UK Guidelines for Management of Acute Pancreatitis - 2005

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UK Guidelines for Management of Acute
Pancreatitis - 2005
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Acute Pancreatitis

• BSG guidelines originally 1998 (Gut 199842suppl
  2)
• Aimed to provide recommendations for initial Dx,
  Invx, Rx
• Did not cover surgical Rx of necrosis
• Modified over recent years
• Updated 2005 (Gut 200554suppl 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

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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

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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
• SEs 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
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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)
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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 CS
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
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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
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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
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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