A 30-year-old female with no past medical history presents to the emergency department complaining of severe abdominal pain after a night of binge drinking. She is noted to have a low-grade temperature of 100.4°F with the following vital signs:
On examination, she has focal moderate to severe tenderness in her mid-epigastrium without peritoneal signs. Her laboratory test results are notable for
An abdominal ultrasound shows no evidence of cholelithiasis. She is diagnosed with acute alcoholic pancreatitis and admitted to the hospital. All of the following are important initial steps in the management of moderate-severe acute pancreatitis EXCEPT:
Correct Answer: C
Acute pancreatitis is an inflammatory disease of the pancreas with a variety of etiologies but is most commonly caused by gallstones or alcohol use. The resultant systemic inflammatory response and potential resultant organ failure are currently used in the severity assessment of individual cases. Initial management of a patient presenting with moderate to severe acute pancreatitis involves admission to a monitored bed including consideration for admission to an ICU if appropriate, as well as initiation of isotonic crystalloid resuscitation with Lactated Ringer solution. CT at the time of initial presentation rarely alters management and thus is not required when the diagnosis is clear based on clinical and biochemical grounds. Early initiation of oral feeding is strongly recommended given multiple studies demonstrating the safety of early enteral feeding in addition to reduced rates of infectious complications, multisystem organ failure, and mortality. Current guidelines recommend against the use of prophylactic antibiotics. This is based on review of the literature including 10 randomized control trials that showed no difference in infectious outcomes or mortality.
All of the following statements are true regarding nutrition in patients with moderate to severe acute pancreatitis EXCEPT:
Correct Answer: E
Historically, patients presenting with moderate to severe episodes of acute pancreatitis were made nil per os in an attempt to provide bowel rest and avoid further pancreatic stimulation. Multiple studies looking at all severities of acute pancreatic have demonstrated that not only is initiation of early enteral feeding safe, but it also has favorable effects on infectious outcomes and mortality. It is believed that early enteral nutrition maintains the integrity of the gut mucosal barrier, thereby limiting bacterial overgrowth and intestinal atrophy, which may play a role in bacterial gut translocation. If oral feeding can be tolerated, it is recommended to resume an oral diet within 24 hours and allowing up to 3 to 5 days before initiating enteral feeding with nasogastric or nasojejunal feeding tube placement. In general, enteral nutrition is preferred over total parenteral nutrition for the aforementioned reasons, and thus the role of total parenteral nutrition is limited to those patients who are unable to tolerate any form of enteral nutrition despite maximal support. Despite the theoretical reasons to avoid gastric feeding, including avoidance of pancreatic stimulation, multiple studies have shown that there are no differences in nasogastric and nasojejunal feeding.
A 45-year-old male was admitted to the intensive care unit (ICU) 2 days ago with a diagnosis of acute pancreatitis secondary to alcohol abuse. After initial resuscitation with large volume isotonic crystalloid solution for persistent hypotension, he developed worsening pulmonary edema with an increased oxygen requirement ultimately requiring intubation. In addition to Acute Respiratory Distress Syndrome, another potential complication seen in severe pancreatitis requiring large volume resuscitation is abdominal compartment syndrome. All of the following are signs/symptoms of abdominal compartment syndrome EXCEPT:
Correct Answer: A
Abdominal compartment syndrome (ACS) is defined as end organ dysfunction related to sustained intra-abdominal hypertension (IAH). The average intra-abdominal pressure in critically ill patients is 5 to 7 mm Hg, not including patients with obesity or pregnancy, which may predispose them to slightly higher baseline pressures. IAH is defined as sustained pressures >12 mm Hg and is further subdivided into Grades I-IV based on escalating pressure intervals. ACS is defined as sustained IAH with new IAH-induced organ dysfunction, which includes increased peak inspiratory and mean airway pressures leading to alveolar barotrauma, renal impairment both from renal vein compression and renal artery vasoconstriction, decreased cardiac output secondary to cardiac compression and decreased venous return, and decreased mesenteric perfusion causing intestinal mucosal ischemia. There is no set intraabdominal pressure that defines ACS, but sustained intra-abdominal pressures >20 mm Hg is typically required to cause the physiologic disturbances described above. Because of these relatively high pressures, these patients present with a tense and distended abdomen (Answer B). Although intra-abdominal compartment pressures can be measured through a number of indirect methods (intragastric, intracolonic, inferior vena cava), the standard method is intravesicular via a foley catheter.
A 35-year-old male is hospitalized following a first episode of acute severe gallstone pancreatitis. Initially, he presented to the emergency department with tachycardia, hypotension, and signs of end organ dysfunction. After aggressive resuscitation and supportive management in the ICU he showed signs of improvement. On hospital day 18 he develops new fevers and an associated leukocytosis. A computed tomography (CT) abdomen/pelvis is obtained that showed new air in areas of previously noted pancreatic necrosis.
Which of the following statements is true regarding this patient’s condition?
Correct Answer: D
Acute pancreatitis is an acute inflammatory reaction caused by a variety of etiologies. A subset of patients with acute pancreatitis develops necrosis of a portion of the pancreatic parenchyma and surrounding tissues, which is termed necrotizing pancreatitis. In the acute setting, these necrotic collections are comprised of fluid and necrotic tissue, which over time organize into walled off pancreatic necrosis. Initially presumed sterile, 15% to 30% of collections eventually become infected, which is manifested by clinical deterioration, usually several weeks after an episode of acute pancreatitis. This patient likely has infected pancreatic necrosis. CT imaging demonstrates the presence of gas or air within the collections. Gas within necrosis is due either due to the presence of gas-forming microorganisms or fistulization into the gastrointestinal tract. This is diagnostic of infection and Fine Needle Aspiration is not required for the diagnosis of infected pancreatic necrosis. The first step in management is initiation of intravenous antibiotic therapy. In patients who fail to respond to IV antibiotic therapy alone, a step-up approach is used, which involves percutaneous or endoscopic drainage followed by minimally invasive or endoscopic necrosectomy. With the widespread utilization of minimally invasive approaches rather than traditional open necrosectomy, mortality associated with infected necrotizing pancreatitis has significantly decreased from 40%-60% to 10%-20%. Prophylactic use of antibiotics has not been shown to prevent superinfection of initially sterile pancreatic necrosis and thus is not recommended.
A 30-year-old obese female with a past medical history of cholelithiasis presents to the emergency room with progressive abdominal pain, nausea, and emesis for 2 days. While in the emergency department, she was noted to be afebrile with the following vital signs:
Her laboratory evaluation was notable for:
An abdominal ultrasound shows cholelithiasis without secondary signs of cholecystitis and a common bile duct measuring 5 mm. She is admitted for supportive management and the following day her total bilirubin is 0.6 mg/dL, lipase is 500 U/L, and her pain and nausea are significantly improved.
What is the best next step in management?
Correct Answer: B
This patient’s presentation is consistent with mild gallstone pancreatitis. After initial resuscitation, her laboratory test results improved (normalizing total bilirubin and lipase). With no evidence of ongoing biliary obstruction and no signs/symptoms of cholangitis, there is no indication to proceed with further imaging (MRCP) or ERCP. Current recommendations are for laparoscopic cholecystectomy during the same admission for patients who present with gallstone pancreatitis. This is based on the clear reduction in risk for recurrent gallstone-related events and that surgical outcomes do not differ in same admission versus delayed cholecystectomy. There is no evidence to support the use of prophylactic antibiotics in patients with gallstone pancreatitis, regardless of severity. The patient presented in this question has no evidence of ongoing or active infection to warrant antibiotic therapy.
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