the context of CP is more
Endoscopic therapy (ET)
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ET has no role in asymptomatic and uncomplicated CP. (GRADE 2B, agreement). This section deals with the technical aspects of ET and the treatment for pain is detailed in section 8.
Treatment of pancreatic pseudocysts (PPC)
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Chronic PPC should be treated in the presence of symptoms, complications (infection, bleeding, or rupture), or compression of surrounding organs (gastric, duodenal or biliary obstruction). (Grade 2A, strong agreement).
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Treating asymptomatic PPCs, which have reached a size of >5 cm in diameter and which do not resolve within 3–6 months, should also be considered due to the risk of PPC complications. (GRADE 2C, strong agreement).
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In the presence of a recent episode of acute pancreatitis or if the
Treatment of pain in CP
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Pain is the first presentation of CP in the majority of patients. (GRADE 1B, strong agreement). There is no evidence that pain symptoms ‘burn out’ in all patients with ongoing CP. (GRADE 2C, moderate agreement). There is no convincing evidence that endocrine and exocrine pancreatic insufficiencies are associated with pain relief. (GRADE 2C, moderate agreement).
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Pain intensity and the pain pattern over time (constant vs intermittent pain) have been shown to reduce QoL in patients with CP. (GRADE
Nutritional evaluation
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Malnutrition is common among patients with CP. (GRADE 2B, strong agreement). PEI, anorexia secondary to abdominal pain, nausea and vomiting, alcohol and other substance abuse and diabetes mellitus may all contribute to malnutrition in patients with CP. (GRADE 2C, strong agreement).
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Patients with CP should undergo initial screening for malnutrition either with the community malnutrition universal screening tool (MUST) or hospital nutritional risk screening (NRS-2002) [15]. More specifically,
Definition and risk factors
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Diabetes mellitus secondary to CP (as well as to other pancreatic diseases) is classified as pancreatogenic diabetes or, previously, type 3c diabetes. The American Diabetes Association has recently classified it as CP-related diabetes (CPRD) [16].
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Diabetes is a common complication of CP, although its occurrence varies widely from 5% to >80%, depending largely on aetiology, geographical location and duration of follow-up. It appears to be a common complication of both idiopathic/tropical CP and
Evaluation and treatment of smoking
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There is no specific, widely accepted questionnaire for assessing smoking status. Several studies have reported positive findings regarding the relationship between smoking and CP using different questionnaires. (GRADE 2C, strong agreement).
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The key components for the treatment of smoking dependence are combinations of therapeutic education, behavioural support and medication. (GRADE 1A, strong agreement). Nicotine replacement therapy, bupropion and varenicline are efficiently proven first-line
Acknowledgements
The financial support by a LINK award from the UEG to HaPanEU consortium is greatly acknowledged.
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