MANAGEMENT OF ACUTE PANCREATITIS: ARE WE COMPLYING WITH THE UK WORKING PARTY GUIDELINES? L. Dunphy1, A. Doulatabadi1, M. Maatouk2, M. Raja3, D.C. McWhinnie3. 1. Surgical FY1 Oxford Foundation School, 2. Surgical Registrar, 3. Consultant Surgeon. Department of Surgery, Milton Keynes University Hospital Audit Awards. .

CONTENTS Introduction Aim of the Audit Method and inclusion criteria Results Discussion Conclusion Questions

INTRODUCTION: ACUTE PANCREATITIS Definition: An acute inflammatory process of the pancreas Incidence: 5-80 per 100,000 per year 20% develop organ failure and / or local complications 50% with severe pancreatitis pancreatic necrosis Mortality 30-40% .

PATHOGENESIS OF ACUTE PANCREATITIS.

AUDIT RATIONALE Guidelines provide clinical recommendations and audit standards.

DIAGNOSIS Standards: British Society of Gastroenterology UK Guidelines. The correct diagnosis of acute pancreatitis should be made in all patients within 48 hours of admission. Recommendation grade C

AETIOLOGY Recommendation grade B. The aetiology of acute pancreatitis should be determined in at least 80% of cases and no more than 20% should be classified as idiopathic. Recommendation grade B.

SEVERITY STRATIFICATION Attempt to grade severity in all patients within 48 hours. Within 24 hours of admission: Clinical assessment BMI >30 Pleural effusion APACHE II  8 24-48 hours: Repeat APACHE II Score After 48 hours: Above + Glasgow  3, CRP ≥150 + multiple organ failure Recommendation grade B.

MANAGEMENT Severe acute pancreatitis should be managed in HDU/ITU. Extensive necrotizing pancreatitis or with other complications who may require ITU care or interventional radiological, endoscopic or surgical procedures should be referred to a Specialist Unit.

IMAGING Recommendation grade B. Radiological facilities should be available to permit USS examination of the gall bladder within 24 hours of diagnosis of acute pancreatitis. Patients with persisting organ failure, signs of sepsis or deterioration in clinical status 6-10 days after admission should have CT using dedicated pancreas protocol. Recommendation grade B.

GALLSTONE PANCREATITIS All patients with biliary pancreatitis should undergo definitive management of gall stones during the same hospital admission, unless a clear plan for definitive treatment within the next two weeks has been made. Recommendation grade C

GALLSTONE PANCREATITIS Urgent therapeutic ERCP with sphincterotomy should be performed for predicted or actual severe pancreatitis due to gallstones or when there is cholangitis/jaundice/dilated CBD. Best carried out  72h onset pain. Recommendation grades B and C.

MORTALITY < 10% overall < 30% in severe (complicated) pancreatitis.

AIM To determine if acute pancreatitis is managed according to the UK Working Party Guidelines in the Department of Surgery at Milton Keynes University Hospital.

PRIMARY OUTCOMES Mortality in acute pancreatitis < 10% and severe acute pancreatitis < 30% Diagnosis < 48 hours of admission Aetiology > 80%, idiopathic < 20% Severity stratification < 48 hours of diagnosis CT Pancreas if persisting organ failure, sepsis or clinical deterioration 6–10 days post admission

PRIMARY OUTCOMES Antibiotic prophylaxis < 14 days unless positive blood cultures Biliary pancreatitis: definitive gallstone management during same admission, unless definitive treatment plan < 2 weeks Specialist Unit management if necrotising Access to USS < 24 hours of diagnosis

METHOD A retrospective case note review Trust data coding for “Pancreatitis” Data was retrieved from EDM, PICs and PACs using MRN January 1st 2014 – December 31st 2014. Exclusion criteria: chronic pancreatitis

DEMOGRAPHICS 100 patients 55 males / 45 females Mean age 59 years Range 21 - 90 years 52% patients ≥ 55 years old

CORRECT DIAGNOSIS (Guideline Standard – correct diagnosis within 48 hours) 85% - raised amylase and clinical diagnosis 15% - CT

CLINICAL EXAMINATION

AETIOLOGY OF ACUTE PANCREATITIS Fig.1. Gallstones resulted in pancreatitis in 68%.

ASSESSMENT OF SEVERITY: ON ADMISSION. CRP checked in all patients [100%] CRP > 150 in 23 patients BMI calculated in 23 patients [24%] BMI > 30 in 7 patients 12 patients had a documented BM [A+E notes]

ASSESSMENT OF SEVERITY: ON ADMISSION. Severity scoring completed in 20 patients [20%] GLASGOW [20] Not documented [80] APACHE II [0] 6 patients had a previous cholecystectomy

Modified Glasgow Score. Gut 1998; 42 (suppl 2):S1-S13

ASSESSMENT OF SEVERITY: ON ADMISSION Missing parameters Glucose [10] LDH [7] pO2 [4] Calcium [3] ≥2 parameters not measured in 6 patients, score calculated anyway Incomplete Glasgow score in 10/20 [50%]

ASSESSMENT > 48 HOURS CRP re-check: 90% Glasgow score: 25% 5 patients had a Glasgow Score > 3 Blood cultures [18] Fasting plasma lipids [8] Viral antibody titres [6]

INVESTIGATIONS Chest radiograph [81] Atelectasis [2] Pleural effusion [6] Abdominal radiograph 42 Fig.2. Bilateral pleural effusion and basal atelectasis.

