Excerpt

People with pancreatitis are at long-term risk of nutritional problems and diabetes, and also have an increased risk of pancreatic cancer, which is even higher in people with hereditary pancreatitis. It is necessary to identify those who need to be followed up and what tests are required.

Pancreatitis is a serious and complex condition. It causes immense suffering, can have a severe effect on quality of life and may result in reduced life expectancy. In the past, there has been lack of knowledge on how to manage pancreatitis and this has resulted in clinicians avoiding those with the disease and conflicting advice being offered. With this guideline it is hoped that sound advice will be provided to enable people with pancreatitis to receive appropriate care to improve the outcomes from this difficult condition.

Contents

• Guideline committee members
• NGC technical team members
• Co-optees
• Acknowledgements
• 1. Guideline summary
  • 1.1. Full list of recommendations
  • 1.2. Research recommendations
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Searching for evidence
  • 4.3. Identifying and analysing evidence of effectiveness
  • 4.4. Identifying and analysing evidence of cost effectiveness
  • 4.5. Developing recommendations
• Information and Support
  • 5. Patient information
    • 5.1. Introduction
    • 5.2. Review question: What information and support should people with acute or chronic pancreatitis, their family and carers receive after diagnosis?
    • 5.3. Qualitative evidence
    • 5.4. Economic evidence
    • 5.5. Evidence statements
    • 5.6. Recommendations and link to evidence
  • 6. Lifestyle interventions: stopping or reducing alcohol consumption
    • 6.1. Introduction
    • 6.2. Review question: What is the clinical effectiveness and cost effectiveness of stopping or reducing alcohol consumption in reducing recurrent episodes of acute pancreatitis and improving quality of life in people with either chronic or acute pancreatitis?
    • 6.3. Clinical evidence
    • 6.4. Economic evidence
    • 6.5. Evidence statements
    • 6.6. Recommendations and link to evidence
  • 7. Lifestyle interventions: stopping or reducing smoking
    • 7.1. Introduction
    • 7.2. Recommendation
• Acute Pancreatitis
  • 8. Aetiology of Acute Pancreatitis and Identifying the cause
    • 8.1. Introduction
    • 8.2. Review question: What is the clinical effectiveness and cost effectiveness of assessing the aetiology of acute pancreatitis to prevent recurrent attacks in people in whom the aetiology is unconfirmed by first-line test results within normal ranges?
    • 8.3. Clinical evidence
    • 8.4. Economic evidence
    • 8.5. Evidence statements
    • 8.6. Recommendations and link to evidence
  • 9. Prophylactic antimicrobial agents to prevent infection in people with acute pancreatitis
    • 9.1. Introduction
    • 9.2. Review question: What is the clinical effectiveness and cost-effectiveness of prophylactic antimicrobial agents to prevent infection in people with acute pancreatitis?
    • 9.3. Clinical evidence
    • 9.4. Economic evidence
    • 9.5. Evidence statements
    • 9.6. Recommendations and link to evidence
  • 10. Type of intravenous fluid for resuscitation in people with acute pancreatitis
    • 10.1. Introduction
    • 10.2. Review question: What is the most clinically effective and cost-effective type of intravenous fluid for resuscitation in people with acute pancreatitis?
    • 10.3. Clinical evidence
    • 10.4. Economic evidence
    • 10.5. Evidence statements
    • 10.6. Recommendations and link to evidence
  • 11. Speed of intravenous fluid for resuscitation in people with acute pancreatitis
    • 11.1. Introduction
    • 11.2. Review question: What is the most clinically effective and cost-effective speed of administration of intravenous fluid for resuscitation in people with acute pancreatitis?
    • 11.3. Clinical evidence
    • 11.4. Economic evidence
    • 11.5. Evidence statements
    • 11.6. Recommendations and link to evidence
  • 12. Route of feeding in people with severe acute pancreatitis
    • 12.1. Introduction
    • 12.2. Review question: What is the most clinically effective and cost-effective route of feeding at time of admission to the hospital in people with severe acute pancreatitis?
    • 12.3. Clinical evidence
    • 12.4. Economic evidence
    • 12.5. Evidence statements
    • 12.6. Recommendations and link to evidence
