Uk guidelines for management of acute pancreatitis 2005
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UK Guidelines for Management of Acute Pancreatitis - 2005. Acute Pancreatitis. BSG guidelines originally 1998 (Gut 1998:42;suppl 2) Aimed to provide recommendations for initial Dx, Invx, & Rx Did not cover surgical Rx of necrosis Modified over recent years Updated 2005 (Gut 2005:54;suppl 3).

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Acute pancreatitis l.jpg
Acute Pancreatitis

  • BSG guidelines originally 1998 (Gut 1998:42;suppl 2)

  • Aimed to provide recommendations for initial Dx, Invx, & Rx

  • Did not cover surgical Rx of necrosis

  • Modified over recent years

  • Updated 2005 (Gut 2005:54;suppl 3)


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  • Diagnosis inc. aetiology

  • Initial management

  • Severity assessment

  • Radiological assessment

  • Use of antibiotics

  • Nutrition

  • Treatment of gallstones

  • Surgical Rx for necrosis/abcess

  • Critical care/specialist care


Diagnosis l.jpg
Diagnosis

  • Clinical features c/w  amylase

  • Lipase more accurate than amylase

  • Where doubt exists  imaging (CT preferable)

Correct diagnosis should be made in all patients  48h


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Aetiology

  • 50% gallstones, 20-25% alcohol, 25-30% other (viral, hyperlipidaemia, hypercalcaemia, drugs, neoplasm, trauma, idiopathic)

  • Invx in recovery phase

    • lipids, Calcium, viral titres

    • repeat US, if –ve CT

    • Recurrent attacks – MRCP/ERCP/EUS/SOOF

Aetiology of AP should be determined in 80% of cases, &  20%

cases should be idiopathic


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Initial management

  • Aggressive fluid resuscitaion/O2/monitoring

  • Aim to reverse/reduce organ failure

Patients with SAP should be managed on HDU with access to ITU when appropriate


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Assessment of Severity

  • helps clinically to target care on those pts with severe AP

  • helps in comparison of outcome between units

  • entry criteria into trials of new Rx


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Severity Scoring

  • Ransons - 1974, USA, alcohol, 48h, modified 1979   3 mortality 60%

  • Glasgow –1978 (modified 1985)   3 severe

  • APACHE II

  • APACHE II  Obesity

  • Atlanta Criteria 1992

    • Local complications – pseudocyst/ascites/necrosis

    • Systemic complications – cvs, resp, cns, renal, haem

  • CRP  150mg/l

  • Others – Trypsinogen, TNF, Se amyloid, IL6, IL8


  • Severity scoring9 l.jpg
    Severity Scoring

    No single scoring system is accurate enough facilitate clinical decision making

    Attempt to grade severity on all patients within 48h

    Initial - clinical assessment, BMI 30+, pleural effusion, APACHE II  8

    24h – above + Glasgow  3, CRP  150mg/l, persisting organ failure

    48h – above + multiple organ failure


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    CT imaging in pancreatitis

    • Aids diagnosis

    • Helps determine necrosis/extent

    • Not indicated in everyone

    • Done too early may underestimate necrosis

    • Done too frequently may worsen renal function

    • CT severity index (Balthazar) – oedema  necrosis


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    CT imaging in pancreatitis

    Patients with severe AP who have persisting organ failure should undergo CT within 6-10d of admission


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    Prophylactic Antibiotics

    • No role in mild AP

    • Do prophylactic Abx prevent infection of pancreatic necrosis in severe AP & improve outcome?

      • 6 RCTs

      • Different Abx, varying duration, all small nos

      • Evidence varied & inconclusive

    No consensus – if given then give for max 14d then stop


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    Nutrition

    • Traditionally – NBM, then introduce oral nutrition when tolerating. TPN for severe cases who failed to settle

    • SE’s of TPN (line, metabolic) may offset any advantages

    • Recently trials of enteral feeding shown to be safe, well tolerated in SAP

    • Controlled trials enteral v TPN - no difference or marginal benefit for enteral

    Try to establish enteral nutrition in all pts with SAP. Reserve TPN for those pts with persistent ileus


    Gallstones l.jpg
    Gallstones

    • Aetiology in 50%

    • MAP – no place for ERCP, but plan Rx of gallstones to prevent further attack

    All patients with biliary mild pancreatitis should undergo definitive Rx of their gallstones during the same hospital admission, unless a clear plan has been made for definitive Rx within 2w. (LC + OTC, or ERCP/S)


    Gallstones15 l.jpg
    Gallstones

    • SAP – 3 RCTs of ERCP v no Rx

      • Benefit in pts with cholangitis, jaundice but in other pts results inconclusive

    Urgent therapeutic ERCP + S all for pts with SAP due to gallstones OR when there is cholangitis/jaundice/dilated CBD

    Best carried out  72h onset pain


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    Surgical Intervention for Necrosis

    • Difficult area, high mortality, no controlled trials

    • Decision to intervene depends on clinical picture/evidence of sepsis/demonstration of necrosis on CT

    • General agreement that infected necrosis requires drainage, sterile necrosis treated conservatively

    • Infection diagnosed by FNA aspiration or gas bubbles on CT


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    Surgical Intervention for Necrosis

    SAP with persistent symptoms +  30% necrosis, or those with smaller areas but signs of sepsis should undergo FNA for C&S

    Infected necrosis requires intervention/drainage


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    Surgical Intervention for Necrosis

    Pancreatic necrosis

    Signs of sepsis

    No sepsis

    FNA

    Gas on CT

    Conservative Rx

    Infected

    Sterile

    Deterioration

    Recovery

    Debridement


    Surgical intervention for necrosis19 l.jpg
    Surgical Intervention for Necrosis

    • Choice of procedure

      • Necrosectomy/tube drain

      • Necrosectomy/post op lavage

      • Necrosectomy/drainage/scheduled relap

      • Necrosectomy/laparastome

      • Laparascopic necrosectomy/tube drain

      • Radiological drainage

    Necrosectomy can be achieved surgically (open or laparoscopically) or radiologically dependent on expertise


    Provision of services specialist intervention l.jpg
    Provision of Services/Specialist Intervention

    A single team should manage all patients with AP

    Management in/referral to a specialist unit of pts with  30% necrosis, or complications requiring surgical, radiological, or endoscopic procedures


    Summary l.jpg
    Summary

    • Over past 20y considerable re-evaluation of Rx of AP & in particular severe AP

    • These guidelines help focus treatment along evidence based pathways where possible, but also highlights the weakness of the evidence in some areas & need for more research


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