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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

Scoring systems

Ranson’s Criteria (for gallstone related)

  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)

  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

Predicting Severity

Severe pancreatitis can be predicted from the following:

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

Feeding in Pancreatitis

Timing of surgery