Recommendations

Guidance

1.1 Information and support
1.2 Acute pancreatitis
1.3 Chronic pancreatitis
Terms used in this guideline

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Information and support

Patient information

1.1.1

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.

1.1.2

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.

1.1.3

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 centres, and primary care services for people with acute, chronic or hereditary pancreatitis
welfare benefits, education and employment support, and disability services.

1.1.4

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.

1.1.5

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% to 20% of adults with severe acute pancreatitis die in hospital.

1.1.6

Tell adults with pancreatitis that there is a NICE guideline on patient experience in adult NHS services that will show them what they can expect about their care.

Passing information to GPs

1.1.7

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

1.1.8

Advise people with pancreatitis caused by alcohol to stop drinking alcohol.

1.1.9

Advise people with recurrent acute or chronic pancreatitis that is not alcohol-related, that alcohol might exacerbate their pancreatitis.

1.1.10

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

1.1.11

Be aware of the link between smoking and chronic pancreatitis and advise people with chronic pancreatitis to stop smoking in line with the NICE guideline on tobacco.

1.2 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

1.2.1

Do not assume that a person's acute pancreatitis is alcohol-related just because they drink alcohol.

1.2.2

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

1.2.3

Do not offer prophylactic antimicrobials to people with acute pancreatitis.

Fluid resuscitation

1.2.4

For guidance on fluid resuscitation, see the NICE guidelines on intravenous fluid therapy in adults in hospital and in children and young people in hospital.

Nutrition support

1.2.5

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).

1.2.6

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.

1.2.7

Offer anyone with severe or moderately severe acute pancreatitis parenteral nutrition only if enteral nutrition has failed or is contraindicated.

Managing complications

Infected necrosis

1.2.8

Offer people with acute pancreatitis an endoscopic approach for managing infected or suspected infected pancreatic necrosis when anatomically possible.

1.2.9

Offer a percutaneous approach when an endoscopic approach is not anatomically possible.

1.2.10

When deciding on how to manage infected pancreatic necrosis, balance the need to debride promptly against the advantages of delaying intervention.

Pseudocysts

1.2.11

For guidance on managing pseudocysts, see the recommendations in the section on pseudocysts in managing complications of chronic pancreatitis.

Pancreatic ascites and pleural effusion

1.2.12

For guidance on managing pancreatic ascites and pleural effusion secondary to pancreatitis, see the recommendation in the section on pancreatic ascites and pleural effusion in managing complications of chronic pancreatitis.

Type 3c diabetes

1.2.13

For guidance on managing type 3c diabetes secondary to pancreatitis, see the recommendations in the section on type 3c diabetes in managing complications of chronic pancreatitis.

Referral for specialist treatment

1.2.14

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 treatment of the complications.

1.2.15

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.

1.3 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. The guideline committee looked at evidence on diagnosing chronic pancreatitis, and the evidence review can be found in the full guideline. We have made a recommendation for research on the most accurate diagnostic test to identify whether chronic pancreatitis is present in the absence of a clear diagnosis following these tests.

Investigating upper abdominal pain

1.3.1

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

1.3.2

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

1.3.3

Be aware that all people with chronic pancreatitis are at high risk of malabsorption, malnutrition and a deterioration in their quality of life.

1.3.4

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.

1.3.5

Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis.

1.3.6

For guidance on nutrition support for people with chronic alcohol-related pancreatitis, see the section on enzyme supplementation for chronic alcohol-related pancreatitis in the NICE guideline on alcohol-use disorders.

1.3.7

For guidance on nutrition support, see the NICE guideline on nutrition support for adults.

Managing complications

Pancreatic duct obstruction

1.3.8

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.

1.3.9

Consider extracorporeal shockwave lithotripsy for adults with pancreatic duct obstruction caused by a dominant stone if surgery is unsuitable.

Pseudocysts

1.3.10

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).

1.3.11

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.

1.3.12

Consider surgical (laparoscopic or open) drainage of pseudocysts that need intervention if endoscopic therapy is unsuitable or has failed.

Neuropathic pain

1.3.13

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

1.3.14

Consider referring a person with pancreatic ascites and pleural effusion for management in a specialist pancreatic centre.

Type 3c diabetes

1.3.15

Assess people with type 3c diabetes every 6 months for potential benefit of insulin therapy.

1.3.16

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.

1.3.17

For guidance on managing type 3c diabetes for people who need insulin, see:

the recommendations on insulin therapy and insulin delivery (including rotating injection sites within the same body region) in the NICE guidelines on type 1 diabetes in adults and 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. [2018, amended 2020]

1.3.18

For guidance on education and information for people with pancreatitis and type 3c diabetes requiring insulin, see the recommendations on education and information in the NICE guideline on diagnosing and managing type 1 diabetes in adults, and diagnosing and managing diabetes in children and young people.

1.3.19

For guidance on self-monitoring blood glucose for people with pancreatitis and type 3c diabetes requiring insulin, see the recommendations on blood glucose management in the NICE guideline on diagnosing and managing type 1 diabetes in adults, and blood glucose monitoring in the NICE guideline on diagnosing and managing diabetes in children and young people.

Follow-up investigation

Follow-up of pancreatic exocrine function

1.3.20

Offer people with chronic pancreatitis monitoring by 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.

1.3.21

Offer adults with chronic pancreatitis a bone density assessment every 2 years.

Follow-up to identify pancreatic cancer

1.3.22

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.

1.3.23

Consider annual monitoring for pancreatic cancer in people with hereditary pancreatitis.

Follow-up to identify diabetes

1.3.24

Be aware that 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.

1.3.25

Offer people with chronic pancreatitis monitoring of HbA1c for diabetes at least every 6 months.

Terms used in this guideline

Moderately severe acute pancreatitis

Moderately severe acute pancreatitis is characterised by organ failure that resolves within 48 hours (transient organ failure), or local or systemic complications in the absence of persistent organ failure (as defined by the revised Atlanta classification published in GUT).

Severe acute pancreatitis

Severe acute pancreatitis is characterised by single or multiple organ failure that persists for more than 48 hours (persistent organ failure; as defined by the revised Atlanta classification).

Type 3c diabetes

Diabetes mellitus secondary to pancreatic disease. When this is associated with pancreatitis, the primary endocrine defect is insufficient insulin secretion (the abnormality in type 1 diabetes) rather than insulin resistance (which is characteristic of type 2 diabetes).