Pancreatitis Flashcards
Acute pancreatitis Tx requires
early and aggressive IVF resuscitation, management similar to sepsis
Sx of acute pancreatitis are related to
activation of enzymes in the pancreas 2/2 pain, n/v, and intestinal ileus
Etiology of acute pancreatitis is
Alcohol gall stones trauma, surgery acute d/c of diabetes or HLD drugs s/p endoscopic retrograde cholangiopancreatography
MC meds that cause pancreatitis are
ACE, ARB, Thiazide diuretics, Furosemide Azathioprine Corticosteroids Glyburide Mesalamine Bactrim Valproic acid Statins (esp. Simvastatin)
The meds that cause acute pancreatitis do so 2/2
direct toxic effects of the drug or it’s metabolites
hypersensitivity
drug induced hypertriglyceridemia
alterations of cellular function in pancreas/pancreatic duct
Analgesics used to Tx acute pancreatitis are
Hydromorphone
Fentanyl
Morphine (but can increase pressure in sphincter of oddi)
AVOID: demerol! normeperidine (metabolite) can accumulate and become toxic
Does acute pancreatitis require antibiotics and if so, which
Prophylaxis no longer recommended
Ascending cholangitis or necrotizing pancreatitis: Piperacillin-Tazobactam
Cholangitis allergic to penicillin: Levofloxacin
Does acute pancreatitis require fluids
Yes! Isotonic crystalloid solution, NS or LR to reduce risk of persistent SIRS and organ failure
Other acute pancreatitis Tx are
Enteral or parenteral nutrition
Can start oral alimentation after pain subsides and ileus has resolved (small amounts of high carb, low fat/protein)
NPO or NG if vomiting persists
Dc w/: diet modification (reduce fat, alcohol, added sugar)
Algorithm for acute pancreatitis says start with
screen for SIRS Fluid replacement w/ LR correct lytes treat metabolic abn pain control assess meds and contributing factors consider ERCP if cholangitis or biliary pancreatitis
Algorithm for acute pancreatitis says step 2 based on severity is
Mild: PO food when pain decreases and labs improve
mod: +/- ICU, Tx systemic complications, Gradual diet advance
Severe: ICU. Tx systemis Sx, Enteral tube feed. If no improvement and you r/o pancreatic necrosis, Tx w/ abx
Hallmark complications of chronic pancreatitis are
Chronic pain
malabsorption w/ steatorrhea
DM
Pancreatic cancer
Primary treatments for malabsorption 2/2 chronic pancreatitis are
Pancreatic enzyme supplement (enteric coated)
Reduce dietary fat intake
What can be added to pancreatic enzyme supplement for choronic pancreatitis
Antisecretory agent to increase effect on malabsorption and steatorrhea
H2 blocker or PPI
What analgesics can be used in treating chronic pancreatitis
Tramadol (first line)
Chronic opioid (morphine, fentanyl)
Gabapentin, pregabalin, SNRI, TCA (adjunct)
(pancreatic enzymes can also be used to Tx pain form the diseasE)
Should you take coated or non-coated enzymes
Uncoated (Viokase) are more effective in pain control when given w/ a PPI, but are controversial
What IV drug is beneficial therapy for pancreatic ductal fistulae
Octreotide
What can you take for autoimmune pancreatitis
Individualized dose of corticosteroids
In order to treat malabsorption and steatorrhea, how should you take pancreatic enzymes
Start at 25-40K USP Lipase with each meal
Admin dose during or just after meal
Max dose is 75K
Enteric coated microsphere products may be more effective
Why do pancreatic enzymes provide pain relief
They can break down CCK
normally, CCK causes an increase in pancreatic secretion but can be inhibited by Trypsin
Patients with chronic pancreatitis show a decrease in
Trypsin production- which normally inhibits the release of CCK
When CCK is released, pain increases 2/2 unabated pancreatic secretion
Proteases in pancreatic supplements act as
substitutes for endogenous trypsin= decrease in CCK
Available pancreatic enzymes are
Creon (enteric coated minimicrospheres)
Pancreaze and Ultresa (enteric coated minitabs/microtabs)
What is celiac disease
AI immune mediated response to gluten
Sensitivity to Gliadin fraction in glutens
Tissue transglutaminase modified proteins (not sure what she is saying about these)
Immunologic cross reactivity, inflammation, and tissue damage cause malabsorption
Mnemonic for celiac disease Tx is (CELIAC)
Consultation w/ dietician Education about dz Lifelong gluten free adherence Identify and treat ntr deficiency Access to advocacy group Continuous long term f/u
Overlooked sources of gluten are
Oral Rx drugs
Non-Rx drugs
vitamins and minerals
health and beauty aids
What are safe foods to eat
Rice Corn Soybean flour Uncontaminated oats Tapioca Quinoa Amaranth Sorghum
What Ig normalizes when you remove gluten
IgA!
In refractory celiac reports, treat with
Steroids Azathioprine (caution, leads to lymphoma) Cyclosporine Tacrolimus Infliximab, Alemtuzumab
What nutrients do you need to sub in celiac
A, D, E, B12 Calcium Carotene copper zinc folic acid ferritin iron
Celiac disease is associated with
hyposplenism; give pneumovac!!
