Part III Intercollegiate exam / UK guidelines for the management of acute pancreatitis (2003)

The following recommendations were taken from GUT on line

Recommendations 2003 (*Unchanged from the 1998 recommendations)
Diagnosis

*The correct diagnosis of acute pancreatitis should be madein all patients within 48 hours of admission (recommendationgrade C).
The aetiology of acute pancreatitis should be determinedinat least 80% of cases and no more than 20% should be classifiedas idiopathic (recommendation grade B).
Although amylase iswidely available and provides acceptableaccuracy of diagnosis,where lipase estimation is availableit is preferred for thediagnosis of acute pancreatitis (recommendationgrade A).
Wheredoubt exists, imaging may be used: ultrasonography isoftenunhelpful and pancreatic imaging by contrast enhancedcomputedtomography provides good evidence for the presenceor absenceof pancreatitis (recommendation grade C).

Assessment

The definitions of severity, as proposed in the Atlanta criteria,should be used. However, organ failure present within the firstweek, which resolves within 48 hours, should not be consideredan indicator of a severe attack of acute pancreatitis (recommendationgrade B).
Available prognostic features which predict complicationsinacute pancreatitis are clinical impression of severity, obesity,or APACHE II>8 in the first 24 hours of admission, and Creactive protein >150 mg/l, Glasgow score 3 or more, or persistingorgan failure after 48 hours in hospital (recommendation gradeB).
Patients with persisting organ failure, signs of sepsis,ordeterioration in clinical status 6–10 days after admissionwill require computed tomography (recommendation grade B).

Prevention of complications

The evidence to enable a recommendation about antibiotic prophylaxisagainst infection of pancreatic necrosis is conflicting anddifficult to interpret. Some trials show benefit, others donot. At present there is no consensus on this issue.
If antibioticprophylaxis is used, it should be given for amaximum of 14days (recommendation grade B). Further studiesare needed (recommendationgrade C).
The evidence is not conclusive to support the useof enteralnutrition in all patients with severe acute pancreatitis.However,if nutritional support is required, the enteral routeshouldbe used if that can be tolerated (recommendation gradeA).
The nasogastric route for feeding can be used as it appearsto be effective in 80% of cases (recommendation grade B).

Treatment of gall stones

Urgent therapeutic endoscopic retrograde cholangiopancreatography(ERCP) should be performed in patients with acute pancreatitisof suspected or proven gall stone aetiology who satisfy thecriteria for predicted or actual severe pancreatitis, or whenthere is cholangitis, jaundice, or a dilated common bile duct.The procedure is best carried out within the first 72 hoursafter the onset of pain. All patients undergoing early ERCPfor severe gall stone pancreatitis require endoscopic sphincterotomywhether or not stones are found in the bile duct (recommendationgrades B and C).
Patients with signs of cholangitis requireendoscopic sphincterotomyor duct drainage by stenting to ensurerelief of biliary obstruction(recommendation grade A).
Allpatients with biliary pancreatitis should undergo definitivemanagement of gall stones during the same hospital admission,unless a clear plan has been made for definitive treatment withinthe next two weeks (recommendation grade C).

Management of necrosis

*All patients with severe acute pancreatitis should be managedin a high dependency unit or intensive therapy unit with fullmonitoring and systems support (recommendation grade B).
Allpatients with persistent symptoms and greater than 30% pancreaticnecrosis, and those with smaller areas of necrosis and clinicalsuspicion of sepsis, should undergo image guided fine needleaspiration to obtain material for culture 7–14 days afterthe onset of pancreatitis (recommendation grade B).
Patientswith infected necrosis will require intervention tocompletelydebride all cavities containing necrotic material(recommendationgrade B).
The choice of surgical technique for necrosectomy,and subsequentpostoperative management, depends on individualfeatures andlocally available expertise (recommendation gradeB).

Provision of services

Every hospital that receives acute admissions should have asingle nominated clinical team to manage all patients with acutepancreatitis (recommendation grade C).
*Management in, orreferral to, a specialist unit is necessaryfor patients withextensive necrotising pancreatitis or withother complicationswho may require intensive therapy unit care,or interventionalradiological, endoscopic, or surgical procedures(recommendationgrade B)

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