I Got Drunk and Now My Pancreas Hurts

So there I was, a few shifts ago, minding my own business, when I was assigned to a call for a 35-year-old male with abdominal pain.  I was driving but I had a strong partner attending.  It was about 7am, but we found the patient to be pretty heavily intoxicated – blitzed, as a matter of fact.  Hammered.  He had upper abdominal pain that radiated to his back, consistent with his previous experience with pancreatitis. 

We found out that he signed out AMA from the nearby hospital last night during treatment for pancreatitis.  He wanted to leave, get himself all likkerd up, and then take care of his belly pain.  Nice.  Anyway, we took him back to the hospital.  My partner blew my mind, though.  You see, normally I hate to be the driver when running a pancreatitis call.  There are a lot of paramedics who don’t actually treat an intoxicated pancreatitis patient.  Sure, they will give them a ride to the hospital – usually sitting on the bench rather than the bed, with a nice rant about how drinking caused their problems so they should quit drinking thrown in at no extra cost.  I think it is shameful.  My partner on this call, however, started an IV and gave the patient plenty of Fentanyl along with some fluids. 

It bothers me that it seems as though many paramedics don’t adequately treat pancreatitis patients.  I don’t know what causes that.  They either don’t know what it is, how serious it can be, how painful it probably is, or don’t want to treat a condition caused by alcohol.

Let me try to fix that.

What is pancreatitis?

In the simplest way of thinking, pancreatitis is inflammation (-itis) of the pancreas.  The pancreas secretes hormones (e.g. insulin, glucagon, etc.) and pancreatic juice.  Pancreatic juice is comprised of digestive enzymes that aid digestion and absorption of nutrients in the small intestine.  Pancreatic juice can be activated in the pancreas, rather than in the small intestine.  Digestion outside of where digestion is supposed to be hurts.

Pancreas
(Public domain via Wikimedia Commons.)

It affects between 5 and 35 people per 100,000, depending on which study you look at.  Mortality is pretty consistently reported to be about 5% (1.5% in mild and 17% in severe pancreatitis).  Necrotizing pancreatitis results in even higher mortality.

What causes pancreatitis?

The most common causes are gallstones and alcoholism.  Those two causes result in about 75% of cases.  Other causes include trauma, steroid use, mumps, autoimmune disease, hyperlipidemia, some medical procedures, genetic disorders, and (I’m sure) others.  But those are the main ones.

The etiology of pancreatitis is not well-understood, but this is one of the easiest ways to think of what’s going on.  A gallstone can travel down the common bile duct and block the outflow of the pancreatic duct – so pancreatic juice can’t flow into the duodenum.  A fatty, alcoholic liver can screw with the outflow, as well, by pinching off smaller pancreatic ductules.  Thus, the juice (especially the trypsin) starts to do its work in the pancreas itself.  What we’re talking about is auto-digestion.  That’s as horrible and painful as it sounds.

Now, I understand that this is overly simplified and there are other causes of pancreatitis.  But this is a blog post, not a GI textbook entry, and it is a decent model to understand what’s going on.

Are there different kinds?

Besides acute and chronic, pancreatitis is also divided into mild and severe.  Essentially, acute pancreatitis is hurting now and chronic pancreatitis isn’t hurting at the moment.  The difference between mild and severe is that severe acute pancreatitis results in shock, abscess formation, necrosis, and/or organ failure.  So the guy at the beginning of the post most likely was suffering from mild acute pancreatitis.

How does pancreatitis present?

The most common presentation is upper abdominal pain or left upper quadrant pain.  It can radiate to the back, and (interestingly) the amount of pain is worse than the amount of tenderness.  Nausea and vomiting associated with eating is common.  Blood pressure, heart rates, and respiratory rates can all be elevated due to pain, but blood pressure can be decreased if bleeding or dehydration occurs. 

In about three percent of pancreatitis patients, Cullen’s sign (periumbilical ecchymosis) or Grey-Turner’s sign (flank ecchymosis) are visible.  These are signs of hemorrhage.  So lift a shirt and look at the belly.

Cullen's sign
(By Herbert L Fred, MD and Hendrik A van Dijk via Wikimedia Commons)

Grey-Turner's sign
(By Herbert L Fred, MD and Hendrik A van Dijk via Wikimedia Commons)

Diagnosis results from characteristic abdominal pain with elevated blood amylase and lipase.  The blood amylase and lipase can be 3-6 times as high as the normal reference value.  Ultrasound can illuminate the cause of pancreatitis, such as alcoholic fatty liver or gallstones, plus an inflamed pancreas is visible.  CT scans can also be helpful.

What should be on the differential diagnosis list?

Consider other causes of epigastric abdominal pain – peptic ulcer disease, gallstones (cholelithiasis), acute cholecystitis, perforated viscus, occult trauma, intestinal obstruction, mesenteric ischemia, and hepatitis. 

What is the treatment for pancreatitis?

Hospital protocols begin with fluid replacement (5-10ml/kg/hr of isotonic crystalloid), with reassessment based on lab values and patient fluid status.  Opioid analgesia is administered – plenty of Fentanyl or Dilaudid are commonly used.  “Plenty” in this case means a patient administered pump set for 20-50 micrograms of Fentanyl every 10 minutes.  Morphine has fallen out of favor for pancreatitis patients.

Patients are held NPO (nothing per oral) until the pain decreases and inflammatory markers improve.  While this occurs usually after 24-48 hours, the NPO duration can easily last 3-5 days.  Severe pancreatitis can result in longer periods without oral food, so enteral or parenteral nutrition would be required.  Antibiotics are used for extrapancreatic infections.  The symptoms of alcohol withdrawal are treated for admitted alcoholics.

So, what should we be doing in the field for these patients?

Fluids and analgesia.  Don’t go nuts on the fluids, though.  We can get a liter of crystalloid into a patient in ten or fifteen minutes, if we try.  That would probably be excessive, except in cases of severe shock.  I just run the IV a little faster than the normal TKO drip rate to end up delivering a few hundred milliliters during transport.  As for analgesia, Fentanyl is a good choice with a good safety profile. 

Pancreatitis is a weird pathology to me.  I don’t understand how paramedics can commonly minimize or ignore the problem.  I have seen medics lecture patients about how drinking with pancreatitis is dumb, rather than treat the problem.  That doesn’t occur for very many other issues, even those that are patient caused.  We treat suicide attempts, right?  We treat people after they say, “Hey, ya’ll, hold my beer and watch this!” don’t we?  We treat cardiac arrests from alcoholism, right?  Do you think a lecture to a drunk changes his or her future behavior?  Do you think nontreatment will teach them a lesson? 

Please, start treating your pancreatitis patients appropriately, if you aren’t already.  Even when they are self-intentionally drunk.