PAINCREATITIS
Emmanuel, Minette
Hamsain Sara Mae
Hasan, Irshada
Lakibul, Jehan
Contoso
Pharmaceuticals
General Data
A.J
28 y/o
Female
Married
Arena Blanco
Tausug
CC: Epigastric pain Contoso
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History of Present Illness
11 days PTA 2 days PTA At ER
(+) Epigastric pain: Persistence of • Admitted
boring, radiating to the
back, not associated with
symptoms
food intake or change in (+) generalized
position, PS 10/10
weakness
(+) Vomiting: post
prandial, several episodes, (+) consult at ZCMC:
previous ingested food advised admission for acute
pancreatitis with elevated
(+) anorexia amylase x3 refused
(-) fever, LBM, jaundice, given tramadol 50 mg tab
dysuria, dyspnea, chest Symptoms persisted.
pain, weight loss Contoso
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page 3
Past Medical (+) S/P CS 2017, no known comorbidities
History No current meds, no prev OCP use
No hypertension, diabetes mellitus, cancer, cardiac
problems, asthma
Family History
Personal and Housewife, non-alcoholic, non smoker, denies drug
social History use
G3P3(3003), LMP 1/16/2019, regular, 2-3 pads/day,
no amenorrhea
Gyne History Contoso
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(-) weight loss General HEENT
(-) Headache, nape
pain, BOV, dysphagia
Respira- Cardiao-
(-) cough tory vascular
(-)palpitations
(-) bloatedness, early
satiety, melena, GI GU
hematemesis (-) Oliguria,
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General Awake, tachypneic, in pain
Vital signs BP: 100/80 T: 36.7 PR 107 RR: 22 02:
99 % BMI: 27.4
Skin
Dry and warm to touch, (-) lesions
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Anicteric sclerae, pink palpebral conjunctiva,
HEENT
dry lips and oral mucosa , no
lymphadenopathies
Chest and
lungs Equal chest expansion, clear breath
sounds
Cardiac Adynamic precordium, tachycardic, refular
rhythm
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Flabby, no dilated veins or lesions,
Abdomen normoactive bowel sounds, soft, direct
tenderness on epigastric area on palpation,
(-) murphy’s sign, (-) rebound tenderness
Extremities
Good pulses, no edema, no clubbing
of fingernails, no lesions
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Impression Acute pancreatitis with
moderate dehydration
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Approach
Epigastric pain
Severe
abdominal pain,
abdominal
tenderness,
guarding
Acute Non-Acute
surgical surgical
abdomen abdomen
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EPIGASTRIC
PAIN
• Cardiac
• Biliary
• Pancreas
• Vascular
Contoso
• GI Pharmaceuticals
page 11
Approach
Epigastric pain
Cardiac Biliary Pancreas GI
ACS Cholecystitis Pancreatitis PUD
- cardio- -RUQ pain -Radiates to -Burning
vascular D. radiates the back -associated
-older age to the back -Steady, with food
-pain as -associated boring pain intake
‘heaviness’ with food -4Fs
-usually intake (female fat, Dyspepsia
with DOB -jaundice forty,
-Murphy’s fertile) -Burning/
bloatedness
-associated
with food Contoso
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intake
Gallstones
Alcohol
Hypertriglyceridemia
ERCP
Risk factor
Drugs
S/P CS 2017
Trauma Obese
Female, fat, fertile
Postoperative Contoso
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page 13
Acute Chronic
Epigastric pain radiation to the back Abdominal pain
Threefold or greater elevation in serum Weight loss
lipase and/or amylase
Maldigestion
Acute pancreatitis in abdominal imaging
Normal amylase and lipase
Radiographic evidence
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page 14
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2 days PTA
Acute Pancreatitis
Blood chemistry H. pylori: negative
Sodium: 137
Potassium: 4.3 Severe boring, epigastric pain
Amylase: 506 (H)
Crea: 43 (L)
radiating to the back
Hct: 0.36
Elevated serum amylase
CBC
Hg: 121
WBC: 15.5
Predominance of
neutrophils
Urinalysis WBC: 5-10
RBC: 0-2
Mucus threads: rare
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Acute Pancreatitis
• Phases
Early Late
<2 weeks >2 weeks
Risk factors
• Severity • Age > 60 y.o
Mild Moderate Severe
• Obesity
• Comorbids
(-) organ failure, local Local complications Persistent organ failure
complications and/or transient organ >48 hrs
failure <48 hrs
• Imaging
Interstitial Necrotizing
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page 18
Markers of severity at admission or within 24 hours
SIRS (presence of 2/more)
Core temperature of <36o or > 38o
Heart rate >90 bpm
Respirations >20/min or PCO2 <32 mmHg
WBC count > 12,000 μL, <4000 μL, or 10% bands
APACHE II
Hct > 44%
