Clinical

Chronic management

Chronic pancreatitis

Background

  • Chronic pancreatitis is a chronic inflammatory condition characterised by irreversible destruction of pancreatic tissue. In its’ early stages it is often characterised by recurrent attacks of ‘acute pancreatitis’ or acute pain which might be the only clinical symptom.
  • After an interval of several years the symptoms of permanent exocrine and endocrine insufficiency will become manifest.
  • Acute biliary pancreatitis almost never progresses to chronic pancreatitis while acute alcoholic pancreatitis often does.
  • Alcohol is the most common identifiable cause of chronic pancreatitis in the Western World. There are other causes but these are rare and include metabolic disorders (e.g. hypercalcaemia), duct obstruction (e.g. pancreatic trauma), and hereditary pancreatitis (e.g. mutations in the trypsinogen 3 gene). Many cases remain “cryptogenic”.
  • There are few studies that document the prevalence of chronic pancreatitis in the UK however a few studies have demonstrated dramatic increases in incidence over successive time periods. There are also significant regional variations in incidence that cannot be explained by patterns of alcohol consumption however data from England and Wales does show a correlation between alcohol consumption per head of population and the number of hospital discharges with chronic pancreatitis. It is therefore safe to say that as alcohol consumption per capita continues to rise that the prevalence of chronic pancreatitis will also do the same but with a lag period of perhaps 5 years.

Patient View

  • Patients generally value being given a cause for their symptoms and an explanation of how they can modify their symptoms by lifestyle changes. They value appropriate investigation and symptomatic treatment.

Current Practice

  • Medical: Elective presentation with symptoms suggestive of chronic pancreatitis should lead to prompt cross sectional imaging with onward referral to either a gastroenterologist or regional (hepato)pancreatobiliary surgeon. A clinic appointment should be offered within 4 weeks. Patients should have a symptomatic assessment and be offered pancreatic exocrine and endocrine replacement therapy when appropriate, they should also be offered adequate analgesia and if necessary a referral to a chronic pain service. Adequate cross sectional imaging should be performed with further investigations as necessary and guided by a regional pancreaticobiliary service. In a small selected group of patients surgical options can be offered. If surgery is indicated and accepted then it should be offered within the 18 week referral to treatment target. Interventional strategies for chronic pain management will often only be offered at a tertiary centre and these options should be considered.
  • Surgery: A combination of partial and total pancreatectomy or pancreatic duct drainage can be offered in select patients. Splanchnicectomy using an endoscopic USS approach, radiofrequency ablation using a radiological approach or a thoracoscopic splanchnicectomy are potential surgical options in pain management.
  • Specialist multi-disciplinary management: Is usually necessary for most patients with severe symptoms at some point during their illness. However many patients have difficulty with clinic attendance and are serial non-attendees, these patients will often present intermittently via the Emergency Department.

Recommended Practice and Opportunities for Integrated Working

Our principal recommendations are

  • Dedicated Pathway for Patients with Chronic Pancreatitis: This would reduce the waiting time for symptomatic patients, reduce emergency admissions and increase the proportion of patients receiving appropriate care and achieving symptom relief.
  • Emergency Admissions: The development of rapid assessment patient pathways for emergency admissions would speed up the provision of chronic pain input for these patients. This would ultimately result in a greater proportion of patients receiving symptom relief during their index admission and therefore possibly reduce rates of readmission.
  • Access to Addiction Services: Rapid access using specific patient pathways to addiction services would support patients in maintaining abstinence and therefore reduce future pancreatic damage. This might result in a reduction in readmission rates.

Opportunities for Savings

  • The most scope for saving is to ensure that patients have access to chronic pain services, gastroenterology services, addiction services, have been adequately investigated and appropriate patients referred to specialist services when added benefit is possible. This could prevent re-admission.

Quality Indicators (Outcomes)

Quality Metrics and Outcome measures (minimum, good and ideal standards):

Process metrics likely to impact on outcomes

There are as yet no nationally agreed standards for management of chronic pancreatitis.

Suggested process measures include:

  • In elective patients symptom onset to:
    • ultrasound scan
    • definitive cross sectional imaging
    • outpatients appointment with GI specialist
    • referral to chronic pain services
  • Attendance rate at OPA
  • Proportion patients referred for a tertiary opinion
  • Definitive diagnosis during index admission for emergency patients

Outcome measures

  • Attendance rate at OPA
  • Proportion patients referred for a tertiary opinion
  • Definitive diagnosis during index admission for emergency patients
  • Readmission rate
  • Symptom control

Future measurements

These measures will soon be supplemented by patient PROMs (satisfaction and/or disease specific quality of life) which are under development and an update of the EQ5-D (generic quality of life, DH).

Social Policy & Understanding

  • Patients will have a significant time off work when symptomatic; often have a rapid social decline, the majority of those severely affected will be on social support and become generally unemployable. Treatment costs to the NHS are significant with repeated attendances via the Emergency Department.
  • Public and employer understanding of alcohol induced disease and specifically chronic pancreatitis is poor. Information is available on the internet but can be misleading. Public education of the results of alcohol misuse is required. Patients with chronic pancreatitis need not have an alcohol addiction and support in abstinence can lead to significant symptomatic and lifestyle improvements.