Pancreatitis (Chronic) and PEI

Overview

Chronic Pancreatitis

Please see the CKS guidelines on Chronic Pancreatitis. (2)

Suspect chronic pancreatitis in any person with chronic or recurrent upper or generalized abdominal pain, particularly if they have a history, or clinical features of, alcohol misuse. 

Symptoms

• Abdominal pain is typically dull, deep, and severe epigastric pain, which may radiate to the back, or localize to the right or left upper quadrants. It may be relieved by sitting upright and leaning forward, and is often precipitated by eating.  Abdominal pain may be absent in 20% of people, regardless of the cause of pancreatitis.
• Nausea and Vomiting
• Symptoms of exocrine insufficiency - Steatorrhoea (foul-smelling, oily stools that are difficult to flush away), diarrhoea, bloating, abdominal cramps, excessive flatus, weight loss, and malnutrition.
• Symptoms of endocrine insufficiency - Diabetes

These symptoms can be non - specific and will often instigate initial investigations to exclude malignancy or other underlying causes.

If there are no red flags (see red flag section below) then initial investigations and diagnosis can be often be undertaken in primary care before considering referral.

Complications

• Chronic pain.
• Endocrine insufficiency with failure to produce insulin, causing impaired glucose regulation and diabetes mellitus.
• Exocrine insufficiency with failure to produce digestive enzymes, causing maldigestion and malabsorption.
• Pancreatic calcification.
• Pseudocyst formation.

Who to Refer

Consider urgent admission if the person presents with an episode of acute pancreatitis.

Consider 2WW referral if there are red flags suspicious for pancreatic cancer (see red flag section below.

Consider referral, depending on clinical judgement, if the person presents with a complication of chronic pancreatitis.

Consider investigations in primary care if no urgent admission or referral is required. Investigations may be helpful when the diagnosis is uncertain or to exclude other conditions (see 'What to do before referral' section below). A diagnosis can then often be made and management instigated in primary care.

Consider routine referral if diagnosis is in doubt, or further specialist management is required (see referral options in Referral section below). Prompt dietetic referral should be made for those who present in a malnourished state and ongoing nutritional decline in spite of initiating PERT.

Consider referral to a pain service  if pain is the predominate symptom and cannot be managed in primary care - see advice below. 

Red Flags

Acute pancreatitis

Suspect acute pancreatitis in any person who presents with acute upper or generalized abdominal pain, particularly if they have a history or clinical features of gallstones or alcohol misuse.

Nausea, anorexia, and vomiting are also commonly present.

Arrange surgical admission to your local hospital

Pancreatic cancer

See the Pancreas - Urgent Suspected Cancer - USC (2WW) page.

Consider in patients with jaundice and/or other RAT (risk assessment tool) symptoms such as: Loss of weight, abdominal pain, nausea or vomiting, malaise, constipation, diarrhoea, new onset diabetes, back pain.

What to do before referral

Investigations

Consider investigations in primary care for patients with suspected chronic pancreatitis (2):

• Blood tests should be directed according to symptoms and possible other causes but should include LFTs and blood glucose/HbA1c to rule out diabetes.
• Serum amylase level is not routinely raised and is not diagnostic in chronic pancreatitis. Testing should therefore not be performed.
• Faecal elastase - can help in diagnosis of pancreatic exocrine insufficiency (3,4), although is less reliable in mild-moderate PEI (4). Treatment can often be started based on clinical picture without this test or while awaiting the result.
• USS can help to exclude other conditions such as gallstones and identify signs of chronic pancreatitis, such as pancreatic calcification.
• CT scan if pancreatic insufficiency is suspected to rule out pancreatic malignancy (3)

Management in Primary Care

Lifestyle advice -recommend complete abstinence from alcohol and smoking. Refer to local alcohol services if the patient is alcohol dependent.

Pancreatic exocrine insufficiency - this can often be diagnosed clinically if other conditions have been excluded. A dietician referral may also be helpful if diagnosis is confirmed, and patients started on Pancreatic Enzyme Replacement Therapy - PERT (3,4). Creon is used first line and is green on the BNSSG formulary - reduced exocrine secretions page. Referral should be considered if symptoms are not improving with this treatment or diagnosis is in doubt.

Key Points when prescribing PERT

• All products are porcine based
• Starting dose should be a minimum of 50000units of lipase (e.g Creon) per meal and 25000units with snacks and nourishing drinks
• Starting doses need to be reviewed and dose possibly increased to optimise therapy (there is no maximum dose).
• Timing of enzymes – should be given just before eating.

See Resources section for further details on prescribing and monitoring PERT(3,4)

There is also a Patient information Leaflet on PERT

***Update July 2024 - PERT shortages***

Please see the PERT Shortage Memo To Primary Care V3.4 FINAL document. Key points include:

• Only prescribe one month supply at a time.
• Do not switch between products as they are all in short supply.
• Consider prescribing PPI or H2 antagonise to optimise efficacy (omeprazole 20mg bd or equivalent).
• Only escalate to secondary care teams in exceptional circumstances.

Pain management - simple analgesia such as paracetamol and NSAIDs can be used, with addition of weak opioids for more severe pain if necessary (avoid strong opioids).  Neuropathic pain medication such as amitriptyline and gabapentin can also be tried. (2) . See also the Persistent (chronic) Pain page on Remedy for general advice about management of chronic pain or the BNSSG Chronic pain guidelines in the Formulary.

Services

Suspected pancreatic cancer - Refer via Urgent Suspected Cancer - USC (2WW) pathway.

Chronic pancreatitis-  Consider advice and guidance or referral if a patient is not responding to management in primary care and according to symptoms to:

• Hepatobiliary and pancreatic surgery via eRS - to access the HPB service at the BRI who are the regional pancreatitis centre. There is also an advice and guidance service for this team, also available via eRS
• Gastroenterology via eRS (UHBW or NBT)- if non-specific GI symptoms and diagnosis in doubt. 
• Dietician - if support in managing PEI and PERT are required, particularly if malnourished or in nutritional decline or not responding to PERT. This support may be available with your PCN dietician if available. 
• Pain clinic  (UHBW or NBT) via eRS . Consider referral to a pain service if pain is the predominant symptom and cannot be managed in primary care (and if referral criteria are met).

Resources

(1) Acute Pancreatitis - CKS

(2) Chronic Pancreatitis - CKS

(3) Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines | BMJ Open Gastroenterology

(4) The Prescribing and Monitoring of PERT (UHBW Clinical Guideline) -October 2021

Patient information Leaflet on PERT

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.