1. Clinical Case for a Clinical Pharmacist
 George, 40 years old male chronic alcoholic started taking
Sulfasalazine for his UC. After few days he suffered from severe
vomiting, severe pain upper abdomen, radiating to back, not releived
by some antispasmodic drug, the patient took at home. There was no
fever or history of GI or respiratory tract infection otherwise. There is
history of gall stones 1 year back.
 Pulse 110/min
temp: 37 C
 Lab: ESR: 28 mm/1H, Hb 10 G%
TLC: 20000/mm3, DLC: N: 80%
 S.Cr: 1.1 mg/dL, ALT: 100U/l, ALP: 300U/L
 Physician asked for following tests also:
 Serum Amylase: 450 U/L
Serum Lipase: 600 U/L
 Serum Ca++ : 8 mg/dL
Albumin: 2 G/dL
 What is the diagnosis?
 What is the cause? Is there any correlation with UC or its therapy?
 Manage, How?
 Take 5 minutes, discuss, and come up with your opinion now
After completion of this module, student will be able
Define acute and chronic pancreatitis
Describe the epidemiology, etiology, and prognosis of
Identify medications with possible, probable, or
definite associations with acute pancreatitis.
Plan Treatment Goals for Acute Pancreatitis
Construct Therapeutic Plan, (with importance of fluid
therapy., opioids as analgesics, prophylactic antibiotics)
Recommend appropriate nutritional support for
patients with acute pancreatitis.
Design follow up plan for patient of acute pancreatitis
4. Dr. Afzal
5. Acute Pancreatitis (AP)
An inflammatory disorder of the pancreas characterized
 severe pain in the upper abdomen
 Increased serum concentrations of pancreatic lipase and
 Complete recovery in most cases
Severe AP is associated with local complications
 Acute fluid collection
 Pancreatic necrosis,
 Pseudo cyst.
Exocrine and endocrine pancreatic functions may remain
impaired for variable periods after an acute attack,
AP rarely progresses to chronic pancreatitis (CP).
Atlanta classification, acute pancreatitis can be divided
into two broad categories :
 Interstitial edematous acute pancreatitis, : acute inflammation of
the pancreatic parenchyma and peripancreatic tissues, but without
 Necrotizing acute pancreatitis: inflammation associated with
pancreatic parenchymal necrosis and/or peripancreatic necrosis.
According to the severity, acute pancreatitis is divided
into the following:
 Mild acute pancreatitis:
Absence of organ failure and local or systemic complications
 Moderately severe acute pancreatitis:
No organ failure or transient organ failure (<48 hours) and/or local
 Severe acute pancreatitis:
Persistent organ failure (>48 hours) that may involve one or multiple organs
3% of all cases of abdominal pain admitted to
40 cases per year per 100,000 adults.
Ranges between 5 and 80 per 100,000 population
The highest incidence recorded in the United
States and Finland
In 80% of cases: mild and resolves without
Sex No predilection exists.
Age- 35-64 years
8. Dr. Afzal
9. Causes by demographic
The most common causes of pancreatitis, are as
Western countries - chronic alcoholism and gallstones
accounting for more than 85% of all cases
Eastern countries - gallstones
Children - trauma
Adolescents and young
adults - mumps
10. Etiology: Causes
Most common causes
 Ethanol use
 Unknown (idiopathic pancreatitis).
 Causes of pancreatitis spells.doc
 Many medications Medications Associated with Acute Pancreatitis.doc
5-Aminosalicylic acid, Azathioprine
Sulindac Valproic acid/salts
Ampicillin ACEI, Losartan
Ifosfamide Cisplatin Cytarabine
Corticosteroids Interferon alfa-2b
AP is initiated by:
 Premature activation of pancreatic zymogens (inactive
enzymes) within the acinar cells,
 Pancreatic ischemia,
 Pancreatic duct obstruction.
Release of active pancreatic enzymes directly causes local
or distant tissue damage.
 Trypsin digests cell membranes and leads to the activation of other
 Lipase damages fat cells, producing noxious substances that cause
further pancreatic and per pancreatic injury.
Release of cytokines injures the acinar cell and enhances
the inflammatory response
Injured acinar cells liberate chemoattractants
Attract neutrophils, macrophages, and other cells
to the area of inflammation
Increase vascular permeability promotes tissue
Pancreatic infection may result from colonic
Local complications: acute fluid collection, pancreatic
necrosis, abscess, pseudo cyst formation, and
Systemic complications include cardiovascular, renal,
pulmonary, metabolic, hemorrhagic, and central
nervous system abnormalities.
13. Clinical Presentation
The initial presentation:
Moderate abdominal discomfort to excruciating pain,
 Occurs in 95% of patients and is usually epigastric, often radiating to
the upper quadrants or back.
