pancreatitis

1. A CASE OF ACUTE
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 Present Illness
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 Present Illness
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 Present Illness
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 Present Illness
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 10.96 g/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 Present Illness
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 Present Illness
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 Present Illness
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
• Sexual history:
• G4P4 (4004) mother, all delivered via NSD
• One male sexual partner
• Denies any risky sexual practices
• No contraceptive use

15. Personal History
• No history 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. Acute cholecystitis
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
Strict NPO
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 the Wards
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 the Wards
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 the Wards
Laboratories
Upper abdominal CT scan:
Remarks:
Unremarkable CT scan study of the upper
abdomen. Incidental pneumonia, both
lower lungs.

29. Course in the Wards
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 the Wards
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. Final diagnosis
Acute Pancreatitis

32. Etiology &
Pathogenesis Disease
Presentation
Clinical Course
Approach to
Diagnosis
Laboratories
& Imaging
Management

33. Causes of Acute Pancreatitis
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 Acute Pancreatitis
• Typical abdominal pain
• 3x or greater elevation in serum Lipase & or
Amylase
• Confirmatory findings on cross-sectional abdominal
imaging

35. Acute Pancreatitis Management
Fluid Resuscitation 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 patient is 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 Severity and 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 for Severity
• 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 Based on Etiology
Gallstone Pancreatitis
Hypertriglyceridemia
Drug-induced pancreatitis
Hypercalcemia
Post-ERCP pancreatitis
Autoimmune pancreatitis

41. Management of Local Complications
Necrosis
Pseudocyst formation
Pancreas and duct disruption
Peripancreatic vascular complications
Extrapancreatic infections

42. Follow up care
Hospitalization for 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. Thank you.