PANCREATITIS, ACUTE   35A

A 58-year-old woman presents to the emergency department with a 2-day history of epigastric abdominal pain, fever, anorexia, and nausea. Serum amylase and lipase levels are markedly elevated. Two months ago, she had an episode of right upper quadrant abdominal pain and ultrasound imaging demonstrated multiple gallstones without gallbladder wall edema. She is admitted to the hospital. On hospital day 3, the physician is called urgently to evaluate her for hypotension and shortness of breath. Respiratory failure ensues, requiring endotracheal intubation and mechanical ventilation. A chest radiograph and severe hypoxia support the diagnosis of acute respiratory distress syndrome (ARDS).

What are the salient features of this patient’s problems? How do you think through her problems?

Salient features: Fever; epigastric abdominal pain; anorexia, nausea, history of gallstones; markedly elevated serum lipase and amylase levels; associated ARDS

How to think through: Undifferentiated abdominal pain is a common clinical challenge. In this case, markedly elevated serum amylase and lipase levels point to a diagnosis of acute pancreatitis. What are the leading causes of acute pancreatitis? (Alcohol abuse, gallstones, hypertriglyceridemia, medications, pancreatic duct stricture or obstruction, pancreatic or other malignancy, or compressive adenopathy.) Given her age, sex and prior evaluation, cholelithiasis is most likely. Nevertheless, alcohol use should be assessed. What does initial treatment entail? (Nothing by mouth, intravenous [IV] hydration, and pain control.) A major challenge is to identify the 15% to 25% of cases that will progress to severe, necrotizing pancreatitis. Predictive models, such as the Ranson criteria, are used but have low specificity. Should the patient have imaging when her condition deteriorates? (Yes. Imaging may be omitted at presentation if the diagnosis is clear cut, but worsening clinical status is an indication for computed tomography [CT] or magnetic resonance cholangiopancreatography [MRCP]. Both can distinguish necrosis from edema.) Does development of shock and ARDS indicate necrosis or infection? (Necrosis is likely; a cytokine-mediated systemic inflammatory response syndrome can precipitate these complications even in the absence of infection.) What are the treatments for severe pancreatitis? (Opioids; calcium gluconate for tetany; fresh-frozen plasma [FFP] for coagulopathy with bleeding; vasopressors for shock; nutritional support; antibiotics and debridement for infection.)

PANCREATITIS, ACUTE   35B

What are the essentials of diagnosis and general considerations regarding acute pancreatitis?

Essentials of Diagnosis

Abrupt onset of deep epigastric pain, often with radiation to the back

Nausea, vomiting, sweating, weakness, fever, abdominal tenderness and distention

Leukocytosis, elevated serum amylase, elevated serum lipase

History of previous episodes, often related to alcohol intake

General Considerations

Most often caused by a passed gallstone, usually less than 5 mm in diameter, or heavy alcohol intake

Rarely, may be the initial manifestation of a pancreatic or ampullary neoplasm

Pathogenesis may include edema or obstruction of the ampulla of Vater, bile reflux into pancreatic ducts, and direct injury of the pancreatic acinar cells

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