Pancreatitis Case Based Presentation



Pancreatitis Case Based Presentation

Case Presentation and Questions:

Question assignments:

Todd – Questions 1, 7, 13

Noemie – Questions 2, 8, 14

Neil – Questions 3, 9, 15

Marios – Questions 4, 10

Naisan – Questions 5, 11

Yoan – Questions 6, 12, 16

The patient is a 25-year-old obese woman with a history of non-insulin-dependent diabetes mellitus (NIDDM) and hypercholesterolemia who presents to the emergency department for evaluation of the acute onset of abdominal pain. The patient describes the pain, which she says began 12 hours before her evaluation, as a constant epigastric cramping associated with nausea and vomiting. She denies fever, chills, change in bowel habits, or alteration in the character of her stool or urine. The patient's past medical history is significant for obesity, NIDDM, hypercholesterolemia, and depression. She is uncertain of the names of the oral hypoglycemic and antilipidemic drugs that had been prescribed to her. She does not use tobacco or alcohol. There has been no recent travel. Laboratory studies performed 3 months before her admission revealed an elevated cholesterol level of 15.44 mmol/L, with an HDL level of 1.09 mmol/L, and an elevated triglyceride level of 34.27 mmol/L.

The physical examination is significant for morbid obesity (weight, 301 lb); temperature, 37°C; blood pressure, 100/50; pulse, 110/min; respiratory rate, 16/min; regular heart rate; clear lungs on auscultation; and a diffusely tender abdomen without rebound or guarding. The stool is guaiac negative.

|Laboratory studies: |

|White blood cell count |11.6 x 103 |

|Hemoglobin |137 g/L |

|Hematocrit |40.4% |

|Sodium |135 mmol/L |

|Potassium |4 mmol/L |

|Chloride |101 mmol/L |

|Bicarbonate |11.2 mmol/L |

|Blood urea nitrogen |2.5 mmol/L |

|Creatinine |0.062 mol/L |

|Calcium |1.82 mmol/L |

|Glucose |12.16 mmol/L |

|Albumin |39.4 mmol/L |

|Amylase |222 U/L |

|Lipase |5562 U/L |

|Aspartate aminotransferase (AST) |48 U/L |

|Alanine aminotransferase (ALT) |28 U/L |

|Alkaline phosphatase |88 U/L |

|Total bilirubin |14 mcmol/L |

|Cholesterol |20.28 mmol/L |

|Triglycerides |59.29 mg/dL |

An abdominal ultrasound reveals no gallstones and normal biliary ducts. Figure 1 depicts the patient's serum compared to normal serum. Figure 2 depicts an abdominal CT scan.

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Figure 1

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Figure 2

1. What is the diagnosis? Define severe acute pancreatitis (SAP). Todd

2. What are the most common etiologies of SAP in developed countries? How about in North America (i.e. the USA)? What are some other causes of pancreatitis? What is the most likely cause in this patient? Noemie

3. What is the pathogenesis of SAP? Neil

4. How is pancreatitis diagnosed? What are the roles and timing of amylase and lipase elevation, and how do they differ depending on the underlying etiology? What is the role and appropriate role and timing of imaging? Marios

5. What are some of the prognostic scoring systems used to predict severity of pancreatitis? Please discuss both clinical and radiographic scoring systems, but focus on those that are clinically relevant and useful for an intensivist. Naisan

6. What is the appropriate initial management approach for a patient with SAP? Yoan

7. When should the patient with SAP be monitored in an ICU or step-down unit? Todd

The patient was admitted to the intensive care unit and was treated with intravenous fluids, narcotic analgesia, and insulin for her diabetes. Twenty-four hours after admission, the patient was noted to be tachypneic and dyspneic, requiring oxygen administration.

8. What is the frequency of lung injury in SAP? What is the proposed mechanism? Discuss the main preventive and therapeutic strategies. Noemie

Forty-eight hours after admission, the patient was found to have marked hypocalcemia (calcium, 2.8 mg/dL) and hypophosphatemia (phosphorus, 1.6 mg/dL), requiring supplementation. On rounds, you need to make a decision on nutrition, as the patient has not yet been fed.

9. What is the etiology of the hypocalcemia and hypophosphatemia? Neil

10. What is the optimal mode and timing of nutritional support for the patient with SAP? Are there any specific nutritional supplements that are beneficial in SAP? Are probiotics useful? Marios

On the seventh hospital day, the patient develops a leukocytosis (white blood cell count, 13.35 x 103) with 32% bands. Panculturing is performed. You are concerned about the possibility of a secondary pancreatic infection.

11. What is the frequency of infectious complication in SAP? What is the impact on prognosis? Naisan

12. Should patients with SAP receive prophylactic antibiotics? What is the evidence? What about selective decontamination of the digestive tract (SDD)? Yoan

Cultures all come back negative, and the empiric antibiotic therapy you initiated is discontinued. A repeat abdominal CT scan reveals worsening phlegmonous changes of the pancreas. The WBC continues to rise, as do the lipase and amylase.

13. What are the indications for surgery in acute pancreatitis and what is the optimal timing for intervention? What are the roles for less invasive approaches, including percutaneous drainage and laparoscopy? Are there any specific approaches that need to be considered with this etiology? Todd

14. Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? Noemie

15. Is there a role for therapy targeting the inflammatory response in patients with SAP? Neil

The patient's abdominal pain and laboratory values stabilize and improve slightly with medical management, and surgical intervention is withheld. However, on day 11, the patient’s hemoglobin drops to 85 from 110 the day before.

16. List at least 4 potential causes of GI bleeding in SAP. Which are most common; which are least? Yoan

During the remainder of her hospitalization, the patient's abdominal pain and laboratory values continue to improve. She recovers with conservative medical management and does not require surgical intervention.On hospital day 20, the patient is discharged in good condition. She is followed by her primary care physician and is compliant with gemfibrozil therapy and continues without reported recurrent episodes of pancreatitis for more than 1 year.

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