Gastroenterologists adopt S3 guidelines for pancreatitis

28.10.2021 11:33

The most common causes of acute pancreatitis, the inflammation of the pancreas, are gallstones and excessive alcohol consumption. Although it is a benign disease that is usually overcome within a few weeks, if it is severe, up to 15 percent of those affected die of organ failure. A new guideline from the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) e. V., in collaboration with other specialist societies, has now summarized the rapidly developing knowledge about pancreatitis in its various forms in recent years and is intended to provide doctors, those affected and their relatives as well as service providers and insurance companies with current diagnostic and treatment recommendations.

The main symptoms of acute pancreatitis are sudden, extremely severe upper abdominal pain. “It is crucial for the success of treatment to recognize the disease early and to correctly assess its severity in order to initiate the appropriate therapy quickly,” says Professor Dr. med. Markus M. Lerch, medical director and chairman of the board of the LMU Klinikum Munich, who together with Prof. Dr. med. Julia Mayerle, director of the Medical Clinic and Polyclinic II at the LMU Clinic, is responsible for coordinating the guidelines.

The most feared form of acute pancreatitis is necrotizing pancreatitis due to its high mortality rate. In their case, those affected particularly benefit from experienced experts in centers that specialize in therapy and diagnostics. Here, interdisciplinary collaboration between surgeons, radiologists and gastroenterologists plays an outstanding role in the quality of treatment. Studies show that removing dead and infected tissue using a minimally invasive endoscopic procedure is clearly superior to open surgery, but complications can arise that require rapid action by a surgeon experienced in pancreatic surgery.

In contrast, in acute pancreatitis caused by gallstones, caution is usually required with regard to early therapy using ERCP. “As long as there is no inflammation of the bile ducts with a risk of bloodstream infection, endoscopic therapy should not be carried out or should be carried out as late as possible in the course of the disease,” says Mayerle, explaining the results of the APEC study from the Netherlands. The most effective way to prevent relapses is to surgically remove the gallbladder, as this is where most of the causative gallstones arise.

A second part of the guideline deals with chronic pancreatitis, a disease that leads to progressive destruction of the pancreas through repeated bouts of inflammation and is associated with significant restrictions on the quality of life of those affected. Important triggers for this disease are long-term consumption of alcohol and tobacco. Abdominal pain is also the most important symptom of chronic pancreatitis. If these are caused by a disruption in the drainage of the pancreatic duct, the ESCAPE study demonstrated that surgical treatment as early as possible is the most sustainable long-term therapy concept for patients.

Another important treatment recommendation concerns bile duct strictures that arise as a result of chronic pancreatitis. This is a narrowing of the large bile duct before it opens into the duodenum. It has now been shown that stents inserted with an endoscope widen the narrowing and that in around 80 percent of cases, a significant improvement can be achieved for those affected, at least in the medium term.

Particularly in the chronic form of pancreatitis, it often happens that patients suffer from malnutrition, which is why the specialist societies involved have included nutritional recommendations in the guidelines. In addition to treatment with additional digestive enzymes, the guidelines advise in many cases the use of additional food to increase the BMI (body mass index) after receiving nutritional advice. Another recommendation concerns strict alcohol abstinence. “Pancreatitis is often triggered by excessive alcohol consumption, which also causes serious damage to other internal organs. We therefore recommend strict avoidance of pancreatitis; Even small amounts of alcohol can be harmful under certain circumstances,” warns Lerch.

The guideline also covers autoimmune pancreatitis for the first time, based on the recently published European guidelines. Anyone interested can find a complete overview of the guidelines and further additional information on the DGVS website.

Literature:

• Hoffmeister A, Mayerle J, Beglinger C, et al. S3-Consensus guidelines on definition, etiology, diagnosis and medical, endoscopic and surgical management of chronic pancreatitis German Society of Digestive and Metabolic Diseases (DGVS). Z gastroenterol. 2012 Nov;50(11):1176-224.
• van Brunschot S, van Grinsven J, van Santvoort HC et al. Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicenter randomized trial. Lancet, 2018; 391: 51-58.
• Schepers NJ, Hallensleben NDL, Besselink MG et al. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicenter randomized controlled trial. Lancet 2020; 396: 167-176.
• Issa Y, Kempeneers MA, Bruno MJ et al. Effect of Early Surgery vs Endoscopy-First Approach on Pain in Patients With Chronic Pancreatitis: The ESCAPE Randomized Clinical Trial. Jama 2020; 323: 237-247.

About the guideline:

•         https://www.dgvs.de/wissen/leitlinien/leitlinien-dgvs/chronische-pankreatitis/