From the Guidelines
The appropriate treatment for a 28-year-old male with hypertension, tachycardia, epigastric pain, and alcohol use history should prioritize immediate symptom management and addressing the underlying cause, with a focus on benzodiazepines for alcohol withdrawal symptoms, as recommended by the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1. The patient's presentation suggests possible alcoholic gastritis, pancreatitis, or early alcohol withdrawal, and thus, initial management should include:
- IV fluids for potential dehydration
- Blood pressure control with medications like labetalol (10-20 mg IV) which addresses both hypertension and tachycardia
- Pain management with non-hepatotoxic analgesics such as acetaminophen (650-1000 mg every 6 hours)
- Proton pump inhibitors like pantoprazole (40 mg daily) for epigastric pain
- Laboratory tests including liver function tests, lipase, amylase, and abdominal imaging
- Thiamine (100 mg IV) and folate (1 mg daily) supplementation to prevent Wernicke's encephalopathy, as recommended by the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 1
- Symptom-triggered benzodiazepines like lorazepam (1-2 mg every 4-6 hours as needed) for alcohol withdrawal risk, with careful monitoring to avoid drug accumulation and encephalopathy in patients with hepatic insufficiency 1 Long-term management must include:
- Alcohol cessation counseling
- Nutritional support
- Outpatient follow-up for continued blood pressure management and substance use disorder treatment, with a goal of restricting alcohol consumption to less than 14 units/week for men, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 2
From the Research
Diagnosis and Treatment of Acute Pancreatitis
The patient's symptoms, including hypertension, tachycardia, and epigastric pain, along with a history of alcohol use, suggest a possible diagnosis of acute pancreatitis. The diagnosis of acute pancreatitis requires the satisfaction of two out of three criteria: abdominal pain radiating to the back, serum lipase or amylase levels three or more times the upper limit of the normal level, and findings indicating pancreatitis obtained via a computed tomography (CT) scan or magnetic resonance imaging (MRI) 3.
Initial Management
The initial management of acute pancreatitis includes:
- Oxygen supplementation
- Provision of intravenous fluids
- Pain control
- A nutrition regime 3
- Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes 3
Risk Stratification and Complications
Risk stratification is crucial in the management of acute pancreatitis, as it helps identify patients at high risk of complications and mortality. Several scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity and mortality 4. Complications of acute pancreatitis include necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation 3.
Long-term Management
Long-term management of acute pancreatitis involves:
- Regular follow-ups
- Abstinence from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis 3
- Risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis 4
Treatment Considerations
The treatment of acute pancreatitis should be individualized, taking into account the patient's underlying etiology, disease severity, and presence of complications. Current treatment trials are focused on targeting pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses, which are critical in the pathogenesis of acute pancreatitis 5.