A case study on Pangastritis with pancreatitis

this case study describes about Pangastritis with pancreatitis , which details about the treatment, management , diagnosis, patient counselling, pharmacist interventions & discussions are followed in this case .
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1. CASE STUDY BASED ON DISEASE { Pangastritis with pancreatitis } PREPARED BY MARTIN SHAJI Pharm D

2. Patient name –Ms. x IP no. –165608 Admission date- 11-11- 2020 Discharge date – 26 -11-2020 Age-48 Sex-Male Department – Gastroenterology PATIENT DEMOGRAPHY

3. 1. Physical examination: patient conscious and coherent Vital signs: Temperature ( o F ): Afebrile. Pulse rate (/min): 78beats / min Respiratory rate : 20 / min Blood Pressure (mm of Hg):130/90mm of Hg 2. Systems Examination: CVS: S1, S2 + RS: NVBS + CNS : NFND P/A : , tenderness( upper left side ), wall muscles are rigid ,very few intestinal sounds , lower abdomen + ve General Examinations

4. CHIEF COMPLAINTS; Abdominal pain x 2days Constipation x 1 week , Vomiting 4-5 episodes on 6/2 PAST MEDICAL HISTORY N/K/C/O- DM/SHT/IHD/Epilepsy/BA Past case of Hyperthyroidism x 2years H/O: Abdominal pain 2 weeks ago, admitted and was diagnosed with small tiny cystic lesion of liver in CECT. Past Medication History: T. Carbimazole 5mg OD ALLERGY :(food/drug/other) No known allergies.

5. Personal History: Takes mixed diet, ash exposure in work x 4yrs , has a family history of DM Social Habits: Alcoholic for 6-8 yrs. monthly 3-4 days, pan chewer

6. LAB INVESTIGATIONS T EST Report values N ormal range HB 11.3 12 – 16 g/dl TLC 7400 3800 – 11000 Cells/mm³ ESR 7/14 – 29 mm/hr DC N-61, L-37, E-2 N: 45-75, L: 16-46, E: 0-8 BT/CT 2’00”/4’15” 2-7/8-15 mins BUN 20 8 – 25mg/dl Cr 0.5 0.5 – 1.1 mg/dl Na+ 132 135-145 mEq/L BILI (T) 0.6 0.1 – 1.2 mg/dL BILI (D) 0.4 <0.3 mg/dL ALT 21 7- 56 U/L AST 19 10 – 40 U/L Albumin 2.7 3.5 – 5.5 g/dL ALP PHOS 99 44 – 147 IU/L T. Protein 6.6 6 – 8.3 g/dL FT4 2. 1 0.9 – 1.7 ng/dL

7. T est Report values Normal range Amylase 200U/L 23-85 U/L Lipase 210 U/L 0-160 U/L

8. Other investigation: USG, Peripheral smear, OGD ( oesophago -gastro-duodenoscopy) , Multislice CT, CT Angiogram, Stool occult blood, ERCP . Impression: USG – N, CT Angiogram – N, Peripheral smear – Microcytic Hypochromic type Multislice CT – Tiny cystic lesion in segment 4b of liver. Suspicious filling defect noted in SMA (Superior Mesenteric Artery) – suggested abd . Angiogram – others found to be normal

9. OGD- Pharynx, Vocal cord, Oesophagus – N; Stomach – Fundus, Body, Antrum, Pylorus – Gastritis ; Duodenum – N ERCP - pancreatitis Stool Occult Blood- 18/11 – Positive 22/11 - Negative

10. SUBJECTIVE EVALUATION A 48 years old male patient was consulted with the complaints Abdominal pain x 2days Constipation x 1 week & Vomiting 4-5 episodes on 6/2. OBJECTIVE EVALUATION On Examination, the patient was conscious & coherent. Lab data reveals slight elevation in direct bilirubin , FT4 and decreased levels of sodium ,albumin , along with a tiny cystic lesion in the liver, filling defect in SMA, inflammation in stomach ,stool occult blood and altered levels of amylase and lipase . ASSESSMENT: Based on subjective & objective evaluation the physician confirmed it as Pancreatitis, Pangastritis with anaemia SOAP NOTES

