Management of Pancreatitis at NMUH Chris Bretherton Surgical FY1 Audited against UK guidelines for the management of acute pancreatitis from British Society of Gastroenterology – GUT 2005

What I did Obtained a list of patients with diagnosis of acute pancreatitis from April 2011 – April 2012 Went through the notes to determine were patients : 1.Being scored on admission 2.Being scored appropriately 3.Being rescored with 48hours of admission 4.Receiving abdominal Ultrasound Scan within 24 hours 5.Receiving timely ERCP as appropriate 6.Having definite management of Gall stone disease (Laparoscopic Cholecystectomy)

Glasgow Score P – O2 <8 kPa A – ge >55 N – eutrophilia – WCC >15 x 10 9 /L C – alcium <2 mmol/L R – aised Urea >16 mmol/L E – nzymes – LDH >600 units/L AST > 100 units A – lbumin < 32 g/L S – ugar – Blood glucose > 10 mmol/L (non diabetics)

Severity Scoring Scored on AdmissionScored within 48 hours Yes12 (32%)11 (30%) No17 (46%)25 (70%) Partial8 (22%) Total3736 Severity stratification should be made in all patients within 48 hours of diagnosis

Ultrasound Delay in USSNumber in 2011Number in Days28 1 Day79 2 Days54 3 Days13 4 days1 5 days1 MRCP/ previous Gall stones21 CT instead81 Delay > 1 day not due to a weekend 71 Total2826 Radiological facilities should be available to permit ultrasound examination of the gall bladder within 24 hours of diagnosis of acute pancreatitis.

Management of Gallstone Pancreatitis Urgent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) should be performed in patients with acute pancreatitis of suspected or proven gall stone aetiology who satisfy the criteria for predicted or actual severe pancreatitis, or when there is cholangitis, jaundice, or a dilated common bile duct. The procedure is best carried out within the first 72 hours after the onset of pain. All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct (recommendation grades B and C).

Management of Gallstone Pancreatitis Time to ERCPNumber from January 2012 – April random sample in 2011 <3 days4 4 days1 6 days1 15 days1 No ERCP despite meeting guidelines2 Total meeting guidelines for ERCP9

May 2012 – July 2012 Time to ERCPMay 2012 – July days1 3 days1 4 days ( within 1 day of US result)1 52 Had unnecessary MRCP3 Total5

All patients with Biliary Pancreatitis should undergo definitive management of gall stones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks (recommendation grade C). Laparoscopic Cholecystectomy January 2012 – April random sample in 2011 May 2012 – July month16 Booked 2 months31 needs echo before 3 months3 1 Year (pregnant)1 Lap chole at RFH/ UCLH2 Hot Lap Chole UCLH1 Waiting since March Not Booked2 Seen in Clinic2 Total177

Proforma Aims 1 – All patients should be severity scored on admission and within 48 hours 2 – All suitable patients should be considered for ERCP 3 – All patients with Gallstone Pancreatitis should have a Laparoscopic Cholecystectomy booked before discharge

Questions? Comments? Thank you Average length of stay 6.6 days (0-47) (Mode 3) (Median 5) 132 cases from April recurrent (excluding obviously chronic pancreatitis) – of which 1 person recurred 2 x

Causes of Pancreatitis Cause of pancreatitis at NMH Gall stones24 (40%) Alcohol15 (25%) High Triglycerides2 (3.3%) Post ERCP/ Gallstones1 (1.6%) Idiopathic18 (30%) Total60 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)