4/1/2022

ACG International Webinar Series:

Diagnosis and Management of Chronic Pancreatitis
Hosted by the Italian Society of Gastroenterology (SIGE)

ACG International Webinar Series:

Moderator:
Special Guest:
Gabriele Capurso, MD, PhD
Deputy Director, Pancreas Translational and Clinical Research Luca Frulloni, MD, PhD
Center, San Raffaele Scientific Institute, Milan, Italy Full Professor of Gastroenterology
and Head of Gastroenterological Unit, Department of Medicine,
Chief Clinical Research, PancreatoBiliary Endoscopy and EUS Institute of Pancreas
Division at the Pancreas Translational and Clinical Research University of Verona
Center in San Raffaele Scientific Institute, Milan, Italy

American College of Gastroenterology

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Participating in the Webinar

All attendees will be muted and

will remain in Listen Only Mode.

Type your questions here so

that the moderator can see
them. Not all questions will be
answered but we will get to
as many as possible.

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Diagnosis and Management of

Chronic Pancreatitis

Timothy B. Gardner, MD, MS, FACG

Professor of Medicine
Geisel School of Medicine at Dartmouth
Section of Gastroenterology and Hepatology
Dartmouth-Hitchcock Medical Center

Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Case Presentation
Chief Complaint: Chronic abdominal pain
History of Present Illness:
- 42 year old male
- Insidious onset of pain for several years
- Epigastric with radiation to the back
- 20-30 ounces of alcohol daily
- Unremarkable lab testing
- Normal fecal elastase
- CFTR ΔF508 heterozygote

Case Presentation
Serology: Normal amylase, lipase, TTG, IgG4, CA 19-9

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Case Presentation
Hyperechoic strands and foci Hyperechoic duct wall

Lobularity 4 EUS Morphologic Criteria

• Hyperechoic duct wall (body)
• Hyperechoic foci (head, body, tail)
• Hyperechoic strands (head, body, tail)
• Lobularity in body and tail

Case Presentation

How does one interpret these results?

Does he have chronic pancreatitis?

How should be treated?

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Designing Clinical Guidelines

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Designing Clinical Guidelines

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Designing Clinical Guidelines

Literature Search – major databases from 1946-present

Best evidence – i.e. RCTs, systematic review and

meta-analysis

PICO questions for answerable questions

- Population/Problem
- Intervention
- Comparison
- Outcome

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Designing Clinical Guidelines

PICO QUESTIONS

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Designing Clinical Guidelines

Once you have designed the PICO questions…

- Evaluate the literature

to answer your questions

- If you have enough

evidence to answer the
questions, start the GRADE
evaluation process

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Designing Clinical Guidelines

A few reminders about guidelines…

- They are limited by the amount of clinical trial evidence

available

- There are multiple types of guidelines – beware of those

that do not follow the GRADE system (i.e. beware of expert
opinion)

- Not all important clinical questions can be answered – or

even addressed – if using evidence-based guidelines

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Designing Clinical Guidelines

Two Types of
Statements
1. Recommendations
- Evidence
- Grade System

2. Key Concepts
- Not amenable to Grade
- Often expert opinion

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Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Diagnosis
Recommendation Statements

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EUS Diagnosis: The Perfect Storm

No gold standard
Wide
Highly
interobserver
sensitive test
variation

Confusing Lack of
nomenclature specificity

Increasing Heavy reliance on

availability expert opinion
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Diagnosis
Recommendation Statements

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Diagnosis
Recommendation Statements

Gardner and Levy. GIE 2010;71(7):1280-90.

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Diagnosis
Key Concepts

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Diagnosis

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Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Etiology and Natural History

Recommendation Statements

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Etiology and Natural History

Recommendation Statements

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Etiology and Natural History

Key Concepts

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Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Management of Pain
Recommendation Statements

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Management of Pain
Recommendation Statements

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Management of Pain
Recommendation Statements

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Management of Pain
Recommendation Statements

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Management of Pain
Key Concepts

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Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Management of EPI
Recommendation Statements

Gardner TB et al. Am J Gastroenterol 2014109:624-5.

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Management of EPI
Key Concepts

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Objectives

1. Designing Clinical Guidelines

2. Diagnosis

3. Etiology and Natural History

4. Management of Pain

5. Management of EPI

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Future Areas of Investigation

Investigate the Mechanistic Definition of CP…

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Future Areas of Investigation

Further comparative effectiveness treatment
trials…

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Future Areas of Investigation

A reckoning of how these patients are
demonized, mistreated, and cared for by our
profession…

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Thank You
“Man cannot discover new oceans unless he has the courage to lose sight of
the shore”
- Andre Gide
1947 Nobel prize for literature

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