ACG issues new guidelines for chronic pancreatitis
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The American College of Gastroenterology has issued new clinical guidelines for the diagnosis and treatment of patients with chronic pancreatitis.
Timothy B. Gardner, MD, MS, FACG, director of pancreatic disorders at Dartmouth-Hitchcock Medical Center, told Healio Gastroenterology and Liver Disease that although chronic pancreatitis is pretty common, these are the first guidelines from the ACG on chronic pancreatitis.
“[The ACG has] done guidelines for acute pancreatitis and pancreatic cysts, but chronic pancreatitis really has no guidelines for the membership,” he said. “These are also evidence-based guidelines. They really take into account the available literature, and I think they will be very valuable for the clinician moving forward.”
Gardner said there is currently a lot of variability for how chronic pancreatitis is diagnosed. With no American guidelines, the process differed practice to practice, but Gardner hoped that the diagnostic algorithm established in the new guidelines can lend some clarity.
The guideline includes 11 recommendations for the diagnosis, etiology and natural history of the disease, as well as management of pain and exocrine pancreatic insufficiency. Gardner said some of the significant, strong recommendations include:
- Using computed tomography or MRI for the first-line diagnosis of chronic pancreatitis;
- Because of low-specificity and invasiveness, endoscopic ultrasound should only be used for diagnosis if the diagnosis is in questions after cross-sectional imaging is performed;
- First-line endoscopic therapy; and
- Surgical intervention in patients with obstructive chronic pancreatitis for the long-term relief of pain if first-line endoscopic therapy has been exhausted or unsuccessful.
Gardner said having a uniform approach should provide practicing GIs with a better tool to help their patients.
“This is a standardized algorithm for how to diagnose and treat this really challenging disease,” he said. “There really aren’t a lot of great treatment options, but we are hoping for more standardization so that all the patients that the GIs see have some structure as far as their overall management.” – by Alex Young
Disclosure: Gardner reports receiving research grants from the ChiRhoClin Research Foundation. Please see the full guidelines for all other authors’ relevant financial disclosures.
Perspective
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Tyler Stevens, MD
These guidelines summarize the current state-of-the-art of the diagnosis and treatment of chronic pancreatitis. I especially appreciate its guidance on appropriate use of second line tests such as endoscopic ultrasound and MRI. The authors produce a very nice algorithm incorporating CT, EUS, and MRI for diagnosing advanced and “minimal change” chronic pancreatitis. They also acknowledge the relatively weak evidence supporting these diagnostic tests due to the paucity of studies comparing them to a histological gold standard.
The authors also do a nice job enumerating the risk factors for chronic pancreatitis, especially the genetic basis of the disease. It is very important that clinicians understand the complex, multifactorial etiology of this disease, even before they begin to embark on costly and/or invasive testing. The authors also provide rationale for ordering genetic testing in selected patients, which has been considered controversial. I think the chronic pancreatitis field is moving in the direction of a personalized medicine approach that accounts for the patient’s underlying susceptibility, in addition to their environmental exposures and habits. Further therapies may even be tailored toward the patients underlying genetics. Even at the present, I believe the results of genetic testing impacts surgical decision making for many patients.
The authors also review the relatively sparse evidence of pharmacologic, endoscopic, and surgical treatments for pancreatic pain. The recommendation for antioxidants for pain is a bit controversial, based on the mixed results seen in trials. All considered, these guidelines will serve as a very practical reference for gastroenterologists and surgeons caring for this challenging patient group.
Department of Gastroenterology, Hepatology & Nutrition
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