• These guidelines have been formulated to aid in the management of acute pancreatitis. They are for use as an aid to, rather than a replacement of, clinical judgement.
• British Society for Gastroenterology (BSG) Guidelines for the management of Acute Pancreatitis¹
• The 2012 revision of the Atlanta Classification of Acute Pancreatitis²
• The 2016 NCEPOD review of the quality of care provided to patients treated for acute pancreatitis “Treat the Cause”³
• Please discuss cases with a Consultant UGI surgeon if there are any dilemmas in diagnosis or management.

This is a controlled document. If you are using a printed copy, check it against the version on the guidelines platform to ensure you are using the latest edition.

Abbreviations

Contents

2 or more of:

• Abdominal pain consistent with acute pancreatitis

• Serum amylase > 3X upper limit of normal (with appropriate history suggestive of pancreatitis). Serum lipase is available and should be requested in patients with a pre-hospital history of longer than 3 days.

• Characteristic finding of acute pancreatitis on imaging ¹

N.B. CT should only be used in the acute phase of pancreatitis where the diagnosis is in doubt or there is a suspicion of a co-existing acute abdominal condition, e.g., perforated DU.

• Supplemental oxygen for all patients

  • IV fluid resuscitation with crystalloid, if the patient is the critical care environment Goal directed therapy is recommended.

  • 1 hourly fluid balance chart for all patients, aim UO >0.5 ml/kg/hr

  • Urinary catheter if NEWS 5 or more, or predicted severe (using modified Glasgow score)

  • Patients NOT to be nil by mouth unless profuse vomiting, allow free fluids and prescribe nutritional supplements, e.g., fortisips, fortijuice, etc. Early (24-72 hours) is to be encouraged.

  • Prescribe:

  • Prophylactic dalteparin + TEDS

  • Generous analgesia (consider PCA)

  • IV Pantoprazole 40mg o.d.

N.B. there is no indication for antibiotics in the initial phase of acute pancreatitis, unless to treat co-existing pathology, e.g., ascending cholangitis³.

• Bloods

  • Amylase, FBC, U&Es (inc. Albumin), LFTs, CRP, Calcium, LDH

  • ABG

  • Erect chest X-Ray

  • ECG

  • USS abdomen (this MUST happen within 24 hours of admission)³, if no gallstones seen then discuss with senior and consider MRCP

  • CT is reserved for cases of diagnostic doubt or where co-existing pathology suspected¹

  • All patients should have a modified Glasgow Severity assessment at 24 and 48 hours.

• Modified Glasgow score of 3 or more

  • If NEWS score 5 or more or more than 3 in any single parameter, call ITU outreach⁴

  • If urine output persistently less than 0.5 ml/kg/hr despite adequate fluid resuscitation, discuss with senior for consideration of referral to ITU outreach

  • Patients should be re-scored (Atlanta revision 2012) on discharge from ITU.

Patients should be reassessed regularly, with daily blood tests and strict fluid balance monitoring. In particular, the following cut-offs should be considered:

• 24 hours

• Repeat of all admission bloods except amylase, request fasting lipids

• Re-evaluation of severity

• Check that USS has been performed; if not, then escalate to Consultant

• 48 hours

• Repeat blood testing (except amylase)

• Re-evaluation of severity

• If not tolerating diet, refer to dietician and consider NG/NJ tube

• 5-7 days

• If pancreatitis persisting, then consider CT scan to look for presence and extent of pancreatic necrosis³

• Involve specialist UGI surgeon in ongoing management of patient’s care if predicted severe or not progressing towards discharge.

• Severe complicated cases of acute pancreatitis (as per 2012 revision of Atlanta classification)

• Ensure discussion with Local Upper GI consultant

• If radiological or gastroenterological intervention is required and is not provided at Wexham Park Hospital (this should be rare, e.g., EUS cystgastrostomy / drainage)

  • Consider referral to, or discussion with Frimley Park Hospital

    • Upper GI team (Mr Singh, Mr Rae, Mr Veeramootoo)

    • Radiology (Dr Hatrick)

• Specialised HPB unit at the Royal Surrey County Hospital, Guildford

  • Provides MDT / advice / intervention

  • Referral should be made to using the form in Appendix 2.

