A previously healthy 63-year-old woman presents to the emergency department with 24 hours of severe abdominal pain, nausea, and vomiting. Vital signs include:
On examination, she is in moderate distress with diffuse epigastric pain and diminished bowel sounds. Laboratory results include:
What is the recommended management?A. Start aggressive intravenous fluid repletion, and obtain an abdominal ultrasound, early enteral feeding
Correct Answer: A
The diagnosis of acute pancreatitis (AP) can be made when patients meet two of the following three criteria: abdominal pain consistent with pancreatitis (constant, generally severe epigastric or left upper quadrant pain that may radiate to the back, chest, or flank), serum amylase or lipase greater than three times the upper limit of normal, and/or characteristic findings on imaging. Serum lipase level is the laboratory test of choice. The American Society for Clinical Pathology even chose testing lipase instead of amylase in cases of suspected AP as one of its recommendations for the Choosing Wisely initiative. ICU admission criteria should be the same as with other patients, but ICU or step-down admission should also be considered for patients who are at high risk of deterioration, such as those at risk of severe AP. Patient characteristics that increase the risk of developing severe AP include age >55 years, BMI >30 kg/m2 , altered mental status, and presence of comorbid disease. No specific laboratory or imaging results have been able to reliably predict severity in AP, so close monitoring for hypovolemic shock and evidence of organ dysfunction are important. Other risk factors for severe AP include the presence of systemic inflammatory response syndrome, evidence of hypovolemia (elevated BUN or creatinine, hemoconcentration), pleural effusions or pulmonary infiltrates, and presence of multiple or extensive extrapancreatic fluid collections. Death within the first week is usually due to progressive organ dysfunction. Routine use of prophylactic antibiotics is not recommended, even in the presence of severe disease, unless there is evidence of extrapancreatic infection. All patients should receive an abdominal ultrasound to evaluate for cholelithiasis, which is the most common cause of AP (40%-70% of cases). Patients with mild AP can begin eating a low-fat diet as soon as tolerated. Patients with severe AP should be started on enteral nutrition to prevent infectious complications. Parenteral nutrition should only be used if the enteral route is not available, not tolerated, or not meeting caloric requirements.