ABDOMINAL RADIOGRAPH Fig.3. Abdominal radiograph.

IMAGING USS performed [73]: < 24 hours: 40 24 – 48 hours: 10 10 performed as OP Fig.4. Thick walled gallbladder containing stones.

IMAGING CT Abdomen and Pelvis [57]

INVESTIGATIONS Fig.7. Enlargement of pancreas with indistinct shaggy margins (blue arrow), peri-pancreatic fluid (red arrow) and inflammation of surrounding fat (black arrow).

IMAGING MRI Pancreas [5] CT Pancreas [5] Fig.5. MRI of the pancreas. Pseudocysts noted.

IMAGING MRCP [52] < 24 hours: 8 24 – 48 hours: 12 > 72 hours: 32 12 as OP Fig.6. Intra and extra hepatic CBD dilatation and pancreatic collection.

HDU / ITU MANAGEMENT 4 patients transferred to DOCC: Glasgow Score > 4 1 patient was transferred to the JR Hospital necrotising pancreatic pseudocyst

MANAGEMENT ERCP [25] < 24 hours: 0 24 – 48 hours: 1 12 as OP Fig.7. ERCP. Major papilla. 1 patient developed post ERCP pancreatitis.

MANAGEMENT Antibiotics [45 patients] Blood culture results Metronidazole [24] Co-amoxiclav [22] Meropenem [7] Imipenem [6] Ciprofloxacin [6] Tazocin [3] Gentamicin [2] Blood culture results

HEPATOBILIARY REVIEW OXFORD 8 patients transferred for further management INDICATIONS: 1 patient transferred from ITU INDICATION: Pancreatic pseudocyst with severe necrosis

LENGTH OF STAY Range 2 – 40 days Average: 5 days > 10 days: 22 patients Discharged on oral antibiotics [2]

MORTALITY Total deaths [2] 69 female: RIP day 2 Glasgow score 4 on admission Severe sepsis and multiple organ failure 41 male: RIP day 9 Severe sepsis ARDS Multiple organ failure

CHOLECYSTECTOMY Target: definite treatment within 2 weeks Laparoscopic [49] Converted to open procedure [5] Waiting list [5] Fig.8. Cholecystectomy

CHOLECYSTECTOMY Mean 67.5 days Within 2 weeks 2/54 4%

COMPLICATIONS

1 patient underwent urgent therapeutic ERCP THERAPEUTIC ERCP Urgent therapeutic ERCP with sphincterotomy should be performed for predicted or actual severe pancreatitis due to gallstones or when there is cholangitis/jaundice/dilated CBD. Best carried out  72h onset pain. On admission, 5 patients satisfied criteria of predicted or actual severe pancreatitis At 48 hours, 5 patients still satisfied criteria of predicted or actual severe pancreatitis 1 patient underwent urgent therapeutic ERCP

Results: Definitive management of Gallstone Pancreatitis. Cholecystectomy 54 Previous cholecystectomy 6 No Cholecystectomy 2 patients died during admission 1 patient refused operation 2 patients assessed as not fit for surgery 5 patients remain on waiting list 4 patients remain under review [asymptomatic].

Results: Time to Cholecystectomy Cause of Delays: 1. Co-morbidities: cardiomyopathy, sickle cell, Factor V Leiden. 2. Anaesthetic concerns 3. Waiting List Accounting for reasonable delays Mean 61 days Median 45 days

RESULTS: READMISSIONS [9%] Pancreatitis 4 Cholangitis 3 Cholecystitis 2 Total Readmissions Duration 95 days Proportion of Readmissions > 2 weeks 98%

DISCUSSION TARGET OUTCOME Aetiology 80% 98% Severity Score 100% 20% Severe acute HDU USS < 72 hours 55% Cholecystectomy 4% ERCP < 72 hours 20% 4% 4%

RECOMMENDATIONS Aware of severity stratification scores for acute pancreatitis Predicted severity to be derived from proven prognostic factors on admission Low threshold for HDU care in patients with predicted severe AP Perform cholecystectomy / ERCP within 2 weeks Regular and prospective audit This audit activity should be co-ordinated at a Regional Level

PROPOSALS Improved and prompt communication with ITU/HDU regarding patients with predicted and severe pancreatitis Use scoring sheet for severity scoring on admission at 24 and 48hrs Acute Pancreatitis Management to be started on admission Discussion with Imaging Department to help devise protocol for earlier USS of the gallbladder Re-audit management in 6 months

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