UK Guidelines for Management of Acute Pancreatitis - 2005

1. UK Guidelines for Management of Acute Pancreatitis - 2005

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. CT imaging in pancreatitis Patients with severe AP who have persisting organ failure should undergo CT within 6-10d of admission

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. Surgical Intervention for Necrosis Pancreatic necrosis Signs of sepsis No sepsis FNA Gas on CT Conservative Rx Infected Sterile Deterioration Recovery Debridement

19. 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

20. 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

21. 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