UK Guidelines Acute Pancreatitis

8/13/2019 UK Guidelines Acute Pancreatitis

http://slidepdf.com/reader/full/uk-guidelines-acute-pancreatitis 1/21

UK Guidelines for Management

of Acute Pancreatitis - 2005



Acute Pancreatitis

• BSG guidelines originally 1! "Gut

1!#$2%su&&l 2'

• Aimed to &ro(ide recommendations for initial )*+,n(*+ .*

• )id not co(er surgical .* of necrosis

• Modified o(er recent years• U&dated 2005 "Gut 2005#5$%su&&l /'



• )iagnosis inc aetiology

• ,nitial management

• Se(erity assessment

• .adiological assessment

• Use of antiiotics

• utrition

•3reatment of gallstones

• Surgical .* for necrosis4acess

• ritical care4s&ecialist care



)iagnosis

• linical features c46 ↑ amylase

• 7i&ase more accurate t8an amylase

• 98ere dout e*ists → imaging "3 &referale'

orrect diagnosis s8ould e made in all &atients ≤ $!8



Aetiology

• 50: gallstones+ 20-25: alco8ol+ 25-/0: ot8er "(iral+

8y&erli&idaemia+ 8y&ercalcaemia+ drugs+ neo&lasm+

trauma+ idio&at8ic'

• ,n(* in reco(ery &8ase

• li&ids+ alcium+ (iral titres

• re&eat US+ if ;(e 3

• .ecurrent attac<s ; M.P4=.P4=US4S>>?

Aetiology of AP s8ould e determined in !0: of cases+ ≤ 20:

cases s8ould e idio&at8ic



,nitial management

• Aggressi(e fluid resuscitaion4>24monitoring

• Aim to re(erse4reduce organ failure

Patients 6it8 SAP s8ould e managed on @)U 6it8 access to ,3U 68en

a&&ro&riate



Assessment of Se(erity

• 8el&s clinically to target care on t8ose &ts 6it8 se(ere AP

• 8el&s in com&arison of outcome et6een units

• entry criteria into trials of ne6 .*



Se(erity Scoring

• .ansons - 1$+ USA+ alco8ol+ $!8+ modified 1 → ≥ /mortality 0:

• Glasgo6 ;1! "modified 1!5' → ≥ / se(ere

• APA@= ,,

• APA@= ,, + >esity

• Atlanta riteria 12

• 7ocal com&lications ; &seudocyst4ascites4necrosis

• Systemic com&lications ; c(s+ res&+ cns+ renal+ 8aem

• .P ≥ 150mg4l

• >t8ers ; 3ry&sinogen+ 3?+ Se amyloid+ ,7+ ,7!



Se(erity Scoring

Attem&t to grade se(erity on all &atients 6it8in $!8

o single scoring system is accurate enoug8 facilitate clinical decision

ma<ing

,nitial - clinical assessment+ BM, /0C+ &leural effusion+ APA@= ,, > !

2$8 ; ao(e C Glasgo6 ≥ /+ .P ≥ 150mg4l+ &ersisting organ failure

$!8 ; ao(e C multi&le organ failure



3 imaging in &ancreatitis

• Aids diagnosis

• @el&s determine necrosis4e*tent

• ot indicated in e(eryone• )one too early may

underestimate necrosis

• )one too freDuently may 6orsen

renal function• 3 se(erity inde* "Balt8aEar' ;

oedema → necrosis



3 imaging in &ancreatitis

Patients 6it8 se(ere AP 68o 8a(e &ersisting organ failure s8ould

undergo 3 6it8in -10d of admission



Pro&8ylactic Antiiotics

• o role in mild AP

• )o &ro&8ylactic A* &re(ent infection of

&ancreatic necrosis in se(ere AP im&ro(eoutcomeF

• .3s

• )ifferent A*+ (arying duration+ all small nos

• =(idence (aried inconclusi(e

o consensus ; if gi(en t8en gi(e for ma* 1$d t8en sto&



utrition• 3raditionally ; BM+ t8en introduce oral nutrition

68en tolerating 3P for se(ere cases 68o failedto settle

• S=s of 3P "line+ metaolic' may offset anyad(antages

• .ecently trials of enteral feeding s8o6n to e safe+6ell tolerated in SAP

• ontrolled trials enteral ( 3P - no difference ormarginal enefit for enteral

3ry to estalis8 enteral nutrition in all &ts 6it8 SAP .eser(e 3P for

t8ose &ts 6it8 &ersistent ileus



Gallstones

• Aetiology in 50:

• MAP ; no &lace for =.P+ ut &lan .* of

gallstones to &re(ent furt8er attac<

All &atients 6it8 iliary mild &ancreatitis s8ould undergo definiti(e .*of t8eir gallstones during t8e same 8os&ital admission+ unless a clear

&lan 8as een made for definiti(e .* 6it8in 26 "7 C >3+ or

=.P4S'



Gallstones

• SAP ; / .3s of =.P ( no .*• Benefit in &ts 6it8 c8olangitis+ Haundice ut in ot8er

&ts results inconclusi(e

Urgent t8era&eutic =.P C S all for &ts 6it8 SAP due to gallstones >.

68en t8ere is c8olangitis4Haundice4dilated B)

Best carried out ≤ 28 onset &ain



Surgical ,nter(ention for ecrosis

• )ifficult area+ 8ig8 mortality+ no controlled trials

• )ecision to inter(ene de&ends on clinical &icture4e(idence

of se&sis4demonstration of necrosis on 3

• General agreement t8at infected necrosis reDuires

drainage+ sterile necrosis treated conser(ati(ely

• ,nfection diagnosed y ?A as&iration or gas ules on

3




SAP 6it8 &ersistent sym&toms C ≥ /0: necrosis+ or t8ose 6it8 smaller

areas ut signs of se&sis s8ould undergo ?A for S

,nfected necrosis reDuires inter(ention4drainage




Pancreatic necrosis

Signs of se&sis o se&sis

?A

,nfected Sterile

Gas on 3

)eridement

onser(ati(e .*

)eterioration .eco(ery




• 8oice of &rocedure

• ecrosectomy4tue drain

• ecrosectomy4&ost o& la(age

• ecrosectomy4drainage4sc8eduled rela&

• ecrosectomy4la&arastome

• 7a&arasco&ic necrosectomy4tue drain

• .adiological drainage

ecrosectomy can e ac8ie(ed surgically "o&en or la&arosco&ically' or

radiologically de&endent on e*&ertise



Pro(ision of Ser(ices4S&ecialist ,nter(ention

A single team s8ould manage all &atients 6it8 AP

Management in4referral to a s&ecialist unit of &ts 6it8 ≥ /0: necrosis+ or

com&lications reDuiring surgical+ radiological+ or endosco&ic &rocedures



Summary

• >(er &ast 20y considerale re-e(aluation of

.* of AP in &articular se(ere AP

• 38ese guidelines 8el& focus treatment along

e(idence ased &at86ays 68ere &ossile+

ut also 8ig8lig8ts t8e 6ea<ness of t8e

e(idence in some areas need for moreresearc8

Documents

UK Guidelines Acute Pancreatitis