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Acute pancreatitis: Problems in adherence to guidelines

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ABSTRACTAlthough evidence-based guidelines on managing acute pancreatitis are available, many physicians are not following them. The authors identify and discuss several problems in adherence to guidelines on testing, imaging, and treatment.

KEY POINTS

  • Serum amylase and lipase levels are often needlessly measured every day.
  • Often, severity assessments are not performed regularly or acted on.
  • Often, not enough fluid is replaced, or fluid status is not adequately monitored.
  • In many severe cases, enteral or parenteral feeding is not started soon enough.
  • Computed tomography is not done in many patients with severe acute pancreatitis, or it is performed too soon.
  • In many cases of suspected infected necrosis, fine-needle aspiration is not done.
  • Broad-spectrum antibiotics are often used inappropriately in patients with mild acute pancreatitis and in patients with sterile necrotizing pancreatitis who are clinically stable and have no signs of sepsis.


 

References

Several major gastroenterological and surgical societies have issued guidelines on how to manage acute pancreatitis, based on evidence from high-quality randomized trials and nonrandomized studies as well as on expert opinion.1–3 Information is limited on how well physicians in the United States comply with these guidelines, but compliance is suboptimal in other developed countries, according to several studies,4–8 and we suspect that many US physicians are not following the guidelines either.

Acute pancreatitis is a frequent inpatient diagnosis that internists, gastroenterologists, and surgeons all confront. The most common causes are gallstones and heavy alcohol intake. Its management is typically straightforward: intravenous fluids, analgesia, and nothing by mouth. However, treatment of severe cases can be quite complex, particularly if multiple organ systems are involved or if there are local complications.

The primary aim of this article is to raise awareness of recognized deviations from established recommendations that may lead to adverse patient outcomes.

MEASURING ENZYME LEVELS DAILY ADDS COST BUT LITTLE BENEFIT

Problem: Serum amylase and lipase levels are often needlessly measured every day.

Measuring the serum amylase and lipase levels is useful in diagnosing acute pancreatitis, which requires two of the following three features1:

  • Characteristic abdominal pain
  • Levels of serum amylase or serum lipase, or both, that are three or more times the upper limit of normal
  • Findings of acute pancreatitis on computed tomography (CT).

However, the magnitude or duration of the serum enzyme elevation does not correlate with the severity of the attack. Further, we have noticed that physicians at our hospital often order daily serum amylase and lipase levels in patients admitted with acute pancreatitis.

The American College of Gastroenterology (ACG) guidelines1 state that daily monitoring of amylase and lipase has limited value in managing acute pancreatitis. Rechecking these concentrations may be reasonable if pain fails to resolve or worsens during a prolonged hospitalization, as this may suggest a recurrent attack of acute pancreatitis or a developing pseudocyst. But in most cases of acute pancreatitis, daily serum enzyme measurements add cost but little benefit.

REGULAR ASSESSMENT IS IMPORTANT

Problem: Often, severity assessments are not performed regularly or acted on.

Most cases of acute pancreatitis are mild, with rapid recovery and excellent prognosis. However, 15% to 20% are severe and may result in a prolonged hospitalization, systemic inflammatory response syndrome (SIRS), multiorgan system failure, and death.

In severe acute pancreatitis, as pancreatic enzymes and inflammatory cytokines damage the blood vessels, a vast amount of fluid leaks out into the interstitial (“third”) space. This fluid extravasation leads to decreased effective circulating volume, local pancreatic necrosis, hemodynamic instability, and end-organ failure.

It is important to recognize severe acute pancreatitis early because the patient needs to be transferred to a step-down unit or intensive care unit to receive optimal fluid resuscitation and supportive care for organ dysfunction. After 48 to 72 hours, a prediction of severe acute pancreatitis should also prompt the physician to order CT to detect pancreatic necrosis, and also to initiate nutritional support.

Assessment of severity begins in the emergency room or on admission to the hospital. Older age, obesity, organ failure, and pulmonary infiltrates or pleural effusions are initial indicators of poor prognosis. Signs of SIRS (high or low core body temperature, tachycardia, tachypnea, low or high peripheral white blood cell count) or organ failure (eg, elevated serum creatinine) are present on admission in 21% of patients with acute pancreatitis.9

Hemoconcentration is a marker of decreased effective circulating volume in severe acute pancreatitis. A hematocrit higher than 44% at admission or that rises in the first 24 to 48 hours of admission predicts necrosis.10,11 However, a more robust marker of organ failure may be the blood urea nitrogen level.12

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