Admission BUN (>22 mg/dL)
BISAP score
(B) BUN > 25 mg/dL
(I) Impaired mental status
(S) SIRS >/= 2 of 4 present
(A) Age > 60 y.o
(P) Pleural effusion
Organ Failure (Modified Marshall score)
Cardiovascular: systolic BP <90 mmHg, HR > 130 bpm
Pulmonary: PaO2 < 60 mmHg Contoso
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Renal: serum creatinine > 2.0 mg %
page 19
At the ER
S O A P
Epigastric pain, BP: 100/80 T: 36.7 Acute pancreatitis with -NPO
vomiting, weakness PR 107 RR: 22 moderate dehydration -IVF PLR at 975 cc -IV
02: 99 % bolus then RA
P. #1 epigastric pain
Epigastric tenderness
SIRS (presence of 2/more) CBC, Crea, K, lipase, SIRS
o o
Core temperature of <36 or > 38 CBG-114 BUN, preg test, stool No organ
Heart rate
Organ >90 bpm
Failure (Modified exam, H.pylori
Respirations
Marshall score)>20/min or PCO2 <32 CBC
failure
mmHg
CXR PA, flat plate BSAP <3
BISAP score
Cardiovascular: Hct: 0.35
WBC
(B) count
BUN ><90
> 25 12,000
mg/dL μL, <4000 μL, Hg: 118
abdomen sup. and
systolic BP mmHg, HR > 130
or
(I)
bpm 10% bandsmental status
Impaired WBC: 11.4 upright)
(S) SIRS >/= 2 of 4 present
Pulmonary: Predominance of neutrophils ECG
(A)
PaO2Age > 60
< 60 y.o
mmHg WAB UTZ
Crea: 44
(P) Pleural effusion
Renal: Potassium: 3.8 -MEDS:
serum creatinine > 2.0 mg % Amylase: 91 Meperidine 50 mg
Lipase: 652 IVT Q8 hrs
UA
Metoclopromide 10 Contoso
WBC: 5-10 mg IVT Q8 hr Pharmaceuticals
RBC: 5-10 -monitor VS
Fluid Resuscitation and Monitoring Therapy
• NPO to rest the pancreas
• IV analgesics given to control abdominal pain
• Non opioids
• Opioids
• IV Fluids of Lactated Ringer’s or Normal Saline are initially bloused
at 15-20cc/kg (1050-1400), followed by 3mg/kg per hour (200-250
mL/h), to maintain urine output >0.5cc/kg per hour.
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Reassessment
S O A P
UO: 0.7ml/kg/h Acute pancreatitis with IVF:
moderate dehydration PLR at 30 gtts/min
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page 22
• Lactated ringer’s has been shown to decrease
systemic inflammation and may be a better
crystalloid than normal saline.
• Targeted Resuscitation Strategy with
measurement of haematocrit and BUN every 8-
12 hours is recommended to ensure adequacy of
fluid resuscitation and monitor response therapy.
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Course in the ward (Day 1)
S O A P
(-) epigastric pain, BP: 110/70 T: 36 PR 83 Acute pancreatitis Meperidine 50 mg IV
fever, vomiting RR: 20 02: 99 % Q8hrs
AS, PPC, moist oral Metoclopromide 10
mucosa mg IV Q8 hrs
ECE, CBS, AP, NRRR
(-)murmur PLR x 30 gtts/ min
Flat, nontender soft
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Nutritional Therapy
• Alow fat solid diet can be administered to
subjects with mild acute pancreatitis after
abdominal pain has resolved.
• Enteral nutrition should be considered 2-3 days
after admission in subjects with more severe
pancreatitis instead of TPN (Total parenteral
nutrition)
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Antibiotic Therapy
• Prophylactic antibiotic is not recommended unless there is a
suspected or confirmed infection.
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Course in the ward (Day 2)
S O A P
(-) epigastric pain, BP: 110/80 T: 36.2 Acute pancreatitis Discharged
fever, vomiting PR 85 RR: 20
02: 99 %
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Female, obesity, fertile (Gallstone
Previous Operation
formation) S/P CS 2017
Proteolytic enzymes are
Initial Phase activated in the pancreas
acinar cell rather than in the
intestinal lumen
Activated proteolytic
enzymes esp Trypsin
Trypsin activation
Digest pancreatic and peripancreatic Amylase (506)
tissuesacincar cells Lipase (652)
Activation, chemoattraction, and WBC (15.5)
Second Phase sequestration of leukocytes and Contoso
macrophages in the pancreas Pharmaceuticals
Enhanced intrapancreatic
Right Upper Quadrant
inflammatory reaction /Epigastric Pain radiating
Fluid meperidine
resuscitation
- to the back
-
Effects of activated Trypsin
proteolytic enzymes and activation metoclopr
cytokines omide
Tachycardia Vomiting
Tachypnea
-
Activate other enzymes such
as elastase and
phospholipase A2
Third Phase
Proteolysis, edema, interstitial
hemorrhage, vascular damage,
coagulation necrosis, fat
necrosis, and parenchymal cell
necrosis Contoso
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Cellular injury and death
Liberation of bradykinin
peptides, vasoactive
substances, and histamine
Increased vascular
permeability, and edema
with profound effects on
many organs.
SIRS
Multi-Organ Failure
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