Nick Wytiaz University of Pittsburgh PharmD Candidate, 2012

 CC: severe abdominal pain  HPI: 79 yo WF presenting to ED with abdominal pain persisting for over 1 day. Also had nausea and 1 episode of vomiting (no blood). Admitted to ICU for further care.  PMH: asthma/COPD, afib, DM 2, GERD, HTN, macular degeneration, stroke/TIA

 Home Meds:  amtriptyline 15mg PO QHS  aspirin 81mg PO daily  clopidogrel 75mg PO daily  glimepiride 4mg PO daily  indapamide 2.5mg PO daily  lisinopril 2.5mg PO daily  Novolog 6 units SQ TID AC  Lantus 70 units SQ QHS  oxycodone/APAP 5/325mg PO QID  esomeprazole 40mg PO BID  montelukast 10mg PO daily  multivitamin 1 tab PO daily  polyethylene glycol g PO daily  pregabalin 100mg PO BID  magnesium oxide 400mg PO daily  sennosides 8.5mg PO QHS  solifenacin 5mg PO daily Social History: denies tobacco, EtOH abuse Family History: noncontributory

 Physical Exam:  T 98.6 o F, BP 127/83, HR 98, RR 20, Wt 106kg  Abdomen obese, tender, 8/10 pain  Slight lower limb, bilateral edema  Pertinent Labs:  WBC 26, Hgb 12.8, Hct 38.7, Plts 295  Gluc 217, Alb 3.1, Elytes WNL, SCr 1.0, CrCl >60  Lipase 1159, Amylase 162, AST 11, Alt 24

 Tests :  Abdominal CT scan  Abdominal ultrasound moderate - severe acute pancreatitis

 Definition  Inflammatory condition of pancreas characterized by acute and constant abdominal pain  Epidemiology  About 80,000 cases in US each year  17 cases per 100,000 ▪ 10-fold increase from  Mortality rate 1% to 9% 1 Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008:371: Swaroop VS, Chari ST, Clain JE. Severe acute pancreatitis. JAMA. 2004;291:

 Etiology  Gallstones: 35-40%  Alcohol Abuse: 30-35%  Indeterminable: 15-25%  Other Causes: <10% ▪ Post-ERCP ▪ Hereditary ▪ Drug-Induced 3 Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics, Gastroenterology. 2004;126:1448–53. 4 Badalov N, Baradarian R, Kadirawel I, et al. Drug-induced acute pancreatitis: an evidence-based review. Clin Gastrienterol Hepatol 2007;5:648.

 Pathophysiology  Exact mechanism unknown  Likely unregulated trypsin activation in acinar cells  Autodigestion of gland and local inflammation  Symptoms / Presentation  Upper abdominal pain ▪ Sudden, may persist for several days ▪ May extend through back  Swollen, tender abdomen  Nausea / vomiting, fever, tachycardia 5 National Digestive Diseases Information Clearinghouse. Pancreatitis. NIH Publication No. 08–1596. July Available at

 Diagnosis  Difficult due to non-specific symptoms  Based on medical history and physical exam  Elevated pancreatic enzymes ▪ Serum amylase, lipase 3x ULN  Confirm with imaging test ▪ Ultrasound, CT, or MRI 6 Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-6.

MILD PANCREATITIS  Self-limiting, most common  Supportive care  Fluid resuscitation  Oxygen  Analgesia  Antiemetics  NPO until pain relief  Monitoring  Vitals  Hemodynamics  Signs of infection  Organ system failure MODERATE – SEVERE PANCREATITIS  Organ failure, complications  Ranson criteria, CT severity index to categorize  ICU Support & Monitoring  Antibiotics  IV carbapenem x 14 days  Prophylaxis not recommended  Nutritional Support  After hemodynamics stabilize  NJ vs. NG vs. TPN TREAT UNDERLYING CAUSE! 7 Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatits. Gastroenterology. 2007;132:2022.

 Acute fluid collections / Pseudocyst  Intra-abdominal infections  Within 1-3 weeks  Fluid collections or necrotic pancreas  Intestinal florae predominant source  Infected vs. sterile pancreatic necrosis  Sterile: 25% mortality ▪ aggressive medical management  Infected: 60% mortality ▪ surgical debridement or percutaneous drain 8 Heinrich S, Schafer M, Rousson V, et al. Evidenced-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006;243:

1. Moderate-severe acute pancreatitis  D5NS 200mL/hr  NPO except meds  Hydromorphone 0.5mg IVP Q6H for pain  Ondasetron 4mg IVP Q6H for nausea  Calcium level, lipid panel  Blood culture, CBC

 Leukocytosis  WBC 26, unknown origin, no micro results  Imipenem-cilastatin 500mg IV Q8H  Severe Abdominal Pain  “More than 10” on pain scale  Increases hydromorphone to Q4H  Nutrition Support  Clear liquids ordered

 3 days post-ICU admission  Hemodynamically stable  Denies abdominal pain  Lipase from 1159 to 240  WBC from 26 to 18  Started on clear liquid diet  Contrast CT for possible necrosis or infection  Transferred to the floor

 Inflammatory condition of pancreas  Abdominal pain, elevated pancreatic enzymes  Identify and correct underlying cause  Gallstones  Alcohol  Indeterminate

 Categorize by severity  Mild: supportive care, monitoring, NPO  Mod-Severe: ICU monitoring / support, nutrition  Necrosis increases morbidly & mortality  Sterile: ICU management  Infx: carbapenem IV x14d, surgical debridement

1 Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008:371: Swaroop VS, Chari ST, Clain JE. Severe acute pancreatitis. JAMA. 2004;291: Russo MW, Wei JT, Thiny MT, et al. Digestive and liver disease statistics, Gastroenterology. 2004;126:1448–53. 4 Badalov N, Baradarian R, Kadirawel I, et al. Drug-induced acute pancreatitis: an evidence-based review. Clin Gastrienterol Hepatol 2007;5: National Digestive Diseases Information Clearinghouse. Pancreatitis. NIH Publication No. 08–1596. July Available at 6 Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2): Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatits. Gastroenterology. 2007;132: Heinrich S, Schafer M, Rousson V, et al. Evidenced-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006;243: