Download Pancreatitis Guideline

Acute severe pancreatitis – guidelines for the management of patients with
acute severe pancreatitis (ASP)
These guidelines are to aid surgical and critical care teams managing patients
with acute severe necrotising pancreatitis. They describe who and when to refer
to the Morriston Hospital based specialists and outline a recommended treatment
strategy.
Who to Refer
1. Patients with severe acute necrotising pancreatitis requiring critical care
support for more than 7 days.
2. Patients who develop complications from their severe acute necrotising
pancreatitis including
a. Failure to thrive
b. Infected pancreatic necrosis and/or pancreatic abscess
c. Pancreatic pseudocyst
d. Bleeding/pseudo-aneurysm
3. Patients that may require an interventional procedure
Please contact the Pancreato-biliary team in Morriston Hospital prior to any
interventional procedures.
Recommended Management Strategy
Initial phase (weeks 1-3)

Assess severity of pancreatitis (APACHE II, Balthazar criteria, Glasgow,
Imrie, World Association Guidelines etc.)

Admit to critical care if attack considered severe and/or patients clinical
condition deteriorating

Attempt to identify aetiology – abdominal USS to assess for gallstones.

CT is not the first line investigation in ASP, as when performed early it will
underestimate the extent of necrosis. However, consider a contrasted
abdominal CT if diagnostic uncertainty exists

CT in the first week is unlikely to affect management unless diagnosis is in
doubt

Urgent endoscopic retrograde cholangiopancreatography (ERCP) of
patients with suspected or proven gallstone pancreatitis who satisfy
criteria for acute severe pancreatitis, or when there is cholangitis, (Within
72 hours after onset of pain).

Patients displaying signs of cholangitis require Urgent endoscopic
retrograde cholangiopancreatography to establish biliary drainage

In patients with persisting organ dysfunction / failure, symptoms and/or
signs of sepsis or clinical deterioration 6-10 days following admission a
contrast-enhanced CT is indicated to assess for pancreatic necrosis.

There is little evidence for use of antibiotic prophylaxis in this phase
unless there is a likely or confirmed infectious process

There is little or no role for surgical intervention in this phase. Identification
of aetiology, monitoring for development of complications and supportive
care are the main focuses of care at this time. If the patient is at this stage
the Pancreato-biliary team can be contacted (see below) to be made
aware of the patient, for advice and to review imaging

Contact Pancreatico-biliary Unit at Morriston Hospital (week days) via Mr
Tim Brown (Consultant Surgeon), Mr Bilal Al-Sarireh (Consultant Surgeon)
or their secretaries

If this is not possible then contact ITU and/or Surgical Registrar on call at
Morriston Hospital. Contact via switchboard: 01792 702222

Contact can be made via the critical care and/or surgical teams

Continue support for organ dysfunction / failure (Cardiovascular,
Nutritional, Renal and/or Respiratory)

Enteral nutrition is tolerated in up to 80% of patients with acute severe
pancreatitis. Post-pyloric / nasojejunal (NJ) feeding may improve this

If a patient dies during this phase it is usually due to the severity of the
attack and surgical/radiological intervention would have no impact on
survival
Septic phase / Infected pancreatic necrosis (weeks 3-6)

In patients with persisting organ dysfunction / failure, symptoms and/or
signs of sepsis or clinical deterioration a contrast-enhanced CT is
indicated to assess for pancreatic necrosis or infection of established
pancreatic necrosis. It may rule in or out other causes of deterioration.
Interval CT scans are not indicated. CT scanning should be clinically
guided. (Please refer to appendix 1 for technical details of CT scanning)

Contact Pancreatico-biliary team to review images and/or arrange patient
transfer if required

Fine needle aspiration is used rarely due to the risk of introducing infection
into sterile necrosis. It should therefore be avoided
Later phase
If a patient develops a pancreatic pseudocyst, abscess or pseudo aneurysm, it is
suggested that contact with the Pancreatico-biliary team at Morriston Hospital is
made for advice prior to any intervention

Percutaneous radiological drainage should be avoided if possible due to
the significant risk of introducing infection, dislodging of stents or drains or
the development of a pancreatic fistula. It may be preferrable for such
patients to be transferred to Morriston Hospital for surgical intervention

If patients develop diabetes mellitus or steatorrhoea this can be managed
locally.
*Reference
UK guidelines for the management of acute pancreatitis
UK Working Party on Acute Pancreatitis
Gut 2005;54;1-9
Also available at:
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/pancreatic/pancreat
ic.pdf
This guideline was written by T Brown, B Al-Sarireh and D Hope.
Sponsored by the South Wales Critical Care Network.
March 2012
Appendix 1:
Technical Details of CT Scanning
Precise technique will depend on scanner specifications but all patients should
be given approximately 500 mL of oral contrast by mouth or nasogastric tube. An
initial scan without intravenous contrast allows pancreatic levels to be identified
and demonstrates the extent of peripancreatic change. A post contrast series is
obtained after a bolus intravenous injection of 100 mL of nonionic contrast
delivered at 3 mL/s using a power injector. Images through the pancreatic bed
should be obtained using thin collimation (5 mm or less) commencing
approximately 40 seconds after the start of the injection. Non-opacification of at
least one third of the pancreas, or an area .3 cm diameter, indicates necrosis. A
second series of images beginning at 65 seconds after injection (portal venous
phase) will give information about patency of the main peripancreatic veins. CT
of the pancreas without intravenous contrast enhancement gives suboptimal
information and should be avoided.