Case presentation(ACUTE PANCREATITIS)

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Case presentation Friday, April 08, 2011 GMSSC The One Family date MHSC 1

A 42-year-old woman presents to the emergency department complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spon- taneously within an hour or two. This time the pain did not improve, so she sought medical attention. She has no medical history and takes no medications. She is married, has three children, and does not drink alco- hol or smoke cigarette. :

A 42 -year-old woman presents to the emergency department complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals , but the episodes always resolved spon - taneously within an hour or two . This time the pain did not improve, so she sought medical attention. She has no medical history and takes no medications. She is married, has three children, and does not drink alco - hol or smoke cigarette. Friday, April 08, 2011 GMSSC The One Family date MHSC 2

ON EXAMINATION, she is afebrile, tachycardic with a heart rate of 104 bpm, blood pressure 115/74 mm Hg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. Laboratory studies are significant for a total bilirubin (9.2 g/dL) with a direct fraction of 4.8 g/dL, alkaline phosphatase 285 IU/L, aspar- tate aminotransferase (AST) 78 IU/L, alanine aminotransferase (ALT) 92 IU/L, and elevated amylase level 1249 IU/L. Her leukocyte count is 16,500/mm:

ON EXAMINATION, she is afebrile , tachycardic with a heart rate of 104 bpm , blood pressure 115/74 mm Hg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus . Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. Laboratory studies are significant for a total bilirubin (9.2 g/ dL ) with a direct fraction of 4.8 g/ dL , alkaline phosphatase 285 IU/L, aspar - tate aminotransferase (AST) 78 IU/L, alanine aminotransferase (ALT) 92 IU/L, and elevated amylase level 1249 IU/L . Her leukocyte count is 16,500/mm Friday, April 08, 2011 GMSSC The One Family date MHSC 3

A plain film of the abdomen shows a nonspecific gas pattern and no pneumoperitoneum. :

A plain film of the abdomen shows a nonspecific gas pattern and no pneumoperitoneum . Friday, April 08, 2011 GMSSC The One Family date MHSC 4

➤ What is the most likely diagnosis? A-acute pancreatitis b-acute cholecystitis c-biliary colic d-ascending cholangitis ➤ What is the most likely underlying etiology? A-choledocholitiasis b-infection c-alcohol d-trauma :

➤ What is the most likely diagnosis? A-acute pancreatitis b-acute cholecystitis c- biliary colic d-ascending cholangitis ➤ What is the most likely underlying etiology? A- choledocholitiasis b-infection c-alcohol d-trauma Friday, April 08, 2011 GMSSC The One Family date MHSC 5

What is your next diagnostic step? A-CT Abdomen b- Right upper quadrant abdominal ultrasonography. C-MRI :

What is your next diagnostic step? A-CT Abdomen b- Right upper quadrant abdominal ultrasonography . C-MRI Friday, April 08, 2011 GMSSC The One Family date MHSC 6

ANSWERS: Summary: A 42-year-old woman with a prior history consistent with sympto- matic cholelithiasis now presents with epigastric pain and nausea for 24 hours, much longer than would be expected with uncomplicated biliary colic. Her symptoms are consistent with acute pancreatitis. She also has hyperbiliru- binemia and an elevated alkaline phosphatase level, suggesting obstruction of the common bile duct caused by a gallstone, which is the likely cause of her pancreatitis.:

ANSWERS: Summary: A 42-year-old woman with a prior history consistent with sympto - matic cholelithiasis now presents with epigastric pain and nausea for 24 hours, much longer than would be expected with uncomplicated biliary colic . Her symptoms are consistent with acute pancreatitis. She also has hyperbiliru - binemia and an elevated alkaline phosphatase level, suggesting obstruction of the common bile duct caused by a gallstone, which is the likely cause of her pancreatitis . Friday, April 08, 2011 GMSSC The One Family date MHSC 7

➤ Most likely diagnosis: Acute pancreatitis. ➤ Most likely etiology: Choledocholithiasis (common bile duct stone). ➤ Next diagnostic step: Right upper quadrant abdominal ultrasonography. :

➤ Most likely diagnosis: Acute pancreatitis. ➤ Most likely etiology: Choledocholithiasis (common bile duct stone). ➤ Next diagnostic step: Right upper quadrant abdominal ultrasonography . Friday, April 08, 2011 GMSSC The One Family date MHSC 8

