thera II test II pancreatitis and alcohol withdrawl

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thera II test II pancreatitis and alcohol withdrawl
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thera II test II pancreatitis and alcohol withdrawl
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  1. 10 pharmmacological etiologies of pancreatitis
    • glyburide
    • sulfamethoxazole and trimethoprin
    • statins
    • hydrochlorothiazide
    • ibuprofen
    • tetracycline
    • furosemide
    • ACE-I/some ARBS
    • corticosteroids
    • estrogens
  2. etiology of AP top 4
    • structural - gallstone disease & pancreatic tumors
    • toxins - ethanol consumption, scorpion bites, medications (.1-2%)
    • infections - bacterial, viral, parasitic
    • trauma - ERCP
  3. clinical presentation of AP
    • Abdominal pain
    • N/V
    • abdominal distention
    • jaundice
    • signs of systemic inflammation or necrosis
    •    low-grade fever
    •    HoTN
    •    tachycardia
  4. local complications of AP
    • acute fluid collection
    • pancreatic necrosis
    • abscess
    • pseudocyst
  5. systemic complications of AP
    • cardiovascular
    • renal
    •    hypovolemia
    • pulmonary
    •    pleural effusion
    •    ARDS
    • metabolic
    • hemorrhagic
    • CNS abnormalities
    •    altered mental status
  6. abdominal pain in AP
    • Stabbing pain, sudden onset, persistent
    • In alcoholic pts. the pain may be dull and less localized or not reported as a problem
  7. serum amylase in AP
    • 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
  8. serum lipase in AP
    • Serum lipase (0 – 110 units/L)
    • Specific to pancreas
    • Concentrations usually elevated in AP
    • Persists longer than serum amylase elevations
  9. Indicators for severity of AP on admission
    • Age >55 years
    • White cell count >16,000 mm3
    • Glucose >200 mg/dL
    • Lactic dehydrogenase >350 IU/L
    • AST >250 units/L
  10. Indicators for severity of AP within 48 hours
    • 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
  11. 4 main goals of AP Tx
    • Correct underlying predisposing factors if possible
    • Replace fluids
    • Relieve abdominal pain
    • Minimize systemic complications
    •     Pancreatic necrosis & infection
  12. 5 Tx approaches of AP
    • Remove offending agent, if possible
    • Withhold food or liquids
    • Aggressive fluid resuscitationCorrect metabolic deficiency states
    • Pain control, nutrition, antibiotics & surgical intervention
  13. first line pain control of AP
    • Parenteral fentanyl
    •    Good safety profile
    •    Short acting agent
    •    Can be used in a PCA (patient controlled administration)
  14. second line pain control in AP
    • Parenteral morphine
    •    Longer duration of action
    •    Can cause increased biliary pressure
    •    No evidence contraindicated in AP pts
  15. 3 pharmacological therapy for AP
    • 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
  16. Three approaches to decrease bacterial infections in acute necrotizing pancreatitis
    • 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
  17. main difference between acute and chronic pancreatitis
    acure only affects gastric secretions (exocrine) where chronic affects both; exocrine and endocrine
  18. Four clinically distinct stages of chronic pancreatitis
    • Preclinical inflammatory stage
    • Acute attacks resembling acute pancreatitis
    • Intermittent or constant abdominal pain
    • Burnout stage (diminished pain, malabsorption syndrome, diabetes)
  19. 4 etiologies of chronic pancreatitis
    • Toxic: alcohol (~70-80%); tobacco (dose dependent
    • Metabolic: chronic hypercalcemia associated with hyperparathyroidism, chronic renal failure
    • Obstructive: pancreatic duct obstruction (tumor)
    • Idiopathic (~20%)
  20. 3 hallmark clinical presentations of chronic pancreatitis
    • abdominal pain
    • fat malabsorption
    • diabetes
  21. abdominal pain presentation of CP
    • Consistent or episodic
    • Dull
    • Epigastric
    • Radiating to the back
    • Deep-seated
    • Positional
    • Nocturnal
    • Unresponsive to medication
  22. clinical presentation of fat malabsorption in CP
    • Weight loss
    • Steatorrhea
  23. clinical presentation of diabetes in CP
    • Jaundice (10%)
    • Neuropathy
  24. lab test of CP - amylase & lipase; WBC, fluids, electrolytes
    • 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
  25. 6 complicatons of CP
    • 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)
  26. most common cause of death in CP
    CV disease - people generally die from complications not CP itself
  27. 4 main goals of Tx of CP
    • Remove offending agent, if possible
    • Control  chronic abdominal pain
    • Correct malabsorption syndrome with pancreatic enzymes
    • Manage complications
  28. 5 general approaches to Tx of CP
    • Avoidance of alcohol
    • Smoking cessation
    • Small meals to reduce steatorrhea
    •    Dietary fat reduction (50-75 grams/day)
    • Pharmacologic pain control
    • Pancreatic enzyme supplementation
  29. 3 analgesic therapies for CP
    • 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.
  30. 2 general guidelines for analgesic therapy of CP
    • Give before meals and schedule around the clock
    •    Oral before parenteral therapies
    • Individualized treatment
    •    Lowest effective dose
  31. 3 administration pearls of pancreatic enzyme therapy
    • Acid suppressants may allow for fewer capsules needed at each meal
    • Administer during or after a meal
    • May be poured out into applesauce
  32. pancreatic enzyme dosing
    • 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
  33. 2 therapies for malabsorption in CP
    • 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
  34. 4 symptoms of alcoholism
    • 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
  35. CAGE Questionnaire
    • 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
  36. how is alcoholism characterised
    what happens when you don't have the alcohol rather than the number of drinks you have
  37. symptoms and onset of minor withdrawal - alcohol
    • Tremulousness
    • mild anxiety
    • HA
    • diaphoresis
    • palpitations
    • anorexia
    • GI upset

    6-36hrs
  38. symptoms and onset of seizures in alcohol withdrawl
    • generalized
    • TC
    • SE (rare)

    6-48hrs
  39. symptoms and onset of alcoholic hallucinosis of withdrawal
    visual (occasionally audiorty or tactile) hallucinations

    12-48hrs
  40. symptoms and onset of delirium tremors in withdrawal
    • delirium
    • tachycardia
    • HTN
    • agitation
    • fever
    • diaphoresis

    48-96hrs
  41. Goals of Alcohol Detoxification
    • Prevent and treat withdrawal symptoms, medical, and/or psychiatric complications
    • Long-term abstinence after detox
    • Entry into ongoing medical and alcohol-dependence treatment
  42. Supportive Care of detox
    • Intravenous fluids
    • Nutritional supplementation
    •   Thiamine
    •   Glucose
    •   MVI
    •   Folic acid
    •   Other electrolyte deficiencies
    • Frequent clinical reassessment
  43. Pharmacologic Therapy of detox
    • 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
  44. Treatment Regimens of detox
    • 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
  45. which Tx regimen for alcohol detox tends to overtreat
    fixed-schedule therapy
  46. which Tx regimen for alcohol detox tends to undertreat
    front loading
  47. Treatment of Alcohol Withdrawal Seizures
    • 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
  48. Alcohol Dependence Treatment
    • Naltrexone
    • Acamprosate
    • Disulfuram
  49. Naltrexone (Vivitrol) 6 features
    • 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
  50. Acamprosate (Campral) 5 features
    • 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
  51. Disulfiram (Antabuse) 5 features
    • 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.

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