11. CONFIRMATORY DIAGNOSIS { Pancreatitis, Pangastritis with anaemia } }

12. DRUG CHART S.No Drug name Dose ROA Freq. No. of days 1 IVF. RL 2 pint IV BD 11, 14, 23-26 2 Inj. Ciprofloxacin 200mg IV BD 11-13 3 Inj. Ranitidine 50 mg IV 1-0-1 11-14, 22 4 Inj. Metronidazole 5 00mg IV BD 11-13 5 Inj. Ondansetron 1cc IV Stat 11, 23-26 6 T. Serratiopeptidase 10mg P/O TDS 12- 20 7 Inj. Dicyclomine 20mg/2ml IM BD 12 - 18 8 Inj. Pantoprazole 40mg IV 1-0-1 14 - 24 9 Syp. Lactulose 10ml P/O HS 15 – 26 10 T. Dicyclomine 10mg P/O 1-1-1 14 - 22 11 Cap. Bifilac I cap P/O OD 21 - 26 12 T. Acetaminophen 500mg P/O TDS 22 13 T. Lupizyme 1 tab P/O 0-1-0 23 - 26 14 Inj. Tramadol 2CC IM SOS 23, 24

13. Discharge summary : On 26/11/2020 ,the patient was found to be conscious and coherent ,and relieved from chief complaints such as Abdominal pain Constipation , Vomiting episodes , Suspicious filling defect noted in Superior Mesenteric Artery found to be normalized . On 22 / 11 the stool occult blood also found to be negative .OGD reveals that the patient is free from gastritis & pancreatitis. Advised to review after 2 weeks …………………………… Discharge medication as follows

14. Discharge Medication : Patient discharged on 27.11.20 with the following drugs T. Ondansetron 4mg BD T. Rantac 150mg 1-0-1 Syp . Lactulose 10ml HS T. Lupizyme 1 tab 0-1-0 The patient was asked to review after 2 weeks.

15. Regarding Medication 1.RANTAC ( Ranitidine) It is an anti ulcerative agent and should be taken twice a day before food. 2. CYCLOPAM( Dicyclomine) It is the drug used for several intestinal problems like intestinal bowel syndromes . It help to reduce the symptoms to stomach the intestinal cramping , it reduces intestinal muscle spasms thereby the pain induced over the regions of stomach and intestines. Its an anticholinergic / antispasmodic drug. 3.FLAGYL(Metronidazole) It is an antibiotic used against certain bacteria and protozoa , used to treat a wide variety of infections induced by microbes but it wont stand against viruses. 4 . ONDAN(Ondansetron) It is an antiemetic agent used to treat nausea and vomiting caused due to certain medical conditions. It works by blocking the action of a chemical substance that causes nausea and vomiting.

16. 5. Syp . Lactulose Lactulose is a non-absorbable sugar used in the treatment of constipation 6 . Serratiopeptidase Serratiopeptidase helps relieve pain and swelling associated with post-operative wounds and inflammatory diseases. Take it 30 minutes before a meal or as directed by your doctor. 7. Cap . bifilac Bifilac HP capsule is a combination supplement with Probiotic, Prebiotic & immunobiotic properties. 8 . Lupizyme   Capsule contains Fungal Diastase and Pepsin as main active ingredients which increase digestion of body. 

17. PHARMACIST INTERVENTIONS Findings: Major interaction : Tramadol & Ondansetron Ciprofloxacin & Metronidazole Assessment: Tramadol & Ondansetron – concurrent use result in increase risk of serotonin syndrome Ciprofloxacin & Metronidazole– concurrent use results in QT prolongation. Resolution: Avoid concurrent administration. Monitoring: Monitor ECG during the course of therapy.