Considerations This 42-year-old woman complained of episodes of mild right upper quadrant abdominal pain with heavy meals in the past. These prior episodes were short- lived. This is very consistent with biliary colic. However, this episode is dif- ferent in severity and location of pain (now radiating straight to her back and accompanied by nausea and vomiting). The elevated amylase level confirms the clinical impression of acute pancreatitis. She likely has acute pancreatitis caused by a stone in the common bile duct. Biliary obstruction is suggested by the elevated bilirubin level. She is moderately ill but is hemodynamically sta- ble and has only one prognostic feature to predict mortality—her elevated white blood cell (WBC) count .She likely can be managed on a hospital ward without the need for intensive care. :

Considerations This 42-year-old woman complained of episodes of mild right upper quadrant abdominal pain with heavy meals in the past. These prior episodes were short- lived. This is very consistent with biliary colic. However, this episode is dif- ferent in severity and location of pain (now radiating straight to her back and accompanied by nausea and vomiting). The elevated amylase level confirms the clinical impression of acute pancreatitis. She likely has acute pancreatitis caused by a stone in the common bile duct. Biliary obstruction is suggested by the elevated bilirubin level. She is moderately ill but is hemodynamically sta - ble and has only one prognostic feature to predict mortality—her elevated white blood cell (WBC) count .She likely can be managed on a hospital ward without the need for intensive care. Friday, April 08, 2011 GMSSC The One Family date MHSC 9

RANSON CRITERIA FOR SEVERITY OF PANCREATITIS Initial • Age >55 years • WBC >16,000/mm3 • Serum glucose >200 • Serum lactate dehydrogenase (LDH) >350 IU/L • AST >250 IU/L :

RANSON CRITERIA FOR SEVERITY OF PANCREATITIS Initial • Age >55 years • WBC >16,000/mm3 • Serum glucose >200 • Serum lactate dehydrogenase (LDH) >350 IU/L • AST >250 IU/L Friday, April 08, 2011 GMSSC The One Family date MHSC 10

Within 48 hours of admission • Hematocrit drop >10 points • Blood urea nitrogen (BUN) rise >5 mg/dL after intravenous hydration • Arterial Po2 <60 mm Hg • Serum calcium <8 mg/dL • Base deficit >4 mEq/L • Estimated fluid sequestration of >6 L:

Within 48 hours of admission • Hematocrit drop >10 points • Blood urea nitrogen (BUN) rise >5 mg/ dL after intravenous hydration • Arterial Po2 <60 mm Hg • Serum calcium <8 mg/ dL • Base deficit >4 mEq /L • Estimated fluid sequestration of >6 L Friday, April 08, 2011 GMSSC The One Family date MHSC 11 2

CLINICAL APPROACH Acute pancreatitis can be caused by many processes, but in the United States, alcohol use is the most common cause, and episodes are often precipitated by binge drinking. The next most common cause is biliary tract disease, usually due to passage of a gallstone into the common bile duct. Hypertriglyceridemia is another common cause and occurs when serum triglyceride levels are more than 1000 mg/dL, as is seen in patients with familial dyslipidemias or diabetes (etiologies are given in Table 14–2). When patients appear to have “idiopathic” pancreatitis, that is, no gallstones are seen on ultrasonography and no other pre- disposing factor can be found, biliary tract disease is still the most likely cause— either biliary sludge (microlithiasis) or sphincter of Oddi dysfunction.:

CLINICAL APPROACH Acute pancreatitis can be caused by many processes, but in the United States, alcohol use is the most common cause, and episodes are often precipitated by binge drinking. The next most common cause is biliary tract disease, usually due to passage of a gallstone into the common bile duct. Hypertriglyceridemia is another common cause and occurs when serum triglyceride levels are more than 1000 mg/ dL , as is seen in patients with familial dyslipidemias or diabetes (etiologies are given in Table 14–2 ). When patients appear to have “idiopathic” pancreatitis, that is, no gallstones are seen on ultrasonography and no other pre- disposing factor can be found, biliary tract disease is still the most likely cause— either biliary sludge ( microlithiasis ) or sphincter of Oddi dysfunction . Friday, April 08, 2011 GMSSC The One Family date MHSC 12

