AUDIT OF LABORATORY SUPPORT FOR DIAGNOSIS

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AUDIT OF LABORATORY SUPPORT FOR DIAGNOSIS
GRADING OF ACUTE PANCREATITIS IN TRENT REGION

• Dr Paul Masters
• Consultant Chemical Pathologist
• Chesterfield Royal Hospital

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UK GUIDELINES FOR THE MANAGEMENT OF ACUTE
PANCREATITIS

• Guidelines commissioned by British Society for
  Gastroenterology
• Published Gut 1998 42 (Supp 2) S1-13
• Endorsed by Assn of Surgeons, Assn of Upper GI
  Surgeons, Pancreatic Society

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RECOMMENDATIONS

• Mortality Overall lt10, if severe lt30
• Correct diagnosis in lt48 h
• Severity stratification in lt48 h
• Aetiology idiopathic lt20-25
• Mild gallstone pancreatitis surgery in lt2-4 wks
• All severe cases go to ITU/HDU
• Full radiological facilities
• Dynamic CT on all severe cases at 3-10 days
• Facilities for ERCP
• Referral to specialist unit for necrotising
  pancreatitis/other complications

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STANDARDS RELEVANT TO CLINICAL BIOCHEMISTRY

• Diagnosis
• Amylase gt 4 X ULN
• Urine amylase if equivocal (no cut off)
• Lipase more specific/elevated longer

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STANDARDS RELEVANT TO CLINICAL BIOCHEMISTRY

• Severity stratification
• Glasgow score CRP recommended
• GS predicts severity in 79 of episodes
• CRP gt 210 mg/l 1st 4 d or gt120 at 7 d has 80
  accuracy
• (APACHE II equally accurate)

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GLASGOW SCORE

• Age gt55 years
• WCC gt15000
• Glucose gt 10 mmol/l (not diabetic)
• Urea gt 16 mmol/l
• pO2 lt 8 kPa
• Albumin lt 32 g/l
• Calcium lt 2.00 mmol/l
• LDH gt 600 u/l
• AST or ALT gt100 u/l

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STANDARDS RELEVANT TO CLINICAL BIOCHEMISTRY

• Aetiology
• After acute phase blood lipids Ca
• lt25-30 should be idiopathic, (ie
  75-80 should have cause identified)

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METHODOLOGY

• Autumn 2000
• Questionnaire sent to each NHS lab in Trent
• Complementary questions for local surgeon
• Replies matched together
• Results anonymised
• 17 sent out, replies from 13 labs (10 surgeons)

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RESULTS

• Amylase
• URLs 80 - 150 u/l
• Pancreatitis 3 to 11 X URL quoted
• 2/13 labs, 1/10 surgeons use 4 X URL
• 9/13 Labs aware of lipaemia, 1 surgeon
• Urine amylase available in all labs, but no
  agreement on protocol
• No lab offers lipase

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RESULTS

• Severity scoring
• 7/13 labs do not know which is in use
• 4/10 surgical units not using Glasgow score
• 12/13 labs report corr. uncorr. Ca
• Some URLs encompass albumin LDH cutoffs (32 g/l
  600 u/l)
• LDH not always available in lt48 h
• Transaminases should be deleted!

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RESULTS

• Aetiology
• 1/10 surgeons consider hyperlipidaemia an
  important cause

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RECOMMENDATIONS

• Increase awareness of BSG guidelines
• Agree local application, eg proforma
• Adapt Glasgow score to local assays
• All assays need lt48 h TAT
• Report uncorrected Ca
• Delete transaminases from Glasgow score
• Urine amylase needs standardisation
• Education re significance of lipids