Chronic pancreatitis clinical practice guidelines: acute pancreatitis 2017

The most dangerous of the pathological processes that arise in the pancreas is chronic pancreatitis, which forms over a long period of time.

It affects the functioning of adjacent organs, and also provokes dangerous complications.

This is a long-term inflammatory disease of the pancreas, which is manifested by irreversible changes that cause pain or persistent deterioration of function.

There are recommendations for chronic pancreatitis regarding clinical treatment and dietary nutrition, assessment of the work of the organ in question, drug relief and preventive measures.

Recommendations for chronic pancreatitis

The purpose of these clinical guidelines is to develop practical rules for the examination and treatment of chronic pancreatitis for specialists, based on a rigorous drug approach.

The disease in question needs to follow a special diet, drug treatment, and in some situations, surgery.

Since the chronic form of pancreatitis has various causes and differs in the degree of poisoning, therapy pathology provides for an immediate call to the ambulance and referral of the patient to the hospital for further survey.

Diagnosis and Recommended Clinical Research

The diagnosis is made taking into account the attacks of abdominal pain, manifestations of insufficiency of the function of the external secretion of the pancreas in a patient who constantly drinks alcohol.

In contrast to acute pancreatitis, in chronic pancreatitis, an increase in the content of enzymes in the bloodstream is rarely observed, or urine, because when this happens, it is possible to make an assumption about the formation of a pseudocyst or pancreatic ascites.

The choice of imaging methods is based on the availability of the technique, the presence of the necessary skills among specialists and the invasiveness of the diagnostic method.

• Radiography. In 1/3 of situations, this procedure helps to identify pancreatic calcification or calculi inside the duct. This will make it possible to eliminate the need for subsequent diagnosis in order to confirm the disease. The level of reliability of the evidence is 4. The level of persuasiveness of the recommendations is C.
• Transabdominal ultrasound. This diagnostic measure lacks sensitivity and specificity. It rarely gives information that is sufficient to identify pathology. Its main purpose will be to exclude other factors of pain in the abdominal cavity. The degree of persuasiveness of the recommendations - A.
• CT with the introduction of a contrast agent. Today it is considered the method of choice for the initial diagnosis of the disease. The most effective technique for establishing the location of pancreatic calculi. The level of persuasiveness of the recommendations - B.
• Endoscopic ultrasound. The method is minimally invasive. Used for medicinal purposes. It is considered the most proven method of visualizing changes in the parenchyma and pancreatic ducts at the initial stage of chronic pancreatitis.
• ERCP. High probability of detecting the disease in question.

Management tactics

The tactics of managing a patient with such a pathology is based on the following components:

• Establishing a diagnosis of chronic pancreatitis;
• An attempt to identify the origin of the disease;
• Establishing the stage;
• Diagnosis of pancreatitis;
• Development of a therapeutic regimen;
• Forecast based on the current situation and the selected treatment regimen.

Conservative treatment

Conservative therapy of patients with the disease under consideration is aimed at relieving symptoms and preventing the occurrence of adverse consequences, the following tasks are distinguished:

• refusal to use alcoholic beverages and tobacco smoking;
• identification of provoking factors of pain in the abdominal cavity and a decrease in their intensity;
• therapy of insufficiency of the function of external secretion of the pancreas;
• detection and therapy of endocrine insufficiency at the initial stages before the formation of adverse consequences;
• nutritional support.

Behavior change

A complete elimination of alcoholic beverages is recommended to reduce the frequency of dangerous consequences and death.

It is extremely difficult to single out the role of tobacco smoking with excessive consumption of alcoholic beverages as a provoking factor, which affects the course of chronic pancreatitis, as it often accompanies excessive consumption alcohol.

However, refusal to take alcohol does not in all cases slow down the progression of the pathological process.

In such a situation, patients with the disease under consideration are advised to quit smoking. Strength of recommendation C.

Relief of abdominal pain

Often painful sensations are caused by pseudocysts, duodenal stenosis, pronounced obstruction of the ducts.

In a situation where clinical diagnosis confirms the presence of an unpleasant pathology and justifies the relationship with abdominal pain, at the initial stage of therapy it is required to use endoscopic and surgical therapeutic ways.

Usually, such cases are discussed collectively by specialists of various profiles to develop an optimal treatment regimen.

In case of intense pain, episodic or course use of non-narcotic analgesics is recommended: paracetamol 1000 mg three times a day.

The duration of permanent treatment with paracetamol is no more than 3 months with monitoring the patient's well-being, blood counts. Strength of Recommendations - C.

