Acute Pancreatitis With UTI A 35 year old

Acute Pancreatitis With UTI A 35 year old male patient was presented with complaints of fever since 2 days, pain in the abdomen which was sudden in onset and gradually progressing since 5 days and relieved on medication. H/O two episodes of vomiting. He had no history of recent bleeding, fever, or heart disease. He had not been exposed to medications or toxins. He is a chronic smoker and alcoholic, and had no previous hospitalizations. He works as Cooli and is on mixed diet but has anorexia. His sleep, bowel and bladder habits are normal.

Findings on the physical examination were unremarkable except for mild tachycardia at rest (100 bpm), a blood pressure of 120/70 mm Hg, 18 cycles/min and 101 o F. Abdomen shows diffuse tenderness, Normal S 1&S 2 sounds, Bilateral air entry and normal vestibular breath sounds, and no focal neuronal deficit. The results of Laboratory investigations were Hb: 9 gm/dl, WBC: 13, 000 cells/mm 3, Serum amylase: 200 U/L, Serum lipase: 300 U/L Pus cells: 15 -20 cells/µl of urine, CECT Abdomen: Acute pancreatitis with minimal peripancreatic inflammatory changes. ECG: Tachycardia, based on these results he was hospitalised.

1. Acute Pancreatitis 2. Urinary tract infection

ACUTE PANCREATITIS: Abdominal pain which was sudden in onset and gradually progressing since 5 days Fever Two episodes of vomiting. Anorexia Tachycardia Anemia WBC: 13, 000 cells/mm 3 Serum amylase: 200 U/L, Serum Lipase: 300 U/L Bilirubin: 2 mg/dl CECT: Acute pancreatitis with minimal peripancreatic inflammatory changes.

ECG: Tachycardia Current Medications: Tab. Dolo 650 mg, TID - Day 7 -9 Inj. Pantop 40 mg, OD, IV - Day 7 -12 Inj. Tramadol in 100 ml NS TID - Day 7 th Tab. Ultracet TID - Day 8 -12 th IV Fluids NS/DNS@75 ml/hr Day 7 -12 ASSESSMENT: Etiology: Alcoholism Risk factors: Alcohol

ACUTE PANCREATITIS: Yes patient needs therapy to 1. Alleviate symptoms and prevent further complications like necrosis, Acute pseudo-cyst, pancreatic abscess, acute cholicystitis, pancreatic ascites, obstructive jaundice, pneumonitis, ARDS, portal vein thrombosis, erosive gastritis 2. Eradicate the cause. 3. To reduce the pain and inflammation. 4. To improve clinical symptoms

PLANNING RECOMMEND DRUG TREATMENT( DRUGS TO BE AVOIDED; FURTHER TESTS) ACUTE PANCREATITIS: Aggressive volume repletion, pain control, close monitoring of hemodynamic and volume status, attention to nutritional needs, and monitoring for complications are essential in patients with acute pancreatitis. Infection of necrosis is the most serious local complication of acute pancreatitis. So it can be prevented by administration of prophylactic antibiotics like Imipenem - 500 mg IV every 8 hours for 10 -14 days

Alternatives: cefuroxime (1. 5 g IV every 8 hours), for 10 days Drugs To be avoided: Avoid drugs like Azathioprine 6 -mercaptopurine Sulfonamides Estrogen Tetracycline Valproic acid Hydrochlorothiazide Corticosteroids Furosemide, erythromycin Carbamazepine

Goals : 1. Eradicate the cause 2. Normalize biochemical markers 3. Prevent progression to necrosis, pancreatic ascites, obstructive jaundice, pneumonitis, ARDS, portal vein thrombosis, erosive gastritis 4. Improve clinical symptoms Monitoring parameters: 1. WBC 2. Bilirubin 3. Serum amylase and lipase 4. Liver enzymes

Side effects of Tramadol: Side effects of Ultracet: § Sweating § Dizziness § Nausea § Vomiting § Dry mouth § Fatigue § Asthenia § Somnolence § Confusion § Constipation § Flushing § Headache § Nausea, vomiting § Constipation § Diarrhoea § Abdominal pain § Dry mouth § Dyspepsia § Flatulence Side effects for Pantop: § Diarrhoea § Dizziness § Pruritus § Skin rashes § GI tract infections

URINARY TRACT INFECTION Fever WBC: 13, 000 cells/mm 3 Pus cells: 15 -20 cells/µl of urine Current Medications: Tab. Dolo 650 mg, TID Day 7 -9 ASSESSMENT: Etiology: Unhygienic habits Risk factors: 1. Urinary tract obstruction