Abdominal pain is the cardinal symptom of pancreatitis and often is severe, typically in the upper abdomen with radiation to the back. The pain often is relieved by sitting up and bending forward, and is exacerbated by food. Patients commonly experience nausea and vomiting that is precipitated by oral intake. They may have low-grade fever (if temperature is >101°F, one should suspect infection) and often are volume depleted because of the vomiting, inability to tolerate oral intake, and because the inflammatory process may cause third spac- ing with sequestration of large volumes of fluid in the peritoneal cavity.:

Abdominal pain is the cardinal symptom of pancreatitis and often is severe, typically in the upper abdomen with radiation to the back. The pain often is relieved by sitting up and bending forward, and is exacerbated by food. Patients commonly experience nausea and vomiting that is precipitated by oral intake. They may have low-grade fever (if temperature is >101°F, one should suspect infection) and often are volume depleted because of the vomiting, inability to tolerate oral intake, and because the inflammatory process may cause third spac - ing with sequestration of large volumes of fluid in the peritoneal cavity. Friday, April 08, 2011 GMSSC The One Family date MHSC 13

The most common test used to diagnose pancreatitis is an elevated serum amylase level. It is released from the inflamed pancreas within hours of the attack and remains elevated for 3 to 4 days. Amylase undergoes renal clearance, and after serum levels decline, its level remains elevated in the urine. Amylase is not specific to the pancreas, however, and can be elevated as a consequence of many other abdominal processes, such as gastrointestinal ischemia with infarction or perforation; even just the vomiting associated with pancreatitis can cause elevated amylase of salivary origin. Elevated serum lipase level, also seen in acute pancreatitis, is more specific than is amylase to pancreatic origin and remains elevated longer than does amylase. When the diagnosis is uncer- tain or when complications of pancreatitis are suspected, computed tomo- graphic (CT) imaging of the abdomen is highly sensitive for showing the inflammatory changes in patients with moderate to severe pancreatitis.:

The most common test used to diagnose pancreatitis is an elevated serum amylase level . It is released from the inflamed pancreas within hours of the attack and remains elevated for 3 to 4 days . Amylase undergoes renal clearance, and after serum levels decline, its level remains elevated in the urine. Amylase is not specific to the pancreas, however, and can be elevated as a consequence of many other abdominal processes, such as gastrointestinal ischemia with infarction or perforation; even just the vomiting associated with pancreatitis can cause elevated amylase of salivary origin. Elevated serum lipase level , also seen in acute pancreatitis, is more specific than is amylase to pancreatic origin and remains elevated longer than does amylase. When the diagnosis is uncer - tain or when complications of pancreatitis are suspected , computed tomo - graphic (CT) imaging of the abdomen is highly sensitive for showing the inflammatory changes in patients with moderate to severe pancreatitis . Friday, April 08, 2011 GMSSC The One Family date MHSC 14

TREATMENT of pancreatitis is mainly supportive and includes “pancreatic rest,” that is, withholding food or liquids by mouth until symptoms subside and adequate narcotic analgesia, usually with meperidine. Intravenous fluids are necessary for maintenance and to replace any deficits. In patients with severe pancreatitis who sequester large volumes of fluid in their abdomen as pancreatic ascites, sometimes prodigious amounts of parenteral fluid replace- ment are necessary to maintain intravascular volume. Patients with adynamic ileus and abdominal distention or protracted vomiting may benefit from naso- gastric suction. When pain has largely subsided and the patient has bowel sounds, oral clear liquids can be started and the diet advanced as tolerated.:

TREATMENT of pancreatitis is mainly supportive and includes “ pancreatic rest ,” that is, withholding food or liquids by mouth until symptoms subside and adequate narcotic analgesia, usually with meperidine . Intravenous fluids are necessary for maintenance and to replace any deficits. In patients with severe pancreatitis who sequester large volumes of fluid in their abdomen as pancreatic ascites , sometimes prodigious amounts of parenteral fluid replace- ment are necessary to maintain intravascular volume. Patients with adynamic ileus and abdominal distention or protracted vomiting may benefit from naso - gastric suction. When pain has largely subsided and the patient has bowel sounds, oral clear liquids can be started and the diet advanced as tolerated. Friday, April 08, 2011 GMSSC The One Family date MHSC 15