Treatment of exocrine pancreatic insufficiency

Violation of the digestibility of fats and proteins is manifested only when the pancreas function deteriorates by more than 90%.

Surgical intervention on this organ can provoke the formation of exocrine insufficiency and the implementation of enzyme replacement treatment.

Appropriate and timely therapy makes it possible to prevent the occurrence of dangerous consequences and reduce mortality in case of malnutrition.

The purpose of substitution treatment will be to improve the patient's ability to consume, process and assimilate a certain amount of basic food components.

Laboratory signs for the implementation of such therapy:

• steatorrhea;
• chronic diarrhea;
• nutritional deficiency;
• pancreatic necrosis, a severe form of chronic pancreatitis;
• undergone surgery on the pancreas with impaired passage of food;
• condition after surgery on this organ with manifestations of exocrine insufficiency.

Prescription of pancreatic enzyme replacement therapy is recommended for patients with chronic pancreatitis and insufficiency of exocrine function, as it helps to improve the processing and absorption of fats.

Strength of recommendations - A.

Treatment of endocrine pancreatic insufficiency

Diet food for pancreatogenic diabetes mellitus needs to be corrected for malabsorption. Fractional nutrition is used in the preventive measures of hypoglycemia.

If insulin therapy is prescribed, the target glucose level is the same as for type 1 diabetes.

It is necessary to teach the patient to prevent severe hypoglycemia, to focus on refusing to take alcoholic beverages, to increase physical activity, to observe fractional nutrition.

In the treatment of diabetes mellitus in chronic pancreatitis, it is recommended to monitor the glucose content in the bloodstream in order to prevent adverse effects. The persuasiveness of the recommendations -V.

Surgery

With a complex course of the pathological process, in some situations with intractable pain in the abdominal cavity, endoscopic or surgical therapy is prescribed.

The decision is made by doctors who specialize in treating diseases of the pancreas.

With the usual course of pathology, invasive intervention is aimed at correcting changes in the ducts of this organ, inflammation of the parenchyma.

The decision to carry out the operation must be balanced, taking into account all the risks of adverse consequences.

It is required to exclude other factors of pain in the gastrointestinal tract. Such treatment will be necessary if there is no proper relief of discomfort within 3 months of conservative therapy, as well as with a significant deterioration in the quality of life.

Endoscopic treatment

There are no studies evaluating the impact of endoscopic therapy on pancreatic function in patients.

Treatment of pseudocysts is not prescribed regardless of their size. Drainage may be more appropriate than surgery, as it has a better benefit / risk profile.

Strength of recommendations - A.

Prevention and dispensary observation

Preventive measures of chronic pancreatitis are based on the extrapolation of research data, according to the results of which it is possible to express the assumption that the exclusion of alcohol consumption and smoking is a cause that reduces the likelihood of progression of the considered diseases.

Recommendations on dietary preventive measures, the validity of refusing coffee, chocolate products, various fats at the moment are not based on grounds.

It is likely that more significant provoking factors of exacerbation of chronic pancreatitis there will be obesity, overeating and hypokinesia after eating, a constant lack of antioxidants in food products.

However, it should be remembered that some patients scrupulously adhere to a rigid diet in order to prevent a recurrence of the disease.

As a result, they can bring themselves to nutritional deficiencies. Based on the foregoing, based on the results of various studies, such lifestyle changes are recommended to prevent the disease in question:

• articulate nutrition (up to 6 times a day, in small portions with an even distribution of fatty foods), avoidance of overeating;
• taking various foods with a low concentration of fats and cholesterol (unrefined vegetable fats are limited only in those patients who are overweight);
• drawing up a menu with the required amount of dietary fiber, which are found in cereals, vegetables and fruits;
• maintaining a balance between food eaten and physical activity (in order to stabilize body weight in order to achieve optimal weight, taking into account age indicators).

For the purpose of effective primary prevention of chronic pancreatitis, it would be optimal to conduct a total dispensary control of the population for the timely detection of the considered disease of the bile ducts, hyperlipidemia.

However, today, on the planet, this idea has no practical implementation, since it requires significant material investments.

The validity of such tactics can be confirmed by pharmacoeconomic diagnostics.

However, due to the relatively low incidence of chronic pancreatitis, such studies should be unlikely.

The 2017 clinical guidelines for the treatment of chronic pancreatitis regulate and try to find a general therapeutic regimen, to find a unified laboratory and dietary approach.

These prescriptions are a comprehensive practical guide to the elimination of the disease in question.

Such recommendations are the result of a critical appraisal of the evidence already available, taking into account medical practice.

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