4. History of present illness
Abdominal pain
Upper abdomen
Dull aching constant severe pain
Radiating to the back
Relieved by bending forwards
Associated with vomiting
5. History of present illness
Vomiting
03-04 episodes
Non projectile
Non bilious
Not mixed with blood
Not associated with abdominal distention
6. History of present illness
No h/o fever
No h/o hematemesis, malena, hematochezia
No h/o yellowish discoloration of eyes, urine
No h/o burning micturition, dysuria,reduced urine output
No h/o chest pain, palpitation, diaphoresis, breathlessness,
syncope
No h/o recent blood transfusion, high risk behaviour, easy
bruisability, altered sleep rhythm, confusion
7. Past history
No h/o similar complaints in the past
No h/o DM/ HTN/ TB/ drug allergy
Not taking any long term medications
8. Personal history
Consumes 80-100 gm of alcohol/day X 12 yrs
Alcohol consumer:eye opening drinking
behaviour
Last consumption 1 day prior to symptoms
Consumes mixed diet
Normal pre morbid bowel and bladder habits
Sleep disturbed since the onset of symptoms
10. Summary
10
47 yrs old male, with history of significant alcohol
consumption , presented with history of
pancreatic type of pain, with no h/o jaundice or
fever
16. Binge drinking
More than 5 drinks per occasion for men
More than 4 drinks per occasion per women
A pattern of drinking that brings blood alcohol
concentration to 0.08 g% or above.
18. Safe limits of alcohol
18
NICE public health guideline on preventing harmful
drinking cites the following weekly limits (in units)
19. Dependence criteria for
addiction?
19
A strong desire or sense of compulsion to take the
substance
Impaired capacity to control substance-taking
behaviour in terms of onset, termination or level of use
Physiological withdrawal state when substance use is
reduced or ceased
Evidence of tolerance to the effects of the substance
Preoccupation with substance use, as manifested by
Giving up important alternative pleasures or interests
Great deal of time spent in activities necessary to obtain the
substance, take the substance, or recover from its effects
Persisting with substance use despite clear evidence
of harmful consequencesWorld Health Organization. (1992).
30. Acute Pancreatitis
30
Acute inflammatory process of the pancreas with
variable involvement of other regional tissues or
remote organ systems
1992 Atlanta Symposium
31. Acute Pancreatitis - criteria
31
Two of the following criteria
(1) symptoms, such as epigastric pain, consistent with
the disease
(2) a serum amylase or lipase greater than three times the
upper limit of normal (no correlation with severity)
(3) radiologic imaging consistent with the diagnosis,
usually using computed tomography (CT) or magnetic
resonance imaging (MRI)
Pancreatitis is classified as acute unless there are CT,
MRI, or endoscopic retrograde cholangiopancreatography
(ERCP) findings of chronic pancreatitis.
32. Causes of Acute Pancreatitis
32
Common
Gallstone ( including microlithiasis)
Alcohol ( acute and chronic alcoholism)
Trauma ( blunt abdominal trauma)
ERCP, biliary manometry
Hypertriglyceridemia
Postoperative
Drugs ( azathioprine, 6 mercaptopurine, sulphonamides,
estrogen, tetracycline, valproic acid, anti HIV medications)
Sphincter of Oddi dysfunction (SOD pressure > 40mmHg)
36. Pathophysiology
36
Cellular injury and death result in the liberation of
bradykinin peptide, vasoactive substance and histamine,
causing vasodilation, increased vascular permeability and
edema with effects on many organs, most notably the lung
37. 37
During acute pancreatitis the
gut barrier is broken down
due to gut ischemia
secondary to hypovolemia
and pancreatitis induced AV
shunting in the gut, this
leads to penetration of the
gut barrier by entric bacteria.
Thus pancreatic infection
can occur either from the
hematogenous route or
translocation of bacteria
39. BISAP (Bedside Index for Severity in Acute
Pancreatitis)
40
Blood urea nitrogen (BUN) greater than 25 mg/dL
Impaired mental status
Systemic inflammatory response syndrome
Age > 60
Pleural effusion - and/or the presence of a pleural effusion
A BISAP score greater than 3 is associated with a
seven- to twelve-fold increase in developing organ
failure.