CLINICAL CASES The large majority of patients with acute pancreatitis will recover sponta- neously and have a relatively uncomplicated course. Several criteria have been developed in an attempt to identify the 15% to 25% of patients who will have a more complicated course. These include the Ranson (United States) and Glasgow/Imrie (United Kingdom) criteria, as well as the APACHE (Acute Physiology and Chronic Health Evaluation) II scoring system. When three or more of the following criteria are present, a severe course complicated by pan- creatic necrosis can be predicted by Ranson criteria). The most common cause of early death in patients with pancreatitis is hypovolemic shock, which is multifactorial: third spacing and sequestration of large fluid volumes in the abdomen, as well as increased capillary permeability. Others develop pulmonary edema, which may be noncardiogenic as a consequence of acute respiratory distress syndrome (ARDS), or cardiogenic as a consequence of myocardial dysfunction. :

CLINICAL CASES The large majority of patients with acute pancreatitis will recover sponta - neously and have a relatively uncomplicated course. Several criteria have been developed in an attempt to identify the 15% to 25% of patients who will have a more complicated course. These include the Ranson (United States) and Glasgow/ Imrie (United Kingdom) criteria, as well as the APACHE (Acute Physiology and Chronic Health Evaluation) II scoring system. When three or more of the following criteria are present, a severe course complicated by pan- creatic necrosis can be predicted by Ranson criteria). The most common cause of early death in patients with pancreatitis is hypovolemic shock, which is multifactorial : third spacing and sequestration of large fluid volumes in the abdomen, as well as increased capillary permeability. Others develop pulmonary edema, which may be noncardiogenic as a consequence of acute respiratory distress syndrome (ARDS), or cardiogenic as a consequence of myocardial dysfunction. Friday, April 08, 2011 GMSSC The One Family date MHSC 16

PANCREATIC COMPLICATIONS include a phlegmon, which is a solid mass of inflamed pancreas, often with patchy areas of necrosis. Sometimes, extensive areas of pancreatic necrosis develop within a phlegmon. Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis. If pancreatic abscesses are not drained, mortality approaches 100%. Pancreatic necrosis and abscess are the leading causes of death in patients after the first week of illness. A pancreatic pseudo- cyst is a cystic collection of inflammatory fluid and pancreatic secretions, which unlike true cysts do not have an epithelial lining. Most pancreatic pseudocysts resolve spontaneously within 6 weeks, especially if they are smaller than 6 cm. However, if they are causing pain, are large or expanding, or become infected, they usually require drainage. Any of these local complications of pancreatitis should be suspected IF PERSISTENT PAIN, FEVER, ABDOMINAL MASS, OR PERSISTENT HYPERAMYLASEMIA OCCURS.:

PANCREATIC COMPLICATIONS include a phlegmon , which is a solid mass of inflamed pancreas, often with patchy areas of necrosis. Sometimes, extensive areas of pancreatic necrosis develop within a phlegmon . Either necrosis or a phlegmon can become secondarily infected, resulting in pancreatic abscess. Abscesses typically develop 2 to 3 weeks after the onset of illness and should be suspected if there is fever or leukocytosis . If pancreatic abscesses are not drained, mortality approaches 100%. Pancreatic necrosis and abscess are the leading causes of death in patients after the first week of illness. A pancreatic pseudo- cyst is a cystic collection of inflammatory fluid and pancreatic secretions, which unlike true cysts do not have an epithelial lining. Most pancreatic pseudocysts resolve spontaneously within 6 weeks, especially if they are smaller than 6 cm. However, if they are causing pain, are large or expanding, or become infected, they usually require drainage. Any of these local complications of pancreatitis should be suspected IF PERSISTENT PAIN, FEVER, ABDOMINAL MASS, OR PERSISTENT HYPERAMYLASEMIA OCCURS . Friday, April 08, 2011 GMSSC The One Family date MHSC 17

A 43-year-old man who is an alcoholic is admitted to the hospital with acute pancreatitis. He is given intravenous hydration and is placed NPO. Which of the following findings is a poor prognostic sign? A. His age B. Initial serum glucose level of 60 mg/dL C. Blood urea nitrogen (BUN) level rises 7 mg/dL over 48 hours D. Hematocrit drops 3% With Amylase level of 1000 IU/L:

A 43-year-old man who is an alcoholic is admitted to the hospital with acute pancreatitis. He is given intravenous hydration and is placed NPO. Which of the following findings is a poor prognostic sign? A. His age B. Initial serum glucose level of 60 mg/ dL C. Blood urea nitrogen (BUN) level rises 7 mg/ dL over 48 hours D. Hematocrit drops 3% With Amylase level of 1000 IU/L Friday, April 08, 2011 GMSSC The One Family date MHSC 18

