PAINCREATITIS

Emmanuel, Minette
Hamsain Sara Mae
Hasan, Irshada
Lakibul, Jehan

Contoso
Pharmaceuticals
General Data

A.J
28 y/o
Female
Married
Arena Blanco
Tausug

CC: Epigastric pain Contoso

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History of Present Illness

11 days PTA 2 days PTA At ER

(+) Epigastric pain: Persistence of • Admitted

boring, radiating to the
back, not associated with
food intake or change in
position, PS 10/10
(+) Vomiting: post
prandial, several episodes,
previous ingested food
(+) anorexia
(-) fever, LBM, jaundice,
dysuria, dyspnea, chest
pain, weight loss
symptoms
(+) generalized
weakness
(+) consult at ZCMC:
advised admission for acute
pancreatitis with elevated
amylase x3 refused 
given tramadol 50 mg tab
Symptoms persisted.
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page 3
 Past Medical (+) S/P CS 2017, no known comorbidities
History No current meds, no prev OCP use

No hypertension, diabetes mellitus, cancer, cardiac

problems, asthma
Family History

Personal and Housewife, non-alcoholic, non smoker, denies drug

social History use

G3P3(3003), LMP 1/16/2019, regular, 2-3 pads/day,

no amenorrhea
Gyne History Contoso
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(-) weight loss General HEENT
(-) Headache, nape
pain, BOV, dysphagia

Respira- Cardiao-
(-) cough tory vascular
(-)palpitations

(-) bloatedness, early

satiety, melena, GI GU
hematemesis (-) Oliguria,
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General Awake, tachypneic, in pain

Vital signs BP: 100/80 T: 36.7 PR 107 RR: 22 02:

99 % BMI: 27.4

Skin
Dry and warm to touch, (-) lesions
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 Anicteric sclerae, pink palpebral conjunctiva,
HEENT
dry lips and oral mucosa , no
lymphadenopathies

Chest and
lungs Equal chest expansion, clear breath
sounds

Cardiac Adynamic precordium, tachycardic, refular

rhythm
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 Flabby, no dilated veins or lesions,
Abdomen normoactive bowel sounds, soft, direct
tenderness on epigastric area on palpation,
(-) murphy’s sign, (-) rebound tenderness

Extremities

Good pulses, no edema, no clubbing

of fingernails, no lesions
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Impression Acute pancreatitis with
moderate dehydration

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Approach
Epigastric pain

Severe
abdominal pain,
abdominal
tenderness,
guarding

Acute Non-Acute
surgical surgical
abdomen abdomen
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 EPIGASTRIC
PAIN
• Cardiac
• Biliary
• Pancreas
• Vascular
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• GI Pharmaceuticals

page 11
Approach
Epigastric pain

Cardiac Biliary Pancreas GI

ACS Cholecystitis Pancreatitis PUD

- cardio- -RUQ pain -Radiates to -Burning

vascular D. radiates the back -associated
-older age to the back -Steady, with food
-pain as -associated boring pain intake
‘heaviness’ with food -4Fs
-usually intake (female fat, Dyspepsia
with DOB -jaundice forty,
-Murphy’s fertile) -Burning/
bloatedness
-associated
with food Contoso
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intake
 Gallstones

Alcohol

Hypertriglyceridemia

ERCP

Risk factor
Drugs
S/P CS 2017
Trauma Obese
Female, fat, fertile
Postoperative Contoso
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page 13
 Acute Chronic
Epigastric pain radiation to the back Abdominal pain
Threefold or greater elevation in serum Weight loss
lipase and/or amylase
Maldigestion
Acute pancreatitis in abdominal imaging
Normal amylase and lipase
Radiographic evidence
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2 days PTA

Acute Pancreatitis
Blood chemistry H. pylori: negative
Sodium: 137
Potassium: 4.3  Severe boring, epigastric pain
Amylase: 506 (H)
Crea: 43 (L)
radiating to the back
Hct: 0.36
 Elevated serum amylase
CBC
Hg: 121
WBC: 15.5
Predominance of
neutrophils
Urinalysis WBC: 5-10
RBC: 0-2
Mucus threads: rare
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Acute Pancreatitis
• Phases
Early Late
<2 weeks >2 weeks

Risk factors
• Severity • Age > 60 y.o
Mild Moderate Severe
• Obesity
• Comorbids
(-) organ failure, local Local complications Persistent organ failure
complications and/or transient organ >48 hrs
failure <48 hrs

