GI Epic Dot phrases VCU
## Acute Pancreatitis
(Necrotizing vs Non-necrotizing, Interstitial vs hemorrhagic)
Etiology: Gallstone, Alcohol induced, trauma, infection (HIV, Hep B, Bacterial), Hypercalcemia, hereditary, autoimmune, pancreas divisum, papillary stenosis (sphincter of oddi dysfunction), tumors (benign and malignant) vs medication Induced. If -ive w/u, any of following: age > 40, cigarette smoking, wt loss, cholestatic enzymes and glucose intolerance (especially in setting of low or normal BMI) should raise suspicion of pancreatic neoplasia.
Disease severity: BISAP Score= **, HAPS criteria= **
Complications: Local pancreatic (pancreatic psuedocyst, necrotizing pancreatitis, interstitial edematous pancreatitis, APFC, ANC, WON, Disrupted PD) and local non pancreatic (ileus & gastroparesis, ascites or pleural effusion, Bile duct obstruction or splenic vein thrombosis)
Workup:
- Amylase:**, Lipase:**, AST:**, ALT:**, ALP:**, Total Bilirubin:**
- Abdominal US to rule out Galls Stone Etiology.
- Abdominal CT-Scan (Pancreatic Protocol?): Imaging of choice
- MRCP Indication: Better parenchymal evaluation for occult malignancy
- EUS: Consider in idiopathic pancreatitis to diagnose microlithiasis (or biliary stone), occult pancreatic malignancy, pancreatic cysts/IPMN, early Chronic pancreatitis and pancreas divisum.
- ERCP: Indicated for suspected gallstone pancreatitis in setting of findings of cholangitis. If no cholangitis features, but suspicion of retained CBD stone, an MRCP or EUS should be considered prior to ERCP to document choledocholithiasis.Plan:
- Recommend supportive care: IV hydration, electrolyte replacement, antiemetics and analgesics as needed.
- NG suction: Indicated/Not indicated (alleviate the symptoms of nausea, emesis and abdominal distension). Usually not done now.
- Fluid: LR 20ml/kg bolus followed by 3ml/kg/hr maintainence (repeat bolus and maintainence at 12hr if hematocrit, BUN or creatinine is increasing). Continue to monitor HR, MAP, UO and downward trend of BUN & Hct in titrating the amounts of fluids. Alternative regimen: LR 250cc/hr for 24 hours, followed by 150cc/hr until patient able to tolerate oral nutrition
- If symptoms do not resolve and an oral diet can not be resumed in 5-7 days, other avenues for
nutritional support must be considered (enteral TF delivered to jejunum)
- Mild pancreatitis: no nutritional support. Moderate to sever pancreatitis: initiation of enteral feeding at 72 hours from admission via NG or NJ tube.
- TPN: No indication. Enteral tube feeding preferred.
- Prophylactic antibiotics: No indicatios
- Pain Control: Agree with IV pain medications. Transition to PO regimen when able to tolerate
Patient was discussed with attending on service, Dr. and plan is same unless addended below.
Disease severity: BISAP Score= **, HAPS criteria= **
Complications: Local pancreatic (pancreatic psuedocyst, necrotizing pancreatitis, interstitial edematous pancreatitis, APFC, ANC, WON, Disrupted PD) and local non pancreatic (ileus & gastroparesis, ascites or pleural effusion, Bile duct obstruction or splenic vein thrombosis)
Workup:
- Amylase:**, Lipase:**, AST:**, ALT:**, ALP:**, Total Bilirubin:**
- Abdominal US to rule out Galls Stone Etiology.
- Abdominal CT-Scan (Pancreatic Protocol?): Imaging of choice
- MRCP Indication: Better parenchymal evaluation for occult malignancy
- EUS: Consider in idiopathic pancreatitis to diagnose microlithiasis (or biliary stone), occult pancreatic malignancy, pancreatic cysts/IPMN, early Chronic pancreatitis and pancreas divisum.
- ERCP: Indicated for suspected gallstone pancreatitis in setting of findings of cholangitis. If no cholangitis features, but suspicion of retained CBD stone, an MRCP or EUS should be considered prior to ERCP to document choledocholithiasis.
## ACLF
Impression:CLIF-C grade:
Rule out precipitants:
- Infectious workup (Blood cultures, UA, Urine culture, CXR, C. diff)
- Rule out GI bleeding, active alcoholism (within 3 months)
- Non-identifiable precipitant in around 44% of cases
1) Renal Failure
- ATN is very common that can progress to HRS
- Recommend checking Urine electrolytes
- Order urine sediment to look for proteinuria
- Rule out nephrotoxic agents (NSAIDS) or diuretics
- Bile cast nephropathy reported in patients with increased T. bili
- Volume expansion with IV Albumin (1g/kg/day; max 100g/day) over 48 hours. Avoid crystalloid.
- If HRS (present in only ~13% of ACLF patients), initiate AMO (Albumin, Midodrine max 15mg PO TID, Octreotide 100mcg TID subq)
2) Encephalopathy
- Intubation for grade III/IV encephalopathy
- Avoid benzos/narcotics
- Lactulose start at q2hourly and titrate to 4-6 BM's
- Start Rifaximin 550mg BID (takes two weeks for full effect)
3) Cardiopulmonary management
- Please get TTE to assess volume status, LVEF and cardiac output
- Rule out adrenal insufficiency. If present start hydrocortisone 50mg Q6H IV
- ACLF patients at high risk for PE, Pulmonary Edema and ARDS.
4) Coagulopathy
- Conservative strategy for transfusions
- No routine FFP administration for correction of INR
- Plt goal >20k for invasive procedures
- Hemoglobin goal >7g/dl
- Please get Factor VIII level to evaluate for DIC
- Consider DVT prophylaxis, unless absolutely contraindicated
5) Liver Transplant Evaluation
- Will initiate workup
- TAM Score = ** (>2 almost futile to cosnider LT) [Lactate >4, MV w/ PaO2/FiO2 < 200mmhg, Age >/= 53, WBC </= 10]
- Strict psychosocial criteria needs to be met
a) First liver decompensation
b) No history of ETOH-related hospitalizations, rehab attempts or other legal issues
c) Presence of close, supportive family members
d) Absence of severe psychiatric disorders
e) No other substance abuse (esp tobacco)
f) Agreement to lifelong total abstinence; preferably monitoring with alcohol biomarkers.
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