18. PATIENT COUNSELLING – Regarding Life Style Modifications Drink enough water Avoid eating late nights and close to bed time at least 3hrs before sleeping Reduce stress Quit smoking and avoid too much alcohol Avoid regular use of pain killer drugs Avoid taking spicy foods, coffee, milk ,tomatoes ,citrous fruits and juices . Start taking probiotic foods ,garlic, coconut water, ginger water , papaya, foods rich in anti oxidants etc……

19. DISCUSSION The pancreas is a large gland behind the stomach and next to the small intestine. Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic d amage h a p p e n s wh e n th e di g e s tiv e e n z y mes are activated before they are released into the small intestine and begin attacking the pancreas. There ar e tw o form s o f pa n cr e a titis: ac u t e and chronic. Acute pancreatitis. Acute pancreatitis is a sudden inflammation that lasts for a short time. In severe cases, acute pancreatitis can result

20. Ch r o n ic p a n c r e atiti s . Chr o ni c p a n c r e atiti s is long-lasting inflammation of the pancreas. It mo s t o f t e n h a p p e n s after an e p is o d e o f a c u t e pancreatitis. Heavy alcohol drinking is another big cause. Damage to the pancreas from h e a v y al c o ho l u s e may n o t cause symptoms for many years, but then the person may suddenly develop severe pancreatitis symptoms. Symptoms of acute pancreatitis: Upper abdominal pain that radiates into the b a c k ; it may b e a g g r a v ate d by e a ti n g, especially foods high in f at. Swollen and tender abdomen Nausea and vomiting Fever Increased heart rate

21. Symptoms of chronic pancreatitis: The symptoms of chronic pancreatitis are simil a r t o t h o s e o f a c u t e p a n c r e ati t is. P a t ie n t s frequently feel constant pain in the upper abdomen that radiates to the back . In some patients, the pain may be disabling. Causes I n mo s t c a s e s , a c u t e p a n c r e atiti s is c a u s e d by gallstones or heavy alcohol use. Other causes include medications, autoimmune disease, infections, trauma, metabolic disorders, and surgery. In up to 15% of people with acute pancreatitis, the cause is unknown. I n a b o u t 7 % o f p e o p le, c h r o ni c p a n c r e atitis is caused by long-time alcohol use.

22. Diagnosis: Pan c reatic fun c t i o n t e s t t o f i n d ou t if t h e pa ncr eas is m aking the right amounts of digestive enzymes Glucose tolerance test to measure damage to the cells in the pancreas that make insulin Ultrasound, CT scan, and MRI, which make images of the pancreas so that problems may be seen Biopsy, in which a needle is inserted into the pancreas to remove a small tissue sample for study Treatment for acute pancreatitis People with acute pancreatitis are typically treated with IV fluids and pain medications in the hospital. An acute attack of pancreatitis caused by gallstones may require removal of the gallbladder or surgery of the bile duct. After t h e ga l lstones ar e remov e d an d t h e i nfla m mat i o n goes away, the pancreas usually returns to normal. Treatment for chronic pancreatitis Chronic pancreatitis can be difficult to treat. Doctors will try to relieve the patient's pain and improve the nutrition problems. Pat i ent s ar e generall y give n panc reatic en zy mes an d m ay need insulin. A low-fat diet may also help.

23. pangastritis Acute gastritis is a term covering a broad sp e ctr u m o f e n titie s tha t i n du ce infla m mat o ry changes in the gastric mucosa. The inflam m atio n m ay invol v e th e entir e st o ma c h ( eg , pan g astr iti s ) o r a r e gio n o f th e s tom a c h (eg , antral gastritis). Acute gastritis can be broken down into 2 categories: erosive (eg, superficial erosions, deep erosions, hemorrhagic erosions) and nonerosive (general l y caused by Heli c oba c ter pylori ). Symptoms include nausea, vomiting, loss of app e tite, b e lchin g , an d bloati n g . O cc a sion a lly, acute abdominal pain can be a presenting sy m pto m . Fe v er , c hills , an d h iccu p s als o may be present. The diagnosis of acute gastritis may be suspec te d fro m th e p atien t's hist o ry an d c a n be confirmed histologically by biopsy specimens

24. Acute gastritis has a number of causes, in c luding c e rtain drug s ; al c ohol ; bac terial, viral, and fungal infections; acute stress (shock); radiation; allergy and food poisoning; bile; ischemia; and direct trauma. Medications used to treat gastritis include: Antibiotic medications to kill H. pylori antibiotics Me d ica t io n s t h a t bl oc k a c id p r o d u c tion and promote healing. Proton pump inhibitors (omeprazole) Medications to reduce acid