Pancreatitis

Why this is important

People with chronic pancreatitis usually present with chronic abdominal pain. However, there are many other causes of chronic abdominal pain (for example, peptic ulcer disease, gallstone disease, gastric cancer, pancreatic cancer and abdominal aortic aneurysm). First-line tests to exclude these other causes include abdominal ultrasound, upper GI endoscopy and abdominal CT scan. Where the diagnosis has still not been confirmed following these first-line tests, it is important to have a clinical algorithm of specialist tests to be able to identify people with chronic pancreatitis. Appropriate management options can then be offered. A diagnostic cohort study is needed to determine the accuracy of MRCP with or without secretin and endoscopic ultrasound in diagnosing chronic pancreatitis.

Why this is important

There is clinical uncertainty about the optimal rate of fluid for resuscitation in severe acute pancreatitis. Severe acute pancreatitis causes the depletion of body fluids and reduction of the intravascular volume severe enough to cause hypotension, acute renal failure and pancreatic hypoperfusion, aggravating the damage to the pancreas. In addition, there is conflicting evidence about the effect of aggressive or conservative fluid management on outcomes in other conditions with a pathophysiology.

Current guidelines recommend using goal-directed therapy for fluid management, but do not recommend a particular type of fluid. A randomised controlled trial is needed to determine whether aggressive rates of intravenous fluid administration for the initial period of fluid resuscitation are more clinically or cost effective than conservative rates in people with acute pancreatitis.

Why this is important

Chronic pancreatitis is a complex condition needing biopsychosocial management. The pain is varied in nature, intensity, duration and severity, along with acute exacerbations. It is also multifactorial, making it difficult to have a standard regimen that can work for everyone. Some people also develop psychosocial factors such as reduction in quality of life, relationship issues, addiction to painkillers and financial difficulties.

Chronic pancreatitis is usually managed pharmacologically with a combination of opioids and other interventions. However, the use of opioids in managing chronic pancreatitis is known to cause serious side-effects – including tolerance, addiction, tiredness and constipation. These side-effects are frequently worse than the disease itself. Therefore, the whole rationale for the use of opioids in chronic pancreatitis is questionable. A cohort study is needed to determine how effective long-term opioid use is in this population compared with non-opiate pain management strategies, including analgesia and psychological therapies.

Why this is important

Chronic pancreatitis with small duct disease is more difficult to treat than without the disease because there is no anatomically correctable pancreatic abnormality – for example, pancreatic duct obstruction, inflammatory mass or pseudocysts. A randomised controlled trial study is needed to determine what the most effective intervention is for treating small duct disease. The following interventions should be compared with each other and with no treatment: surgery (partial resection, total resection with or without islet transplant, or drainage), endoscopic treatment, or standard care (for example, pharmacological treatment only, enzyme replacement therapy, nerve blocks).

Why this is important

Type 3c diabetes is associated with metabolic instability and risk of decompensation leading to severe hypoglycaemia and ketoacidosis, in addition to poor quality of life. However, there is no evidence available in this population to inform practice. Therefore, research specifically on type 3c diabetes is essential to inform future updates of key recommendations in this guideline. National adoption of evidence-based insulin management in type 3c diabetes has the potential to cost effectively improve health and wellbeing, reducing the incidence of acute and long-term complications of poorly controlled glucose levels in chronic pancreatitis. A randomised controlled trial is needed to determine the most effective insulin therapy regimen in this population, comparing twice daily insulin injections, an insulin analogue multiple daily dose basal bolus regimen, and insulin pump therapy.