Abstract:
BACKGROUND: Chronic pancreatitis (CP) is defined as a continuing
inflammatory disease of the pancreas characterised by irreversible
morphological changes, often associated with pain and with the
loss of exocrine and/or endocrine function that may be clinically
relevant. Alcohol is the predominant cause of CP in the western
world and is particularly prevalent in South Africa, especially in
the indigent patient. CP ranks high among intractable diseases
of the gastrointestinal tract. The tendency for substance abuse in
the alcohol-induced group poses major psychological and socioeconomic
problems.
OBJECTIVE: CP is a disease with significant clinical and pathological
heterogeneity. Level 1 evidence to support definitive guidelines
for diagnosis, medical management and interventional therapy
is lacking. Despite this paucity of robust scientific evidence, it is
important to provide some assistance based on the best available
evidence as to the current standard of care for CP in the South
African context; this will aid all involved in the management of the
disease, and includes clinicians, health care managers and funders.
Scope. The guidelines were developed as recommendations
addressing the diagnosis, medical management and interventions,
both endoscopic and surgical, for the management of a very complex
and heterogeneous disease of the pancreas. The recommendations
are particularly relevant in the South African context where the
predominant patho-aetiological agents are alcohol-associated with
smoking.
RECOMMENDATIONS: The guidelines provide clear recommendations
regarding the diagnostic modalities available, both imaging (which
includes MRI and endoscopic ultrasound (EUS)) and pancreatic
function tests. The section on medical management makes
recommendations on the use of analgesics, enzyme replacement and
other therapeutic options in the non-interventional management of
the majority of patients with CP. The section on interventional
procedures identifies the indications and options available for the
interventional management of both uncomplicated and complicated
CP. The role of endoscopic and surgical modalities is defined, but it is
in this context especially that the best available evidence, combined
with the experience of the group, influenced the recommendations
put forward. Owing to the lack of evidence and the complexity of
the disease, it is recommended that, where possible, CP is managed
in the context of a multidisciplinary team.
Validation. The guidelines are based on best practice principles
determined by the available evidence and the opinions of the
group, which comprised 7 medical and surgical gastroenterologists
with significant experience in dealing with patients with chronic
pancreatitis in the South African context. The group convened
between May 2009 and August 2010 under the auspices of the
Hepato-Pancreatico-Biliary Association of South Africa (HPBASA)
and the South African Gastroenterology Society (SAGES), and the
guidelines are the result of broad consensus within this group. The
draft was presented to other experts in this field of endeavour to
ensure broader participation and consensus.
Plans for guideline revision. HPBASA and SAGES will publish a
revised modification of the recommendations when new levels 1
and 2 evidence data are published.