40. Ranson’s Criteria
Parameter 1974 criteria
(Non Gallstone)
1982 criteria
( Gall stone)
At Admission
Age >55 >70
TLC >16000 >18000
Glucose >200 >220
LDH >350 >400
AST >250 >250
During 1st 48 hrs
Hct decrease >10 >10
BUN increase >5 >2
Ca <8 <8
pO2 <60 NA
Base deficit >4 >5
Fluid sequestration >6 >4
41. APACHE-II Scores
42
Acute Physiology And Chronic Health Evaluation
II
The 12 variables are temperature; heart rate; respiratory
rate; mean arterial blood pressure; oxygenation; arterial pH;
serum potassium, sodium, and creatinine; hematocrit; white
blood cell (WBC); and Glasgow Coma Scale.
42. Atlanta Criteria for Severe Acute
Pancreatitis
43
Organ Failure
a. Shock: systolic blood pressure <90 mm Hg
b. Pulmonary insufficiency: Pao2 ≤60 mm Hg
c. Renal failure: serum creatinine >2 mg/dL
d. Gastrointestinal bleeding: >500 mL/24 hr
Local Complications
a. Necrosis
b. Abscess
c. Pseudocyst
Unfavorable Early Prognostic Signs
a. Ranson’s signs (>3)
b. APACHE-II points (>8)
44. Determinant Based Classification
Mild AP Moderate
AP
Severe AP Critical AP
Pancreatic
necrosis
No Sterile Infected Infected
AND AND/OR OR AND
Organ failure No Transient Persistent Persistent
46. Radiology
Abdominal plain film
Localized ileus
Sentinel loop / Colon cut off sign
Excludes perforation / obstruction
Etiology
Calcified gall stones, Pancreatic calcification
47. Radiology
USG
Usually during 1st 24 hrs
For gallstones, CBD calculi, ascites
Pancreas obscured 25 – 35% times
Fluid collection
48. Radiology
* J Gastroenterol Hepatol 2002; 17:S15–S39 , Radiology 2002; 223:603–613
#UK Guidelines, Gut 2005;54;1-9
CT Scan
Indications in Ac pancreatitis
To exclude other serious intra-abdominal conditions
To stage the severity
To look for complications
Done during 1st 72 hrs,
Follow up scan indicated at 7 – 10 days if 1st scan
showed severe disease (CTSI 3 – 10)*
Patients with persisting organ failure, signs of
sepsis, or deterioration in clinical status 6–10 days
after admission will require CT#
49.
50. Modified CT Severity Index
51
Pancreatic inflammation
Normal pancreas (0)
Intrinsic pancreatic abnormalities with or without inflammatory
changes in peripancreatic fat (2)
Pancreatic or peripancreatic fluid collection or peripancreatic fat
necrosis Pancreatic necrosis (4)
Necrosis
None (0)
≤ 30% (2)
> 30% (4)
Extrapancreatic complications (one or more of pleural
effusion, ascites, vascular complications, parenchymal
complications, or gastrointestinal tract involvement) (2)
52. MRI
Information similar to CT
Better for ductal anatomy and CBD calculi
53. Management
Mgt as a c/o Acute Necrotising Pancreatitis
IV fluids
Analgesics
Injectable broad spectrum antibiotics & other
supportive care
Referred to our centre
54. On the day of admission at CH(SC)
(D4)
Had symptoms of
Abnormal behaviour: abusing relatives
Agitation
Confusion
Disorientation to time, place
Profuse sweating and tremulessness of hands
55. General Examination
Conscious, disoriented to time, place & person
Temp-99.2 F, SpO2-96% room air
Pulse-120/min, regular, RR 24/min
BP-160/100 mmHg RAS
Profuse diaphoresis, moist palms
56. Systemic Examination
CVS- S1S2 normal. No murmur heard
Resp – Reduced air entry rt infra scapular
area
PA: Guarding noted in the epigastric region,
bowel sounds feeble and reduced
CNS-Disoriented with auditory hallucinations
57. Psychiatry evaluation
Patient lying in bed
Agitated ,eye contact not maintained
Speech-increased in rate, irrelavent, incoherant,
prosody not maintained
Restless with increased psycomotor activity
Pulling out catheters
Anxious affect
Disoriented
63. Wernicke’s Encephalopathy
64
It is a neurological disorder of acute onset caused by
thiamine deficiency
It is characterized by
Nystagmus, abducens nerve and conjugate gaze palsy
(29%)
Ataxia (23%)
Global confusional state (82%)
( Classical triad of ataxia, ophthalmoplegia and
confusion occurs in only 16% of cases)
Other findings may include evidence of peripheral
neuropathy, severe malnutrition and hypothermia
67. 68
Test Reference range
γ-glutamyl transferase >35.0 U/L
Carbohydrate-deficient
transferrin
>3.0%
Mean corpuscular volume >91.0 µm3
Uric acid >6.4 mg/dL for men
>5.0 mg/dL for
women
SGOT >45.0 IU/L
SGPT >45.0 IU/L
68. Management
Managed as case of Acute pancreatitis with
delirium tremens
Started on IV fluids
Analgesics:tramadol
Inj Thiamine
Tab Lorazepam 2 mg 6 hrly with tapering doses
Early enteral nutrition
70. Delirium tremens (DT) is defined by hallucinations,
disorientation, tachycardia, hypertension, fever,
agitation, and diaphoresis in the setting of acute
reduction or abstinence from alcohol.
