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Too many repeat admissions for acute pancreatitis

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Patients with acute pancreatitis are being repeatedly admitted to hospital because the cause is not always identified or treated properly, an assessment of care has revealed.

Acute pancreatitis affects over 14,000 cases every year. Often caused by gallstones or excessive alcohol consumption, treatments are straightforward and effective when administered early.

“Clinicians are missing a significant opportunity to change the future quality of life”

Derek O’Reilly

But the National Confidential Enquiry into Patient Outcome and Death has claimed there was an extraordinarily high level of readmission with the same problem due to diagnosis failures.

In one in five of the 692 cases looked at by NCEPOD patients had experienced one or more previous episodes of acute pancreatitis.

NCEPOD identified that gallstones were the most common cause – being responsible for 46.5% of cases – while in 22% it was alcohol excess and 17.5% no underlying cause was identified.

Only 19% patients with acute pancreatitis caused by gallstones had gallstone surgery during their admission. NCEPOD stated that 37% of 179 patients who did not undergo early surgery should have.

In 20% of acute pancreatitis cases it was very likely that patients would develop a severe form of the disease and be at risk of death, noted NCEPOD’s Treat the Cause report, which was published last week.

However, in 93% of the 130 patients readmitted for recurrence of acute pancreatitis the cause was the same as their previous admission.

“In too many cases of acute pancreatitis clinicians never found the underlying cause”

Simon McPherson

Although the initial assessment was deemed prompt in the majority of patients, it did not include any form of early warning score in 30.7% of emergency department admissions for the condition.

The report recommended that patients with an episode of mild acute pancreatitis should have an early cholecystectomy, either during the index admission or on a planned list within two weeks.

For those with severe acute pancreatitis, cholecystectomy should be undertaken when clinically appropriate after resolution of pancreatitis.

In addition, NCEPOD said formal networks should be established so patients had access to specialist interventions, regardless of where they presented.

Indications for when to refer a patient for discussion with a specialist tertiary centre and when a patient should be accepted for transfer, should also be explicitly stated, said NCEPOD.

Derek O’Reilly, report co-author and NCEPOD clinical co-ordinator, highlighted the worryingly high number of repeat admissions where the cause had been the same as in the previous admission.

“The majority of patients are admitted to hospital with gallstones, and the failure to clear them completely results in unacceptable rates of readmission with recurrent pancreatitis and other gallstone-related complications,” he warned.

“Repeat hospital stays would be reduced significantly if patients with mild acute pancreatitis had surgery to remove gallstones within two weeks of admission,” he stated.

NCEPOD

Too many repeat admissions for acute pancreatitis

Mr O’Reilly also highlighted antibiotic overuse for the condition. “Our report found that 20% of the patients in the study had been given antibiotics unnecessarily,” he said. “It is ineffective in the early stages of acute pancreatitis.”

In addition, he cited concerns about how hospitals cared for acute pancreatitis patients with alcohol problems.

“Where alcohol misuse was associated with acute pancreatitis, we found that only half of the patients reviewed were referred to an alcohol liaison service, despite 80% of hospitals in the study having onsite services,” he said.

“Clinicians are missing a significant opportunity to change the future quality of life for patients by helping them to stop harmful levels of drinking, and importantly prevent acute pancreatitis reoccurring,” he added.

Meanwhile, report co-author and NCEPOD clinical co-ordinator Simon McPherson criticised the number of cases where clinicians never found the underlying cause of the illness. He called for more ultrasound scans to detect gallstones, along with more complex imaging where the cause remained obscure.

Mr McPherson also said the report again revealed the inconsistent use of early warning systems in hospitals and called for their use to be a national “priority”.

“This is not the first time that NCEPOD has identified how important it is to use early warning systems to monitor the severity of a patient’s illness,” he said. “Only last year our report into sepsis called for a single national system to be introduced to all hospitals and GP surgeries.” 

Joanne Bishop, hepato-pancreato-biliary nurse specialist, was involved as one of the small group of specialists who advised NCEPOD on the design of the study.

 

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Readers' comments (2)

  • For four years I had frequent admissions to my A&E via 999 calls, had expensive CT / MRI scans, x-rays, you name I had it, but still felt constantly nauseous and in pain. I was given a diagnosis of costochondritis, norovirus, tummy bug, atrial fibrillation, chest infection, the list goes on and on.
    At a friends house I was taken ill, called an ambulance, admitted to another hospital in a neighbouring town, given a ultra sound scan, diagnosed with gall stones, operated on and have never looked back.

    I often look back and think how much all my tests must have costed the hospital, the constant use of ambulances, time, cost of hospital beds etc, when a every simple test was all that was required.
    How on earth do these professionals get it so wrong?

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  • There is also a problem with diagnosis at primary leve. It took me 7 GP visits, 1 walk-in centre visit and 3 different GPs before I was referred to a GI consultant. Over those 3 months I was mis-diagnosed with osteo-arthritis, trapped nerve and a peptic ulcer, and underwent 2 painful sessions with a physiotherapist. My symptoms of upper abdominal pain, pain around the bottom of the ribs and pain in the centre of my back along with weight loss, vomiting and wind seemed to fool them, and I felt they thought I was over-anxious. Luckily with a different GP, I was referred promptly, but this was many weeks after first presenting. Now, 2 months later, I am still suffering pain and fatigue, and am finding it difficult to balance painkillers against side-effect constipation/ laxative induced diarrhoea have as I return to work. I think patients need much more support with information about pain management and diet for recovery from acute pancreatitis.

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