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- 1. A CASE OFACUTE PANCREATISTIS Melvin M. Garcia | 1st Year IM Resident
- 3. General Data Name: O.E. Age& Gender: 55/F Status: Married Nationality: Filipino Occupation: Housewife Address: San Miguel, Sto.Tomas, Batangas Chief complaint: Epigastric pain
- 4. History of PresentIllness 2 months PTA Onset of on/off epigastric pain, lasting for minutes to hours, radiating to the RUQ, with PS of 5-6/10, aggravated by food intake, especially by large meals. (-) Fever (-) Vomiting (-) Melena (-) Hematochezia (-) Change in bowel habits
- 5. History of PresentIllness 1 month PTA 11 days PTA Still with on/off epigastric pain, of the same characteristics. No medications taken. No consult done. Consult with a gastroenterologist. W.A. UTZ was requested, revealing unremarkable studies of the liver, gallbladder, pancreas, spleen, kidneys, & bladder. Prescribed unrecalled medications.
- 6. History of PresentIllness 6 days PTA (+) Epigastric pain, PS of 8/10, radiating to the RUQ pain (+) Vomiting, 1 episode, non-mucoid/bloody (+) Bloated sensation (+) Fever, Tmax of 38.5 (-) Change in bowel habits (-) Jaundice Admitted in DMMC
- 7. History of PresentIllness 6 days PTA Treated as a case of Acalculous Cholecystitis. Meds: 1. Sultamicillin 750 mg IV Q8 2. HNBB 10 mg IV Q8 PRN 3. Pantoprazole 40 mg IV OD 4. Paracetamol 300 mg IV PRN for T > 38.5 C
- 8. Laboratories CBC Results Hemoglobin 10.96g/dL Hematocrit 35.86 % WBC 14.28 x 1012/L Neutrophils 82.6 % Platelet count 656 x 109/L Blood Chemistry Results Creatinine 0.72 mg/dL BUN 10.92 mg/dL Na+ 146.2 mmol/L K + 4.27 mmol/L HGT 151 mg/dL SGPT 229 U/L SGOT 144 U/L Amylase 70 U/L Lipase 78 U/L
- 9. Laboratories Fasting Blood Chem.Results FBS 89.27 mg/dL Total Cholesterol 251.35 mg/dL Triglycerides 167.26 mg/dL HDL 35.52 mg/dL LDL 182.7 mg/dL Blood Chemistry Results PT Patient 10.8 sec PT Control 11.9 sec PT INR 0.91 % CV PT Percent Activity 100 %
- 10. History of PresentIllness 4-5 days PTA WA UTZ: Mild fatty liver changes. Consider acalculous cholecystitis. WA Xray: Unremarkable. Chest Xray: Atherosclerotic aorta. ECG: NSR, NA, WNL Urinalysis: Unremarkable
- 11. History of PresentIllness 3 days PTA Discharge improved after 3 hospital days. Home meds: 1. Sultamicillin 750 mg tab BID x 7 days 2. Pantoprazole 40 mg tab OD x 14 days 3. Paracetamol+HNBB 1 tab TID PRN 4. Ursodeoxycholic acid 300 mg tab BID x 14 days
- 12. History of PresentIllness Few hours PTA Consult Recurrence of severe, persistent, sharp, epigastric pain, with PS of 10/10, lasting for few minutes to hours, radiating to the back. (+) Vomiting, 3 episodes (-) Fever (-) LBM Re-admitted
- 13. Past Medical History •Not a known hypertensive, diabetic, or asthmatic • No known cardiac, liver, lung or thyroid problems in the past • No history of blood transfusion or needle stick injury • Immunization status unknown • No known food and drug allergies
- 14. Personal History • Sexualhistory: • G4P4 (4004) mother, all delivered via NSD • One male sexual partner • Denies any risky sexual practices • No contraceptive use
- 15. Personal History • Nohistory of • IV drug use or any recreational drugs • Psychiatric illness • STIs
- 16. Social History • Diet: •Rice, and pork, with occasional fruits and vegetables • With predilection to salty, and fatty foods • Not a known smoker • Occasional alcoholic beverage drinker
- 17. Family History (+) Hypertension– maternal side (-) DM type II (-) Asthma (-) PTB (-) Malignancy (-) Gallstones
