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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.