• Imaging
Interstitial Necrotizing

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Markers of severity at admission or within 24 hours
SIRS (presence of 2/more)
Core temperature of <36o or > 38o
Heart rate >90 bpm
Respirations >20/min or PCO2 <32 mmHg
WBC count > 12,000 μL, <4000 μL, or 10% bands
APACHE II
Hct > 44%
Admission BUN (>22 mg/dL)
BISAP score
(B) BUN > 25 mg/dL
(I) Impaired mental status
(S) SIRS >/= 2 of 4 present
(A) Age > 60 y.o
(P) Pleural effusion
Organ Failure (Modified Marshall score)
Cardiovascular: systolic BP <90 mmHg, HR > 130 bpm
Pulmonary: PaO2 < 60 mmHg Contoso
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Renal: serum creatinine > 2.0 mg %
page 19
 At the ER
S O A P
Epigastric pain, BP: 100/80 T: 36.7 Acute pancreatitis with -NPO
vomiting, weakness PR 107 RR: 22 moderate dehydration -IVF PLR at 975 cc -IV
02: 99 % bolus then RA
P. #1 epigastric pain
Epigastric tenderness
SIRS (presence of 2/more)  CBC, Crea, K, lipase, SIRS
o o
Core temperature of <36 or > 38 CBG-114 BUN, preg test, stool No organ
Heart rate
Organ >90 bpm
Failure (Modified exam, H.pylori
Respirations
Marshall score)>20/min or PCO2 <32 CBC
failure
mmHg
 CXR PA, flat plate BSAP <3
BISAP score
Cardiovascular: Hct: 0.35
WBC
(B) count
BUN ><90
> 25 12,000
mg/dL μL, <4000 μL, Hg: 118
abdomen sup. and
systolic BP mmHg, HR > 130
or
(I)
bpm 10% bandsmental status
Impaired WBC: 11.4 upright)
(S) SIRS >/= 2 of 4 present
Pulmonary: Predominance of neutrophils  ECG
(A)
PaO2Age > 60
< 60 y.o
mmHg  WAB UTZ
Crea: 44
(P) Pleural effusion
Renal: Potassium: 3.8 -MEDS:
serum creatinine > 2.0 mg % Amylase: 91  Meperidine 50 mg
Lipase: 652 IVT Q8 hrs
UA
 Metoclopromide 10 Contoso
WBC: 5-10 mg IVT Q8 hr Pharmaceuticals

RBC: 5-10 -monitor VS

Fluid Resuscitation and Monitoring Therapy
• NPO to rest the pancreas

• IV analgesics given to control abdominal pain

• Non opioids
• Opioids

• IV Fluids of Lactated Ringer’s or Normal Saline are initially bloused

at 15-20cc/kg (1050-1400), followed by 3mg/kg per hour (200-250
mL/h), to maintain urine output >0.5cc/kg per hour.

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Reassessment

S O A P
UO: 0.7ml/kg/h Acute pancreatitis with IVF:
moderate dehydration PLR at 30 gtts/min

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• Lactated ringer’s has been shown to decrease
systemic inflammation and may be a better
crystalloid than normal saline.
• Targeted Resuscitation Strategy with
measurement of haematocrit and BUN every 8-
12 hours is recommended to ensure adequacy of
fluid resuscitation and monitor response therapy.

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Course in the ward (Day 1)

S O A P
(-) epigastric pain, BP: 110/70 T: 36 PR 83 Acute pancreatitis Meperidine 50 mg IV
fever, vomiting RR: 20 02: 99 % Q8hrs

AS, PPC, moist oral Metoclopromide 10

mucosa mg IV Q8 hrs
ECE, CBS, AP, NRRR
(-)murmur PLR x 30 gtts/ min
Flat, nontender soft

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Nutritional Therapy
• Alow fat solid diet can be administered to
subjects with mild acute pancreatitis after
abdominal pain has resolved.
• Enteral nutrition should be considered 2-3 days
after admission in subjects with more severe
pancreatitis instead of TPN (Total parenteral
nutrition)

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Antibiotic Therapy
• Prophylactic antibiotic is not recommended unless there is a
suspected or confirmed infection.

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Course in the ward (Day 2)

S O A P
(-) epigastric pain, BP: 110/80 T: 36.2 Acute pancreatitis Discharged
fever, vomiting PR 85 RR: 20
02: 99 %

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 Female, obesity, fertile (Gallstone
Previous Operation
formation) S/P CS 2017

Proteolytic enzymes are

Initial Phase activated in the pancreas
acinar cell rather than in the
intestinal lumen

Activated proteolytic
enzymes esp Trypsin

Trypsin activation

Digest pancreatic and peripancreatic Amylase (506)

tissuesacincar cells Lipase (652)

Activation, chemoattraction, and WBC (15.5)

Second Phase sequestration of leukocytes and Contoso
macrophages in the pancreas Pharmaceuticals
 Enhanced intrapancreatic
Right Upper Quadrant
inflammatory reaction /Epigastric Pain radiating
Fluid meperidine
resuscitation
- to the back

-
Effects of activated Trypsin
proteolytic enzymes and activation metoclopr
cytokines omide
Tachycardia Vomiting
Tachypnea

-
Activate other enzymes such
as elastase and
phospholipase A2
Third Phase

Proteolysis, edema, interstitial

hemorrhage, vascular damage,
coagulation necrosis, fat
necrosis, and parenchymal cell
necrosis Contoso
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Cellular injury and death

Liberation of bradykinin
peptides, vasoactive
substances, and histamine

Increased vascular
permeability, and edema
with profound effects on
many organs.

SIRS
Multi-Organ Failure

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