The use of imaging in acute pancreatitis in United Kingdom hospitals: findings from a national quality of care study.

BJR Received: 8 April 2017 © 2017 The Authors. Published by the British Institute of Radiology Revised: 2 August 2017 Accepted: 21 August 2017 https://doi.org/10.1259/bjr.20170224 Cite this article as: McPherson SJ, O’Reilly DA, Sinclair MT, Smith N. The use of imaging in acute pancreatitis in United Kingdom hospitals: findings from a national quality of care study. Br J Radiol 2017; 90: 20170224. Short Communication The use of imaging in acute pancreatitis in United Kingdom hospitals: findings from a national quality of care study 1,2 Simon John McPherson, MRCP, FRCR, 2,3Derek A. O’Reilly, PhD, FRCS, 2,4Martin T. Sinclair, MB ChB, FRCS and Neil Smith, PhD 2 1 Department of Radiology, Consultant Vascular and Interventional Radiologist, Leeds Teaching Hospitals NHS Trust, Leeds, UK NCEPOD [National Confidential Enquiry into Patient Outcome and Death], London, UK 3 Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK 4 The Ipswich Hospital NHS Trust, Ipswich, UK 2 Address correspondence to: Dr Simon John McPherson E-mail: Objective: To assess use of imaging in patients admitted to UK hospitals with acute pancreatitis (AP). Methods: 4,479 patients had a diagnosis AP in the first 6 months of 2014. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) selected patients with more severe AP for case review. Clinicians completed 712 questionnaires and case reviewers assessed 418 cases. The use of imaging in patients with AP is reported. Results: The common causes of AP were gallstones (46.5%) and alcohol excess (22%) with no cause identified in 17.5%. Imaging was needed to diagnose AP in 12%. 60.1% of patients had one or more CT scan. The timing of the CT scan(s) was appropriate in 90% of patients. The number of CTs was appropriate in all except 6.6% (equally split between too many and too few). AP collection intervention was radiological in 49/613 and surgical in 23/613. 69.8% had an ultrasound scan which diagnosed gallstones in 46.4% and bile duct dilatation in 12.9%. At least 21% had ultrasound scan inappropriately omitted. The National Confidential Enquiry into Patient Outcome and Death recommends gallstones are excluded in all patients with AP, including suspected alcohol-related AP. 29.8% underwent magnetic resonance cholangio- pancreatography diagnosing gallstones in 62.4%, bile duct dilatation in 25.4% and common bile duct stones in 14.4%. 20.6% had recurrent pancreatitis with gallstones accounting for a third. 17% with gallstone AP had a cholecystectomy within the guideline recommended time period. Conclusion: Imaging is rarely required for the diagnosis of AP. CT is used responsibly in AP management. Imaging should be used more to exclude gallstones, including in presumed alcohol related AP. Increased diagnostic efforts will not reduce recurrent biliary AP unless matched by earlier gallstone treatment. Advances in knowledge: Whilst CT is used responsibly in AP greater use of other diagnostic modalities is required to identify reversible causes, in particular gallstones, in order to prevent recurrent AP. Introduction Acute pancreatitis (AP) is an acute inflammatory process affecting the pancreas, most commonly caused by gallstones (50%) or alcohol excess (25%). A UK hospital serving a population of 300,000–400,000 people will admit around 100 patients with AP each year.1 There is a spectrum of severity. In 80% it is a self-limiting condition requiring hospital admission for a few days. In 20% it is severe with prolonged hospital stays, multiple organ failure, a need for critical care support and a 15–20% risk of death.2 MethodS and materials The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent organization whose remit is to review medical and surgical practice and make recommendations to improve the quality of the delivery of care. This paper describes the use of imaging in AP as reported in the quality of care study ‘‘Treat the Cause’’ published by the NCEPOD in 2016.3 Data were obtained from questionnaires completed by the consultant clinician caring for the patient (http://www.ncepod.org.uk/pdf/curr ent/AP/APClinicalQuestionnaire.pd), organizational questionnaires (http://www.ncepod.org.uk/pdf/current/AP/ BJR McPherson et al APOrganisationalQuestionnaire.pdf) and structured multidisciplinary case note review. The clinical questionnaires detailed what happened to the patient and the case note review questionnaires were more focussed on the quality of care and what could have been done better. 14,479 patients were identified by NCEPOD as having a hospital admission with a primary diagnosis of AP during the first 6 months of 2014. The multidisciplinary study advisory group considered that opportunities to improve care were more likely in those with more severe pancreatitis. Inclusion criteria were one or more of (1) an inpatient stay of 3 or more days, (2) admission to critical care and (3) death in hospital. A random sample of 987 patients was selected (up to five cases per hospital) for inclusion; 712 (72%) completed clinician questionnaires and 697 copies of case notes were returned to NCEPOD. The case reviewers were able to assess 418 cases. The commonest reason for the case reviewers not being able to assess the case notes was because they were incomplete. The denominator varies in the data according to whether it comes from the clinical questionnaires or the case reviewers and whether the question was answerable. RESULTS with DISCUSSION As the case review was focussed on patients with more severe AP, and smaller hospitals were likely over-represented by the sampling of a maximum of five case per hospital, some of the numbers described will not be extrapolatable to the wider unselected AP population. Patient characteristics Optimal care of patients with AP requires timely diagnosis, assessment of severity, fluid resuscitation to maintain tissue perfusion and prevent end-organ damage, nutritional support, analgesia, management of co-morbidities, appropriate use of antibiotics, early recognition of deterioration with escalation of care and prompt attention to the underlying cause to prevent recurrence. The clinician caring for the patient reported the cause as gallstones in 46.5% and alcohol excess in 22%. In 17.5% no underlying cause was identified. The median age for alcohol related AP (49.5 years) was approximately 20 years younger than gallstone (67 years) and unknown cause AP (69 years). Idiopathic pancreatitis should account for 10%.1 Rare causes include microlithiasis, drugs (e.g. valproate, steroids, azathioprine), pancreas divisum, hypertriglyceridaemia or lipoprotein lipase deficiency, hypercalcaemia and some viral infections (mumps, coxsackie B4). More diligent clinico-radiological assessment would be expected to increase the diagnostic rate and diminish recurrent AP. In the total AP population of 14,479 for the study period, 52% (7,572) were coded with (...truncated)