Case of Necrotizing pencriatitis

[dr mahavir singh]

Sir i have a pt in my icu with c/o Necrotizing pencriatitis, 53 M , known case NAD. Businessman, presented with abdominal distension , abdominal pain , vomiting admitted on 22/12/22. Primarily he was in ward then we shifted him to icu. My point here is the CRP is not reducing sir. Today is 5th day of Inj Meropenam 1gm TDS. On 25th dec crp was 125, on 28 it was 170 , on 31st its 207. Also total count increased to 18000. Now intermittent fever is there since past 2 3 days and abdominal pain is still there. Although we are giving inj buscopan and inj contramol round the clock. Elecctrolytes are normal. How can we go further in this case , should i add any another antibiotic ? Gastro ref alrdy done. I'm attaching few report and treatment here

 

[drankur]

ok.

just see whether its inflammation or infection . in the earlier days , inflammation can cause rise in CRP and counts. so you can actually de-escalate the antibiotics if necessary . can take help of PCT though it also rises in pancreatitis.

also giving albumin will help to reduce the third spacing. keep electrolytes (K) around 4.5.

hydrate well in cover of albumin.( now as its already 5th day, don't over-rescuiate ) but avoid diuretics.

CRP is a marker, it will go down as the inflammation will go down,

 

[Dr Viquar Shaikh]

Sir we lost one similar young female patient. Unfortunately we were never able to diagnose the cause of her acute pancreatitis but when we did it came out to be SLE and till then she was severely deteriorated with severe AKI, severe pleural effusion and cardiac failure eventually died in the end. What do we in such cases sir where the cause of pancreatitis is not yet known.

 

[drankur]

actually treatment remains more or less same.

Steroids play the important role . I am quoting the text from Uptodate :

Glucocorticoid therapy — For most patients requiring treatment, we recommend initial treatment with glucocorticoid monotherapy.

Dose and duration — Our approach is to initiate treatment with prednisone 0.6 mg/kg (typically 40 mg) per day for four to six weeks . Most patients demonstrate clinical and/or radiologic improvement within the first four to six weeks; many patients respond even earlier. Administration of high-dose glucocorticoids results in more rapid and successful induction of remission than conservative management . Treatment may prevent progression to chronic pancreatitis .

Induction therapy with prednisone/prednisolone 20 to 30 mg/day with a minimum of 12 weeks of treatment may also achieve a response. Although lower doses of prednisolone appear to have comparable efficacy in retrospective studies, randomized trials are lacking [8]. In one retrospective, multicenter study of 65 AIP patients who were treated with one of three different prednisone regimens at the discretion of the treating clinician (low dose [10 to 20 mg daily]; medium dose [30 mg daily], and high dose [40 to 60 mg daily]), at six-month follow up, nearly all patients had complete resolution of symptoms . In patients treated with 10 or 15 mg/day, this dose was maintained for at least six months. Patients treated with higher initial daily doses were continued for two to four weeks, after which the dose was tapered, usually by 5 mg per one to two weeks.

Efficacy — The majority of patients with AIP respond to glucocorticoids (80 to 99 percent), but patients may require a second course of treatment due to disease relapse.

In a retrospective study in Japan that included 563 patients with AIP, of whom 459 (82 percent) received glucocorticoids, remission rates were significantly higher in patients treated with glucocorticoids as compared with patients who did not receive glucocorticoid therapy (98 versus 74 percent) [5]. Indications for the use of glucocorticoids included obstructive jaundice (60 percent), abdominal pain (11 percent), associated extrapancreatic lesions except the biliary duct (11 percent), and diffuse enlargement of the pancreas (10 percent). In another retrospective, international multicenter study of 1064 patients (684 with type 1 AIP and 52 with type 2 AIP), remission rates in patients with type 1 and type 2 AIP who were treated with glucocorticoids were 99 and 82 percent, respectively [4]. Rates of relapse were significantly higher in patients with type 1 AIP as compared with type 2 AIP (31 versus 9 percent), and in those with associated IgG4-SC (56 versus 26 percent).


so read more about steroids in autoimmune pancreatitis