Acute Pancreatitis Presentation

7/28/2019 Acute Pancreatitis Presentation

1/24

Case PresentationFamily Medicine Team C

Gerry Martin, MDChristie Prendergast, MS3

Annie Lim, MS3


2/24

Case Presentation

CC: Epigastric painHPI: 46 YO AA female presented to ER

with 2 day Hx of abdominal pain. Pain is

epigastric & periumblical, constant, 10/10,and radiates to back. Pain is worse with

food, improved in fetal position. Denies

NV, +diarrhea, +night chills. Precipitatedby EtOH binge 2 days prior.


3/24

Case Presentation Continued

PMHx: HTNx13 yrs, DMII x13yrs,

hyperlipidemia, major depressive

d/o (Hx of 5150), hx of acutepancreatitis.

Pt also states BS have been in

400s and has not f/u in clinic since

3/07


4/24


PSurgHx: lumpectomyFamHx: mother HTN, father DM, mother CAD

SocHx: 5-pack year hx, EtOH abuse (2-3 largedrinks/day)

Meds:

DM: Metformin 100mg, Glipizide 10mg,Pioglitazone 30 mg, Gabapentin 600 mg

HTN: HCTZ 25mg, Simvastatin 40mg, ASA 81mg, Losartan 50 mg

Depression: Citalopram 40 mg, Risperdal 6 mg

Allergies: NKDA


5/24

Case Presentation ContinuedPhysical Exam

Vitals: BP:163/109 P:91 T:96 R:18

Gen: pleasant, mildly distressed, obese female

HEENT: non-icteric sclera

CV: RRR, no murmurs appreciated

Resp: CTAx2, no wheezing, rales, rhonchi

GI: epigastric & RUQ tenderness, no rebound

tenderness, negative Murphys, neg Cullens &Turners sign, +BSx4

Ext/MSK: 5/5 bilateral UE, 5/5 bilateral LE, 2/4

posterior tibal, 2/4 dorsalis pedis, 2/4 popliteal

+ monofilament test


6/24


Labs:133 99 11

4.4 21 0.88.8

13.9

40.2221

Accucheck: 363 216

HgA1c = 13.9

Lipids (3/07)

TG 64

Chol 250

LDL 161

441

Lipase on admission 333

AST/ALT = 13/12

Urine

B-hydroxy = 2.60 ( )

+ketones + glucose

Cardiac enzymes neg x2


7/24


Imaging

CT scan: acute on chronic pancreatitis

CXR: normalEKG: NSR


8/24

Diagnosis

Acute Pancreatitis secondary

to EtOH abuse


9/24

Assessment/Plan

1. Acute Pancreatitis 2/2 EtOH abuseRansons criteria score 1clear liquids, IV fluids, Morphine sulfateCBC/Chem, Lipid panel

2. DM II poor controlHgA1c=14.9Start Levemir 14U qHS

Hold oral hypoglycemic meds3. HTN poor control

continued current BP meds and BPmonitoring


10/24

Assessment/Plan Continued

4. HyperlipidemiaLDL 161 (3/07)Continue ZocorRechecked fasting lipid panel (LDL 103)

5. Major Depressive D/O stable

Continue current management

6. EtOH abuse

Counseled patient on EtOH complications &importance of cessation

7. Tobacco abuse

Smoking cessation counseling


11/24

Differential Diagnosis

1. Acute cholecystitis

2. Intestinal obstruction

3. Mesenteric vascular occlusion4. Renal colic

5. MI

6. Pneumonia


12/24

Ransons Criteria/Prognosis

On admission:1. Age >55 YO

2. WBC > 16K

3. Glucose > 2004. LDH > 350

5. AST >250

At 48 hrs:1. Ca < 8

2. Hct > 10%

3. BUN > 5mg/dL4. Base deficit > 4meq/L

5. PaO2 < 60mmHg

6. Fluid seq > 6L


13/24

Hospital Course

Patient was placed on clear liquids, IVhydration, and given morphine for paincontrol. She stayed in the hospital for 2

days. On HD#2 pain decreased,amylase/lipase levels decrease (17/86)and patient tolerated diabetic diet withoutany exacerbation of symptoms. Pt was

extensively counseled on diabetic control,and smoking/EtOH cessation. Pt was thendischarged home with follow-up in clinic.


14/24

DISCUSSIONQuestions?


15/24

Introduction

Definition: Acute pancreatitis is aninflammatory condition of the pancreascharacterized clinically by abdominal pain

and elevated levels of pancreatic enzymesin the blood

Prevalence in United States is79.8/100,000 per year, thus resulting in185,000 new cases of acute pancreatitisannually


16/24

Etiology of Pancreatitis

1. Gallstones2. Alcohol3. Hypertriglyceridemia4. Hypercalcemia5. ERCP6. Trauma7. Postoperative

8. Rx (sulfas, diuretics, HIV Rx, ASA)9. Infections10.+many more uncommon causes


17/24

Signs & Symptoms

Acute upper abdominal pain (90%)

Radiates to the back

NauseaVomiting

Relief on bending forward


18/24

Physical Exam

Mild: epigastric tenderness

Severe:

fever, tachycardia, shock, coma

Respiratory distress

Grey turners or Cullens sign

Epigastric mass


19/24

Laboratory/Imaging

Elevated amylase/lipase

CRP >150 mg/dl discriminates severefrom mild

Ultrasound to r/o gallstone pancreatitis

Abdominal X-ray range from unremarkableto localized ileus (sentinel loop/colon cutoff

sign) CXR to r/o pleural effusion, elevation of

diaphragm, ARDS


20/24

Laboratory/Imaging

CT Scan assess the severity

MRI lacks nephrotoxicity, better

categorize fluid collection, necrosis,

abscess, hemorrhage and pseudocyst.

Equivocal to ERCP


21/24

CLINICAL PREDICTORS

Scoring systems

APACHE II uses physiology, age and

chronic health to calculate prognosis

Ranson, Glasgow, Bank takes 48 hours to

complete, can be used only once


22/24

Treatment

General Principles: Correction of

underlying predisposing factors

Gallstone Pancreatitis: Early ERCP in

patients with biliary sepsis and obstructive

jaundice

Reversal of hypercalcemia

Cessation of causative agent/drugs

Administration of insulin to poorly controlled

diabetics with hypertriglyceridemia


23/24

Treatment Mild pancreatitis supportive care

Severe pancreatitis ICU monitoring

Support of pulmonary, renal, circulatory,hepatobiliary function

Fluid resuscitation(250-300 cc/hr) Pain management meperidine, morphine,

fentanyl

Preventing infection: Selective decontamination

of the gut by oral nonabsorbable abx Systemic Antiobiotics: studies evaluating its

benefit and harm is still unsettled


24/24

Treatment

Nutritional support with early enteralfeeding reduces complications

Parenteral nutrition required if enteral

feeding not tolerated Necrotizing Pacreatitis (30% of pancreas),

meropenem/imipenem

Surgical referral: unstable, failure of Rx

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Acute Pancreatitis Presentation