• Other units include: Oxford

Gallstones

• ERCP within 72 hrs for ascending cholangitis² or non-urgent ERCP if persisting biliary obstruction without cholangitis.

• Must have MRCP prior to surgery or operation performed by surgeon competent to perform on table cholangiogram if LFT’s abnormal or dilated ducts on imaging.

• Patients with identified ductal calculi should be discussed with gastroenterologists for urgent ERCP before laparoscopic cholecystectomy or consider laparoscopic bile duct exploration.

• For patients with mild acute gallstone pancreatitis, cholecystectomy should be performed on the index admission, or on a planned list within 2 weeks of discharge²

• For patients with severe acute gallstone pancreatitis, cholecystectomy should be undertaken when clinically appropriate after resolution of pancreatitis (discuss case with Consultant UGI surgeon)³

Alcohol

• Patients with suspected alcoholic pancreatitis should still have at least an USS to exclude gallstones³

• These patients should be prescribed IV pabrinex 2 ampules twice a day for 1 week and diazepam/chlordiazepoxide as required prescribed on admission⁴

• Patients should be referred to the Wexham or Frimley Park Hospital Alcohol Liaison Team³

• Patients should be discharged with thiamine 100 mg t.d.s. and vitamin B co-strong 2 tablets o.d. for 2 weeks⁴

Miscellaneous Risk Factors

• Cannabis - advise to stop

• IBD Drug related, e.g., azathiaprine, mesalazine

• Renal failure avoid nephrotoxic drugs, careful fluid balance and involve renal physicians early

• Pancreatic carcinoma ensure CA 19-9 and CT performed.

No cause identified on index admission

• Make sure that fasting lipids have been checked pre-discharge

• Ensure that all medications are reviewed (not limited to recent medications started), e.g., statin.

• Ensure that any patient over 50 years of age has a CT scan of their abdomen and pelvis

• Ensure MRCP and repeat USS performed or requested

• Refer to UGI surgeon for further investigation (e.g., IgG4, EUS)

There is no role for antibiotics in acute, uncomplicated pancreatitis³.

Infective complications are rare within the first week of severe pancreatitis¹.

Infected pancreatic necrosis should be diagnosed on the basis of a strong clinical and radiological suspicion, e.g., CT findings of the presence of gas within a pancreatic collection¹.

Antibiotic choice should be in accordance with the current trust antimicrobial guidelines³.

These high risk patients may be unsuitable for a laparoscopic cholecystectomy

• Discussion with Upper GI consultant is required

• Consider prophylactic ERCP as definitive management

  • To be discussed with endoscopist at Wexham Park Hospital or Frimley Hospital

1. UK guidelines for the management of acute pancreatitis. UK Working Party on Acute Pancreatitis. Gut 2005;54;1-9. Available from: https://gut.bmj.com/content/54/suppl_3/iii1

2. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Banks P.A., Bollen T.L., Dervenis C., Gooszen H.G., Johnson C.D., Sarr M.G., Tsiotos G.G., Vege S.S., Acute Pancreatitis Working Group. Gut 2013; 62: 102-111. Available from: https://gut.bmj.com/content/62/1/102

3. “Treat the Cause” – the NCEPOD review of the quality of care provided to patients treated for acute pancreatitis 2016. http://www.ncepod.org.uk/2016ap.html

4. Trust guidelines, available on intranet/app

Atlanta Classification

• Mild acute pancreatitis

• No organ failure

• No local or systemic complications

• Moderate severe acute pancreatitis

• Organ failure that resolves within 48 hrs (transient organ failure) and/or

• Local or systemic complications without persistent organ failure

• Severe acute pancreatitis

• Persistent organ failure (single or multiple) for >48 hrs

Glasgow-Imrie Criteria

• Arterial pO₂ < 8 kPa

• Age > 55 years

• WCC > 15,000/mm³

• Corrected calcium < 2 mmol/l

• LDH > 600 iU/l

• ALT > 200 iU/l

• Albumin < 32 g/l

  • Glucose >10 mmol/l

N.B. Glasgow-Imrie score of 3 or more is indicative of severe pancreatitis, but is only validated for use at 48 hours post admission.

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version Control Sheet