thera II test II pancreatitis and alcohol withdrawl

• glyburide
• sulfamethoxazole and trimethoprin
• statins
• hydrochlorothiazide
• ibuprofen
• tetracycline
• furosemide
• ACE-I/some ARBS
• corticosteroids
• estrogens

• structural - gallstone disease & pancreatic tumors
• toxins - ethanol consumption, scorpion bites, medications (.1-2%)
• infections - bacterial, viral, parasitic
• trauma - ERCP

• Abdominal pain
• N/V
• abdominal distention
• jaundice
• signs of systemic inflammation or necrosis
•    low-grade fever
•    HoTN
•    tachycardia

• acute fluid collection
• pancreatic necrosis
• abscess
• pseudocyst

• cardiovascular
• renal
•    hypovolemia
• pulmonary
•    pleural effusion
•    ARDS
• metabolic
• hemorrhagic
• CNS abnormalities
•    altered mental status

• Stabbing pain, sudden onset, persistent
• In alcoholic pts. the pain may be dull and less localized or not reported as a problem

• Serum amylase (25 -125 units/L)
• Rises within 6-12 hours of onset
• Usually more than 3x upper limit of normal (ULN)
• Returns to normal in 48-72 hours

• Serum lipase (0 – 110 units/L)
• Specific to pancreas
• Concentrations usually elevated in AP
• Persists longer than serum amylase elevations

• Age >55 years
• White cell count >16,000 mm3
• Glucose >200 mg/dL
• Lactic dehydrogenase >350 IU/L
• AST >250 units/L

• Decrease in HCT >10%
• Increase in BUN >5 mg/dL
• Calcium <8 mg/dL
• PaO2 <60 mmHg
• Base deficit >4 mmol/L
• Fluid sequestration >6 L

• Correct underlying predisposing factors if possible
• Replace fluids
• Relieve abdominal pain
• Minimize systemic complications
•     Pancreatic necrosis & infection

• Remove offending agent, if possible
• Withhold food or liquids
• Aggressive fluid resuscitationCorrect metabolic deficiency states
• Pain control, nutrition, antibiotics & surgical intervention

• Parenteral fentanyl
•    Good safety profile
•    Short acting agent
•    Can be used in a PCA (patient controlled administration)

• Parenteral morphine
•    Longer duration of action
•    Can cause increased biliary pressure
•    No evidence contraindicated in AP pts

• Enteral nutrition
•    If oral nutrition will be withheld > 1 week
•    Stimulation of pancreatic enzyme secretion minimized if administered distally into jejunum
• Parenteral nutrition
•    Begin if target rate of enteral feeding is not achieved within 48-72 hrs
•    Withhold IV lipids if TG > 500 mg/dL
• Surgery
•    ERCP, cholecystectomy, debridement of   necrotic tissue

• Enteral feeding
•    –Earlier is better
• Selective decontamination of the gut
•    –Non-absorable antibiotics to reduce number of bacteria available to translocate–
•    No RCTs to confirm this theory
• Prophylactic systemic antibiotics

acure only affects gastric secretions (exocrine) where chronic affects both; exocrine and endocrine

• Preclinical inflammatory stage
• Acute attacks resembling acute pancreatitis
• Intermittent or constant abdominal pain
• Burnout stage (diminished pain, malabsorption syndrome, diabetes)

• Toxic: alcohol (~70-80%); tobacco (dose dependent
• Metabolic: chronic hypercalcemia associated with hyperparathyroidism, chronic renal failure
• Obstructive: pancreatic duct obstruction (tumor)
• Idiopathic (~20%)

• abdominal pain
• fat malabsorption
• diabetes

• Consistent or episodic
• Dull
• Epigastric
• Radiating to the back
• Deep-seated
• Positional
• Nocturnal
• Unresponsive to medication

• Weight loss
• Steatorrhea

• Jaundice (10%)
• Neuropathy

• Serum amylase and lipase concentrations
•    Usually within the normal reference range
•    Elevated if pancreatic duct is blocked or pseudocyst is present
• WBC count, fluids, and electrolytes
•    Usually remain normal
•    Vomiting and diarrhea may cause fluid and electrolyte loss

• Pancreatic pseudocysts
• Pleural effusions
• Pancreatic ascites
• Non-diabetic retinopathy
• Increased risk for pancreatic carcinoma
•    Alcoholics 15x more likely than general pop.
• Increased mortality
•    20-year survival rate = 45%
•    Generally  due to other causes (CV disease, infection, malignancy)

CV disease - people generally die from complications not CP itself

• Remove offending agent, if possible
• Control  chronic abdominal pain
• Correct malabsorption syndrome with pancreatic enzymes
• Manage complications

• Avoidance of alcohol
• Smoking cessation
• Small meals to reduce steatorrhea
•    Dietary fat reduction (50-75 grams/day)
• Pharmacologic pain control
• Pancreatic enzyme supplementation

• Acetaminophen: Dosage should be limited to 2 grams daily, especially in those who continue to drink
• NSAIDs: Standard dosage regimens.  Use with caution in patients at risk for upper GI bleeding and those with kidney dysfunction
• Tramadol: 50–100 mg every 4–6 hours, not to exceed 400 mg/day; has been shown to successfully treat CP, but at higher doses than what is approved in the U.S.

