Case study on pangastritis with pancreatitis

Pangastritis is a form of gastritis which only affects the whole stomach region.

1. Case study on Pangastritis with pancreatitis J. Anisha Ebens Pharm D intern

2. A male patient of age 48, was admitted in the hospital on 11.02.2019 C/O: Abdominal pain x 2days Constipation x 1 week 23/2 - Abd . Pain H/O: Vomiting 4-5 episodes on 6/2 Abdominal pain 2 weeks ago, admitted in S tandley and was diagnosed with small tiny cystic lesion of liver in CECT. Past Medical History: N/K/C/O- DM/SHT/IHD/Epilepsy/BA Past case of Hyperthyroidism x 2years

3. Past M edication History: T. Carbimazole 5mg OD 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 Vitals : Normal, mild pallor General Examination: Temp . : Afebrile BP: 140/80 PR : 78 beats/min RR: 20 breaths/min Systems examination: CVS: S ₁S₂ + RS: NVBS + CNS: NFND P/A: soft, tenderness lower abdomen++

4. Lab investigation: S. Amylase – 345.6 U/L (<140 U/L), S. L ipase – 380.3 U/L (<140 U/L ) Parameters Report values Normal values HB (On 1/2/19 – 8.5) 11.3 12 – 16 g/dl TLC 7400 3800 – 11000 Cells/mm³ ESR 7/14 0 – 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 2.9 0.9 – 1.7 ng/dL TSH 0.01 0.3 – 4.2 mIU /L

5. Other investigation: USG, Peripheral smear, OGD ( oesophago -gastro-duodenoscopy) , Multislice CT, CT Angiogram, Stool occult blood. Impression: USG – N, CT Angiogram – N, Peripheral smear – Microcytic Hypochromic type Multislice CT – T iny cystic lesion in segment 4b of liver. Suspicious filling defect noted in SMA (Superior M esenteric A rtery) – suggested abd . Angiogram. OGD - Pharynx, Vocal cord, Oesophagus – N; Stomach – Fundus, Body, Antrum, Pylorus – Gastritis; Duodenum – N Stool Occult Blood - 18/2 – Positive 22/2 - Negative Diagnosis: Pancreatitis, Pangastritis with anemia

6. Pancreatitis: 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 damage happens when the digestive enzymes are activated before they are released into the small intestine and begin attacking the pancreas. There are two forms of pancreatitis: acute and chronic. Acute pancreatitis.  Acute pancreatitis is a sudden inflammation that lasts for a short time.  In severe cases, acute pancreatitis can result in bleeding into the gland, serious tissue damage, infection, and cyst formation. Severe pancreatitis can also harm other vital organs such as the heart, lungs, and kidneys.

7. Chronic pancreatitis.  Chronic pancreatitis is long-lasting inflammation of the pancreas. It most often happens after an episode of acute pancreatitis. Heavy alcohol drinking is another big cause. Damage to the pancreas from heavy alcohol use may not 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 back; it may be aggravated by eating, especially foods high in fat. Swollen and tender abdomen Nausea and vomiting Fever Increased heart rate

8. Symptoms of chronic pancreatitis: The symptoms of chronic pancreatitis are similar to those of acute pancreatitis. Patients frequently feel constant pain in the upper abdomen that radiates to the back. In some patients, the pain may be disabling. Causes In most cases, acute pancreatitis is caused 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. In about 70% of people, chronic pancreatitis is caused by long-time alcohol use.

9. Diagnosis: Pancreatic function test to find out if the pancreas is making 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 the gallstones are removed and the inflammation 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. Patients are generally given pancreatic enzymes and may need insulin. A low-fat diet may also help .

10. Pangastritis Acute gastritis is a term covering a broad spectrum of entities that induce inflammatory changes in the gastric mucosa . The inflammation may involve the entire stomach ( eg , pangastritis ) or a region of the stomach ( eg , antral gastritis). Acute gastritis can be broken down into 2 categories: erosive ( eg , superficial erosions, deep erosions, hemorrhagic erosions) and nonerosive (generally caused by  Helicobacter pylori ). S ymptoms include nausea, vomiting, loss of appetite, belching, and bloating. Occasionally, acute abdominal pain can be a presenting symptom. Fever, chills, and hiccups also may be present . The diagnosis of acute gastritis may be suspected from the patient's history and can be confirmed histologically by biopsy specimens taken at endoscopy.

11. Acute gastritis has a number of causes, including certain drugs; alcohol; bacterial, 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 Medications that block acid production and promote healing.  Proton pump inhibitors (omeprazole) Medications to reduce acid production.  Acid blockers — also called histamine (H-2) blockers (ranitidine) Antacids that neutralize stomach acid

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 400mg 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. Discarge advice: Patient discharged on 27 .2.19 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.

14. FARM Notes: Findings : Major interaction : Tamadol & Ondansetron Ciprofloxacin & Metronidazole Assesment : Tamadol & Ondansetron – concurrent use result in increase risk of serotonin syndrome Ciprofloxacin & Metronidazole– concurrent use results in QT prolongation. Resolution : Avoid concurrent administration. Monitoring: M onitor ECG during the course of therapy.