 The onset is usually sudden
 Tends to be steady and usually persists for several days
 Nausea and vomiting occur in 85% of patients and usually follow the
onset of pain
 Respiratory distress.
 Marked epigastric tenderness,
 Abdominal distention,
 Hypotension, and low-grade fever.
 In severe disease,
Bowel sounds are diminished or absent.
Dyspnea and tachypnea are signs of acute respiratory complications.
14. Physical signs
Following finding may benoticed according to
severity of the disease
Fever (76%) and tachycardia (65%); hypotension
Abdominal tenderness, muscular guarding (68%), and
distention (65%); diminished or absent bowel sounds
Dyspnea (10%); tachypnea; basilar rales, especially in
the left lung
In severe cases, hemodynamic instability (10%) and
hematemesis or melena (5%); pale, diaphoretic, and
Occasionally, extremity muscular spasm secondary to
15. Typical signs if necrosis
Cullen sign (bluish discoloration around the
umbilicus resulting from hemoperitoneum)
Grey-Turner sign (reddish-brown discoloration along
the flanks resulting from retroperitoneal blood
dissecting along tissue planes); more commonly,
patients may have a ruddy erythema in the flanks
secondary to extravasated pancreatic exudate
Erythematous skin nodules, usually no larger than 1
cm and typically located on extensor skin surfaces;
16. Grey Turner’s sign
17. Cullin’s sign
18. Diagnosis (guidelines 2013)
Two of the following:
characteristic (severe) abdominal pain,
serum amylase and/or lipase exceeding 3 times the
upper limit of normal, and/or
characteristic abdominal imaging findings (strong
recommendation, moderate quality of evidence).
 A definitive diagnosis by
 Surgical examination of the pancreas
 Pancreatic histology
If not possible then
 recognition of an etiologic factor
 clinical signs and symptoms
 abnormal laboratory tests
 imaging techniques
 Increase Serum amylase (20-110 U/L) and Serum lipase (0-160 U/L)
concentration more than 3 times the normal upper limits
 TLC: 10-30,000
 Hypocalcaemia (9-11mg/mL) Why there is hypocalcaemia in Acute pancreatitis.doc
 hyperglycemia, hypoalbuminemia, mild hyperbilirubinemia, and
elevations in serum alkaline phosphatase and hepatic transaminases
Serum amylase and lipase
Blood urea nitrogen (BUN), creatine, and electrolytes
Serum cholesterol and triglyceride
Complete blood count (CBC) and hematocrit; NLR
C-reactive protein (CRP)
Arterial blood gas values
Serum lactic dehydrogenase (LDH) and bicarbonate
Immunoglobulin G4 (IgG4
 Contrast-enhanced computed tomography (CT)
 distinguishes interstitial from necrotizing pancreatitis.
 Endoscopic retrograde cholangiopancreatography (ERCP)
 used to visualize and remove bile duct stones in patients with gallstone
22. Treatment guidelines
Contrast-enhanced computed tomography (CT)
scanning and/or magnetic resonance imaging (MRI)
of the pancreas should performed only in the absence
of clinical improvement
Assessment of the patient’s hemodynamic status
immediately upon presentation,
Patients with systemic inflammatory response
syndrome (SIRS) and/or organ failure should, be
admitted to an intensive care unit (ICU) or an
intermediary care setting
23. Treatment guidelines
All patients should receive aggressive hydration,
unless heart or renal disease
most effective within the first 12-24 hours, with possibly
little benefit derived from its administration after this
Within 24 hours of admission, patients with
concurrent acute cholangitis should undergo
endoscopic retrograde cholangiopancreatography
(ERCP); in high-risk patients,
The risk of severe post-ERCP pancreatitis should be
reduced through the use of postprocedure rectal
nonsteroidal anti-inflammatory drug (NSAID)
suppositories and/or pancreatic duct stents
24. Treatment guidelines
The guidelines recommend against routinely using
prophylactic antibiotics in cases of severe acute
pancreatitis and/or sterile necrosis; however,
intervention in patients with infected necrosis may be
delayed through the use of antibiotics that penetrate
In mild cases of acute pancreatitis with no nausea and
vomiting, oral feeding can be initiated immediately;
Enteral nutrition should be used in severe cases to
prevent infectious complications, and parenteral
nutrition should be avoided
25. Treatment guidelines
Regardless of lesion size, location, and/or extension,
intervention is not necessary for asymptomatic
pancreatic and/or extrapancreatic necrosis and/or
Surgical, radiologic, and/or endoscopic drainage in
stable patients with infected necrosis should be
postponed (for 4 weeks if possible) to permit a wall to
develop around the necrosis
26. Who should be treated in ICU
APACHE II score >8 in the first 24 hours of admission
Persistent (>48 hours) SIRS
Elevated hematocrit (>44 percent), blood urea
nitrogen (BUN) (>20 mg/dL), or creatinine (>1.8
Age >60 years
Underlying cardiac or pulmonary disease, obesity
27. APACHI score
28. SIRS: systemic inflammatory response syndrome
Two or more of the following conditions:
Temperature >38.3°C or <36.0°C
Heart rate of >90 beats/minute
Respiratory rate of >20 breaths/minute
or PaCO2 of <32 mmHg
WBC count of >12,000 cells/mL, <4000
cells/mL, or >10 percent immature (band)
29. Initial Management
 For severe or mild with vomiting:
 NPO: to minimize exocrine stimulation of the pancreas.
