Acute Pancreatitis
Based on the RCSI Clinical Guidelines for management of pancreatitis
Epidemiology
- Incidence rising
- 32/100,000 population
- Relapse common
- M > F (alcohol)
- Gallstone disease and alcohol main causes
- Mortality should be <10% overall (<30% in severe)
Making the diagnosis
- Appropriate clinical setting with x4 rise in amylase(If equivocal repeat after 24hrs)
- Serum lipase may help (remains elevated longer)
- Trypsinogen, elastase-1 and phospholipase no better than amylase
- Request erect CXR in all
- Request USS liver (lithiasis +/- ductal dilatation)
- LFTs (early abnormal LFTs suggest gall stone aetiology)
- CT if above inconclusive
- Occasionally laparoscopy/laparotomy necessary to exclude other pathology
- After the acute phase, check serum calcium and fasting lipid profile
- ERCP is not warranted for self limiting acute pancreatitis
- Should be considered in recurrent pancreatitis, or persistent elevated LFTs or a dilated CBD on USS
- Consider MRCP & EUS if jaundiced and initial Ix reveal no evidence of gallstones
Severity stratification
Ranson's Criteria
At presentation
- Age > 55 years
- WCC > 16,000/mm
- Glu > 10mmol/L
- LDH > 350IU/L
- AST > 250 IU/L
Developing first 48 hrs
- Haematocrit fall >10%
- Urea >16mmol/L
- Ca++ <2mmol/L
- Pa02 <8 kPa
- Base deficit >4 mmol/L
- Fluid sequestration > 6L
Glasgow criteria used in acute pancreatitis
- WCC >15,000 mm3
- Blood glucose >10 mmol/L
- Blood urea >16 mmol/L
- LDH >600IU/L
- AST>200IU/L
- Plasma albumin <32g/L
- Uncorrected plasma Ca++ <2mmol/L
- Arterial Pa02 <8 kPa
Glasgow scoring system most reflects the patient population seen in Ireland
APACHE II scoring in acute pancreatitis
1. Temperature 2. Mean arterial pressure 3. Heart rate (ventricular response) 4. Respiratory rate (ventilated or non-ventilated) 5. Oxygenation 6. Arterial pH 7. Serum sodium 8. Serum potassium
9. Serum creatinine (Double score if ARF*) 10. Haematocrit 11. WCC 12. Glasgow coma score (score = 15 – actual GCS)
The APACHE II score is given by the sum of the acute physiology score and points given for age and chronic health evaluation.
Glasgow Coma Score
Score |
Eye Opening |
Verbal |
Motor |
|---|---|---|---|
6 |
Obeys commands |
||
5 |
Speech orientated , localises to pain |
||
4 |
Spontaneous eye opening |
Confused speech |
Withdrawal to pain |
3 |
Eye open to speech |
Incoherent words |
Abnormal flexion to pain |
2 |
Eyes open to pain |
Only sounds |
Extends to pain |
1 |
No eye opening |
No sounds |
No movements |
- Serum CRP = best single poor prognostic indicator
- Age and obesity are also poor prognosis
- Those with poor prognosis (> 3 on Glasgow
/ Ranson's) who do not improve (or deteriorate) within 72hrs
should have a dynamic contract enhances CT
- CT confirms Dx
- Assesses severity
- Documents complication
Initial Management
Mild pancreatitis
- IV fluids (NGT only if persistent vomiting)
- Urinary catheter, antibiotics & CT scan are not usually necessary
- The majority of patients with acute pancreatitis fall into this category and will have an uneventful self-limiting illness
Predicted severe pancreatitis
- Call for help - these patients require multidisciplinary care in a HDU setting
- Monitor vitals at least hourly
- Initial management includes intravenous and central venous access for fluid and CVP monitoring
- Insert urinary catheter (+/- NGT if vomiting)
- Assess ABGs regularly (if cardiopulmonary compromise consider Swan-Ganz early)
- Early dynamic CT (ID pancreatic necrosis, (accuracy 82%-90%), fluid collections or abscess
Ongoing care
- Urgent ERCP and sphincterotomy may be necessary in cases of gallstone pancreatitis which do not settle
- Complications and mortality are decreased with early ERCP and sphincterotomy in patients with ductal calculi
- Antibiotics - please consult with local microbiologist early as conflicting evidence exists
- The use of prophylactic broad-spectrum antibiotics reduces infection rates but may not improve survival [Cochrane]
- Some units avoid antibiotics, some use Imipenem, others (local micro profile) use Piperacillin with Tazobactam
- Surgical debridement should be considered in those with appropriate clinical signs of sepsis with proven infected necrosis
- Fine needle aspiration for bacteriology (FNAB) of pancreatic or peripancreatic necrosis appears to be safe and reliable.
- Nutritional support - nasojejunal tube enteral feeding may be superior
- Regular FBC, clotting and biochemical makers for sepsis, DIC and inflammatory. Regular CXR, CT / USS for complications
- Timing of surgery is controversial ( more details in RCSI Guidelines 2005 [Local copy])
Word version (print) local guidelines / proforma British Society of Gastro-Enterology guidelines for management pancreatitis
