Guest guest Posted July 23, 2000 Report Share Posted July 23, 2000 Welcome DeShea! I understand what you went through with your first but I didn't even make it past the first day with my first. You can read my breastfeeding story here http://www.fortunecity.com/millennium/jamestown/1190/bf/bfstory.html Michele, mom of Arran 12-27-93, Keely 12-5-97 & Rowan 3-15-00! ICQ# 13092478Our Family Pages ~ http://www.telusplanet.net/public/jcrocker/index.htmlJoin AllAdvantage.com and get paid to surf the Web! Please use my ID (GJX196) when asked if someone referred you. Thanks! http://www.alladvantage.com/go.asp?refid=GJX196 Do your eyes light up when your child walks into the room? ~ Toni on Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 23, 2000 Report Share Posted July 23, 2000 DeShea, I think you will enjoy being part of this list. We have lots of people from different backgrounds, and you can count on a response shortly no matter when you post--some are early bird and some are more night-owlish trending. Wishing you the best, Amy Lynn mother to 1-25-98 and 2-10-00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 23, 2000 Report Share Posted July 23, 2000 DeShea, I think you will enjoy being part of this list. We have lots of people from different backgrounds, and you can count on a response shortly no matter when you post--some are early bird and some are more night-owlish trending. Wishing you the best, Amy Lynn mother to 1-25-98 and 2-10-00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 23, 2000 Report Share Posted July 23, 2000 DeShea, I think you will enjoy being part of this list. We have lots of people from different backgrounds, and you can count on a response shortly no matter when you post--some are early bird and some are more night-owlish trending. Wishing you the best, Amy Lynn mother to 1-25-98 and 2-10-00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 23, 2000 Report Share Posted July 23, 2000 Hi DeShea, Welcome! I'm new too. I'm also pg (24 wks.) and trying to learn all I can so bfing will hopefully come off without too many kinks! >From: poe_baby@... >Reply-To: breastfeedingegroups >To: breastfeedingegroups >Subject: Introduction >Date: Sun, 23 Jul 2000 02:23:32 -0500 (CDT) > > Hi! I am new to the list and wanted to introduce myself. My name is >DeShea. I am 14 weeks pregnant with my second child. My first child Poe >(ds), was born December 22,1998. I breastfed him for approximatly 5 >weeks but was unable to continue due to latch on problems as well as >having very little to no support with my breastfeeding. > I had never been around anyone who had bf'ed before so I didn't >know what I was doing. My MIL just told me to stick it in his mouth and >he would know what to do! I called my lactation consultant every day and >all she would say to do is keep trying or give him a bottle of sugar >water. My local LLL leader was of NO help, she said that since I was not >a member of the LLL that she could not ( more like would not ) help me. >So as you can tell I have had my share of problems on my breastfeeding >road. > I wholeheartedly plan to breastfeed this child when it is born. I >have since read many books on breastfeeding as well as joined e-mail >circles, found wonderful breastfeeding friends and started breastfeeding >classes. My only main cocern right now is that I am financially unable >to stay at home with my child past my 12 week (unpaid) maternity leave. >I know that I am going to have to purchase a pump. Right now I am unable >tp decide which one would be the best for my needs. I have heard that >the Medela Pump in Style and the Purely Yours by Ameda Egnell were both >fabulous pumps. Can anyone help with this situation? > Oh well, I have knawed off your ears for long enough in this >letter, I will write more later. > >Sincerely, >DeShea >Mom of Poe 12-22-98 > & Baby 01-15-01 > > >------------------------------------------------------------------------ >Visit Ancestry.com for a FREE 14-Day Trial and find your ancestors now. >Search over 600 million names and trace your family tree today. >Click here: >http://click./1/7090/0/_/410002/_/964337014/ >------------------------------------------------------------------------ > >Give the Gift of Life Breastfeed! >http://www.lactivist.com > ________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 24, 2000 Report Share Posted July 24, 2000 > My only main cocern right now is that I am financially unable >to stay at home with my child past my 12 week (unpaid) maternity leave. >I know that I am going to have to purchase a pump. Right now I am unable >tp decide which one would be the best for my needs. I have heard that >the Medela Pump in Style and the Purely Yours by Ameda Egnell were both >fabulous pumps. Can anyone help with this situation? DeShea, Welcome to the list. My name is Suzanne and I have a 6 month old daughter named Gwyneth. I returned to work parttime when my dd was 9 weeks old. I returned fulltime at 12 weeks. I use the Medela pump-in-style and love it. I am on a support group for pumping moms (www.pumpingmoms.org) where it is pretty evenly split between PIS and PY users so either will be a good choice for you. Yes, it is theoretically possible to get milk backed up in the PIS but I have NEVER heard of it actually happening. I've been lucky in my situation in that I have a private office to pump in and a generally good milk supply, so have not had to supplement with formula at all. I recommend checking out the pumpingmoms site for excellent information regarding pumping. I would be happy to chat with you off list if you have specific questions in this area. Suzanne Gwyneth 1/22/00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 24, 2000 Report Share Posted July 24, 2000 > My only main cocern right now is that I am financially unable >to stay at home with my child past my 12 week (unpaid) maternity leave. >I know that I am going to have to purchase a pump. Right now I am unable >tp decide which one would be the best for my needs. I have heard that >the Medela Pump in Style and the Purely Yours by Ameda Egnell were both >fabulous pumps. Can anyone help with this situation? DeShea, Welcome to the list. My name is Suzanne and I have a 6 month old daughter named Gwyneth. I returned to work parttime when my dd was 9 weeks old. I returned fulltime at 12 weeks. I use the Medela pump-in-style and love it. I am on a support group for pumping moms (www.pumpingmoms.org) where it is pretty evenly split between PIS and PY users so either will be a good choice for you. Yes, it is theoretically possible to get milk backed up in the PIS but I have NEVER heard of it actually happening. I've been lucky in my situation in that I have a private office to pump in and a generally good milk supply, so have not had to supplement with formula at all. I recommend checking out the pumpingmoms site for excellent information regarding pumping. I would be happy to chat with you off list if you have specific questions in this area. Suzanne Gwyneth 1/22/00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 24, 2000 Report Share Posted July 24, 2000 > My only main cocern right now is that I am financially unable >to stay at home with my child past my 12 week (unpaid) maternity leave. >I know that I am going to have to purchase a pump. Right now I am unable >tp decide which one would be the best for my needs. I have heard that >the Medela Pump in Style and the Purely Yours by Ameda Egnell were both >fabulous pumps. Can anyone help with this situation? DeShea, Welcome to the list. My name is Suzanne and I have a 6 month old daughter named Gwyneth. I returned to work parttime when my dd was 9 weeks old. I returned fulltime at 12 weeks. I use the Medela pump-in-style and love it. I am on a support group for pumping moms (www.pumpingmoms.org) where it is pretty evenly split between PIS and PY users so either will be a good choice for you. Yes, it is theoretically possible to get milk backed up in the PIS but I have NEVER heard of it actually happening. I've been lucky in my situation in that I have a private office to pump in and a generally good milk supply, so have not had to supplement with formula at all. I recommend checking out the pumpingmoms site for excellent information regarding pumping. I would be happy to chat with you off list if you have specific questions in this area. Suzanne Gwyneth 1/22/00 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 - That is great!! A website is great publicity for this condition. Thanks. Palmer wrote: Hi. I've been on this list for about a week now. I am 22 and have had rosacea for quite a few years now-it's had a large impact on my