Diagnosis

The Gallstone Elimination Report

Gallstone Natural Solutions by David Smith

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Diagnosis of acute pancreatitis is based on the patient's history and presenting signs and symptoms. Evaluation of laboratory results, specifically the serum lipase, aids in diagnosis. Serum amylase is elevated early in the disease process but may return to normal within 12 hours.8 Although an elevated serum amylase had been the diagnostic standard, its utility is limited by lack of specificity. Serum lipase and colipase are now the gold standards for laboratory testing due to greater than 90% specificity for acute pancreatitis. Serum lipase will remain elevated for days after the acute event and may be more useful for diagnosis depending on when the patient presents for evalu-

ation.8,11 CT is more complicated than abdominal radiography or ultrasound, but it is

the most useful tool for diagnosis and staging of acute pancreatitis.

Patient Encounter, Part 1

A 32-year-old woman in her second trimester of pregnancy presents to the emergency department complaining of sharp persistent pain in the RUQ of the abdomen. The pain started 3 days ago and has progressed to become severe. She was nauseated at home and has vomited twice in the emergency department. The patient is at normal weight for this stage in her pregnancy. All prenatal visits were normal. The patient does not smoke or consume ethanol but does have a history of cholelithiasis.

What information about the patient presentation is consistent with acute pancreatitis?

What risk factors does the patient have for acute pancreatitis?

What additional laboratory tests would you recommend?

The patient's history will identify risk factors for acute pancreatitis, such as age above 70 years or history of alcohol abuse. Finally, CT scan or ultrasound of the ab-

domen can help identify pancreatic fluid collections. The APACHE II score is a rating scale of disease severity in critically ill patients. The CT severity index has the highest sensitivity and specificity in the diagnosis of acute pancreatitis.

TREATMENT Desired Outcomes

The goals of treatment for acute pancreatitis include: (a) resolution of nausea, vomiting, abdominal pain, and fever; (b) ability to tolerate oral intake; (c) normalization of serum amylase, lipase, and WBC count; and (d) resolution of abscess, pseudocyst, or fluid collection as measured by CT scan.

Nonpharmacologic Therapy

Many medications can precipitate an attack of acute pancreatitis. If a medication is determined to be the cause of acute pancreatitis, it should be discontinued and an alternative therapy be considered.13,14

Therapy of acute pancreatitis is primarily supportive unless a specific etiology is identified (Fig. 23—2). Supportive therapy involves fluid repletion, nutrition support, and analgesia. Patients with acute pancreatitis are administered IV fluids to maintain hydration and blood pressure. Fluids may be given in the form of crystalloids (e.g., 0.9% sodium chloride for infusion) or colloids (e.g., dextran or albumin for infusion).15 Sodium chloride 0.9% for infusion (normal saline) at a rate of 50 to 100 mL/h is reasonable for patients with mild to moderate fluid depletion. However, as much as 200 mL/h may be required for patients with severe fluid losses.16 Electrolytes such as potassium and magnesium may be added to the infusions if necessary. Hyperglycemia can be managed with insulin-containing IV infusions.

N ec rot i ring intensive cafe requifed Fluid resuscitation Treat systemic complications ERCPfoj- gallstones? Parenlerafanlerai nutrition? Consider antibiotics Consider oclreotide

N ec rot i ring intensive cafe requifed Fluid resuscitation Treat systemic complications ERCPfoj- gallstones? Parenlerafanlerai nutrition? Consider antibiotics Consider oclreotide

It mtecled, Surgical debridement if sterile, continue treatmenl

FIGURE 23-2. Algorithm for evaluation and treatment of acute pancreatitis. (ERCP, endoscopic retrograde cholangiopancreatography.) (From Berardi RR, Montgomery PA. Pancreatitis. In: DiPiro JT, Talbert RL, Yee GC, etal., eds. Pharmacotherapy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008:664, with permission.)

It mtecled, Surgical debridement if sterile, continue treatmenl

FIGURE 23-2. Algorithm for evaluation and treatment of acute pancreatitis. (ERCP, endoscopic retrograde cholangiopancreatography.) (From Berardi RR, Montgomery PA. Pancreatitis. In: DiPiro JT, Talbert RL, Yee GC, etal., eds. Pharmacotherapy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008:664, with permission.)

