BCPS / Gastrointestinal disorder

Aggressive hydration defined, as 250-500mL/hr of isotonic crystalloid solution should be provided to all patients, unless cardiovascular and/or renal comorbidities exist. Lactated Ringer’s solution may be the preferred isotonic crystalloid replacement fluid. Lactated Ringer’s solution appears to be more beneficial, resulting in fewer patients developing SIRS as compared with patients receiving normal (0.9%) saline. Thus, D and B, and C are incorrect.
Reference:
Management of Acute Pancreatitis, Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013

All of the above medications has reported cases of pancreatitis.
Reference:
Acute Pancreatitis. UpToDate. 2016. Available at: https://www.uptodate.com/contents/etiology-of-acute-pancreatitis . Accessed September 29, 2016.
Management of Acute Pancreatitis, Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013

In the absence of gallstones and/or history of significant alcohol use, a serum triglyceride should be obtained and considered the etiology if >1,000 mg/dL. Patient’s triglyceride level is 1751 mg/dL, Primary and secondary hypertriglyceridemia can cause acute pancreatitis. Serum lipase has a sensitivity and specificity for acute pancreatitis and may rise within 4-8 hours of the onset of symptoms, and peak at 24 hours. Thus answers A, B, and D are incorrect.
Reference:
Acute Pancreatitis. UpToDate. 2016. Available at: https://www.uptodate.com/contents/etiology-of-acute-pancreatitis . Accessed September 29, 2016

Patients with very high triglyceride levels (i.e., 500mg/dL or higher) usually require drug therapy in addition to therapeutic lifestyle changes. Fibrates or niacin is practical first0line choices for these patients. The initial goal is to decrease the risk of acute pancreatitis, especially if triglyceride levels are above 1,000mg/dL. Fibrate therapy can reduce triglyceride level by 20-50%, whereas nicotinic acid can reduce triglycerides at a much lower dose ~ 15-25%. Thus, A is incorrect. For patients with a triglyceride level below 500 mg/dL (5.7 mmol/L) in whom pharmacologic therapy is indicated, we suggest treatment with a statin rather than an agent targeted at reduction of triglycerides. Thus, D is incorrect. Insulin therapy is initiated for acute pancreatitis treatment, thus C is incorrect.
Reference:
Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation. 2013;129(25 suppl 2):S1-S45. doi:10.1161/01.cir.0000437738.63853.7a.

Answers C and D are incorrect, as they are utilized for preventative care. If apheresis is unavailable, or if the patient cannot tolerate apheresis, or if the patient's serum glucose level is >500 mg/dL, a continuous IV insulin infusion is initiated. Typically IV infusion of regular insulin is started at a rate of 0.1 to 0.3 units/kg/hour. In patients with blood sugar levels between 150 and 200 mg/dL, IV glucose supplementation with a separate 5 percent dextrose infusion to prevent hypoglycemia due to the insulin infusion is started. The serum glucose should initially be measured every hour to monitor glucose levels and the insulin infusion should be adjusted accordingly. Triglyceride levels should be monitored every 12 to 24 hours with adjustment of the insulin dosage as needed. Intravenous insulin should be stopped when triglyceride levels are <500 mg/dL, which typically occurs within a few days. Heparin’s use is controversial and is not recommended, thus B is incorrect.
Reference:
Hypertriglyceridemia-induced Acute Pancreatitis. UpToDate. 2016. Available at: https://www.uptodate.com/contents/hypertriglyceridemia-induced-acute-pancreatitis Accessed September 29, 2016.
Management of Acute Pancreatitis, Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013

Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheter-acquired infection, bacteremia, urinary tract infection, and pneumonia. Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended. The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended. Also, routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended. Thus, B, C, and D are incorrect. Reference: Management of Acute Pancreatitis, Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013

Thiamine should be administered to prevent Wernicke’s encephalopathy. Reference: Management of moderate and severe alcohol withdrawal syndromes. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016.

Benzodiazepines are the most studied drugs for alcohol withdrawal treatment. Long-acting agents such as Diazepam and Chlordiazepoxide may be used. Antipsychotics are not recommended to treat alcohol withdrawal. Haloperidol is an antipsychotic, an inappropriate choice. Reference: 1) Kosten T, O’Connor P. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786- 95. A good general review of the management of the most common syndromes.
2) Management of moderate and severe alcohol withdrawal syndromes. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?source=machineLearning&search=alcohol+withdrawal+treatment&selectedTitle=1%7E124§ionRank=1&anchor=H13#H13. Accessed May 24, 2016

Acamprosate is indicated for ethanol dependence, but only in patients who have become abstinent. Diazepam is not indicated for ethanol dependence but for acute alcohol withdrawal. Metronidazole may interfere with the metabolism of ethanol, resulting in disulfiram-like effects, not indicated for alcohol withdrawal. Patients should try to avoid ethanol ingestion to avoid the risk of undesirable side effects while on Metronidazole. Duloxetine is not indicated to treat alcohol withdrawal. Reference: 1) Doering P, Boothby L. Substance-related disorders: overview and depressants, stimulants, and halluci¬nogens. In: DiPiro J, Talbert R, Yee G, et al., eds. Pharmacotherapy. A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008.
2) Gold Standard, Inc. Acamprosate (Indications/Dosage). https://www.clinicalpharmacology-ip.com/Forms/Monograph/monograph.aspx?cpnum=2097&sec=monindi&t=0. Accessed May 24, 2016.

Answer D. The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages.
Reference:
The role of proton pump inhibitors in the treatment of Zollinger–Ellison syndrome. Available from: https://www.researchgate.net/publication/7339146_The_role_of_proton_pump_inhibitors_in_the_treatment_of_Zollinger-Ellison_syndrome [accessed Apr 16, 2017].
Tomassetti P, Campana D. Treatment of Zollinger-Ellison Syndrome. World J Gastroenterol 2005 Sep 21; 11(35): 5423–5432. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4320348/
Jensen RT, Gardner JD, Raufman JP, Pandol SJ, Doppman JL, Collen MJ. Zollinger-Ellison syndrome: current concepts and management. Ann Intern Med. 1983;98:59–75

Answer C. Omeprazole is CYP2C19 inhibitor which can prolong the elimination of warfarin, particularly R-warfarin. R-warfarin is partially metabolized by CYP2C19. The combined use of omeprazole and warfarin has been associated with reports of increased INR and prothrombin time (PT).
Reference:
Prilosec (omeprazole) package insert. Wilmington, DE: AstraZeneca; 2016 Dec.