Pancreatitis Learning Objectives (Barber)

- Lipase → fat digestion

- Protease → protein digestion

- Amylase → carbohydrate digestion

- Nuclease → nucleic acid digestion

- Trypsin inhibitor → prevents premature enzyme activation

Exocrine functions

malabsorption/steatorrhea

Exocrine dysfunction

hyperglycemia

Endocrine dysfunction

- Sudden onset

- Key symptom: abdominal pain

- Often associated with recent illness, trauma, or medications

Acute Pancreatitis

- Long-term, recurrent disease

- Characterized by Pain, Endocrine dysfunction, Exocrine dysfunction

Chronic Pancreatitis

- Pancreatic enzymes (lipase, protease, etc.) become involved in pancreatic injury

- Enzymes can enter the bloodstream → systemic effects

- Leads to Inflammation, Tissue damage, Systemic complications

Pathophysiology

- Abdominal pain

- increase Lipase or amylase (≥3x normal)

- Imaging abnormalities

Acute Pancreatitis diagnosis requires >2 of the following

- Chronic/recurrent pain

- Malabsorption (steatorrhea)

- Hyperglycemia

- May have normal labs between flares

Chronic Pancreatitis

- Carbapenems (imipenem, meropenem)

- Quinolones (ciprofloxacin)

- Metronidazole

antibiotics used to treat pancreatitis

- Relieve pain

- Relieve nausea

- Replace fluids

- Correct electrolytes

- Minimize systemic complications

- Manage necrosis and infection

Treatment Goals Acute Pancreatitis

- IV ketorolac

- Hydromorphone (PRN)

- Hydrocodone/APAP

- Taper as pain improves

acute pain management

- Simple analgesics

- Antidepressants

- Pregabalin

- Weak opioids

- Strong opioids

- Opioid adjuncts

chronic pain management

- Prochlorperazine

- Metoclopramide

- Ondansetron

Nausea Management

- replace fluids

- correct electrolytes

fluid therapy

- acute: TPN

- chronic: low-fat diet < 25 g/day

Nutritional Therapy

- Viokase

- Zenpep

- Pertzye

- Creon

- Pancreaze / Ultresa

Malabsorption Treatment drugs

- Dose based on lipase units

- Start: 30,000–50,000 units/meal

- Max benefit: ~90,000 units

- Dose to relief of steatorrhea

- Not interchangeable

- Enteric-coated products release in small intestine (pH >5.5)

Malabsorption Treatment key points

- non-enteric coated

- must use with PPI

Viokase

- Pain improvement

- Nausea control

- Resolution of complications

- Infection/necrosis

- Pain may improve even when enzymes are still elevated

Clinical Outcomes

- Blood glucose (endocrine function)

- Steatorrhea (exocrine function)

- Pain control

Chronic Monitoring

- Temperature

- Blood pressure

- Heart rate

Hemodynamic Monitoring

- Take with meals/snacks

- Dose based on lipase

- Adjust dose based on symptom relief

- Do NOT switch products freely

Patient Counseling Enzyme Therapy

- Viokase requires PPI

- Follow low-fat diet

- Adhere to medication regimen to control symptoms

Patient Special Counseling

- Diagnosis = 2 of 3 criteria

- Pain ≠ resolution of disease

- Enzyme therapy = lipase-based dosing

- Do NOT use antibiotics prophylactically

- Chronic pancreatitis = pain + endocrine + exocrine dysfunction

Key Exam Pearls