Wednesday, April 13, 2011

Intern Report Case Discussion 3.6


Case Presentation by Dr. John Wilburn


Answers: 1.b   2.a   3.d   4.a

Discussion:

This patient is suffering from gallstone pancreatitis. Gallstones are the major cause of acute pancreatitis accounting for 40% of cases. Other causes of pancreatitis include alcohol, ERCP induced, medications, metabolic, and idiopathic. Gallstone pancreatitis takes place when a stone impacts and obstructs the ampulla of vater or the pancreatic duct resulting in early activation of exocrine enzymes and auto digestion of the pancreas.  Prognosis is generally good if pancreatitis is mild and appropriately treated. Mortality of mild to moderate gallstone pancreatitis is around 10% which is a decrease in 10-15% over the past 30 years.

Severe pancreatitis is defined by local complications (pseudocyst, hemorrhage, and infection), or signs of organ damage (hypoxia, ARF, DIC, hypocalcemia <7.5). The overall mortality of severe pancreatitis is 30% which has not changed over the past 30 years.

Risk factors for gallstone pancreatitis include: female, advanced age, obesity, multiparous women, high cholesterol, alcoholism, and smoking. 

Most patients have the cardinal symptom of abdominal pain in the epigastric region, but can be in the left or right upper quadrants. Patients usually describe the pain as rapid in onset, constant steady, or boring pain increasing in intensity till it reaches a maximum. When the pain reaches pinnacle with no relief most patients seek medical attention. Patients can present with tachycardia, febrile, and elevation or depression of blood pressure.  This pain can be associated with nausea and emesis and anorexia. Patients can appear jaundiced as obstruction of the ducts causes back up in the biliary system. Most patients on physical exam are tender in the epigastric region and may have a positive Murphy sign.

Pancreatitis should always be in the differential for any patient with upper abdominal pain. The work up for pancreatitis includes cbc, metabolic panel, LFT, and lipase. There is no gold standard diagnosis of pancreatitis most experts agree that lipase is just as sensitive as amylase and has more specificity at 3x normal values. Recently experts in the United Kingdom recommend that lipase should be used for the diagnosis of pancreatitis. Amylase can still be used to diagnose pancreatitis; however it is not as specific at 3x the normal values. ALT above the level of 150IU/L is the most sensitive and specific liver enzyme for gallstone pancreatitis. If pancreatitis is diagnosed ultrasound should be conducted within the first 24 hours to either confirm or rule out gallstones as the cause. CT may also be indicated in severe pancreatitis to rule out peripancreatic complications such as pseudocyst, hemorrhage, and necrosis of pancreas.

Medical management:
Medical management of pancreatitis is usually supportive and tailored to the cause of pancreatitis with emphasis on avoiding complications.  Patients should be admitted to the hospital for intravenous fluids, pain control, antiemetic, and made NPO in the initial phase.  There should be a consult to general surgery for management, ERCP, and cholecystectomy the same hospital admission. Intravenous fluids are the most important intervention in the initial setting, some patients may require up to 6L of fluid as the inflammation leads to sequestration of fluid out of the intravascular space. Give 2-3L bolus of .9ns initially and reassess, if sufficient; place the patient on infusion at 250ml/hr normal saline. Pain control with morphine, no evidence has shown clinical difference or outcome when compared to meperidine.  Nasogastric tube is only indicated in patients with intractable emesis, severe abdominal distention and ileus. Routine use has shown no clinical benefit and has increased the number of days hospitalized. ERCP with sphincterotomy and stone extraction is indicated after the initial pain has subsided and patient clinically improves. This is usually 24-48 hours after admission; early ERCP is only indicated in severe episodes of pancreatitis not responding to conservative management or cholangitis. ERCP may actually induce pancreatitis 5% of the time and is not the definitive treatment for gallstone pancreatitis.  Studies have shown a 30-50% recurrence of gallstone pancreatitis with ERCP alone. Cholecystectomy is the definitive treatment and should be performed on the same hospital admission. Patients with severe pancreatitis require ICU admission.

There are cardiopulmonary, renal, metabolic, infectious, and hematologic complications of pancreatitis. All complications are caused by the inflammatory reaction of pancreatitis. Usually cardiopulmonary collapse due to hypotension or ARDS is the cause of death within the first week. Patients who develop ARDS have a mortality of 50-60% which is the highest of the complications in pancreatitis.

  References
Rosen’s Emergency Medicine, seventh edition, 2010, pages 1172-1183, Marx
Tintinalli’s Emergency Medicine, sixth edition, 2004, pages 573-577, Tintinalli
Uptodate, Clinical manifestation and diagnosis of acute pancreatitis, 2010, Vege
Pancreatitis, Acute, eMedicine http:emedicine.medscape.com/article/181364
Pancreatitis in Emergency Medicine, eMedicine http://emedicine.medscape.com/article/775867
Dhir, R. et al: Drug-induced pancreatitis: A practical review

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