Alcohol

“Friend or Foe?’’
PRESENTED BY: ISABEL ATHEA VINAS
General Objectives
At the end of the lecture the audience should be able to

◦ Review the Diagnostic and the therapeutic approach

Specific Objectives
To Discuss Different Diagnostic modalities

To Discuss the Management.

To Discuss the compication.

General Data
D, A
35 year old
Male
Filipino
Living – in
Admitted for 7 days from May 17, 2019 – May 24, 2019
CHIEF COMPLAINT
EPIGASTRIC PAIN
History of Present Illness
• Pt. suddenly was awaken from an Epigastric pain, dull
in character, steady, radiating to the back area, with a
pain scale of 7/10.
4hrs. • aggravated by binge drinking of alcohol 7 hrs. prior to
PTC presentation, not associated with nausea and vomiting,
nor diarrhea.
• No medications taken .
 • Still with Epigastric pain, dull in character, steady, radiating to the
back area, with progressing in intensity now with a pain scale of 9/10,
• Now associated with vomiting of previously ingested food, amounting
to about 1 cup.
30mins PTC • No hematemesis, melena, nor changes in bowel movement noted.

• Sought immediate consult at the ER department of RMC.

Day of
consult
Past Medical History
 Previous admission: Patient was diagnosed with Acute pancreatitis last 2014 at Taguig hospital and
was admitted and treated, he was given omeprazole 40mg/tab OD which he took for 1 month and
unrecalled pain reliever affording relief of pain.
Patient was then lost to follow up.
 Non Hypertensive
 No Diabetes mellitus
 Non Asthmatic
 No known history of thyroid dse.
 No known history of PTB
Family History
Hypertension on maternal side
No Diabetes mellitus
No Asthma
No PTB
Personal and Social history
(+) 10 pack years smoker
(+) Alcoholic beverage drinker, 6 bottles/day of San Miguel beer or 4 bottle of Red horse 3-
4x/week for 10 years.
Construction worker
No previous surgery
No known allergy to food and drugs
Review of Systems
General: No weight loss No loss of appetite

EENT: No blurring of vision, no tinnitus, no ear or nasal discharge,

no sore throat, no dysphagia

Cardiovascular: No easy fatigability, no palpitations

Gastrointestinal: No changes in bowel movement, no hematochezia or melena

Neurology: No headache, no dizziness, no focal weakness or numbness

Endocrinology No polyphagia, no polydipsia, no polyuria, no nocturia

Hematology No easy bruisability

Physical Examination
General Survey:

Conscious, coherent, not in cardiorespiratory distress

Vital Signs: BP 110/70, HR 72, RR 20, T 36.7, O2 sat: 98% at room air
Head & Neck
Anicteric sclerae, pink palpebral
conjunctivae, no cervical
lymphadenopathy noted.
There is no tenderness over the head and
neck area.
CHEST & LUNGS
Symmetrical chest expansion, no retractions,
clear breath sounds.
CARDIOVASCULAR
Adynamic precodium, normal rate regular
rhythm, no murmur appreciated.
 ABDOMEN EXTREMITIES
Grossly normal extremeties, Full and
The abdomen is flabby, and symmetrical, equal peripheral pulses, no edema,
with no discolorations masses or lesions. CRT <2secs
(+) Direct tenderness on epigastric area.
There is no hepatomegaly. It has normo
active bowel sounds. Negative for bruits
Salient Features
35 male
Epigastric pain, dull, steady, radiating to the back
1 episode - Vomiting of previously ingested food
(+) 10 pack years smoker
Alcohol binge drinker
Epigastric tender on palpation
Previously diagnosed case of Acute pancreatitis (2014)
DIFFERENTIAL DIAGNOSIS
Differentials
PEPTIC ULCER DISASE
RULE IN RULE OUT
Epigastric pain Radiating to the back
1 episode of Vomiting, previously H. Pylori infection
ingested food
Use of pain reliever Normal amylase and lipase

Stress ulcers Acid reflux

Differentials

ACUTE PANCREATITIS
RULE IN RULE OUT
Epigastric pain Radiating to the back Fever
1 episode of Vomiting, previously Rapid Pulse
ingested food
Alcoholic binge drinker Abdominal pain that feels worse after
eating
10 pack year cigarette smoker
 Differentials

ACUTE CHOLECYSTITIS
RULE IN RULE OUT
Epigastric pain Murphy’s Sign
Pain is radiating to the back Pain may radiates at the shoulder
Eating fatty meals, fever
Vomiting, Indigestion Jaundice
Differentials
GASTRITIS
RULE IN RULE OUT
Alcoholic binge drinker Loss of appetite
Frequent spicy meal intake Burning sensation in the stomach
between meals or at night.
Black tarry stools
Vomiting of previously ingested food Vomiting of blood
WORKING IMPRESSION
Acute Pancreatitis
 Course at the ER – Day 1 - 2
Subjective Objective Assessment Plan