life, especially my time spent at Oberlin College (in a not very positive way). I think stress is my main triggering factor as well as blushing very easily when embarassed, nervous, etc. I've been working on some web pages that I hope will help people deal with the emotional aspects of this disease. Mainly it would be a place for people to share their stories dealing with it etc. since I think writing about it helps a lot. I'll let you know when they are finished and actually up (it could be a while!). I also wanted to mention that citrus bioflavonoids work much the same way as grapeseed extract to strengthen capillaries but are much cheaper. I also take olive leaf extract as a substitute for antiobiotics because I don't feel comfortable taking them for extended amounts of time. I've had good luck with that so far and it actually helps prevent yeast infections. _________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. Share information about yourself, create your own public profile at http://profiles.msn.com. ----------------------------------------------------------------- Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html When replying, please delete all text at the end of your email that isn't necessary for your message. To leave the list send an email to rosacea-support-unsubscribeegroups --------------------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 - That is great!! A website is great publicity for this condition. Thanks. Palmer wrote: Hi. I've been on this list for about a week now. I am 22 and have had rosacea for quite a few years now-it's had a large impact on my life, especially my time spent at Oberlin College (in a not very positive way). I think stress is my main triggering factor as well as blushing very easily when embarassed, nervous, etc. I've been working on some web pages that I hope will help people deal with the emotional aspects of this disease. Mainly it would be a place for people to share their stories dealing with it etc. since I think writing about it helps a lot. I'll let you know when they are finished and actually up (it could be a while!). I also wanted to mention that citrus bioflavonoids work much the same way as grapeseed extract to strengthen capillaries but are much cheaper. I also take olive leaf extract as a substitute for antiobiotics because I don't feel comfortable taking them for extended amounts of time. I've had good luck with that so far and it actually helps prevent yeast infections. _________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. Share information about yourself, create your own public profile at http://profiles.msn.com. ----------------------------------------------------------------- Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html When replying, please delete all text at the end of your email that isn't necessary for your message. To leave the list send an email to rosacea-support-unsubscribeegroups --------------------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 - That is great!! A website is great publicity for this condition. Thanks. Palmer wrote: Hi. I've been on this list for about a week now. I am 22 and have had rosacea for quite a few years now-it's had a large impact on my life, especially my time spent at Oberlin College (in a not very positive way). I think stress is my main triggering factor as well as blushing very easily when embarassed, nervous, etc. I've been working on some web pages that I hope will help people deal with the emotional aspects of this disease. Mainly it would be a place for people to share their stories dealing with it etc. since I think writing about it helps a lot. I'll let you know when they are finished and actually up (it could be a while!). I also wanted to mention that citrus bioflavonoids work much the same way as grapeseed extract to strengthen capillaries but are much cheaper. I also take olive leaf extract as a substitute for antiobiotics because I don't feel comfortable taking them for extended amounts of time. I've had good luck with that so far and it actually helps prevent yeast infections. _________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. Share information about yourself, create your own public profile at http://profiles.msn.com. ----------------------------------------------------------------- Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html When replying, please delete all text at the end of your email that isn't necessary for your message. To leave the list send an email to rosacea-support-unsubscribeegroups --------------------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 : I would agree that it's really hard to have rosacea and be in college. I had rosacea while I was in college too. I have to commend you for starting a website telling people's stories because other than this support group and one on aol, the rosacean's story is not heard. Good luck to you! Matija > Hi. I've been on this list for about a week now. I am 22 and have had > rosacea for quite a few years now-it's had a large impact on my life, > especially my time spent at Oberlin College (in a not very positive way). I > think stress is my main triggering factor as well as blushing very easily > when embarassed, nervous, etc. I've been working on some web pages that I > hope will help people deal with the emotional aspects of this disease. > Mainly it would be a place for people to share their stories dealing with it > etc. since I think writing about it helps a lot. I'll let you know when > they are finished and actually up (it could be a while!). > > I also wanted to mention that citrus bioflavonoids work much the same way as > grapeseed extract to strengthen capillaries but are much cheaper. I also > take olive leaf extract as a substitute for antiobiotics because I don't > feel comfortable taking them for extended amounts of time. I've had good > luck with that so far and it actually helps prevent yeast infections. > > > ______________________________________________________________________ ___ > Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. > > Share information about yourself, create your own public profile at > http://profiles.msn.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 : I would agree that it's really hard to have rosacea and be in college. I had rosacea while I was in college too. I have to commend you for starting a website telling people's stories because other than this support group and one on aol, the rosacean's story is not heard. Good luck to you! Matija > Hi. I've been on this list for about a week now. I am 22 and have had > rosacea for quite a few years now-it's had a large impact on my life, > especially my time spent at Oberlin College (in a not very positive way). I > think stress is my main triggering factor as well as blushing very easily > when embarassed, nervous, etc. I've been working on some web pages that I > hope will help people deal with the emotional aspects of this disease. > Mainly it would be a place for people to share their stories dealing with it > etc. since I think writing about it helps a lot. I'll let you know when > they are finished and actually up (it could be a while!). > > I also wanted to mention that citrus bioflavonoids work much the same way as > grapeseed extract to strengthen capillaries but are much cheaper. I also > take olive leaf extract as a substitute for antiobiotics because I don't > feel comfortable taking them for extended amounts of time. I've had good > luck with that so far and it actually helps prevent yeast infections. > > > ______________________________________________________________________ ___ > Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. > > Share information about yourself, create your own public profile at > http://profiles.msn.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 28, 2000 Report Share Posted August 28, 2000 : I would agree that it's really hard to have rosacea and be in college. I had rosacea while I was in college too. I have to commend you for starting a website telling people's stories because other than this support group and one on aol, the rosacean's story is not heard. Good luck to you! Matija > Hi. I've been on this list for about a week now. I am 22 and have had > rosacea for quite a few years now-it's had a large impact on my life, > especially my time spent at Oberlin College (in a not very positive way). I > think stress is my main triggering factor as well as blushing very easily > when embarassed, nervous, etc. I've been working on some web pages that I > hope will help people deal with the emotional aspects of this disease. > Mainly it would be a place for people to share their stories dealing with it > etc. since I think writing about it helps a lot. I'll let you know when > they are finished and actually up (it could be a while!). > > I also wanted to mention that citrus bioflavonoids work much the same way as > grapeseed extract to strengthen capillaries but are much cheaper. I also > take olive leaf extract as a substitute for antiobiotics because I don't > feel comfortable taking them for extended amounts of time. I've had good > luck with that so far and it actually helps prevent yeast infections. > > > ______________________________________________________________________ ___ > Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. > > Share information about yourself, create your own public profile at > http://profiles.msn.