Acute pancreatitis: Problems in adherence to guidelines
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.
ERCP IN SEVERE BILIARY ACUTE PANCREATITIS
Problem: Endoscopic retrograde cholangiopancreatography (ERCP) often is performed inappropriately in mild biliary acute pancreatitis or is not performed urgently in severe cases.
In most cases of mild biliary pancreatitis, the stones pass spontaneously, as verified by cholangiography done during laparoscopic cholecystectomy. Ongoing ampullary obstruction by impacted biliary stones can perpetuate pancreatic inflammation and delay recovery.
Two early randomized trials showed a benefit from early ERCP (within 72 hours) with sphincterotomy and stone extraction, primarily in those with severe biliary acute pancreatitis or ascending cholangitis,32,33 but a third trial failed to reveal a benefit.34 A Cochrane metaanalysis of these three trials failed to show a lower death rate with ERCP in mild or severe biliary pancreatitis.35 However, early ERCP did prevent complications in severe biliary pancreatitis (odds ratio 0.27, 95% CI 0.14–0.53).
Later, a fourth randomized trial was restricted to patients with suspected biliary pancreatitis, evidence of biliary obstruction, and no signs of cholangitis36: 103 patients were randomized to undergo either ERCP within 72 hours or conservative management. No difference was observed in rates of death or organ failure or in the CT severity index.
Recommendation: ER CP for suspected retained stones
ERCP has a limited role in patients with biliary pancreatitis, being used to clear retained bile duct stones or to relieve ongoing biliary obstruction.
The decision to perform ERCP before surgery should be based on how strongly one suspects retained stones. ERCP is most appropriate if the suspicion of retained stones and the likelihood of therapeutic intervention are high (eg, if the serum bilirubin and alkaline phosphatase levels are rising and ultrasonography shows a dilated bile duct). If there is moderate suspicion, a safer and less-invasive imaging study such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography can be done to screen for bile duct stones before proceeding to ERCP.
The ACG guidelines suggest urgent ERCP (preferably within 24 hours) for those with severe biliary pancreatitis complicated by organ failure or those with suspicion of cholangitis. The level of evidence is I, ie, “strong evidence from at least one published systematic review of multiple well-designed randomized controlled trials.”1
Elective ERCP is recommended for those who are poor surgical candidates. ERCP is also recommended for those with rising liver enzyme values or imaging findings suggesting a retained common bile duct stone (including intraoperative cholangiography). Endoscopic ultrasonography or MRCP is recommended for those with slow clinical resolution, who are pregnant, or in whom uncertainty exists regarding the biliary etiology of pancreatitis.
Compliance rates with these and similar guidelines are not adequate. In an audit of adherence to the British Society of Gastroenterology guidelines, early ERCP was performed in only 25% of patients with severe biliary acute pancreatitis.6
LAPAROSCOPIC CHOLECYSTECTOMY FOR MILD BILIARY PANCREATITIS
Problem: Laparoscopic cholecystectomy is not done at admission or within 2 weeks in many patients with mild biliary pancreatitis.
If the gallbladder is not removed, biliary pancreatitis may recur in up to 61% of patients within 6 weeks of hospital discharge.37 This is the basis for guideline recommendations for surgery (or a confirmation of a surgery date) prior to hospital discharge.
The International Association of Pancreatology recommends early cholecystectomy (preferably during the same hospitalization) for patients with mild gallstone-associated acute pancreatitis.38 In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. The AGA guidelines advocate cholecystectomy as soon as possible and in no case later than 4 weeks after discharge to prevent relapse. ERCP with biliary sphinc-terotomy may also protect against relapse in those who are not fit to undergo surgery.
Recommendations for definitive management of gallstones (laparoscopic cholecystectomy or ERCP, or both) are not always followed. For example, a British study showed 70% compliance with this recommendation.4 A similar compliance audit in Germany revealed that cholecystectomy was performed during the initial hospital stay in only 23% of cases.7 In a New Zealand study, a regular compliance audit with feedback to surgeons resulted in an increase in the early cholecystectomy rate from 54% to 80%.8
