Setting: ED
CC: “My stomach hurts and I am vomiting.”
VS: BP: 92/60 mm Hg; P: 124 beats/minute; T: 101.5°F; R: 22 breaths/minute
HPI: A 45-year-old woman comes to the ED with 2 days of abdominal pain and 1 day of increasingly severe nausea and vomiting. She has never had this before. The pain makes it difficult for her to find a comfortable position in the bed and she is trying to hold herself still. Vomiting has bile but no blood. Pain is described as “sore,” “dull,” and very severe.
PMHX: obesity; denies significant alcohol use
Medications: none
PE:
General: obese woman lying still, uncomfortable
Abdomen: severe midepigastric tenderness; some guarding; not rigid
Initial Orders:
Amylase, lipase
CBC
CHEM-20
NPO (nil per os or no eating)
IV NS: high volume
IV hydromorphone (Dilaudid)
• Pancreatitis causes fever.
• Most deaths from pancreatitis are from inadequate fluid resuscitation.
Which cause of pancreatitis is increasing in incidence the most?
a. Alcohol
b. Gallstones
c. Trauma
d. Drug induced
e. Cancer
Answer b. Gallstones
The incidence of gallstones is markedly increasing. Gallstones leave the gallbladder and get stuck in the ductal system at the point where they can block the pancreatic duct. Any stone, stricture, tumor, or obstruction can cause pancreatitis. Greater obesity increases the incidence of gallstones.
Obesity = Cholesterol = Gallstones
IV fluids are started in high volume. Pain medications are given and the clock is moved forward to obtain the laboratory test results.
On CCS, acute pancreatitis should be treated as an assessment for possible ICU placement until you know that BP and pulse rate are stable. Reexamine the patient and repeat the vital signs in 30 minutes and again in 1 hour until you know the patient is stable.
• Massive amounts of intravascular fluid leaks into tissues.
• Inflammatory mediators in pancreatitis cause a massive capillary leak.
Repeat VS in 30 minutes: BP: 96/62 mm Hg; P: 118 beats/minute; T: 101.5°F; R: 18 breaths/minute
Amylase 850 units/L (elevated)
Lipase 754 units/L (elevated)
CBC: WBC 15,500/μL
CHEM-20: normal bilirubin; normal lactate dehydrogenase (LDH); normal AST
Pain can cause tachycardia and hyperventilation.
Pancreatitis increases the WBC count because of inflammation.
An abdominal US is performed to determine the etiology of the pancreatitis. You do not need to do a US to prove there is pancreatitis. The presence of pain, nausea, vomiting, tenderness, and high amylase/lipase prove the presence of pancreatitis. The sonogram is to detect stones in the ducts and gallbladder.
Orders:
Abdominal US
Triglyceride level
Calcium
Oximeter
Pancreatitis causes hypoxia by capillary leak in the lungs (acute respiratory distress syndrome [ARDS]).
Move the clock forward 4 hours.
VS: BP: 100/70 mm Hg; P: 114 beats/minute
Report:
Abdominal US: stones in gallbladder; dilated pancreatic duct, no stone in duct
Triglyceride level: 445 mg/dL
Calcium: normal
Oximeter: 97% on room air
Triglycerides >1000 mg/dL cause pancreatitis.
High calcium level causes pancreatitis.
Pancreatitis causes low calcium level.
1. Dead Pancreas = Malabsorption of Fat
2. Fat in the bowel binds calcium in the bowel.
3. Calcium bound in the bowel decreases blood calcium.
What is the utility of a CT scan in this patient?
a. Confirm the severity of the ductal obstruction.
b. Look for pancreatic necrosis.
c. Confirm the diagnosis of infected necrotic pancreatitis.
d. Determine the severity of disease.
Answer b. Look for pancreatic necrosis.
Pancreatic necrosis easily becomes infected. You must give antibiotics such as imipenem or meropenem if there is necrosis before it becomes infected. You are doing the CT scan to see if there is >30% necrosis. If there is >30% necrosis, give imipenem or meropenem and do a CT-guided biopsy. If there is necrosis that is already infected, the pancreas must be surgically debrided.
No test can determine the severity of pancreatitis disease in the first 48 hours of presentation of acute pancreatitis. No radiologic test can tell that the pancreatitis is infected. Only a needle biopsy by CT guidance can do that.
More than 30% Necrosis of Pancreas = Antibiotics and Needle Biopsy Infected Necrotic Pancreatitis = Surgical Debridement
No radiologic test can determine infection.
IV fluids and pain medication continue for the patient. The abdominal CT shows pancreatitis and gallstones in the gallbladder. The CT does not show necrosis of the pancreas and no stones are seen in the ductal system. There is currently no ductal dilation.
By the end of the second hospital day, the patient’s BP is 110/74 mm Hg and his pulse rate is 90 beats/minute.
Interval History:
Pain and nausea have improved considerably.
Which of the following is most likely to benefit this patient?
a. NG tube placement
b. MRCP
c. Endoscopic retrograde cholangiopancreatography (ERCP)
d. Surgical evaluation for cholecystectomy
Answer d. Surgical evaluation for cholecystectomy
Even though the ducts are not currently dilated, the cause of pancreatitis in this patient is a stone that caused obstruction and passed. You need to get the rest of the stones out of there before another obstruction occurs.
An NG tube is useless in acute pancreatitis. MRCP and ERCP are not needed if there is no evidence of ductal dilation.
The obstruction is assessed and treated. After the acute episode of pancreatitis has resolved and the gallbladder is removed, you should expect the case to end.