It is common practice to discontinue oral feedings during an attack of acute pancreatitis. In theory, discontinuation of oral intake will decrease the secretory functions of the pancreas and minimize further complications from the disease. Some patients can be fed with minimal oral intake, even in severe acute pancreatitis. Tube feeding delivered via a nasojejunal tube will feed the patient beyond the ampulla of Vater, minimizing stimulation of the pancreas.15,16 If oral intake is discontinued for a protracted period, total parenteral nutrition must be used to maintain adequate nutrition.17,18

If pancreatic necrosis has been identified, surgical debridement is necessary because mortality approaches 100% without drainage or surgical intervention. Percu

taneous drainage is an option for managing pancreatic necrosis but is best used only in unstable patients as a bridge to surgery. Repeated surgery may be required in pa-

2,19

tients with a protracted or progressing disease state.

Pharmacologic Therapy

Analgesics

Meperidine has historically been the most popular analgesic in acute pancreatitis because it is purported to cause less spasm and resulting pain in the sphincter of Oddi than other opioids. However, the clinical importance of this phenomenon is unclear.15,20 As a result, patients with acute pancreatitis should be given the most effective analgesic. Hydromorphone and fentanyl are reasonable alternatives to meperidine and may be more desirable due to other adverse effects associated with meperidine. Refer to Chapter 30 on pain management for guidance in selecting an analgesic dose.

Antibiotics

Empiric antibiotics are not necessary if the patient has mild disease or a noninfectious etiology of acute pancreatitis. Antibiotics have not been shown to prevent the formation of pancreatic abscess or necrosis when given early in the course of acute pancreatitis.

Antibiotics may be appropriate for pancreatic necrosis, which can be infected initially or be susceptible to a secondary infection; however, published data yield conflicting results regarding mortality and infection rate in this setting.16,21,2 As such, the decision to use antibiotics is highly individualized. Selected intravenous antibiotic regimens are shown in Table 23-2. If necrosis is confirmed, antibiotics are insufficient as sole therapy; surgical debridement is necessary for cure.

Broad-spectrum antibiotics with activity against enteric gram-negative bacilli are appropriate. It is often difficult to narrow the spectrum of activity of the antibiotic choice since the infections are usually polymicrobial. As such, patients may receive long courses of broad-spectrum antibiotics such as meropenem and may develop superinfections due to more resistant bacteria or bacteria not susceptible to meropenem.

Antifungal agents such as fluconazole may be considered if peritonitis or GI perfora-

tion develops due to the presence of fungi such as Candida alicans in the GI tract.

Patient Encounter, Part 2: Medical History, Physical Exam, and Diagnostic Tests PMH: Gravida 2, para 1; cholelithiasis

Allergies: No known allergies FH: Father and mother alive and well

SH: No ethanol currently, but one to two drinks per night before pregnancy; no tobacco

Meds: No prescription medications; multivitamin one tablet orally once daily; ferrous sulfate 324 mg orally once daily; calcium carbonate 500 mg orally twice daily

ROS: Positive for sharp RUQ abdominal pain radiating to the back, nausea, vomiting, negative for chest pain, or shortness of breath

VS: Wt 80 kg (176 lb), ht 5'5" (165 cm), BP 110/60 mm Hg, p 120 bpm, RR 18 per minute, T 37.9°C (100.2°F)

CV: Regular rate and rhythm, no murmurs

Abd: Pregnant, (+) rebound tenderness, (+) bowel sounds, no hepatosplenomegaly Labs: Amylase 50 units/L (0.83 pKat/L), lipase 1,000 units/L (16.7 pKat/L) Abdominal Ultrasound: Results pending

Given this additional information, what is your assessment of the patient's condition? Why is the amylase low and the lipase high?

Table 23-2 Selected IV Antimicrobial Regimens for Pancreatic Necrosis

Drug

Usual Dose'1

Notes

Mere pens m

1 g every 8 hours

Risk of

Superinfection

Piperacillin/

337$ g every 6 hours

Avoid if allergic to

itazobactam

penicillin

Cefepime +

2 g every 12 hours +

Will not cover

metronidazole

SOQ mg every 6 houis

enterococci

Aztreonam +

1 cj every S hours +

Option for

vancomycin +

15 mg/kg every

metronidazole

8-12 hours + h>00mg

patients

every b hours

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Get Rid of Gallstones Naturally

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