The most important point in the management of pancreatitis is fluid balance and as such every effort should be made to obtain good IV access and accurate measure of fluid status. The incidence is increasing and estimated to be 150 to 420 cases per million population - so it is a common surgical emergency.

Pancreatitis can be fatal; several deaths a year occur because of it.  It is helpful inl cases of pancreatitis to have a Ransom or Glasgow score estimated to identify those most at risk. These are only useful in the fiorst 48-hrs after the onset of pain; after this the CRP level is much more useful for prognosis and severity of the disease.

Diagnosis

  • Suspect it in all cases of abdominal (& chest) pain
  • Sudden onset abdominal pain radiating to back.
  • Often associated with nausea and vomiting.
  • Grey Turner's sign (flanks) / Cullen's sign (umbilicus) - RARE & A VERY LATE SIGN (patient is most likely to already be on ITU)
  • O/E abdomen can be rigid (peritonitic)
  • Serum Amylase > 1000 i.u. / ml (this is not a marker of severity)
  • Serum Lipase is far more specific (but expensive and not widely available)

Scoring systems

Ranson’s Criteria (for gallstone related)

  • On admission
    • Age > 55 yrs = 1 point
    • WCC > 16,000 = 1 point
    • LDH > 600 U/l = 1 point
    • AST >120 U/l = 1 point
    • Glucose > 10 mmol/l = 1 point
  • Within 48 hours
    • Haematocrit fall >10% = 1 point
    • Urea rise >0.9 mmol/l = 1 point
    • Calcium < 2 mmol = 1 point
    • pO2  < 60 mmHg = 1 point
    • Base deficit > 4 = 1 point
    • Fluid sequestration > 6L = 1 point
  1. Score of >=3 prompts review for admission to HDU
  2. Score <3. mortality risk <1%, >3 = 18%, >5 = 40%, >7 = close to 100%
  3. Can not be applied fully for 48 hours
  4. Poor predictorof outcome later in disease

Glasgow Criteria (alcohol related)

  • Age > 55 years = 1 point
  • Serum albumin < 32 g/L (3.2 g/dL) = 1 point
  • Arterial PO2 on room air < 60 mmHg = 1 point
  • Serum calcium < 2 mmols/L (8 mg/dL) = 1 point
  • Blood glucose > 10.0 mmols/L (180 mg/dL) = 1 point
  • Serum LDH > 600 units/L = 1 point
  • Serum urea nitrogen > 16.1 mmols/L (45 mg/dL) = 1 point and
  • WBC count > 15 x 10^9/L (15 x 10^3/microlitre) = 1 point.
  1. The score can range from 0 to 8.
  2. If the score is greater than 2, the likelihood of severe pancreatitis is high.
  3. If the score less than 3, severe pancreatitis is unlikely.

Atlanta Classification

  • Mild pancreatitis: parenchymal inflammation with no local complications or systemic involvement. It is usually self-limited with uneventful recovery.
  • Severe pancreatitis (necrotising): pancreatic parenchymal inflammation with local or systemic complications that has a protracted clinical course and has a higher mortality rate. Defined by more than 3 Ranson/Glasgow criteria or an APACHE II score greater than 8. Mostly associated with necrosis
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Predicting Severity

Severe pancreatitis can be predicted from the following:

  • Initial assessment
    • Clinical impression of severity
    • BMI > 30
    • Pleural effusion on CXR
    • APACHE II score >8 (details here)
  • 24hr later
    • Clinical impression of severity
    • APACHE II score >8
    • Glasgow score >= 3
    • Persisting organ failure esp if multiple
    • CRP > 150mg/l
  • 48hr later
    • Clinical impression of severity
    • Glasgow score >= 3
    • Ranson Score >= 3
    • CRP > 150mg/l
    • Persisting organ failure
    • Multiple or progressive organ failure

Initial Management consists of:

  1. Obtain wide bore 14G venflon access in both ACF.
  2. Start crystalloid infusion 1 litre stat - monitor response closely
  3. Take blood for: FBC, U&E, LFT, LDH, Ca2+, Amylase, and Arterial Blood Gases.
  4. Insert a catheter.
  5. Ensure the nurses do strict hourly fluid balance.
  6. Consider a CVP line in those initially predicted to have severe pancreatitis.
  7. Nasogastric tube for all patients on free drainage & 4 hrly aspiration.
  8. IV Cefuroxime 750mg TDS – all patients. - see below
  9. Morphine analgesia is not contraindicated, give a decent dose 5-15mg 2-3 hrly.  May need a PCA – ask for anaesthetic help
  10. Patients can have clear fluids PO.
  11. Aim for a urine output of >40 mls per hr.
  12. Monitor SaO2 if PaO2 is low
  13. DVT prophylaxis for all patients
  14. Obstructed biliary systems need Rx within 24-hrs!

Continuing Management:

80% of all cases of pancreatitis are due to gallstones or alcohol; the number of idiopathic cases depends on how hard you look for the rare causes.

  1. All patients need an USS of the biliary system and pancreas
  2. CT scan is indicated for those patients who are not settling after 5/7, persistent pyrexia, and those in whom a cause has not yet been identified. - see below
  3. Repeat all blood investigation at 48 hrs & 72 hrs and then on clinical progress.
  4. There is a lot of evidence that early feeding in pancreatitis is beneficial and all patients should be started on enteral supplements ASAP, usually at 48 hrs if condition permits. - see below
  5. If due to gallstones, don’t forget to consider early laparoscopic cholecystectomy.
  6. the above depends on age and clinical condition!


When to do a CT Scan

The simple answer -

Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6–10 days after admission will require a CT

CT Severity Grading

Grade Criteria
A Normal
B Focal or diffuse glandular enlargement
  Small intra-pancreatic fluid collection
C Any of the above
  Peripancreatic inflammatory changes
  Less than 25% gland necrosis
D Any of the above
  Single extrapancreatic fluid collection
  25-50% gland necrosis
E Any of the above
  Extensive extrapancreatic fluid collection
  Pancreatic abscess
  More than 50% gland necrosis

Antibiotics in Pancreatitis

  • The evidence about antibiotic prophylaxis to prevent infection is conflicting and difficult to interpret
  • Some trials show benefit, others do not
  • The latest guidance (GUT 2005) provide no concensus on the issue
  • If antibiotics are used, use in predicted severe cases only and for a maximum of 14-days
  • Remember there is a difference between antibiotic prophylaxis to prevent infected pancreatic necrosis and the treatment of infective complications of pancreatitis. 
  • There is no evidence that antibiotics in mild cases alter the course of the illness and may in fact cause more problems than they attempt to cure (eg C.diff)

Feeding in Pancreatitis

  • There is no need to restrict food inpatients with pancreatitis
  • If feeding causes pain, consider using enteral supplements
  • The evidence is not conclusive to support enteral feeding in all patients with severe acute pancreatitis. If nutritional support is required the enteral route is best.
    • Nasogastric feeding should be used unless there is conclusive evidence of gastric outflow problems in which case naso-jejunal feeding should be considered. Nasogastric feeding is successful in over 80% of patients.

Timing of surgery

  • Mild gallstone pancreatitis - early (within 2-weeks) laparoscopic cholecystectomy if fit, consider ERCP & sphincterotomy in the unfit
  • Severe gallstone pancreatitis - laparoscopic cholecystectomy after signs of lung injury and systemic disturbance have resolved
  • Acute pancreatic necrosis - the patient should be managed in a specialist hepatobiliary unit.

 

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