C. When the BUN rises by 5 mg/dL after 48 hours despite IV hydra- tion, it is a poor prognostic sign. Notably, the amylase level does not correlate to the severity of the disease. An elevated serum glucose would be a poor prognostic factor. A drop of hematocrit of at least 10% is a significant poor prognostic criteria.:

C. When the BUN rises by 5 mg/ dL after 48 hours despite IV hydra- tion , it is a poor prognostic sign. Notably, the amylase level does not correlate to the severity of the disease. An elevated serum glucose would be a poor prognostic factor. A drop of hematocrit of at least 10% is a significant poor prognostic criteria . Friday, April 08, 2011 GMSSC The One Family date MHSC 19

A 45-year-old man was admitted for acute pancreatitis, thought to be a result of blunt abdominal trauma. After 3 months he still has epigastric pain but is able to eat solid food. His amylase level is elevated at 260 IU/L. Which of the following is the most likely diagnosis? A. Recurrent pancreatitis B. Diverticulitis C. Peptic ulcer disease D. Pancreatic pseudocyst:

A 45-year-old man was admitted for acute pancreatitis, thought to be a result of blunt abdominal trauma. After 3 months he still has epigastric pain but is able to eat solid food. His amylase level is elevated at 260 IU/L. Which of the following is the most likely diagnosis? A. Recurrent pancreatitis B. Diverticulitis C. Peptic ulcer disease D. Pancreatic pseudocyst Friday, April 08, 2011 GMSSC The One Family date MHSC 20

D. A pancreatic pseudocyst has a clinical presentation of abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis.:

D. A pancreatic pseudocyst has a clinical presentation of abdominal pain and mass and persistent hyperamylasemia in a patient with prior pancreatitis. Friday, April 08, 2011 GMSSC The One Family date MHSC 21

Magic shots: ➤ The most common causes of acute pancreatitis in the United States are alcohol consumption, gallstones, and hypertriglyceridemia. ➤ Acute pancreatitis usually is managed with pancreatic rest, intravenous hydration, and analgesia, often with narcotics. ➤ Patients with pancreatitis who have zero to two of the Ranson criteria are expected to have a mild course; those with three or more criteria can have significant mortality. ➤ Pancreatic complications (phlegmon, necrosis, abscess, pseudocyst) should be suspected if persistent pain, fever, abdominal mass, or persistent hyperamylasemia occurs. :

Magic shots: ➤ The most common causes of acute pancreatitis in the United States are alcohol consumption, gallstones, and hypertriglyceridemia . ➤ Acute pancreatitis usually is managed with pancreatic rest, intravenous hydration, and analgesia, often with narcotics. ➤ Patients with pancreatitis who have zero to two of the Ranson criteria are expected to have a mild course; those with three or more criteria can have significant mortality. ➤ Pancreatic complications ( phlegmon , necrosis, abscess, pseudocyst ) should be suspected if persistent pain, fever, abdominal mass, or persistent hyperamylasemia occurs. Friday, April 08, 2011 GMSSC The One Family date MHSC 22

REFERENCES Ahmed A, Cheung RC, Keefe EB. Management of gallstones and their complications. Am Fam Physician. 2000;61:1673-1680. Greenberger NJ, Paumgartner G. Diseases of the gallbladder and bile ducts. In: Braunwald E, Fauci AS, Kasper KL, et al. eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008:1991-2001. Greenberger NJ, Toskes PP. Acute and chronic pancreatitis. In: Braunwald E, Fauci AS, Kasper KL, et al. eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008:2005-2017. Tenner S. Initial management of acute pancreatitis: critical issues during the first 72 hours. Am J Gastroenterol. 2004;99:2489-2494.:

REFERENCES Ahmed A, Cheung RC, Keefe EB. Management of gallstones and their complications. Am Fam Physician. 2000;61:1673-1680. Greenberger NJ, Paumgartner G. Diseases of the gallbladder and bile ducts. In: Braunwald E, Fauci AS, Kasper KL, et al. eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008:1991-2001. Greenberger NJ, Toskes PP. Acute and chronic pancreatitis. In: Braunwald E, Fauci AS, Kasper KL, et al. eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008:2005-2017. Tenner S. Initial management of acute pancreatitis: critical issues during the first 72 hours. Am J Gastroenterol . 2004;99:2489-2494. Friday, April 08, 2011 GMSSC The One Family date MHSC 23

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