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Acute pancreatitis at the Aga Khan University Hospital, Nairobi: a two year audit
Abstract
BACKGROUND: Acute pancreatitis ranges in severity from a mild, self-limiting to a fulminant disease with systemic decompensation. The treatment of the severe form of the disease may be difficult with mortality rates of up to 30%.
There are published, evidence-based guidelines for optimizing outcome of the disease (1,2). We performed this audit to determine whether our clinical practice conformed to these guidelines.
AIM: To audit the management of patients admitted with acute pancreatitis at the Aga Khan University Hospital (AKUH) and compare the current practice with accepted international
guidelines (1,2) with respect to diagnostic modalities, severity stratification, critical care unit (CCU) management for severe disease, timing of treatment intervention strategies and
mortality.
DESIGN: Retrospective audit of hospital records.
METHODS: The medical records of all patients admitted to the AKUH with a diagnosis of acute pancreatitis from 1st January 2005 to 31st January 2007 were reviewed.
RESULTS: Thirty five patients were admitted with a confirmed diagnosis of acute pancreatitis in the two year period. Twenty six patients were males (74%). The median age was 46 years
(range 29-82 years). The aetiology of the acute pancreatitis was alcohol in 51%, gallstones in 11%, other causes in 9% and idiopathic in 29% of patients. The median length of hospital stay
was 11 days (range 1–38). The diagnosis of acute pancreatitis was confirmed by amylase and lipase assays or with CT scan evidence of pancreatitis. Only three patients (8%) had formal
severity stratification (Ranson’s score). Eight patients (23%) had severe disease as defined by pancreatic necrosis and need for critical care. Twenty seven patients with mild disease also
underwent abdominal CT scans and only 54% of all patients had an initial ultrasound to exclude gallstones. The timing of these investigations was arbitrary. Ten patients with mild disease received unnecessary prophylactic antibiotics including
metronidazole, cefuroxime, and tazobactam/piperacillin for a median period of 7 days. In severe disease where antibiotic use is possibly justifiable, a carbapenem based antibiotic was
prescribed for four patients. Nasojejunal feeding was instituted early in six patients with severe disease and parenteral nutrition was also used exclusively in one patient. The overall mortality
was 2.9% with the only death occurring in the severe subgroup thereby making the mortality rate in those patients with severe acute pancreatitis in this audit 12.5%. CONCLUSIONS: The current management of acute pancreatitis at AKUH is physician
dependant and not in conformity with the established and recommended guidelines. The CT scans were over-prescribed, their timing inappropriate and efforts to exclude the cause
of pancreatitis moderate. The mortality rate is acceptable by international standards despite uniform application of diagnostic and risk stratification tools.
There are published, evidence-based guidelines for optimizing outcome of the disease (1,2). We performed this audit to determine whether our clinical practice conformed to these guidelines.
AIM: To audit the management of patients admitted with acute pancreatitis at the Aga Khan University Hospital (AKUH) and compare the current practice with accepted international
guidelines (1,2) with respect to diagnostic modalities, severity stratification, critical care unit (CCU) management for severe disease, timing of treatment intervention strategies and
mortality.
DESIGN: Retrospective audit of hospital records.
METHODS: The medical records of all patients admitted to the AKUH with a diagnosis of acute pancreatitis from 1st January 2005 to 31st January 2007 were reviewed.
RESULTS: Thirty five patients were admitted with a confirmed diagnosis of acute pancreatitis in the two year period. Twenty six patients were males (74%). The median age was 46 years
(range 29-82 years). The aetiology of the acute pancreatitis was alcohol in 51%, gallstones in 11%, other causes in 9% and idiopathic in 29% of patients. The median length of hospital stay
was 11 days (range 1–38). The diagnosis of acute pancreatitis was confirmed by amylase and lipase assays or with CT scan evidence of pancreatitis. Only three patients (8%) had formal
severity stratification (Ranson’s score). Eight patients (23%) had severe disease as defined by pancreatic necrosis and need for critical care. Twenty seven patients with mild disease also
underwent abdominal CT scans and only 54% of all patients had an initial ultrasound to exclude gallstones. The timing of these investigations was arbitrary. Ten patients with mild disease received unnecessary prophylactic antibiotics including
metronidazole, cefuroxime, and tazobactam/piperacillin for a median period of 7 days. In severe disease where antibiotic use is possibly justifiable, a carbapenem based antibiotic was
prescribed for four patients. Nasojejunal feeding was instituted early in six patients with severe disease and parenteral nutrition was also used exclusively in one patient. The overall mortality
was 2.9% with the only death occurring in the severe subgroup thereby making the mortality rate in those patients with severe acute pancreatitis in this audit 12.5%. CONCLUSIONS: The current management of acute pancreatitis at AKUH is physician
dependant and not in conformity with the established and recommended guidelines. The CT scans were over-prescribed, their timing inappropriate and efforts to exclude the cause
of pancreatitis moderate. The mortality rate is acceptable by international standards despite uniform application of diagnostic and risk stratification tools.