UTI: Yes patient needs therapy to 1. Alleviate symptoms and prevent further complications like kidney failure, Acute Nephrotic Syndrome, Chronic Urinary Tract Infections, Congestive heart failure. 2. Eliminate the cause. 3. To improve clinical symptoms

PLANNING RECOMMEND DRUG TREATMENT( DRUGS TO BE AVOIDED; FURTHER TESTS) UTI: Nitrofurantoin – 100 mg PO bid for 5 -7 days • It Should be taken with food. Take with or immediately after meals Fosfomycin 3 gm single dose sachet • Take on an empty stomach 1 hr before or 2 hr after meals Pivmecillinam 400 mg, PO, bid for 3 -7 days • Take Pivmecillinam with meals

Goals: 1. Eradicate the cause 2. Normalize biochemical markers 3. Relive symptoms 4. Prevent progression to Kidney failure, Acute Nephrotic Syndrome, Chronic urinary tract infections Congestive heart failure. Monitoring parameters: 1. Pus cells

Side effects of Nitrofurantoin: ü Headache ü Fever ü Pharyngitis ü Photophobia ü Nausea ü Diarrhoea ü Constipation, ü Headache Side effects of Fosfomycin: ü GI disturbances ü Headache ü Tremor ü Confusion ü Convulsions ü Rashes ü Joint pain ü Phototoxicity

PATIENT EDUCATION About medications: Tab: Ultracet: ØMay be taken with or without food. Tab. Paracetamol: ØTake Paracetamol before or after food. ØYou can take a dose of Paracetamol every 4 -6 hours if needed, but do not take more than four doses in any 24 hour period.

Patient Counseling Tips 1. Stop drinking alcohol 2. Quit smoking 3. Limit the amount of caffeine, spicy and gas-forming foods that you eat. 4. Drinking plenty of water and fluids like cranberry juice which will help in removing the pus cells out of the urinary tract. 5. Avoid resisting the urge to urinate. Holding the urine for long time keeps the harmful bacteria inside the bladder. 6. Bacteria that affect the urinary system pass through stools. So, clean the anus from front to back after defecating 7. Practice good hygiene

Type of problem Possible Cause Comment Needs additional drug therapy Untreated condition Nitrofurantoin – 100 mg PO bid for 5 -7 days Needs additional drug therapy Untreated condition Prochlorperazine at a dose of 5 to 10 mg IV q 6 hourly Needs additional drug therapy Untreated condition One tablet of iron bis-glycinate (Ferrochel, Gentle Iron) contains 27 mg of elemental iron, three times daily can increase the Hb level significantly.

Pharmacotherapy care plan 1. Drug therapy problem: Prophylactic Therapy goals/ Therapy end points: To Prevent necrosis Therapy recommendations: Imipenem (500 mg IV every 8 hours for 10 -14 days ) 2. Drug therapy problem: Untreated condition Therapy goals/Therapy end points: To treat Urinary tract infections Therapy recommendations: Nitrofurantoin – 100 mg PO bid for 5 -7 days

3. Drug therapy problem: Untreated condition Therapy goals/Therapy end points: To treat Vomiting's Therapy recommendations: Prochlorperazine at a dose of 5 to 10 mg IV q 6 hourly 4. Drug therapy problem: Untreated condition Therapy goals/Therapy end points: To Increase hemoglobin levels Therapy recommendations: One tablet of iron bis-glycinate (Ferrochel, Gentle Iron) contains 27 mg of elemental iron, three times daily can increase the Hb level significantly. A 250 mg of ascorbic acid tablet or a half-glass of orange juice is given at the time of iron administration to enhance the degree of iron absorption. Iron should be given two hours before, or four hours after, ingestion of antacids.

References ü Harrison principle of Internal Medicine Vol: 2, Pg. no: 2634 -2643 ü Pharmacotherapy, A pathophysiologic approach by Joseph. T. Dipiro, Pg: no: 659 -675 ü http: //www. merckmanuals. com/professional/gastrointesti nal_disorders/pancreatitis/acute_pancreatitis. html ü http: //www. clevelandclinicmeded. com/medicalpubs/disea semanagement/gastroenterology/acute-pancreatitis/ ü http: //www. gihealth. com/html/education/pancreatitis. html ü http: //www. acep. org/Content. aspx? id=65139 ü http: //umm. edu/health/medical/reports/articles/urinarytract-infection ü http: //www. med. umich. edu/1 info/fhp/practiceguides/uti/u ti. pdf ü http: //pubs. niaaa. nih. gov/publications/arh 21 -1/13. pdf