  • 13. Methods of management of infected necrosis in people with acute pancreatitis
    • 13.1. Introduction
    • 13.2. Review question: What is the most clinically effective and cost-effective method for managing (suspected) infected necrosis in people with acute pancreatitis?
    • 13.3. Clinical evidence
    • 13.4. Economic evidence
    • 13.5. Evidence statements
    • 13.6. Recommendations and link to evidence
  • 14. Timing of management of infected necrosis in people with acute pancreatitis
    • 14.1. Introduction
    • 14.2. Review question: What is the most clinically effective and cost-effective timing of intervention for managing (suspected) infected necrosis in people with acute pancreatitis?
    • 14.3. Clinical evidence
    • 14.4. Economic evidence
    • 14.5. Evidence statements
    • 14.6. Recommendations and link to evidence
  • 15. Management of Pseudocysts
  • 16. Management of pancreatic ascites and Pleural effusion secondary to pancreatitis
  • 17. Management of type 3c diabetes secondary to pancreatitis
  • 18. Receiving specialist input in people with acute pancreatitis
    • 18.1. Introduction
    • 18.2. Review question: What is the clinical effectiveness and cost effectiveness of receiving specialist input in people with acute pancreatitis?
    • 18.3. Clinical evidence
    • 18.4. Economic evidence
    • 18.5. Evidence statements
    • 18.6. Recommendations and link to evidence
• Chronic Pancreatitis
  • 19. Aetiology of chronic pancreatitis
    • 19.1. Introduction
    • 19.2. Review question: What is the clinical effectiveness and cost effectiveness of performing genetic marker and autoantibody tests for identifying the aetiology of chronic pancreatitis in people with no known family history of pancreatitis, no significant alcohol history, and normal serum calcium and lipid levels?
    • 19.3. Clinical evidence
    • 19.4. Economic evidence
    • 19.5. Evidence statements
    • 19.6. Recommendations and link to evidence
  • 20. Diagnosing chronic pancreatitis
    • 20.1. Introduction
    • 20.2. Review question 1: In people with suspected (or under investigation for) chronic pancreatitis, whose diagnosis has not been confirmed by any of CT scan, ultrasound scan or upper gastrointestinal (GI) endoscopy, what is the most accurate diagnostic test to identify whether chronic pancreatitis is present (as indicated by the reference standards: biopsy, clinical follow-up or subsequent CT scan)?
    • 20.3. Review question 2: In people with suspected (or under investigation for) chronic pancreatitis, whose diagnosis has not been confirmed by any of CT scan, ultrasound scan or upper GI endoscopy, what is the most clinically effective and cost effective test to identify whether chronic pancreatitis is present, when each is followed by the appropriate treatment, in order to improve patient outcomes?
    • 20.4. Clinical evidence
    • 20.5. Economic evidence
    • 20.6. Evidence statements
    • 20.7. Recommendations and link to evidence
  • 21. Early compared with late nutritional intervention in people with chronic pancreatitis
    • 21.1. Introduction
    • 21.2. Review question: What is the clinical effectiveness and cost effectiveness of early compared with late nutritional intervention (for example, food supplements, enzyme supplements) in people with chronic pancreatitis and signs of malnutrition or malabsorption?
    • 21.3. Clinical evidence
    • 21.4. Economic evidence
    • 21.5. Evidence statements
    • 21.6. Recommendations and link to evidence
  • 22. Specialist compared with non-specialist nutritional assessment in people with chronic pancreatitis
    • 22.1. Introduction
    • 22.2. Review question: What is the clinical effectiveness and cost effectiveness of a specialist nutritional assessment compared with a non-specialist assessment for managing malabsorption or malnutrition in people with chronic pancreatitis?
    • 22.3. Clinical evidence
    • 22.4. Economic evidence
    • 22.5. Evidence statements
    • 22.6. Recommendations and link to evidence
  • 23. Management of pain in people with chronic pancreatitis
    • 23.1. Introduction
    • 23.2. Review question: What is the most clinically effective and cost-effective intervention for managing chronic pain in people with chronic pancreatitis?
    • 23.3. Clinical evidence
    • 23.4. Economic evidence
    • 23.5. Evidence statements
    • 23.6. Recommendations and link to evidence
  • 24. Management of pancreatic duct obstruction in people with chronic pancreatitis
