uk guidelines acute pancreatitis
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UK Guidelines for Management
of Acute Pancreatitis - 2005
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Acute Pancreatitis
• BSG guidelines originally 1! "Gut
1!#$2%su&&l 2'
• Aimed to &ro(ide recommendations for initial )*+,n(*+ .*
• )id not co(er surgical .* of necrosis
• Modified o(er recent years• U&dated 2005 "Gut 2005#5$%su&&l /'
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• )iagnosis inc aetiology
• ,nitial management
• Se(erity assessment
• .adiological assessment
• Use of antiiotics
• utrition
•3reatment of gallstones
• Surgical .* for necrosis4acess
• ritical care4s&ecialist care
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)iagnosis
• linical features c46 ↑ amylase
• 7i&ase more accurate t8an amylase
• 98ere dout e*ists → imaging "3 &referale'
orrect diagnosis s8ould e made in all &atients ≤ $!8
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Aetiology
• 50: gallstones+ 20-25: alco8ol+ 25-/0: ot8er "(iral+
8y&erli&idaemia+ 8y&ercalcaemia+ drugs+ neo&lasm+
trauma+ idio&at8ic'
• ,n(* in reco(ery &8ase
• li&ids+ alcium+ (iral titres
• re&eat US+ if ;(e 3
• .ecurrent attac<s ; M.P4=.P4=US4S>>?
Aetiology of AP s8ould e determined in !0: of cases+ ≤ 20:
cases s8ould e idio&at8ic
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,nitial management
• Aggressi(e fluid resuscitaion4>24monitoring
• Aim to re(erse4reduce organ failure
Patients 6it8 SAP s8ould e managed on @)U 6it8 access to ,3U 68en
a&&ro&riate
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Assessment of Se(erity
• 8el&s clinically to target care on t8ose &ts 6it8 se(ere AP
• 8el&s in com&arison of outcome et6een units
• entry criteria into trials of ne6 .*
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Se(erity Scoring
• .ansons - 1$+ USA+ alco8ol+ $!8+ modified 1 → ≥ /mortality 0:
• Glasgo6 ;1! "modified 1!5' → ≥ / se(ere
• APA@= ,,
• APA@= ,, + >esity
• Atlanta riteria 12
• 7ocal com&lications ; &seudocyst4ascites4necrosis
• Systemic com&lications ; c(s+ res&+ cns+ renal+ 8aem
• .P ≥ 150mg4l
• >t8ers ; 3ry&sinogen+ 3?+ Se amyloid+ ,7+ ,7!
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Se(erity Scoring
Attem&t to grade se(erity on all &atients 6it8in $!8
o single scoring system is accurate enoug8 facilitate clinical decision
ma<ing
,nitial - clinical assessment+ BM, /0C+ &leural effusion+ APA@= ,, > !
2$8 ; ao(e C Glasgo6 ≥ /+ .P ≥ 150mg4l+ &ersisting organ failure
$!8 ; ao(e C multi&le organ failure
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3 imaging in &ancreatitis
• Aids diagnosis
• @el&s determine necrosis4e*tent
• ot indicated in e(eryone• )one too early may
underestimate necrosis
• )one too freDuently may 6orsen
renal function• 3 se(erity inde* "Balt8aEar' ;
oedema → necrosis
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3 imaging in &ancreatitis
Patients 6it8 se(ere AP 68o 8a(e &ersisting organ failure s8ould
undergo 3 6it8in -10d of admission
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Pro&8ylactic Antiiotics
• o role in mild AP
• )o &ro&8ylactic A* &re(ent infection of
&ancreatic necrosis in se(ere AP im&ro(eoutcomeF
• .3s
• )ifferent A*+ (arying duration+ all small nos
• =(idence (aried inconclusi(e
o consensus ; if gi(en t8en gi(e for ma* 1$d t8en sto&
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utrition• 3raditionally ; BM+ t8en introduce oral nutrition
68en tolerating 3P for se(ere cases 68o failedto settle
• S=s of 3P "line+ metaolic' may offset anyad(antages
• .ecently trials of enteral feeding s8o6n to e safe+6ell tolerated in SAP
• ontrolled trials enteral ( 3P - no difference ormarginal enefit for enteral
3ry to estalis8 enteral nutrition in all &ts 6it8 SAP .eser(e 3P for
t8ose &ts 6it8 &ersistent ileus
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Gallstones
• Aetiology in 50:
• MAP ; no &lace for =.P+ ut &lan .* of
gallstones to &re(ent furt8er attac<
All &atients 6it8 iliary mild &ancreatitis s8ould undergo definiti(e .*of t8eir gallstones during t8e same 8os&ital admission+ unless a clear
&lan 8as een made for definiti(e .* 6it8in 26 "7 C >3+ or
=.P4S'
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Gallstones
• SAP ; / .3s of =.P ( no .*• Benefit in &ts 6it8 c8olangitis+ Haundice ut in ot8er
&ts results inconclusi(e
Urgent t8era&eutic =.P C S all for &ts 6it8 SAP due to gallstones >.
68en t8ere is c8olangitis4Haundice4dilated B)
Best carried out ≤ 28 onset &ain
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Surgical ,nter(ention for ecrosis
• )ifficult area+ 8ig8 mortality+ no controlled trials
• )ecision to inter(ene de&ends on clinical &icture4e(idence
of se&sis4demonstration of necrosis on 3
• General agreement t8at infected necrosis reDuires
drainage+ sterile necrosis treated conser(ati(ely
• ,nfection diagnosed y ?A as&iration or gas ules on
3
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Surgical ,nter(ention for ecrosis
SAP 6it8 &ersistent sym&toms C ≥ /0: necrosis+ or t8ose 6it8 smaller
areas ut signs of se&sis s8ould undergo ?A for S
,nfected necrosis reDuires inter(ention4drainage
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Surgical ,nter(ention for ecrosis
Pancreatic necrosis
Signs of se&sis o se&sis
?A
,nfected Sterile
Gas on 3
)eridement
onser(ati(e .*
)eterioration .eco(ery
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Surgical ,nter(ention for ecrosis
• 8oice of &rocedure
• ecrosectomy4tue drain
• ecrosectomy4&ost o& la(age
• ecrosectomy4drainage4sc8eduled rela&
• ecrosectomy4la&arastome
• 7a&arasco&ic necrosectomy4tue drain
• .adiological drainage
ecrosectomy can e ac8ie(ed surgically "o&en or la&arosco&ically' or
radiologically de&endent on e*&ertise
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Pro(ision of Ser(ices4S&ecialist ,nter(ention
A single team s8ould manage all &atients 6it8 AP
Management in4referral to a s&ecialist unit of &ts 6it8 ≥ /0: necrosis+ or
com&lications reDuiring surgical+ radiological+ or endosco&ic &rocedures
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Summary
• >(er &ast 20y considerale re-e(aluation of
.* of AP in &articular se(ere AP
• 38ese guidelines 8el& focus treatment along
e(idence ased &at86ays 68ere &ossile+
ut also 8ig8lig8ts t8e 6ea<ness of t8e
e(idence in some areas need for moreresearc8