In the absence of complications, symptoms of DT can
persist for up to seven days.
DT is associated with a mortality rate of up to 5
percent
Death usually is due to arrhythmia, complicating
illnesses, such as pneumonia, or failure to identify an
underlying problem that led to the cessation of alcohol
use, such as pancreatitis, hepatitis, or central nervous
system injury or infection
71. Risk factors for DT
A history of sustained drinking
A history of previous DT
Age greater than 30
The presence of a concurrent illness
The presence of significant alcohol withdrawal in
the presence of an elevated alcohol level
A longer period since the last drink (ie, patients
who present with alcohol withdrawal more than
two days after their last drink are more likely to
experience DT than those who present within two
days)
74. Patients should be placed in a quiet, protective
environment
Benzodiazepines are used to control
psychomotor agitation
Supportive care, including intravenous fluids,
nutritional supplementation, and frequent clinical
reassessment including vital signs, is important.
Volume deficits :isotonic intravenous fluid can be
infused rapidly until patients are clinically
euvolemic.
Thiamine and glucose should be administered in
order to prevent or treat Wernicke's
75. Detoxification regimens
76
Fixed dose reduction regimen
Recommended for non specialist inpatient/
community settings
Starting dose calculated from current alcohol
consumption
Variable dose reduction regimen
Based on severity of withdrawal (CIWA-Ar/ SAWS)
Front loading regimen
Initial loading dose followed by dose titration
Taylor D, Paton C, Kapur S. The Maudsley prescribing guidelines in psychiatry. John Wiley & Sons;
2015 Feb 23.
77. 78
All patients undergoing detoxification –
parentral thiamine recommended
Inj Thiamine 300 mg IV BD for 05 days
followed by oral thiamine
For suspected Wernike’s
encephalopathy
Inj Thiamine 500mg IV TID for 3-5 days
followed by 250mg OD for 3-5 days, then
oral thiamine
78. Anticraving medications (FDA
approved)
79
Disulfiram
Deterrent
In motivated patients
Acamprosate
Can start during detoxification
Neuroprotective
Safe in elderly
Avoid in liver dysfunction
Naltrexone
Long acting Naltrexone available to address poor
compliance (380mg/ 190mg)
81. Natural history
82
Interstitial (85%)
Pancreatic necrosis (15%)
Risk of infection is related to the amount of necrosis
< 30% - 22%
30-50% - 37%
> 50% - 45%
Sterile pancreatic necrosis
12% mortality
Infected pancreatic necrosis
Develops in 40-70% cases of severe pancreatitis and has a 30%
mortality
84. Local complications
85
Pseudocyst
Sterile necrosis
Infected necrosis
Abscess
Splenic complications
Infarction
Rupture
Hematoma
Fistulization to or obstruction of small or large bowel
89. Nutrition
90
Nasogatric suction offers no clear cut advantage in the
treatment of mild to moderate disease
In mild pancreatitis, oral intake is usually restored within 3–
7 days of hospitalization, and nutritional support is not
required.(usually initiated when abdominal pain has
subsided)
In severe necrotizing pancreatitis it is prudent to provide
potent oral pancreatic enzymes
90. Nutrition
91
Because enteral feeding stabilizes gut barrier function,
there has been considerable interest in the ability of enteral
feeding not only to provide appropriate nutritional support,
but also to prevent systemic complications and improve
morbidity and mortality.
Whenever possible, enteral feeding rather than total
parenteral nutrition (TPN) is suggested for patients who
require nutritional support. (level II)
Nasogastric feeding was found to be comparable to
nasojejunal feeding
92. Role of Antibiotics
93
Routine use not indicated
Pancreatic penetration
Imipenem – cilastatin
Fluoroquinolones
Metronidazole
High dose cephalosporins
