1. Introduction Management Of Acute Pancreatitis In A District General Hospital: Are We Complying With the UK Working Party Guidelines? Pancreatitis can be defined as an acute inflammatory process of the pancreas. It has an incidence of 5-80 per 100,000 per year. 20% develop organ failure and 50% of patients with severe pancreatitis develop pancreatic necrosis. It has a reported mortality of 30-40%. Audit Rationale Standards: British Society of Gastroenterology UK Guidelines. The correct diagnosis of acute pancreatitis should be made in all patients within 48 hours of admission. The aetiology of acute pancreatitis should be determined in at least 80% of cases and no more than 20% should be classified as idiopathic. Severity Stratification: Attempt to grade severity in all patients within 48 hours. Within 24 hours of admission:  Clinical assessment  BMI >30 Pleural effusion  APACHE II  8 24-48 hours: Repeat APACHE II Score After 48 hours: Above + Glasgow  3, CRP ≥150 + multiple organ failure To determine if acute pancreatitis is managed according to the UK Working Party Guidelines in the Department of Surgery at Milton Keynes University Hospital. Primary Outcomes:  Mortality in acute pancreatitis < 10% and severe acute pancreatitis <30%  Diagnosis < 48 hours of admission  Aetiology > 80%, idiopathic < 20%  Severity stratification < 48 hours of diagnosis  CT Pancreas if persisting organ failure, sepsis or clinical deterioration 6–10 days post admission  A retrospective case note review  Trust data coding for “Pancreatitis”  Data was retrieved from EDM, PICs and PACs using MRN  January 1 st 2014 – December 31 st 2014.  Exclusion criteria: chronic pancreatitis  100 patients: 55 males / 45 females  Mean age 59 years  Range 21-90 years  52% patients ≥ 55 years old Correct Diagnosis  98% correct diagnosis within 48 hours  85% - raised amylase and clinical diagnosis.  15% - CT HDU / ITU Management L. Dunphy, A. Doulatabadi, M. Maatouk, Mazhar Raja, D.W. McWhinney. Department of Surgery, Milton Keynes University Hospital. Aim References Method Severity on Admission CRP checked in all patients [100%] CRP > 150 in 23 patients BMI calculated in 23 patients [24%]. BMI > 30 in 7 patients 12 patients had a documented BM [A+E notes] Severity scoring completed in 20 patients [20%]  GLASGOW [20]  Not documented [80] APACHE II [0] 6 patients had a previous cholecystectomy Missing parameters Glucose [10] LDH [7] pO 2 [4] Calcium [3]  ≥2 parameters not measured in 6 patients, score calculated anyway  Incomplete Glasgow score in 10/20 [50%] Assessment > 48 hours  CRP re-check: 90%  Glasgow score: 25%  5 patients had a Glasgow Score > 3 Blood cultures [18]  Fasting plasma lipids [8]  Viral antibody titres [6] Chest radiograph [81]  Atelectasis [2]  Pleural effusion [6] Abdominal radiograph [42] Fig. 5. CXR. Fig.6. AXR. USS performed [73]:  < 24 hours: 40  24 – 48 hours: 10  > 72 hours: 23  10 performed as OP Fig.9. A CT Abdomen was performed in 57 cases.  MRI Pancreas [5]  CT Pancreas [5] MRCP [52]  < 24 hours: 8  24 – 48 hours: 12  > 72 hours: 32  12 as an Out-Patient Demographics Investigations 4 patients transferred to DOCC: Glasgow Score > 4 1 patient was transferred to the JR Hospital necrotising pancreatic pseudocyst ERCP [25]  < 24 hours: 0  24 – 48 hours: 1  > 72 hours: 24  12 as OP Fig.12, 13. ERCP demonstrating the major papilla. 1 patient developed post ERCP pancreatitis.  Metronidazole [24]  Co-amoxiclav [22]  Meropenem [7]  Imipenem [6]  Ciprofloxacin [6]  Tazocin [3] Fig.14. Blood culture results.  Gentamicin [2 ]  Laparoscopic [49]  Converted to open procedure [5]  Waiting list [5] Fig.15. Cholecystectomy. Fig.16. Time to Cholecystectomy. Fig.17. Complications of Pancreatitis. Aetiology of Acute Pancreatitis MRCP and ERCP Gallstone Pancreatitis [68] Cholecystectomy 54 Previous cholecystectomy 6 No Cholecystectomy 2 patients died during admission 1 patient refused operation 2 patients assessed as not fit for surgery 5 patients remain on waiting list Antibiotics [45] Cholecystectomy [54]  British Society of Gastroenterology. United Kingdom guidelines for the management of acute pancreatitis. Gut 1998;42 (suppl. 2):S1–13. Fig.1, 2. Cullens Sign. Fig.3. Grey-Turner sign. Fig.4. Gallstones resulted in pancreatitis in 68% of cases. Fig.7. Thick walled gallbladder containing stones. Fig.8. CT abdomen. Peri-pancreatic fluid. Fig.10. MRI Pancreas. Pseudocysts noted. Fig.11. Intra and extra hepatic CBD dilatation and pancreatic collection. Fig.18. Definitive management of Gallstone Pancreatitis. Fig.18. 9 patients were readmitted when on the waiting list for a cholecystectomy. Discussion  Aware of severity stratification scores for acute pancreatitis.  Predicted severity to be derived from proven prognostic factors on admission.  Low threshold for HDU care in patients with predicted severe Acute Pancreatitis.  Perform cholecystectomy / ERCP within 2 weeks.  Regular and prospective audit, co-ordinated at a Regional Level.