(+) Epigastric pain VS: 110/70; 68; 20; 36.8; Acute Gastritis r/o IVF: D5LR 250cc/hr
99% at room air Acute pancreatitis Diet: NPO
(+) 1 episode vomiting of Diagnostics:
previously ingested food Conscious, coherent -Lipase
Flabby, soft abdomen, -Crea, BUN
(+) epigastric pain -electrolytes
tenderness on palpation. -CBC
-HBT UTZ
-Lipid profile
Therapeutics:
Omeprazole 40mg TIV now
Tramadol 50mg TIV q8 PRN for
abdominal pain.
Laboratory Results upon Admission

TEST NAME RESULT UNIT REFERENCE

RANGE
LIPASE 17599.00 U/L 73-393
AMYLASE 1598 U/L 25-115
TEST NAME Result Reference Range
Blood Urea Nitrogen 5.4 mmol/L 2.5-6.4
Creatinine 90.00 umol/L 62-115
eGFR 99.0ml/min/1.73m²
Sodium 137.2 mmol/L 136-145
Potassium 3.48 mmol/L 3.5-5.1
Chloride 107.7 mmol/L 98-107
Total Calcium 1.05 mmol/L 2.12-2.52
 Laboratory Results upon Admission
Complete Blood Count
TEST NAME S.I NAME REFERENCE RANGE
Hemoglobin 145 130-160
Hematocrit 0.42 0.370-0.470
Erythrocyte Count 4.95 3.80-5.80
MCV 85.7 80-100
MCH 29.2 27-32
MCHC 341 320-360
RDW 12.2 11.5-14.0
Leukocyte Count 12.64 4.00-10.00
Differential count
Neutrophils 0.94 0.350-0.650
Lymphocytes 0.04 0.200-0.400
Monocytes 0.02 0.030-0.100
Eosinophils 0.01 0.000-0.050
Platelet Count 2688 150-450
MPV 9.4 6.5-12.0
Chest Xray
Acute Pancreatitis
Course in the Wards
DAY 3
SUBJECTIVE DATA OBJECTIVE ASSESSMEN PLAN
DATA T
(+) epigastric pain characterized as Patient is awake,not in Acute Pancreatitis Diet: shift diet to General liquids
dull,steady radiating to the back with a cardiorespiratory distress BISAP 0 IVF: PLR 1L 150cc/hour
pain scale of 5/10 Diagnostics
 AST
Conscious, coherent,and oriented  ALT
to time, place and person.  TB
(-) jaundice, dry and noted with  DB
good skin turgor, No discoloration  IB
in the flanks or umbilicus
Therapeutics
Abdomen is flabby , No visible 1. Omeprazole 40mg TIV OD
pulsations, Normoactive bowel 2. Tramadol 50mg IV q8 prn
sounds 5 to 6 per minute, for pain
tympanitic, epigastric tenderness. WOF: abdominal pain, congestion
Monitor VS q4 and record
Monitor I and O and record
Refer
TEST NAME Result Reference Range

SGOT/AST 28.00 U/L 15-37

SGPT/ALT 33.00 U/L 12-45

Alkaline phosphate 88.00 U/L 46-116

Amylase 1598.00 U/L 25-115

Total Bilirubin 20.90 umol/L <= 17.1

Direct Bilirubin 3.30 umol/L 0-5.0

Indirect Bilirubin 17.6 umol/L 2.0-12.0

Course in the Wards
SUBJECTIVE
DATA
Still with epigastric pain
characterized as dull steady,
radiating to the back with a
pain scale of 5/10, tolerable
(-) nausea
(-) Vomitig
DAY 4
OBJECTIVE ASSESSMENT PLAN
DATA
Patient is awake,at ease and Acute Pancreatitis Diet:: Shift diet to soft diet
not in cardiorespiratory distress IVF: PLR 1L x 125cc/hour
BISAP 0
Diagnostics
-Repeat Lipase,
Abdomen is flat, No visible -BUN
pulsations, Normoactive bowel -Crea
sounds 7 per minute, -Electrolytes
tympanitic, tenderness on
epigastric area, Therapeutics
Omeprazole 40mg TIV OD
Tramadol 50mg IV q8 prn for
pain
Monitor VS q4 and record
Monitor I and O and record
 TEST NAME Result Reference Range
TEST RESULT UNIT REFEREN
NAME CE Blood Urea Nitrogen 5.90 mmol/L 2.5-6.4
RANGE
Creatinine 94.00 umol/L 62-115
eGFR 99.0ml/min/1.73m²