    • 24.1. Introduction
    • 24.2. Review question: What is the most clinically effective and cost-effective intervention for managing pancreatic duct obstruction, with or without an inflammatory mass, in people with chronic pancreatitis presenting with chronic pain?
    • 24.3. Clinical evidence
    • 24.4. Economic evidence
    • 24.5. Evidence statements
    • 24.6. Recommendations and link to evidence
  • 25. Management of small-duct disease in people with chronic pancreatitis
    • 25.1. Introduction
    • 25.2. Review question: What is the most clinically effective and cost-effective intervention for managing small-duct disease (in the absence of pancreatic duct obstruction, inflammatory mass or pseudocyst) in people with chronic pancreatitis presenting with chronic pain?
    • 25.3. Clinical evidence
    • 25.4. Economic evidence
    • 25.5. Evidence statements
    • 25.6. Recommendations and link to evidence
  • 26. Management of pseudocysts
    • 26.1. Introduction
    • 26.2. Review question: What is the most clinically effective and cost-effective intervention for managing pseudocysts in people with pancreatitis presenting with or without pain?
    • 26.3. Clinical evidence
    • 26.4. Economic evidence
    • 26.5. Evidence statements
    • 26.6. Recommendations and link to evidence
  • 27. Management of pancreatic ascites and pleural effusion secondary of pancreatitis
    • 27.1. Introduction
    • 27.2. Review question: What are the most clinically effective and cost-effective interventions for treating pancreatic ascites and pleural effusion secondary to acute or chronic pancreatitis?
    • 27.3. Clinical evidence
    • 27.4. Economic evidence
    • 27.5. Evidence statements
    • 27.6. Recommendations and link to evidence
  • 28. Management of biliary obstruction in people with chronic pancreatitis
    • 28.1. Introduction
    • 28.2. Review question: What is the most clinically effective and cost-effective intervention for treating biliary obstruction in people with chronic pancreatitis?
    • 28.3. Clinical evidence
    • 28.4. Economic evidence
    • 28.5. Evidence statements
    • 28.6. Recommendations and link to evidence
  • 29. Management of type 3c diabetes secondary to pancreatitis
    • 29.1. Introduction
    • 29.2. Review question: What is the most clinically effective and cost-effective insulin regimen strategy specifically for type 3c diabetes secondary to pancreatitis?
    • 29.3. Clinical evidence
    • 29.4. Economic evidence
    • 29.5. Evidence statements
    • 29.6. Recommendations and link to evidence
  • 30. Follow up of pancreatic exocrine function in people with chronic pancreatitis
    • 30.1. Introduction
    • 30.2. Review question: How often should follow-up to assess pancreatic exocrine function and any secondary health issues, if any, be carried out in people with chronic pancreatitis?
    • 30.3. Clinical evidence
    • 30.4. Economic evidence
    • 30.5. Evidence statements
    • 30.6. Recommendations and link to evidence
  • 31. Follow-up to identify pancreatic cancer in people with chronic pancreatitis
    • 31.1. Introduction
    • 31.2. Review question: How often should follow-up to identify the development of pancreatic cancer be carried out in people with chronic pancreatitis?
    • 31.3. Clinical evidence
    • 31.4. Economic evidence
    • 31.5. Evidence statements
    • 31.6. Recommendations and link to evidence
  • 32. Follow-up to identify diabetes in people with chronic pancreatitis
    • 32.1. Introduction
    • 32.2. Review question: How often should follow-up to identify the development of diabetes be carried out in people with chronic pancreatitis?
    • 32.3. Clinical evidence
    • 32.4. Economic evidence
    • 32.5. Evidence statements
    • 32.6. Recommendations and link to evidence
• 33. Reference list
• 34. Acronyms and abbreviations
• 35. Glossary and Acronyms
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Health economic review protocol
  • Appendix E. Clinical study selection
  • Appendix F. Health economic study selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. Health economic evidence tables
  • Appendix J. GRADE tables
  • Appendix K. Forest plots
  • Appendix L. Excluded clinical studies
  • Appendix M. Excluded health economic studies
  • Appendix N. Unit costs
  • Appendix O. Research Recommendations
  • Appendix P. NICE technical team
  • Appendix Q. References

Final

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.