Acute Pancreatitis Practice Guidelines

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Diagnosis

 

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

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

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

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• Imaging - (computed tomography, magnetic resonance, ultrasonography)

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Clinical Course 

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• 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

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• 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

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• 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

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Investigation of Aetiology 

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

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• Trans-Abdominal Ultrasound

• Alcohol history

• Triglyceride screen

• Calcium level

• Medication review

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

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

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Management 

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• Asymptomatic pseudocysts should be managed conservatively

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• 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

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• 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)

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• 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

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• Patients with alcohol induced pancreatitis (25% of all aetiology) should have referral to alcohol liaison service

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

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• 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

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