LIPASE 871.00 U/L 73-393 Sodium 135 mmol/L 136-145

Potassium 3.98 mmol/L 3.5-5.1
Chloride 102.00 mmol/L 98-107
Total Calcium 2.13 mmol/L 2.12-2.52
Course in the Wards
DAY 5
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
DATA DATA
Intermittent epigastric pain Patient is awake ,not in Acute Pancreatitis Diet: Low Fat diet
characterized as dull , with a pain cardiorespiratory distress BISAP 0 IVF: D5NSS 1L x 125cc/hour
scale of 2/10, tolerable
(-) nausea Abdomen is flat, No visible Diagnostics
pulsations, Normoactive bowel BUN
(-) vomiting sounds 7 per minute, tympanitic, Creatinine
tenderness on epigastric area, Amylase
LIpase

Therapeutics
Omeprazole 40mg TIV OD
Tramadol 50mg IV q8 prn for
pain
Atorvastatin 50mg/tab ODHS

Monitor VS q4 and record

Monitor I and O and record
Course in the Wards
SUBJECTIVE DATA
Patient is comfortable
and with minimal to no
epigastric discomfort.
Patient is not nauseated
Patient also stated that he
is hungry.
DAY 6
OBJECTIVE DATA ASSESSMENT
Patient is awake ,not in
cardiorespiratory distress
Abdomen is flat, Normoactive
bowel sounds 11 per minute,
tympanitic, nontender
Full equal pulses, no edema,
>2seconds CRT
Intake and Output: 3000/1800
PLAN
Acute Pancreatitis Diet: LOW FAT DIET
Gallbladder IVF: PLR 1L x 80cc/hour
Hydrops Diagnostics
• Lipid profile
• Lipase
• BUN, Crea
Therapeutics
1. Omeprazole 40mg TIV OD
2. Tramadol 50mg IV q8 prn for pain
Follow up referral to GS for evaluation of
the gallbladder hydrops
Monitor VS q4 and record
Monitor I and O and record
Course in the Wards
Cont. (Hospital Day )
LIPID PROFILE
RESULT Ref Range
Cholesterol 5.20 <5.20
Triglycerides 1.69 <1.70
HDL 0.95 1.04-1.55
LDL 3.48 <2.60
VLDL 0.77 <0.77
CHOL/HDL ratio 5.47 3.35-5.00
LDL/HDL Ratio 3.66 2.12-2.50

RESULT Ref Range

Lipase 1685.00 73-393

Course in the Wards
Cont. (Hospital Day )

RESULT Ref. Range

BUN 3.60 2.5-6.4
Creatinine 86.40 62-115
Potassium 3.90 3.5-5.1
Total 2.28 2.12-2.52
calcium
Course in the Wards
DAY 6
SUBJECTIVE OBJECTIVE DATA ASSESSM PLAN
DATA ENT
May go home
Patient is comfortable and Patient is awake and comfortable Acute Pancreatitis
with no abdominal ,not in cardiorespiratory distress do follow up at OPD.
discomfort. Abdomen is flat, No visible
pulsations, Normoactive bowel
sounds 12 per minute,
tympanitic, nontender
Full equal pulses, no edema,
>2seconds CRT

Intake and Output: 2200/2000

DISCUSSION
Acute Pancreatitis

Acute pancreatitis is an acute inflammatory process of the pancreas.

ETIOLOGIES

Gallstones (30-60%)
The risk of acute pancreatitis in patients with at least one gallstone <5 mm in diameter is fourfold greater than
that in patients with larger stones

Alcohol (15-30%)
ERCP
Hypertriglyceridemia
 PATHOGENESIS
Acinar cell
injury Defective intracellular
Duct Obstruction transport of proenzymes
within
acinar cells

Release of
Interstitial edema intracellular Delivery of
proenzymes and proenzymes to
lysosomal lysosomal
Impaired blood hydrolases compartment
flow Intracellular
Activation of activation
enzymes of enzymes
Ischemia

Acinar cell injury

ACTIVATED ENZYMES

Interstitial Fat necrosis Damage to vessel

inflammatio Proteolysis
+ + + walls, hemorrhage
n and
edema

ACUTE PANCREATITIS
 Several recent studies have suggested that pancreatitis is a disease that
evolves in three phases.

INITIAL PHASE
Intrapancreatic digestive enzyme activation and acinar cell injury. (TRYPSIN ACTIVATION)

SECOND PHASE
involves the activation, chemoattraction, and sequestration of leukocytes and macrophages in the
pancreas, resulting in an enhanced intrapancreatic inflammatory reaction.