• Give before meals and schedule around the clock
•    Oral before parenteral therapies
• Individualized treatment
•    Lowest effective dose

• Acid suppressants may allow for fewer capsules needed at each meal
• Administer during or after a meal
• May be poured out into applesauce

• 25K-40K of lipase per meal
• 5-25K per snack, ▫OR more specifically
• 500 units/kg/meal or 72,000 units/meal if consuming >100g fat per day
• Do not exceed 10,000 units/kg/day

• Pancreatic enzymes
•    Reduce pancreatic stimulation and diminish intraductal pressure
•    Concentration delivered to duodenum 10% of normal maximal enzyme output (lipase, amylase, protease)
• Reduction in dietary fat
•    <25 g/meal

• Craving
•    –Strong need, or urge, to drink
• Loss of Control
•    –Not being able to stop drinking once drinking has begun
• Physical Dependence–
•    Withdrawal symptoms after stopping drinking
• Tolerance
•    Need to drink greater amounts of alcohol to get “high

• 1. Do you ever feel you need to CUT down your alcohol usage?
• 2. Have you ever been ANNOYED by others telling you that you drink too much?
• 3. Have you ever felt GUILTY about your drinking or something you did while drinking?
• 4. Do you ever have an EYE opener?

Yes to 2 or more questions suggests an increased likelihood of EtOh abuse

what happens when you don't have the alcohol rather than the number of drinks you have

• Tremulousness
• mild anxiety
• HA
• diaphoresis
• palpitations
• anorexia
• GI upset

6-36hrs

• generalized
• TC
• SE (rare)

6-48hrs

visual (occasionally audiorty or tactile) hallucinations

12-48hrs

• delirium
• tachycardia
• HTN
• agitation
• fever
• diaphoresis

48-96hrs

• Prevent and treat withdrawal symptoms, medical, and/or psychiatric complications
• Long-term abstinence after detox
• Entry into ongoing medical and alcohol-dependence treatment

• Intravenous fluids
• Nutritional supplementation
•   Thiamine
•   Glucose
•   MVI
•   Folic acid
•   Other electrolyte deficiencies
• Frequent clinical reassessment

• Benzodiazepines
•    Many different meds, similar efficacy
• Longer-acting agents may be more effective in preventing seizures
• Consider potential for abuse
•    Rapid onset of action (may increase abuse potential)
•    Slower onset of action
• Diazepam, lorazepam, & chlordiazepoxide used most frequently

• Fixed-Schedule Therapy
•    Benzodiazepines given regularly at fixed dosing intervals
•    Monitor patients & give additional meds when necessary
• Front Loading
•    Frequent, high doses of medications given to treat early signs and symptoms of withdrawal
• Symptom-Triggered Therapy
•    Medication given only when patient has symptoms
•       –Generally most recommended regimen

fixed-schedule therapy

front loading

• Do not require treatment with an anticonvulsant unless they progress to status epilepticus
• Supportive treatment
• Majority of seizures are self-limited and do not require medication
• History of withdrawal seizures à higher initial benzo dose and taper over 7-10 days

• Naltrexone
• Acamprosate
• Disulfuram

• Competitive opioid antagonist
• Attenuates the reinforcing effects of alcohol
• Reduces relapses & # of drinking days
• CI: hepatitis or liver failure, active opioid use
• 50 mg/day or 380 mg monthly by IM injection
• Monitor LFTs monthly for first 3 months

• Structural analog of GABA
• Combo with naltrexone
• CI: Severe renal impairment (creatinine clearance < 30 mL/min)
• Maintenance of abstinence: 666 mg orally TID
• More efficacious with naltrexone and pyschosocial interventions than Campral alone

• Produces aversive reaction if patient drinks
• Inhibits aldehyde dehydrogenase à acetaldehyde accumulates
• Baseline LFTs
• 500 mg/day for 1-2 wks then decrease to 250 mg/day for duration of therapy
• MANY adverse effects
•    –Severe facial flushing, throbbing headache, nausea and vomiting, chest pain, palpitations, tachycardia, weakness, dizziness, blurred vision, confusion, and hypotension, etc.