 Naso-gastric (NG) aspiration in patients with profound pain, severe
disease, paralytic ileus, and severe vomiting
 Enteral or parenteral nutrition if oral nutrition will be withheld for more
than 1 week
 Fluid Therapy: all patients
 5 to 10 mL/kg per hour of isotonic crystalloid solution (eg, normal saline or
lactated Ringer’s solution)
 If dehydration: hypotension and tachycardia
 20 mL/kg of intravenous fluid given over 30 minutes followed by
3 mL/kg/hour for 8 to 12 hours
 If AP is due to hypercalcemia, only NS
 Stop fluid if goals achieved:
 heart rate <120 beats/minute,
 mean arterial pressure between 65 to 85 mmHg),
 urine output (>0.5 to 1 cc/kg/hour)
 reduction in hematocrit (goal 35 to 44 percent) and BUN over 24 hours
30. Pain control
Patient controlled analgesia: opioids
Fentanyl better, safety profile, especially in renal
Bolus regimen ranges from 20 to 50 micrograms with a 10minute lock-out period (time from the end of one dose
infusion to the time the machine starts responding to
 Parenteral meperidine (50 to 100 mg) every 3 to 4 hours. less spasm
of the sphincter of Oddi. not as effective as other opioids ,
contraindicated in renal failure.
 Parenteral morphine 10-15 mg iv , cause spasm of the sphincter of
Oddi, increase serum amylase and rarely pancreatitis.
 Hydromorphone, longer half-life than meperidine, parenterally by
a patient-controlled analgesia (PCA) pump.
31. Dr. Afzal
32. Antibiotics are not recommended
20 percent of patients develop an extra-pancreatic infection
 bloodstream infections,
 urinary tract infections
Administer antibiotic according to site and C/S report
If severe necrotizing AP:
 Broad-spectrum antibiotics:
Start within the first 48 hours and continued for 2 to 3 weeks.
 IMIPENEM-CILASTATIN (500 mg every 8 hours) may be most
 Ciprofloxacin, Levofloxacin) with metronidazole should be
considered for penicillin-allergic patients
Prophylactic antifungal therapy not recommended
occur in approximately 9 percent of necrotizing pancreatitis.
However, it is not clear if they are associated with higher
Protease inhibitors: anti trypsin
DROTRECOGIN ALFA may benefit patients with
pancreatitis and systemic inflammatory response syndrome
 Recombinant form of human activated protein C that has anti-
thrombotic, anti-inflammatory, and pro-fibrinolytic properties.
 Used mainly in intensive care medicine as a treatment for severe
Octreotide, 0.1 mg subcutaneously every 8 hours, decrease sepsis,
length of hospital stay, and mortality
Morbidity did not differ significantly between the groups. This study did not demonstrate an
inhibitory effect of octreotide on exocrine pancreatic secretion. Based on these results, the
routine use of octreotide after PD cannot be recommended: HPB (Oxford). 2013
Insulin if hyperglycemia.
surgical intervention in severe necrotizing pancreatitis.
 During the FIRST TWO weeks after a SEVERE ATTACK
 Intensive critical care (ICU):
To support the cardiopulmonary (heart and lung), liver and kidneys
that may fail due to RELEASE OF LARGE AMOUNTS TOXINS FROM
THE DEAD PANCREAS in the abdomen.
Almost all patients require intravenous nutrition.
 Surgical treatment for severe acute pancreatitis
 Only in a tertiary medical center by experienced surgeon
35. Complications in Acute pancreatitis
 Pancreatic necrosis -Infected necrosis is almost always fatal without
 Acute Fluid Collections are common in patients with severe
pancreatitis (occurring in 30%-50%).
 Pancreatic abscess is a collection of pus adjacent to pancreas
presenting several months after attack.
 Acute pseudocyst rupture or haemorrhage in pseudocyst.
 Pancreatic ascites occurs when a pseudo-cyst collapses into peritoneal
cavity or major pancreatic duct breaks down and releases pancreatic
juices into peritoneal cavity.