- 18. Review of Systems •General appearance: sthenic, (-) weight loss • Skin: (-) easy bruiseability or dryness • HEENT: (-) headache, blurring of vision, tinnitus, hoarseness of voice, dysphagia, or odynophagia • Respiratory: (-) cough, or dyspnea • Cardiovascular: (-) chest pain, palpitations, orthopnea • GUT: (-) dysuria, tea-colored urine, hematuria, or flank pain • Musculoskeletal: (-) joint pains, or myalgias • Neuro: (-) change in sensorium, mood, attention or speech
- 19. Physical Examination General Survey:Awake, conscious, coherent, ambulatory, not in respiratory distress BP: 140/80mmHg, R arm Wt: 54kg HR: 89bpm Ht: 146cm RR: 20cpm BMI: 26kg/m2 Temp: 38.5 oC/axilla O2Sat: 98%
- 20. Physical Examination • Skin:tan, warm to touch, good turgor, no lesions, no rashes, no jaundice, palmar erythema or spider angioma, no tattoo • HEENT: Icteric sclera, pink palpebral conjunctiva, moist lips and oral mucosa, no tonsillophayngeal swelling • Neck: supple, trachea at midline, no neck vein engorgement, no lymphadenopathy • Back: spine at midline, no deformities
- 21. Physical Examination • C/L:equal chest expansion, resonant on all lung fields, clear breath sounds, no crackles, no wheeze • CVS: adynamic precordium, PMI not visualized, distinct s1 and s2, normal rate, regular rhythm, no murmurs noted
- 22. Physical Examination • Abdomen:flabby, no caput medusae, active bowel sounds, no bruits, soft; tympanitic on all quadrants; liver span: 7cm R MCL, 4cm MSL, edge is smooth and palpable 1 cm below the R costal margin; (+) epigastric tenderness; (-) Murphy’s sign; (-) mass noted • GUT: (-) costovertebral angle tenderness, bilaterally • Extremities: pink nail beds, CRT<2sec, strong peripheral pulse, no edema • CNS: within normal limits
- 23. Salient Features • 55/Female •Epigastric pain, radiating to the back • Previously admitted for acalculous cholecystitis • Vomiting • Fever (Temperature 38.5 oC) • BMI of 26 kg/m2 • No known comorbidities • Core Temperature of 38.5 C • Other vital signs were stable • PE revealed icteric sclerae and epigastric tenderness on palpation
- 24. Differential Diagnosis 1. Acutecholecystitis 2. Acute pancreatitis 3. Peptic ulcer disease 4. Perforated viscus 5. Acute intestinal obstruction 6. Mesenteric vascular occlussion 7. Renal colic 8. Inferior myocardial infarction 9. Dissecting aortic aneurysm 10. Pneumonia
- 25. Initial Management Upon Admission StrictNPO Vital signs q 2 hours including progress of abdominal pain IVF: D5LR 1 L x 8 hours Diagnostics: CBC c platelet, Na, K, BUN, Creatinine, Amylase, Lipase Meds: 1. Piperacillin-Tazobactam 4.5gm IV Q8 2. HNBB 10mg IV Q8 3. Omeprazole 40mg IV OD 4. Tramadol 50mg IV Q8 PRN for pain 5. Metoclopramide 10mg IV Q8 for vomiting 6. Paracetamol 300mg IV Q4 PRN for fever
- 26. Course in theWards Laboratories CBC Results Hemoglobin 11.86 g/dL Hematocrit 37.65 % WBC 18.58 x 1012/L Neutrophils 90.16 % Platelet count 660 x 109/L Blood Chemistry Results Amylase 140 U/L Lipase 554 U/L Creatinine 0.76 mg/dL BUN 7.56 mg/dL Na+ 135.2 mmol/L K+ 3.99 mmol/L
- 27. Course in theWards 1st Hospital Day S: Comfortable (-) Epigastric pain (-) Fever (-) Nausea/vomiting (-) Jaundice O: Alert, coherent, oriented. Vital signs: 110/70, 37.5, 78, 20 Icteric sclerae, PPC SCE, CBS, (-) crackles, (-) wheezes AP, DHS, NR, RR, (-) murmur NABS, soft, (-) tenderness, (-) mass noted A: Acute Pancreatitis P: Imaging: Upper Abdominal CT scan Continue Medications: 1. Piperacillin-Tazobactam 4.5gm IV Q8 2. HNBB 10mg IV Q8 3. Omeprazole 40mg IV OD 4. Tramadol 50mg IV Q8 PRN for pain 5. Metoclopramide 10mg IV Q8 for vomiting 6. Paracetamol 300mg IV Q4 PRN for fever
- 28. Course in theWards Laboratories Upper abdominal CT scan: Remarks: Unremarkable CT scan study of the upper abdomen. Incidental pneumonia, both lower lungs.