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2001 Report Share Posted February 7, 2001 , Go to the main page of this site at yahoogroups.com, click on the word " files " on the left, you will see two files with My Diet in the title, that's them! > Hi to all. My name is and I am new both to the list and cea. I have > been diagnosed with it some 5 months ago. > > Like Amy, who introduced herself not long ago, I have been looking for the diet > everybody talks about, but cannot find it either. If anybody can offer any help > I appreciate it. > > Regards to all, > > > > >>I just want to find this diet > >> everyone mentions. ?I searched the website and didn't find it so I would > >> really appreciate someone directing me. > __________________ > > > > > > > ----------------------------------------------------------------- > Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html > > When replying, please delete all text at the end of your email that isn't necessary for your message. > > To leave the list send an email to rosacea-support-unsubscribe > (: www.leftbehind-themovie.com You're not a kid anymore when you don't remember when you got that mole...or the one next to it. _______________________________________________________ Send a cool gift with your E-Card http://www.bluemountain.com/giftcenter/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2001 Report Share Posted February 7, 2001 , Go to the main page of this site at yahoogroups.com, click on the word " files " on the left, you will see two files with My Diet in the title, that's them! > Hi to all. My name is and I am new both to the list and cea. I have > been diagnosed with it some 5 months ago. > > Like Amy, who introduced herself not long ago, I have been looking for the diet > everybody talks about, but cannot find it either. If anybody can offer any help > I appreciate it. > > Regards to all, > > > > >>I just want to find this diet > >> everyone mentions. ?I searched the website and didn't find it so I would > >> really appreciate someone directing me. > __________________ > > > > > > > ----------------------------------------------------------------- > Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html > > When replying, please delete all text at the end of your email that isn't necessary for your message. > > To leave the list send an email to rosacea-support-unsubscribe > (: www.leftbehind-themovie.com You're not a kid anymore when you don't remember when you got that mole...or the one next to it. _______________________________________________________ Send a cool gift with your E-Card http://www.bluemountain.com/giftcenter/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2001 Report Share Posted February 7, 2001 , Go to the main page of this site at yahoogroups.com, click on the word " files " on the left, you will see two files with My Diet in the title, that's them! > Hi to all. My name is and I am new both to the list and cea. I have > been diagnosed with it some 5 months ago. > > Like Amy, who introduced herself not long ago, I have been looking for the diet > everybody talks about, but cannot find it either. If anybody can offer any help > I appreciate it. > > Regards to all, > > > > >>I just want to find this diet > >> everyone mentions. ?I searched the website and didn't find it so I would > >> really appreciate someone directing me. > __________________ > > > > > > > ----------------------------------------------------------------- > Please read the list highlights thoroughly before posting to the whole group. See http://rosacea.ii.net/toc.html > > When replying, please delete all text at the end of your email that isn't necessary for your message. > > To leave the list send an email to rosacea-support-unsubscribe > (: www.leftbehind-themovie.com You're not a kid anymore when you don't remember when you got that mole...or the one next to it. _______________________________________________________ Send a cool gift with your E-Card http://www.bluemountain.com/giftcenter/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 -Mark, I have read this before, but I am still confused on one point. Why does my " problem " always show with increased liver enzymes. I have had pancreatitis twice, both times induce by an ERCP. Mine seems to of the obstructive nation. Blocked ducts. But I the scaring is definitely there, with the chronic pain, weight loss, and everything else that goes along with this. But I have never understood why it show up in the liver enzymes. Please help if you can. PS: not caused by drinking, never have. Thanks Cheryl -- In pancreatitis@y..., " Mark E. Armstrong " <casca@b...> wrote: > Clear Day > > > > INTRODUCTION > > Background: Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. > > The gland can sometimes heal without any impairment of function or any morphologic changes. This process is known as acute pancreatitis. It can recur intermittently, contributing to the functional and morphologic loss of the gland. Recurrent attacks are referred to as chronic pancreatitis. Both forms of pancreatitis are present in the ED with acute clinical findings. > > > Pathophysiology: Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily. In acute pancreatitis, parenchymal edema and peripancreatic fat necrosis occur first. This process is known as acute edematous pancreatitis. > > When necrosis involves the parenchyma, accompanied by hemorrhage and dysfunction of the gland, the inflammation evolves into hemorrhagic or necrotizing pancreatitis. > > Pseudocysts and pancreatic abscesses can result from necrotizing pancreatitis because of enzymes being walled off by granulation tissue (ie, pseudocyst formation) or bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic abscess formation). An ultrasound or, preferably, a CT scan can be used detect both. > > The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A. These cytokines may cause vasodilation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. Fat necrosis may cause hypocalcemia. Pancreatic B cell injury may lead to hyperglycemia. > > > Frequency: > > > a.. In the US: Annual incidence of acute pancreatitis is 19.5 per 100,000 population and chronic pancreatitis is 8.3 per 100,000 population per year. > Mortality/Morbidity: > > a.. Although acute pancreatitis should be noted, chronic pancreatitis has a more severe presentation as episodes recur. > a.. Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form. > Race: Annual incidence of acute pancreatitis in Native American persons is 4 per 100,000 population, in white persons is 5.7 per 100,000 population, and in black persons is 20.7 per 100,000 population. > > Sex: No predilection exists. > > Age: The risk for African American persons aged 35-64 years is 10 times higher than for any other group. African American persons are at higher risk than white persons in that same age group. > > > > Clinical > > History: > > a.. The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back > a.. Nausea and/or vomiting > a.. Fever > a.. Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia. > a.. Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis. > Physical: > > a.. Tachycardia > a.. Tachypnea > a.. Hypotension > a.. Fever > a.. Abdominal tenderness, distension, guarding, and rigidity > a.. Mild jaundice > a.. Diminished or absent bowel sounds > a.. Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung. > a.. Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia. > a.. Severe cases may have a Grey sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis. > Causes: > > a.. The major causes are long-standing alcohol consumption and biliary stone disease. > a.. In developed countries, the most common cause of acute pancreatitis is alcohol abuse. > > a.. On the cellular level, ethanol leads to intracellular accumulation of digestive enzymes and their premature activation and release. > > b.. On the ductal level, ethanol increases the permeability of ductules, which allow enzymes to reach the parenchyma, resulting in pancreatic damage. > > c.. Ethanol increases the protein content of the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the formation of protein plugs that block the pancreatic outflow and obstruction. > a.. Another major cause of acute pancreatitis is biliary stone disease (eg, cholelithiasis, choledocholithiasis). A biliary stone may lodge in the pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, leading to extravasation of enzymes into the parenchyma. > a.. Minor causes of acute pancreatitis > a.. Medications, including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines > a.. Endoscopic retrograde cholangiopancreatography (ERCP) > a.. Hypertriglyceridemia (When the triglyceride (TG) level exceeds 1000 mg/U, an episode of pancreatitis is more likely.) > a.. Peptic ulcer disease > a.. Abdominal or cardiopulmonary bypass surgery, which may insult the gland by ischemia > a.. Trauma to the abdomen or back, resulting in sudden compression of the gland against the spine posteriorly > a.. Carcinoma of the pancreas, which may lead to pancreatic outflow obstruction > a.. Viral infections, including mumps, sackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubella > a.. Bacterial infections, such as mycoplasma > a.. Intestinal parasites, such as ascaris, which can block the pancreatic outflow > a.. Pancreas divisum > a.. Scorpion and snake bites > a.. Vascular factors, such as ischemia or vasculitis > > > > > DIFFERENTIALS > > Other Problems to be Considered: Perforated viscus > > Acute peritonitis > > Choledocholithiasis > > Macroamylasemia > > Macrolipasemia > > Intestinal obstruction > > Pancreatic cancer > > Malabsorption syndromes/processes > > > Workup > > Lab Studies: > > > a.. A complete blood count (CBC) demonstrates leukocytosis (WBC >12000) with the differential being shifted towards the segmented polymorphs. > a.. If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and crossmatch. > a.. Measure blood glucose level because it may be elevated from B cell injury in the pancreas. > a.. Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually found, secondary to third spacing of fluids. > a.. Measure amylase levels, preferably the Amylase P, which is more specific to pancreatic pathology. Levels more than 3 times higher than normal strongly suggest the diagnosis of acute pancreatitis > a.. Lipase levels also are elevated and remain high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol abuse), lipase may be elevated in the presence of a normal serum amylase level > a.. Perform liver function tests (eg, alkaline phosphatase, serum glutamic-pyruvic transaminase [sGPT], serum glutamic- oxaloacetic transaminase [sGOT], G-GT) and bilirubin, particularly with biliary origin pancreatitis. > Imaging Studies: > > > a.. Perform a plain KUB (Kidneys, ureters, bladder) with the patient in the upright position to exclude viscus perforation (ie, air under the diaphragm). In cases with a recurrent episode of chronic pancreatitis, peripancreatic calcifications may be noted > a.. Ultrasound can be used as a screening test. If overlying gas shadows secondary to bowel distention are present, it may not be specific > a.. CT scan is the most reliable imaging modality in the diagnosis of acute pancreatitis. The criteria for diagnosis are divided by Balthazar and colleagues into 5 grades, as follows: > a.. Grade A - Normal pancreas > a.. Grade B - Focal or diffuse gland enlargement > a.. Grade C - Intrinsic gland abnormality recognized by haziness on the scan > a.. Grade D - Single ill-defined collection or phlegmon > a.. Grade E - Two or more ill-defined collections or the presence of gas in or nearby the pancreas > Other Tests: > > > a.. Para-aminobenzoic acid test (ie, bentiromide [Chymex] test) for chronic pancreatitis > > > Treatment > > Emergency Department Care: Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment. > > a.. Fluid resuscitation > a.. Monitor accurate intake/output and electrolyte balance of the patient. > a.. Crystalloids are used, but other infusions, such as packed red blood cells (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis. > a.. Central lines and Swan-Ganz catheters are used in patients with severe fluid loss and very low blood pressure. > a.. Patients should have nothing by mouth, and a nasogastric tube should be inserted to assure an empty stomach and to keep the GI system at rest. > a.. Begin parenteral nutrition if the prognosis is poor and if the patient is going to be kept in the hospital for more than 4 days. > a.. Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi. > a.. Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved. > a.. Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third generation cephalosporins. > a.. Continuous oxygen saturation should be monitored by pulse oxymetry and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed. > > b.. Perform CT-guided aspiration of necrotic areas, if necessary. > > c.. An ERCP may be indicated for common duct stone removal. > Consultations: Consult a general surgeon in the following cases: > > a.. For phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue. It should be followed by postoperative lavage of the pancreatic bed. > a.. In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis. > a.. Patients who fail to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room. Surgery in these cases may lead to a better outcome or confirm a different diagnosis. > a.. In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction. A cholecystectomy may be performed to clear the system from any source of biliary stones. > > > Medications > > The goal of pharmacotherapy is to relieve pain and minimize complications. > > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Name > Ceftriaxone (Rocephin)- Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins. > Adult Dose 1-2 g IM/IV once or divided bid > Pediatric Dose 50-75 mg/kg/d IM/IV divided q12h > Contraindications Documented hypersensitivity > Interactions Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin > Drug Name > Ampicillin (Marcillin, Omnipen)- Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. > Adult Dose 250-500 IM/IV mg q6h > Pediatric Dose 25-50 mg/kg/d IM/IV divided q6-8h > Contraindications Documented hypersensitivity; viral mononucleosis > Interactions Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction > > > Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > Drug Name > Meperidine (Demerol)- Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. > Adult Dose 15-35 mg/h IV; 50-150 mg IM q3-4h > Pediatric Dose 1.1-1.8 mg/kg IM q3-4h > Contraindications Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated > Interactions Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors > Pregnancy C - Safety for use during pregnancy has not been established. > Precautions Caution in head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex; substantially increased dose levels may aggravate or cause seizures because of tolerance, even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity if seizure history exists > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > > > Followup > > Further Inpatient Care: > > > a.. Transfer patients with Ranson scores of 0-2 to a hospital floor. > a.. Transfer patients with Ranson scores 3-5 to an intensive care unit. > a.. Transfer patients with Ranson scores higher than 5 to an intensive care unit with emergency surgery as a possibility. > Further Outpatient Care: > > > a.. The patient should be followed routinely with physical examination and amylase and lipase assays. > Complications: > > > a.. Infected pancreatic necrosis may result from seeding of bacteria into the inflammation. > a.. An acute pseudocyst is an effusion of pancreatic juice that is walled off by granulation tissue after an episode of acute pancreatitis. > a.. Hemorrhage into the GI tract retroperitoneum or the peritoneal cavity is possible because of erosion of large vessels. > a.. Intestinal obstruction or necrosis may occur. > a.. Common bile duct obstruction may be caused by a pancreatic abscess, pseudocyst, or biliary stone that caused the pancreatitis. > a.. An internal pancreatic fistula from pancreatic duct disruption or a leaking pancreatic pseudocyst may occur. > Prognosis: > > > a.. Ranson developed a series of different criteria for the severity of acute pancreatitis. > a.. Present on admission > > a.. Older than 55 years > > b.. WBC higher than 16,000 per mcL > > c.. Blood glucose