Tuesday, March 30, 2010

Pancreatitis review with emphasis on guideline adherence

This CCJM review emphasizes under appreciated points in the guidelines.

Among these are the need for daily severity assessment. Severity assessment using the Ranson score is of prognostic importance but not useful for daily assessment because the score requires 48 hours to complete. Other assessment tools are available and mentioned in the review. Surveys of guideline adherence indicate that this is often not done, whereas the practice of daily measurement of amylase and lipase is often done but not recommended.

Indications for and timing of CT are frequent sources of confusion.

The need for nutritional support depends on severity assessment.

Hematocrit should be repeated at 12 and 24 hours. A rise consistent with hemoconcentration predicts necrosis. Also, a fall at 48 hrs (Ranson score) is a marker of severity.

There being no high level studies, fluid resuscitation recommendations are supported only by animal data, expert opinion and pathophysiologic rationale. Nevertheless, it is the opinion of some experts that under-resuscitation is common in practice. Recommendations are vague, with statements calling for “tempering” volume resuscitation in the elderly. Volume needs should be assessed and reassessed frequently using vital signs, urine output and hematocrit.

Scoring systems for CT based severity assessment exist. If contrast is contraindicated due to renal dysfunction some assessment parameters can be recorded without contrast.

Absent cholecystectomy, relapse rate is very high in the early weeks following an episode of gallstone associated pancreatitis.

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