- 29. Course in theWards 2nd Hospital Day S: Comfortable. No subjective complaints. O: Alert, coherent, oriented. VS stable at 110/70, 37, 70, 20 Icteric sclerae, PPC SCE, CBS, (-) crackles, (-) wheezes AP, DHS, NR, RR, (-) murmur NABS, soft, (-) tenderness, (-) mass noted (-) edema A: Acute Pancreatitis P: Slow introduction, general liquid diet. Continue Medications: 1. Piperacillin-Tazobactam 4.5gm IV Q8 2. HNBB 10mg IV Q8 3. Omeprazole 40mg IV OD 4. Tramadol 50mg IV Q8 PRN for pain 5. Metoclopramide 10mg IV Q8 for vomiting 6. Paracetamol 300mg IV Q4 PRN for fever
- 30. Course in theWards 3rd Hospital Day S: Comfortable. Able to tolerate soft diet. O: Alert, coherent, oriented. VS stable at 110/70, 36.5, 82, 20 Icteric sclerae, PPC SCE, CBS, (-) crackles, (-) wheezes AP, DHS, NR, RR, (-) murmur NABS, soft, (-) tenderness, (-) mass noted (-) edema A: Acute Pancreatitis P: Soft diet. Subsequently discharged improved.
- 31.
- 32. Etiology & Pathogenesis Disease Presentation ClinicalCourse Approach to Diagnosis Laboratories & Imaging Management
- 33. Causes of AcutePancreatitis 30-60% 15-30% Gallstone Pancreatitis Alcohol 5-10% Post – ERCP 85-95% Self limited (3-7days) 25% Recurrent Pancreatitis 1.3 - 3.8 % 0.1 – 2 % Gallstone Alcohol Triglycerides Drug related
- 34. •Diagnosis of AcutePancreatitis • Typical abdominal pain • 3x or greater elevation in serum Lipase & or Amylase • Confirmatory findings on cross-sectional abdominal imaging
- 35. Acute Pancreatitis Management FluidResuscitation and Monitoring of Response to Therapy Assessment of Severity and Hospital Triage Special Considerations Based on Etiology Nutritional Therapy Management of Local Complications Follow-Up Care
- 36. Fluid Resuscitation The patientis made NPO to rest the pancreas and is given IV narcotic analgesics to control abdominal pain and supplemental oxygen (2L) via nasal cannula. IVF of lactated Ringer’s or NSS are initially bolused at 15-20cc/kg (1050-1400 mL), followed by 3 cc/kg/h (200-250 mL/h), to maintain UO of > 0.5cc/kg/h.
- 37. Assessment of Severityand Hospital Triage The Bedside Index of Severity in Acute Pancreatitis (BISAP) incorporates 5 clinical and laboratory parameters obtained within the first 24H of hospitalization is useful in assessing severity. (B) BUN >25mg/dL (I) Impaired mental status (S) SIRS: ≥2 of 4 present (A) Age >60 (P) Pleural effusion
- 38. Risk Factors forSeverity • Age > 60 years • Obesity, BMI of ≥30 • Comorbid disease (Charlson Comorbidity Index) Markers of Severity at Admission or Within 24H • SIRS – defined by presence of 2 or more criteria: • T <36 or >38 C • Heart rate of >90 bpm • Respiratory rate >20 cpm or PCO2 <32 mmHg • WBC >12,000/uL, <4,000/uL or 10% bands • APACHE II • Hemoconcentration (Hematocrit >44%) • Admission BUN (>22 mg/dl) • BISAP Score • Organ failure (Modified Marshall Score) • Cardiovascular: SBP <90 mmHg, HR >130 bpm • Pulmonary: PaO2 <60 mmHg • Renal: Creatinine >2mg% Markers of Severity During Hospitalization Persistent organ failure Pancreatic necrosis
- 39. Ranson’s Prognostic Criteria 1.At admission or diagnosis a. Age > 55 b. Leukocytosis >16, 000 per cubic ml c. Hyperglycemia > 200 mg/dl d. Serum LDH > 350 IU/L e. Serum AST > 250 IU/L 2. During initial 48 hours a. Fall in hematocrit by 10% b. Fluid deficit > 6, 000 ml c. Hypocalcemia < 1.9 mmol/L d. Hypoxemia (PO2 < 60 mmHg) e. BUN rise > 1.8 mmol/L after IV fluids f. Serum base deficit > 4 meq/L Note: ≥ 3 Factors at the time of admission (1) or during initial 48 hours (2) indicates an increased mortality rate. These patients need closer monitoring.
- 40. Special Considerations Basedon Etiology Gallstone Pancreatitis Hypertriglyceridemia Drug-induced pancreatitis Hypercalcemia Post-ERCP pancreatitis Autoimmune pancreatitis
- 41. Management of LocalComplications Necrosis Pseudocyst formation Pancreas and duct disruption Peripancreatic vascular complications Extrapancreatic infections
- 42. Follow up care Hospitalizationfor moderately severe and severe acute pancreatitis can last weeks to months and often involve a period of ICU admission and outpatient rehabilitation or subacute nursing care. Follow-up evaluation should assess for development of DM, exocrine insufficiency, recurrent cholangitis, or development of infected fluid collections.
- 43.