THIRD PHASE
due to the effects of activated proteolytic enzymes and cytokines, released by the inflamed
pancreas, on distant organs.
DIAGNOSIS
The diagnosis is established by two of the following three criteria:

(1) typical abdominal pain in the epigastrium that may radiate to the back
(2) threefold or greater elevation in serum lipase and/or amylase
(3) confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging
DIAGNOSTICS
Serum Lipase

Serum Amylase

Abdominal Ultrasound

CT scan
BISAP SCORING
The Bedside Index of Severity in Acute Pancreatitis (BISAP)
incorporates five clinical and laboratory parameters obtained within the first 24 h
of hospitalization

BUN >25 mg/dL

Impaired mental status (Glasgow coma score <15)
SIRS
Age >60 years
Pleural effusion on radiography

-useful in assessing severity.

Presence of three or more of these factors was associated with substantially increased
risk for in-hospital mortality among patients with acute pancreatitis.
REVISED ATLANTA CLASSIFICATION

MILD ACUTE MODERATELY SEVERE SEVERE ACUTE

PANCREATITIS PANCREATITIS PANCREATITIS

• Absence of organ • Local complication • Persistent Organ Failure

failure and/OR (>48 hours)
• Absence of local • Transient organ failure
complication (>48 hours)
Modified Marshall Scoring System for Organ Dysfunction
Organ System Score

0 1 2 3 4

Respiratory >400 301-400 201-300 101-200 <101

(PaO2/FiO2)
Renal <134 134-169 170-310 311-439 >439
Serum creatinine <1.4 1.4-1.8 1.9-3.6 3.6-4.9 >4.9
umol/L or mg/dL

Cardiovascular <90 <90 <90

(SBP, mmHg)

A score of >2 in any one of the organ systems defines “organ failure”
Scoring of the patients with pre-existent Chronic Renal Failure depends on the extent of
deterioration over baseline renal function;
MARKERS OF SEVERITY AT ADMISSION or WITHIN 24 HOURS
BISAP Score
SIRS—defined by presence of 2 or more criteria: B) BUN >25 mg/dL
Core temperature <36° or >38°C (I) Impaired mental status
Heart rate >90 beats/min S) SIRS: ≥2 of 4 present
Respirations >20/min or Pco2 <32 mmHg A) Age >60 years
White blood cell count >12,000/μL, <4000/μL, or P) Pleural effusion
10% bands
Organ failure (Modified Marshall Score)
APACHE II
Cardiovascular: systolic BP <90 mm Hg, heart rate
Hemoconcentration (hematocrit >44%) >130 beats/min
Admission BUN (>22 mg/dL) Pulmonary: Pao2 <60 mm Hg
Renal: serum creatinine >2.0 mg %
MANAGEMENT

It is important to note that 85–90% of cases of acute pancreatitis are

self-limited and subside spontaneously, usually within 3–7 days after
initiation of treatment, and do not exhibit organ failure or local
complications.

The patient is made NPO to rest the pancreas and is given intravenous narcotic
analgesics to control abdominal pain and supplemental oxygen (2 L) via nasal
cannula.
 Intravenous fluid resuscitation

Intravenous fluids of lactated Ringer’s or normal saline are initially

bolused at 15–20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour
(200–250 mL/h), to maintain urine output >0.5 mL/kg per hour.
Targeted resuscitation strategy
A targeted resuscitation strategy with measurement
of hematocrit and BUN every 8–12 h is
recommended to ensure adequacy of fluid
resuscitation and monitor response to therapy.
A rise in hematocrit or BUN during serial measurement should be treated with a repeat volume
challenge with a 2-L crystalloid bolus followed by increasing the fluid rate by 1.5 mg/kg per hour.
If the BUN or hematocrit fails to respond (i.e., remains elevated or does not decrease) to this
bolus challenge and increase in fluid rate, consideration of transfer to an intensive care unit is
strongly recommended for hemodynamic monitoring
NUTRITIONAL THERAPY

A low-fat solid diet can be administered to subjects with mild acute

pancreatitis after the abdominal pain has resolved.

Enteral nutrition should be considered 2–3 days after admission in subjects

with more severe pancreatitis instead of total parenteral nutrition (TPN).

Enteral feeding maintains gut barrier integrity, limits bacterial translocation, is

less expensive, and has fewer complications than TPN.
Recurrent Pancreatitis
Approx. 25% of pt. who have had an attack of acute pancreatitis have a recurrence.
The two most common etiologic factors are alcohol and cholelithiasis.
In patients with recurrent pancreatitis without an obvious cause, the differential diagnosis
should encompass occult biliary tract disease including microlithiasis, hypertryglyceredemia,
drugs, pancreatic cancer, pancreas divisum and cystic fibrosis.
Approx 2/3 of pt. w/ recurrent acute pancreatitis without an obvious cause actually have occult
gallstone disease due to microlithiasis
Thank you for listening