1. 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. .

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

3. 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% .

4. PATHOGENESIS OF ACUTE PANCREATITIS.

5. AUDIT RATIONALE
Guidelines provide clinical recommendations and audit standards.

6. 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

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

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

14. 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.

15. 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

16. 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

17. 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

19. DEMOGRAPHICS 100 patients 55 males / 45 females Mean age 59 years
Range years
52% patients ≥ 55 years old

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

21. CLINICAL EXAMINATION

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

23. 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]

24. 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

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

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

27. 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]

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

29. ABDOMINAL RADIOGRAPH
Fig.3. Abdominal radiograph.

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

31. IMAGING
CT Abdomen and Pelvis [57]

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

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

34. 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.

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

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

37. 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

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

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

40. 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

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

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

43. COMPLICATIONS

44. 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

45. 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].

46. 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

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

48. 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%

49. 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

50. 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

51. REFERENCES
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52. THANK YOU!