PANCREATITIS

Question 1

Pertinent Anatomy t of a patient with Pancreatitis

Answer 1

pancreas (retroperitoneal organ located in the upper Abdomen )

Question 2

The pancreas produces enzymes that help digestion and hormones that help regulate the way your body processes ____

Answer 2

sugar (glucose)

Question 3

inflammation in the pancreas

Answer 3

Pancreatitis

Question 4

Two noted ways that cause pancreatitis (most cases)

Answer 4

biliary tract disease (>50)

heavy alcohol intake (younger patients)

Question 5

Two ways that pancreatitis can appear

Answer 5

acute

Chronic

Question 6

Other causes or associations (6)

Answer 6

hyperlipidemia
hypercalcemia
abdominal trauma
vasculitis
infections
medications.

Question 7

Symptoms

Answer 7

(1) Epigastric abdominal pain, generally abrupt in onset, is steady, boring, and severe.
(a) Made worse-walking and lying supine
Made better-sitting and leaning forward.
(b) The pain usually radiates to the back but may radiate to the right or left.
(2) Nausea and vomiting are usually present.
(3) Weakness, sweating, and anxiety are noted in severe attacks.
(4) There may be a history of alcohol intake (alcohol induced) or a heavy meal (gallstone induced) preceding the attack.
(5) Patients may present with a history of milder similar episodes or biliary pain in the past.
(6) Abdominal tenderness (upper part) and distention may be noted.
(7) Fever of 38.4 to 39OC (101.1 to 102.2OF), tachycardia, hypotension, pallor, and cool clammy skin are often present.
(8) Mild jaundice is common.
(9) Occasionally, an upper abdominal mass may be palpated due to the inflamed pancreas

Question 8

Differential Diagnosis

Answer 8

(1) Acute cholecystitis
(2) Duodenal ulcer
(3) Intestinal obstruction
(4) Leaking aortic aneurysm
(5) Renal colic

Question 9

Lab

Answer 9

(1) The following laboratory studies may be abnormal:
(a) CBC: leukocytosis (10,000-30,000/mcL)
(b) Elevated serum Lipase is diagnostic
(c) UA: proteinuria, granular casts, glycosuria (10% of cases)
(d) Glucometer: hyperglycemia
(e) acute pancreatitis caused by hypertriglyceridemia have very high fasting triglyceride levels.
(f) Elevated serum lactic dehydrogenase.
(g) Elevated aspartate aminotransferase

Question 10

RAD

Answer 10

(1) Plain radiographs may show gallstones.
(2) CT scan is useful in showing enlarged pancreas and will demonstrate severity of disease.
(3) Ultrasound not generally helpful.
(4) *ECG may show ST-T wave changes.

Question 11

Treatment

Answer 11

(1) In most patients, acute pancreatitis is a mild disease (“non-severe acute pancreatitis”) that subsides spontaneously within several days.
(2) The pancreas is “rested” by a regimen of withholding food and liquids by mouth, bed
rest, and, in patients with moderately severe pain or ileus and abdominal distention or vomiting, nasogastric suction.
(3) Early fluid resuscitation may reduce the frequency of systemic inflammatory response syndrome and organ failure. Lactated ringer solution may be preferable to normal saline
(a) Fluids: 1/3 of the total 72-hr fluid volume administered within 24 hrs of
presentation, 250-500mL/h initially.
(b) Overly aggressive fluid resuscitation may lead to morbidity as well.
(4) Ketorolac, Morphine, or Hydrocodone as needed. Adequate pain control should be the goal. In those with severe liver or kidney dysfunction, the dose may need to be reduced.
(a) Ketorolac (Toradol)- NSAID
1) Dose: 15-30 mg IV/IM/PO q 6 hours
(b) Morphine 2-8 mg IV every 2 hours as needed
(c) Hydrocodone/acetaminophen (Norco) – opioid
1) Dose: 5mg/325mg PO q 4-6 hours prn pain
(5) Oral intake of fluid and foods can be resumed when the patient is largely free of pain and has bowel sounds (even if the serum lipase is still elevated).
(a) Clear liquids are given first (this step may be skipped in patients with mild
acute pancreatitis), followed by gradual advancement to a low-fat diet,
guided by the patient’s tolerance and by the absence of pain.
(b) Pain may recur on refeeding in 20% of patients.
(6) In more severe pancreatitis
(a) Aggressive intravenous hydration is crucial (500-1000 mL/h for several
hours, then 250- 300 mL/h to maintain intravascular volume).
(b) Aggressive IV hydration targeted to adequate urinary output (0.5-1.0
ml/kg/hr), stabilization of blood pressure and heart rate cannot be overemphasized.
(7) Monitoring in an intensive care unit is required.
(8) Antibiotic use may not improve mortality rates.

Question 12

Disposition

Answer 12

MEDEVAC

Question 13

Initial Care

Answer 13

(1) Patients who present with pancreatitis are to be MEDEVAC’d, initial care requires higher echelon evaluation.
(2) The IDC should stabilize patient and prep as if the patient were a surgery candidate.
(3) In more severe cases, shock could be present, if so, treat for shock and then follow treatment protocol.