higher than 200 mg/dL > > d.. Serum lactate dehydrogenase (LDH) more than 350 IU/L > > e.. SGOT (ie, aspartate aminotransferase [AST]) greater than 250 IU/L > a.. Developing during the first 48 hours > > a.. Hematocrit fall more than 10% > > b.. BUN increase more than 8 mg/dL > > c.. Serum calcium less than 8 mg/dL > > d.. Arterial oxygen saturation less than 60 mm Hg > > e.. Base deficit higher than 4 mEq/L > > f.. Estimated fluid sequestration higher than 600 mL > a.. A Ranson score of 0-2 has a minimal mortality rate. > a.. A Ranson score of 3-5 has a 10%-20% mortality rate. > a.. A Ranson score higher than 5 has a mortality rate of more than 50% and is associated with more systemic complications. > Patient Education: > > > a.. Educate patients about the disease and advise then to avoid alcohol in binge amounts and to discontinue any risk factor, such as fatty meals and abdominal trauma. > > > > Mark E. Armstrong > www.top5plus5.com > Oregon State Chapter Rep > Pancreatitis Association, International > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 -Mark, I have read this before, but I am still confused on one point. Why does my " problem " always show with increased liver enzymes. I have had pancreatitis twice, both times induce by an ERCP. Mine seems to of the obstructive nation. Blocked ducts. But I the scaring is definitely there, with the chronic pain, weight loss, and everything else that goes along with this. But I have never understood why it show up in the liver enzymes. Please help if you can. PS: not caused by drinking, never have. Thanks Cheryl -- In pancreatitis@y..., " Mark E. Armstrong " <casca@b...> wrote: > Clear Day > > > > INTRODUCTION > > Background: Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. > > The gland can sometimes heal without any impairment of function or any morphologic changes. This process is known as acute pancreatitis. It can recur intermittently, contributing to the functional and morphologic loss of the gland. Recurrent attacks are referred to as chronic pancreatitis. Both forms of pancreatitis are present in the ED with acute clinical findings. > > > Pathophysiology: Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily. In acute pancreatitis, parenchymal edema and peripancreatic fat necrosis occur first. This process is known as acute edematous pancreatitis. > > When necrosis involves the parenchyma, accompanied by hemorrhage and dysfunction of the gland, the inflammation evolves into hemorrhagic or necrotizing pancreatitis. > > Pseudocysts and pancreatic abscesses can result from necrotizing pancreatitis because of enzymes being walled off by granulation tissue (ie, pseudocyst formation) or bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic abscess formation). An ultrasound or, preferably, a CT scan can be used detect both. > > The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A. These cytokines may cause vasodilation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. Fat necrosis may cause hypocalcemia. Pancreatic B cell injury may lead to hyperglycemia. > > > Frequency: > > > a.. In the US: Annual incidence of acute pancreatitis is 19.5 per 100,000 population and chronic pancreatitis is 8.3 per 100,000 population per year. > Mortality/Morbidity: > > a.. Although acute pancreatitis should be noted, chronic pancreatitis has a more severe presentation as episodes recur. > a.. Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form. > Race: Annual incidence of acute pancreatitis in Native American persons is 4 per 100,000 population, in white persons is 5.7 per 100,000 population, and in black persons is 20.7 per 100,000 population. > > Sex: No predilection exists. > > Age: The risk for African American persons aged 35-64 years is 10 times higher than for any other group. African American persons are at higher risk than white persons in that same age group. > > > > Clinical > > History: > > a.. The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back > a.. Nausea and/or vomiting > a.. Fever > a.. Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia. > a.. Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis. > Physical: > > a.. Tachycardia > a.. Tachypnea > a.. Hypotension > a.. Fever > a.. Abdominal tenderness, distension, guarding, and rigidity > a.. Mild jaundice > a.. Diminished or absent bowel sounds > a.. Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung. > a.. Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia. > a.. Severe cases may have a Grey sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis. > Causes: > > a.. The major causes are long-standing alcohol consumption and biliary stone disease. > a.. In developed countries, the most common cause of acute pancreatitis is alcohol abuse. > > a.. On the cellular level, ethanol leads to intracellular accumulation of digestive enzymes and their premature activation and release. > > b.. On the ductal level, ethanol increases the permeability of ductules, which allow enzymes to reach the parenchyma, resulting in pancreatic damage. > > c.. Ethanol increases the protein content of the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the formation of protein plugs that block the pancreatic outflow and obstruction. > a.. Another major cause of acute pancreatitis is biliary stone disease (eg, cholelithiasis, choledocholithiasis). A biliary stone may lodge in the pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, leading to extravasation of enzymes into the parenchyma. > a.. Minor causes of acute pancreatitis > a.. Medications, including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines > a.. Endoscopic retrograde cholangiopancreatography (ERCP) > a.. Hypertriglyceridemia (When the triglyceride (TG) level exceeds 1000 mg/U, an episode of pancreatitis is more likely.) > a.. Peptic ulcer disease > a.. Abdominal or cardiopulmonary bypass surgery, which may insult the gland by ischemia > a.. Trauma to the abdomen or back, resulting in sudden compression of the gland against the spine posteriorly > a.. Carcinoma of the pancreas, which may lead to pancreatic outflow obstruction > a.. Viral infections, including mumps, sackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubella > a.. Bacterial infections, such as mycoplasma > a.. Intestinal parasites, such as ascaris, which can block the pancreatic outflow > a.. Pancreas divisum > a.. Scorpion and snake bites > a.. Vascular factors, such as ischemia or vasculitis > > > > > DIFFERENTIALS > > Other Problems to be Considered: Perforated viscus > > Acute peritonitis > > Choledocholithiasis > > Macroamylasemia > > Macrolipasemia > > Intestinal obstruction > > Pancreatic cancer > > Malabsorption syndromes/processes > > > Workup > > Lab Studies: > > > a.. A complete blood count (CBC) demonstrates leukocytosis (WBC >12000) with the differential being shifted towards the segmented polymorphs. > a.. If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and crossmatch. > a.. Measure blood glucose level because it may be elevated from B cell injury in the pancreas. > a.. Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually found, secondary to third spacing of fluids. > a.. Measure amylase levels, preferably the Amylase P, which is more specific to pancreatic pathology. Levels more than 3 times higher than normal strongly suggest the diagnosis of acute pancreatitis > a.. Lipase levels also are elevated and remain high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol abuse), lipase may be elevated in the presence of a normal serum amylase level > a.. Perform liver function tests (eg, alkaline phosphatase, serum glutamic-pyruvic transaminase [sGPT], serum glutamic- oxaloacetic transaminase [sGOT], G-GT) and bilirubin, particularly with biliary origin pancreatitis. > Imaging Studies: > > > a.. Perform a plain KUB (Kidneys, ureters, bladder) with the patient in the upright position to exclude viscus perforation (ie, air under the diaphragm). In cases with a recurrent episode of chronic pancreatitis, peripancreatic calcifications may be noted > a.. Ultrasound can be used as a screening test. If overlying gas shadows secondary to bowel distention are present, it may not be specific > a.. CT scan is the most reliable imaging modality in the diagnosis of acute pancreatitis. The criteria for diagnosis are divided by Balthazar and colleagues into 5 grades, as follows: > a.. Grade A - Normal pancreas > a.. Grade B - Focal or diffuse gland enlargement > a.. Grade C - Intrinsic gland abnormality recognized by haziness on the scan > a.. Grade D - Single ill-defined collection or phlegmon > a.. Grade E - Two or more ill-defined collections or the presence of gas in or nearby the pancreas > Other Tests: > > > a.. Para-aminobenzoic acid test (ie, bentiromide [Chymex] test) for chronic pancreatitis > > > Treatment > > Emergency Department Care: Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment. > > a.. Fluid resuscitation > a.. Monitor accurate intake/output and electrolyte balance of the patient. > a.. Crystalloids are used, but other infusions, such as packed red blood cells (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis. > a.. Central lines and Swan-Ganz catheters are used in patients with severe fluid loss and very low blood pressure. > a.. Patients should have nothing by mouth, and a nasogastric tube should be inserted to assure an empty stomach and to keep the GI system at rest. > a.. Begin parenteral nutrition if the prognosis is poor and if the patient is going to be kept in the hospital for more than 4 days. > a.. Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi. > a.. Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved. > a.. Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third generation cephalosporins. > a.. Continuous oxygen saturation should be monitored by pulse oxymetry and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed. > > b.. Perform CT-guided aspiration of necrotic areas, if necessary. > > c.. An ERCP may be indicated for common duct stone removal. > Consultations: Consult a general surgeon in the following cases: > > a.. For phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue. It should be followed by postoperative lavage of the pancreatic bed. > a.. In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis. > a.. Patients who fail to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room. Surgery in these cases may lead to a better outcome or confirm a different diagnosis. > a.. In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction. A cholecystectomy may be performed to clear the system from any source of biliary stones. > > > Medications > > The goal of pharmacotherapy is to relieve pain and minimize complications. > > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Name > Ceftriaxone (Rocephin)- Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins. > Adult Dose 1-2 g IM/IV once or divided bid > Pediatric Dose 50-75 mg/kg/d IM/IV divided q12h > Contraindications Documented hypersensitivity > Interactions Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin > Drug Name > Ampicillin (Marcillin, Omnipen)- Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. > Adult Dose 250-500 IM/IV mg q6h > Pediatric Dose 25-50 mg/kg/d IM/IV divided q6-8h > Contraindications Documented hypersensitivity; viral mononucleosis > Interactions Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction > > > Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > Drug Name > Meperidine (Demerol)- Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. > Adult Dose 15-35 mg/h IV; 50-150 mg IM q3-4h > Pediatric Dose 1.1-1.8 mg/kg IM q3-4h > Contraindications Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated > Interactions Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors > Pregnancy C - Safety for use during pregnancy has not been established. > Precautions Caution in head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex; substantially increased dose levels may aggravate or cause seizures because of tolerance, even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity if seizure history exists > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > > > Followup > > Further Inpatient Care: > > > a.. Transfer patients with Ranson scores of 0-2 to a hospital floor. > a.. Transfer patients with Ranson scores 3-5 to an intensive care unit. > a.. Transfer patients with Ranson scores higher than 5 to an intensive care unit with emergency surgery as a possibility. > Further Outpatient Care: > > > a.. The patient should be followed routinely with physical examination and amylase and lipase assays. > Complications: > > > a.. Infected pancreatic necrosis may result from seeding of bacteria into the inflammation. > a.. An acute pseudocyst is an effusion of pancreatic juice that is walled off by granulation tissue after an episode of acute pancreatitis. > a.. Hemorrhage into the GI tract retroperitoneum or the peritoneal cavity is possible because of erosion of large vessels. > a.. Intestinal obstruction or necrosis may occur. > a.. Common bile duct obstruction may be caused by a pancreatic abscess, pseudocyst, or biliary stone that caused the pancreatitis. > a.. An internal pancreatic fistula from pancreatic duct disruption or a leaking pancreatic pseudocyst may occur. > Prognosis: > > > a.. Ranson developed a series of different criteria for the severity of acute pancreatitis. > a.. Present on admission > > a.. Older than 55 years > > b.. WBC higher than 16,000 per mcL > > c.. Blood glucose higher than 200 mg/dL > > d.. Serum lactate dehydrogenase (LDH) more than 350 IU/L > > e.. SGOT (ie, aspartate aminotransferase [AST]) greater than 250 IU/L > a.. Developing during the first 48 hours > > a.. Hematocrit fall more than 10% > > b.. BUN increase more than 8 mg/dL > > c.. Serum calcium less than 8 mg/dL > > d.. Arterial oxygen saturation less than 60 mm Hg > > e.. Base deficit higher than 4 mEq/L > > f.. Estimated fluid sequestration higher than 600 mL > a.. A Ranson score of 0-2 has a minimal mortality rate. > a.. A Ranson score of 3-5 has a 10%-20% mortality rate. > a.. A Ranson score higher than 5 has a mortality rate of more than 50% and is associated with more systemic complications. > Patient Education: > > > a.. Educate patients about the disease and advise then to avoid alcohol in binge amounts and to discontinue any risk factor, such as fatty meals and abdominal trauma. > > > > Mark E. Armstrong > www.top5plus5.com > Oregon State Chapter Rep > Pancreatitis Association, International > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 -Mark, I have read this before, but I am still confused on one point. Why does my " problem " always show with increased liver enzymes. I have had pancreatitis twice, both times induce by an ERCP. Mine seems to of the obstructive nation. Blocked ducts. But I the scaring is definitely there, with the chronic pain, weight loss, and everything else that goes along with this. But I have never understood why it show up in the liver enzymes. Please help if you can. PS: not caused by drinking, never have. Thanks Cheryl -- In pancreatitis@y..., " Mark E. Armstrong " <casca@b...> wrote: > Clear Day > > > > INTRODUCTION > > Background: Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. > > The gland can sometimes heal without any impairment of function or any morphologic changes. This process is known as acute pancreatitis. It can recur intermittently, contributing to the functional and morphologic loss of the gland. Recurrent attacks are referred to as chronic pancreatitis. Both forms of pancreatitis are present in the ED with acute clinical findings. > > > Pathophysiology: Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily. In acute pancreatitis, parenchymal edema and peripancreatic fat necrosis occur first. This process is known as acute edematous pancreatitis. > > When necrosis involves the parenchyma, accompanied by hemorrhage and dysfunction of the gland, the inflammation evolves into hemorrhagic or necrotizing pancreatitis. > > Pseudocysts and pancreatic abscesses can result from necrotizing pancreatitis because of enzymes being walled off by granulation tissue (ie, pseudocyst formation) or bacterial seeding of pancreatic or peripancreatic tissue (ie, pancreatic abscess formation). An ultrasound or, preferably, a CT scan can be used detect both. > > The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A. These cytokines may cause vasodilation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. Fat necrosis may cause hypocalcemia. Pancreatic B cell injury may lead to hyperglycemia. > > > Frequency: > > > a.. In the US: Annual incidence of acute pancreatitis is 19.5 per 100,000 population and chronic pancreatitis is 8.3 per 100,000 population per year. > Mortality/Morbidity: > > a.. Although acute pancreatitis should be noted, chronic pancreatitis has a more severe presentation as episodes recur. > a.. Acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock all may be systemic manifestations of acute pancreatitis in its most severe form. > Race: Annual incidence of acute pancreatitis in Native American persons is 4 per 100,000 population, in white persons is 5.7 per 100,000 population, and in black persons is 20.7 per 100,000 population. > > Sex: No predilection exists. > > Age: The risk for African American persons aged 35-64 years is 10 times higher than for any other group. African American persons are at higher risk than white persons in that same age group. > > > > Clinical > > History: > > a.. The main presentation of acute pancreatitis is epigastric pain or right upper quadrant pain radiating to the back > a.. Nausea and/or vomiting > a.. Fever > a.. Query the patient about recent surgeries and invasive procedures (ie, endoscopic retrograde cholangiopancreatography) or family history of hypertriglyceridemia. > a.. Patients frequently have a history of previous biliary colic and binge alcohol consumption, the major causes of acute pancreatitis. > Physical: > > a.. Tachycardia > a.. Tachypnea > a.. Hypotension > a.. Fever > a.. Abdominal tenderness, distension, guarding, and rigidity > a.. Mild jaundice > a.. Diminished or absent bowel sounds > a.. Because of contiguous spread of inflammation (effusion) from the pancreas, lung auscultation may reveal basilar rales, especially in the left lung. > a.. Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia. > a.. Severe cases may have a Grey sign (ie, bluish discoloration of the flanks) and Cullen sign (ie, bluish discoloration of the periumbilical area) caused by the retroperitoneal leak of blood from the pancreas in hemorrhagic pancreatitis. > Causes: > > a.. The major causes are long-standing alcohol consumption and biliary stone disease. > a.. In developed countries, the most common cause of acute pancreatitis is alcohol abuse. > > a.. On the cellular level, ethanol leads to intracellular accumulation of digestive enzymes and their premature activation and release. > > b.. On the ductal level, ethanol increases the permeability of ductules, which allow enzymes to reach the parenchyma, resulting in pancreatic damage. > > c.. Ethanol increases the protein content of the pancreatic juice and decreases bicarbonate levels and trypsin inhibitor concentrations. This leads to the formation of protein plugs that block the pancreatic outflow and obstruction. > a.. Another major cause of acute pancreatitis is biliary stone disease (eg, cholelithiasis, choledocholithiasis). A biliary stone may lodge in the pancreatic duct or ampulla of Vater and obstruct the pancreatic duct, leading to extravasation of enzymes into the parenchyma. > a.. Minor causes of acute pancreatitis > a.. Medications, including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines > a.. Endoscopic retrograde cholangiopancreatography (ERCP) > a.. Hypertriglyceridemia (When the triglyceride (TG) level exceeds 1000 mg/U, an episode of pancreatitis is more likely.) > a.. Peptic ulcer disease > a.. Abdominal or cardiopulmonary bypass surgery, which may insult the gland by ischemia > a.. Trauma to the abdomen or back, resulting in sudden compression of the gland against the spine posteriorly > a.. Carcinoma of the pancreas, which may lead to pancreatic outflow obstruction > a.. Viral infections, including mumps, sackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubella > a.. Bacterial infections, such as mycoplasma > a.. Intestinal parasites, such as ascaris, which can block the pancreatic outflow > a.. Pancreas divisum > a.. Scorpion and snake bites > a.. Vascular factors, such as ischemia or vasculitis > > > > > DIFFERENTIALS > > Other Problems to be Considered: Perforated viscus > > Acute peritonitis > > Choledocholithiasis > > Macroamylasemia > > Macrolipasemia > > Intestinal obstruction > > Pancreatic cancer > > Malabsorption syndromes/processes > > > Workup > > Lab Studies: > > > a.. A complete blood count (CBC) demonstrates leukocytosis (WBC >12000) with the differential being shifted towards the segmented polymorphs. > a.. If blood transfusion is necessary, as in cases of hemorrhagic pancreatitis, obtain type and crossmatch. > a.. Measure blood glucose level because it may be elevated from B cell injury in the pancreas. > a.. Obtain measurements for BUN, creatine (Cr), and electrolytes (Na, K, Cl, CO2, P, Mg); a great disturbance in the electrolyte balance is usually found, secondary to third spacing of fluids. > a.. Measure amylase levels, preferably the Amylase P, which is more specific to pancreatic pathology. Levels more than 3 times higher than normal strongly suggest the diagnosis of acute pancreatitis > a.. Lipase levels also are elevated and remain high for 12 days. In patients with chronic pancreatitis (usually caused by alcohol abuse), lipase may be elevated in the presence of a normal serum amylase level > a.. Perform liver function tests (eg, alkaline phosphatase, serum glutamic-pyruvic transaminase [sGPT], serum glutamic- oxaloacetic transaminase [sGOT], G-GT) and bilirubin, particularly with biliary origin pancreatitis. > Imaging Studies: > > > a.. Perform a plain KUB (Kidneys, ureters, bladder) with the patient in the upright position to exclude viscus perforation (ie, air under the diaphragm). In cases with a recurrent episode of chronic pancreatitis, peripancreatic calcifications may be noted > a.. Ultrasound can be used as a screening test. If overlying gas shadows secondary to bowel distention are present, it may not be specific > a.. CT scan is the most reliable imaging modality in the diagnosis of acute pancreatitis. The criteria for diagnosis are divided by Balthazar and colleagues into 5 grades, as follows: > a.. Grade A - Normal pancreas > a.. Grade B - Focal or diffuse gland enlargement > a.. Grade C - Intrinsic gland abnormality recognized by haziness on the scan > a.. Grade D - Single ill-defined collection or phlegmon > a.. Grade E - Two or more ill-defined collections or the presence of gas in or nearby the pancreas > Other Tests: > > > a.. Para-aminobenzoic acid test (ie, bentiromide [Chymex] test) for chronic pancreatitis > > > Treatment > > Emergency Department Care: Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment. > > a.. Fluid resuscitation > a.. Monitor accurate intake/output and electrolyte balance of the patient. > a.. Crystalloids are used, but other infusions, such as packed red blood cells (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis. > a.. Central lines and Swan-Ganz catheters are used in patients with severe fluid loss and very low blood pressure. > a.. Patients should have nothing by mouth, and a nasogastric tube should be inserted to assure an empty stomach and to keep the GI system at rest. > a.. Begin parenteral nutrition if the prognosis is poor and if the patient is going to be kept in the hospital for more than 4 days. > a.. Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi. > a.. Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved. > a.. Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third generation cephalosporins. > a.. Continuous oxygen saturation should be monitored by pulse oxymetry and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed. > > b.. Perform CT-guided aspiration of necrotic areas, if necessary. > > c.. An ERCP may be indicated for common duct stone removal. > Consultations: Consult a general surgeon in the following cases: > > a.. For phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue. It should be followed by postoperative lavage of the pancreatic bed. > a.. In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis. > a.. Patients who fail to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room. Surgery in these cases may lead to a better outcome or confirm a different diagnosis. > a.. In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction. A cholecystectomy may be performed to clear the system from any source of biliary stones. > > > Medications > > The goal of pharmacotherapy is to relieve pain and minimize complications. > > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Name > Ceftriaxone (Rocephin)- Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins. > Adult Dose 1-2 g IM/IV once or divided bid > Pediatric Dose 50-75 mg/kg/d IM/IV divided q12h > Contraindications Documented hypersensitivity > Interactions Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin > Drug Name > Ampicillin (Marcillin, Omnipen)- Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. > Adult Dose 250-500 IM/IV mg q6h > Pediatric Dose 25-50 mg/kg/d IM/IV divided q6-8h > Contraindications Documented hypersensitivity; viral mononucleosis > Interactions Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives > Pregnancy B - Usually safe but benefits must outweigh the risks. > Precautions Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction > > > Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > Drug Name > Meperidine (Demerol)- Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. > Adult