36. Complications in Acute pancreatitis
Respiratory:Pulmonary oedema/Pleural effusions
Disseminated intravascular coagulopathy (DIC)
Renal dysfunction due to hypovolaemia, intra-vascular
coagulation. Usually avoided by adequate fluid
replacement plus/minus low-dose dopamine but acute
tubular or cortical necrosis can follow.
37. Complications in Acute pancreatitis
38. Evaluation of Therapeutic Outcomes
 Periodic Assessment of:
 Pain control,
 Fluid and electrolyte status, and
 Nutrition should be assessed periodically depending on the degree of
abdominal pain and fluid loss.
 For sever cases in ICU, monitor for:
 Vital signs, fluid and electrolyte status, white blood cell count, blood
glucose, lactate dehydrogenase, aspartate aminotransferase,
 Serum albumin, hematocrit, blood urea nitrogen, serum creatinine,
international normalized ratio (INR).
 Arterial blood gas.
 Serum lipase, amylase, and bilirubin require less frequent
 Signs of infection, relief of abdominal pain, and adequate nutritional
40. Chronic pancreatitis (CP)
A syndrome of destructive and inflammatory
Characterized by irreversible fibrosis and
destruction of exocrine and endocrine tissue
Resulting from long-standing pancreatic injury.
Most patients have periods of intractable
Progressive pancreatic insufficiency leads to
MALDIGESTION and DIABETES MELLITUS
Causes: in United States
 Prolonged ethanol consumption accounts for 70%
 idiopathic 20%
 other causes 10%: gall stones, C.F etc
Chronic alcohol ingestion,….. intraductal protein plugs that
BLOCK SMALL DUCTULES. ………progressive structural
damage in the ducts and acinar tissue.
Calcium complexes with the protein plugs, ….destruction of
Inflammation leads to cellular necrosis, ……..fibrosis
Malabsorption of protein and fat due to …decreased lipase,
Reduced bicarbonate secretion : duodenal pH less than 4.
 Pancreatic pseudocyst, abscess, and ascites or common bile duct
obstruction leading to cholangitis or secondary biliary cirrhosis.
42. Clinicalpain, malabsorption, weight loss, and diabetes. Jaundice occurs
in about 10% of patients.
 dull epigastric or abdominal pain
 radiates to the back.
 consistent or episodic
 frequently nocturnal
 unresponsive to medication
 Nausea and vomiting often accompany the pain.
 Severe attacks last from several days to weeks
 aggravated by eating and relieved by abstinence from alcohol.
 Steatorrhea (excessive loss of fat in the feces) with diarrhea and bloating
 Azotorrhea (excessive loss of protein in the feces) are seen in most patients.
 Weight loss may occur.
 Diabetes usually a late due to pancreatic calcification.
 Neuropathy is sometimes seen.
 Heavy ethanol use
 Attacks of recurrent upper abdominal pain.
CLASSIC TRIAD calcification, steatorrhea, and diabetes
Malabsorption of Fat can be detected by Sudan staining of the feces or
a 72-hour quantitative measurement of fecal fat
 Imaging techniques, Ultrasound, abdominal CT
Surgical biopsy of pancreas is the gold standard for diagnosis of CP.
 ERCP is the most sensitive and specific diagnostic test,
 Serum amylase and lipase concentrations usually remain normal unless the
pancreatic duct is blocked or a pseudo-cyst is present.
 The white blood cell count, fluid balance, and electrolyte concentrations
usually remain normal unless vomiting and diarrhea.
Abstinence from alcohol is the most important
 Small and frequent meals (6 meals/day) and a diet restricted in fat (50
to 75 g/day)
 Acetaminophen or nonsteroidal anti-inflammatory drugs before
meals to prevent postprandial exacerbation of pain
 If not effective tramadol or adding a low-dose opioid (e.g.,
acetaminophen and codeine)
 If pain persists, pancreatic enzymes
 Opioids: oral, if no effect, parentral
 Modulators of chronic pain (e.g., selective serotonin reuptake
inhibitors, tricyclic antidepressants
 The combination of pancreatic enzymes (lipase, amylase, and
protease) 30,000 IU of lipase and 10,000 IU of trypsin
 ENZYME CONTENT OF SELECTED PANCREATIC ENZYME PREPARATIONS.doc
 a reduction in dietary fat (to less than 25 g/meal)
H2 receptor antagonists and PPI’s
45. Evaluation of Therapeutic Outcomes
Analgesic control: Periodic assessment of:
The severity and frequency of abdominal pain
The effectiveness of pancreatic enzyme:
improvement in body weight and stool consistency
The 72-hour stool test for fecal fat
Serum uric acid and folic acid yearly
Blood glucose must be monitored carefully in