Acute Pancreatitis

80% of patients will have a mild course of pancreatitis (no or minimal gland necrosis), a self-limiting condition and can be managed in non-specialist centres

Moderately severe/severe pancreatitis (20%) includes patients with organ failure (48 hours in severe) and/or presence of local complications (necrosis/pseudocyst), most don’t require intervention and may require advice by a centre with a specialist service. A small minority of patients require transfer to a centre with a specialist service

A specialist centre definition- Declared interest in treatment of condition (preferable publication of outcomes), MDT management of patients, including gastroenterology, radiology and nutrition team. Offer full range of treatment including, radiological intervention/endoscopic/surgical cyst-gastrostomy, open and laparoscopic necrosectomy for those few patients who require it

Diagnosis The diagnosis of pancreatitis is confirmed by presence of 2 of 3 criteria:

1. Clinical – sudden onset of epigastric pain radiating to the back, nausea and/or vomiting and pyrexia (>38°C)

2. Serum amylase/lipase >3 times the upper limit of normal

3. Imaging - (computed tomography, magnetic resonance, ultrasonography)

Aetiology must be investigated fully in all cases

All patients as a minimum investigation set should have (except post-ERCP or traumatic pancreatitis)

Trans-Abdominal Ultrasound

Alcohol history

Glyceride screen

Calcium level

Medication review

Those patients without a cause identified should have a CT+/-MRI, autoimmune screen before diagnosis of idiopathic pancreatitis made

Those patients with second admission of idiopathic pancreatitis should be considered for endoscopic ultrasound for exclusion of microlithiasis

Asymptomatic pseudocysts should be managed conservatively

Those patients with symptomatic pseudocysts who require drainage and don’t require cholecystectomy (non-gallstone aetiology) or they are medical unfit should be considered for endoscopic drainage as first line

Endoscopic or Laparoscopic cyst-gastrostomy are equally valid management options for symptomatic

pseudocysts and laparoscopic approach may be preferable if cholecystectomy is also required (single procedure)

Gallstones (50%) should have index cholecystectomy or within 2 weeks of discharge if surgically fit. The exception is those who have an evolving acute fluid collection/pseudocyst, this process should be allowed to mature as laparoscopic cyst-gastrostomy at same time as cholecystectomy might be required

Alcohol (25% of all aetiology) should have referral to alcohol liaison service

C-reactive protein (CRP) has shown most promise in predicting outcomes in pancreatitis

Hospitals treating patients with pancreatitis should have agreed pathway protocols between surgeons/physicians/Intensive care and radiology to facilitate standardisation of care and early escalation of unwell patients

Those hospitals not providing a specialist pancreatitis service (as defined above) should have in place network agreements within their region to a specialist centre