Dose 15-35 mg/h IV; 50-150 mg IM q3-4h > Pediatric Dose 1.1-1.8 mg/kg IM q3-4h > Contraindications Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated > Interactions Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors > Pregnancy C - Safety for use during pregnancy has not been established. > Precautions Caution in head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex; substantially increased dose levels may aggravate or cause seizures because of tolerance, even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity if seizure history exists > > Drug Category: Antibiotics - Used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen usually is based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are made, adjustments in the antibiotic regimen can be done. Drug Category: Analgesics - Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. > > > > Followup > > Further Inpatient Care: > > > a.. Transfer patients with Ranson scores of 0-2 to a hospital floor. > a.. Transfer patients with Ranson scores 3-5 to an intensive care unit. > a.. Transfer patients with Ranson scores higher than 5 to an intensive care unit with emergency surgery as a possibility. > Further Outpatient Care: > > > a.. The patient should be followed routinely with physical examination and amylase and lipase assays. > Complications: > > > a.. Infected pancreatic necrosis may result from seeding of bacteria into the inflammation. > a.. An acute pseudocyst is an effusion of pancreatic juice that is walled off by granulation tissue after an episode of acute pancreatitis. > a.. Hemorrhage into the GI tract retroperitoneum or the peritoneal cavity is possible because of erosion of large vessels. > a.. Intestinal obstruction or necrosis may occur. > a.. Common bile duct obstruction may be caused by a pancreatic abscess, pseudocyst, or biliary stone that caused the pancreatitis. > a.. An internal pancreatic fistula from pancreatic duct disruption or a leaking pancreatic pseudocyst may occur. > Prognosis: > > > a.. Ranson developed a series of different criteria for the severity of acute pancreatitis. > a.. Present on admission > > a.. Older than 55 years > > b.. WBC higher than 16,000 per mcL > > c.. Blood glucose higher than 200 mg/dL > > d.. Serum lactate dehydrogenase (LDH) more than 350 IU/L > > e.. SGOT (ie, aspartate aminotransferase [AST]) greater than 250 IU/L > a.. Developing during the first 48 hours > > a.. Hematocrit fall more than 10% > > b.. BUN increase more than 8 mg/dL > > c.. Serum calcium less than 8 mg/dL > > d.. Arterial oxygen saturation less than 60 mm Hg > > e.. Base deficit higher than 4 mEq/L > > f.. Estimated fluid sequestration higher than 600 mL > a.. A Ranson score of 0-2 has a minimal mortality rate. > a.. A Ranson score of 3-5 has a 10%-20% mortality rate. > a.. A Ranson score higher than 5 has a mortality rate of more than 50% and is associated with more systemic complications. > Patient Education: > > > a.. Educate patients about the disease and advise then to avoid alcohol in binge amounts and to discontinue any risk factor, such as fatty meals and abdominal trauma. > > > > Mark E. Armstrong > www.top5plus5.com > Oregon State Chapter Rep > Pancreatitis Association, International > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 In a message dated 10/11/01 4:04:28 PM Eastern Daylight Time, mmorga3@... writes: > I have read this before, but I am still confused on one point. Why > Cheryl, Liver enzymes are one of the standard chemical tests done with a CBC (Complete Blood Count), My guess is that the digestive system is messed up and thus your liver thinks it is injured, livers are very good at detecting injury and about the only organ that can repair itself. So, digestion process is whacky, liver detects this, then it begins to secrete those enzymes that will repair it's damage. A CBC is done on you and thus detects the out of normal liver enzyme amounts. Just a guess though, have a great evening Poncho Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 In a message dated 10/11/01 4:04:28 PM Eastern Daylight Time, mmorga3@... writes: > I have read this before, but I am still confused on one point. Why > Cheryl, Liver enzymes are one of the standard chemical tests done with a CBC (Complete Blood Count), My guess is that the digestive system is messed up and thus your liver thinks it is injured, livers are very good at detecting injury and about the only organ that can repair itself. So, digestion process is whacky, liver detects this, then it begins to secrete those enzymes that will repair it's damage. A CBC is done on you and thus detects the out of normal liver enzyme amounts. Just a guess though, have a great evening Poncho Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 11, 2001 Report Share Posted October 11, 2001 In a message dated 10/11/01 4:04:28 PM Eastern Daylight Time, mmorga3@... writes: > I have read this before, but I am still confused on one point. Why > Cheryl, Liver enzymes are one of the standard chemical tests done with a CBC (Complete Blood Count), My guess is that the digestive system is messed up and thus your liver thinks it is injured, livers are very good at detecting injury and about the only organ that can repair itself. So, digestion process is whacky, liver detects this, then it begins to secrete those enzymes that will repair it's damage. A CBC is done on you and thus detects the out of normal liver enzyme amounts. Just a guess though, have a great evening Poncho Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2001 Report Share Posted October 12, 2001 Dear Cheryl/Poncho; Another possibility... When I had my GB taken out, I got an infection in my gall stem which led to the liver which led to the pancreas which led to a severe CP episode. What I guess I'm suggesting is that an infection in the GI tract can pretty easily move from one organ to the next very quickly and somewhat effortlessly. At the time, more tests then indicated that my liver enzymes were elevated and I had cirrhosis, jaundice and hepatitis... Yet AMAZINGLY none of them lasted more than a few days, and the infection cleared up... Go figure. <---- praying, " Thank you! Thank you! Thank you!! " The liver DOES regenerate quite well... Today I have a perfectly normal and healthy liver. WooHoo!! Greatful in KC, Terry << In a message dated 10/11/01 4:04:28 PM Eastern Daylight Time, mmorga3@... writes: > I have read this before, but I am still confused on one point. Why > Cheryl, Liver enzymes are one of the standard chemical tests done with a CBC (Complete Blood Count), My guess is that the digestive system is messed up and thus your liver thinks it is injured, livers are very good at detecting injury and about the only organ that can repair itself. So, digestion process is whacky, liver detects this, then it begins to secrete those enzymes that will repair it's damage. A CBC is done on you and thus detects the out of normal liver enzyme amounts. Just a guess though, have a great evening Poncho >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 12, 2001 Report Share Posted October 12, 2001 Dear Cheryl/Poncho; Another possibility... When I had my GB taken out, I got an infection in my gall stem which led to the liver which led to the pancreas which led to a severe CP episode. What I guess I'm suggesting is that an infection in the GI tract can pretty easily move from one organ to the next very quickly and somewhat effortlessly. At the time, more tests then indicated that my liver enzymes were elevated and I had cirrhosis, jaundice and hepatitis... Yet AMAZINGLY none of them lasted more than a few days, and the infection cleared up... Go figure. <---- praying, " Thank you! Thank you! Thank you!! " The liver DOES regenerate quite well... Today I have a perfectly normal and healthy liver. WooHoo!! Greatful in KC, Terry << In a message dated 10/11/01 4:04:28 PM Eastern Daylight Time, mmorga3@... writes: > I have read this before, but I am still confused on one point. Why > Cheryl, Liver enzymes are one of the standard chemical tests done with a CBC (Complete Blood Count), My guess is that the digestive system is messed up and thus your liver thinks it is injured, livers are very good at detecting injury and about the only organ that can repair itself. So, digestion process is whacky, liver detects this, then it begins to secrete those enzymes that will repair it's damage. A CBC is done on you and thus detects the out of normal liver enzyme amounts. Just a guess though, have a great evening Poncho >> Quote Link to comment Share on other sites More sharing options...
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