Presentation of case study on the presentation, etiology and management of acute pancreatitis.
Slides compiled as part of medical school studies.
Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.
2. History
A 33-year-old white man presents to the
Emergency Department 4 hours ago with
acute epigastric pain and nausea and
vomiting of 24 hours durations.
He is obviously uncomfortable, twisting
on the gurney trying to get comfortable.
3. On examination
Vitals:
temperature 37.2oC (98.9oF)
HR 130/min
RR 22/min
BP 124/72mmHg
SpO2 90% on room air.
The patient has epigastric tenderness on
physical examination, but no peritoneal signs.
4. On examination
The cardiac examination is normal, but
the patient has mild bibasilar rales.
Right upper quadrant ultrasonography
shows no biliary tract obstruction.
He has had no recent infections.
The patient received 4 liters of fluid before
your arrival. His urine output has been
120mL since his arrival in the emergency
department.
7. Pancreatitis
Localised pain with nausea/vomiting
Rapid HR (130bpm)
Rapid RR (22/min)
increase in urination and low BP (hypovolemia)
No established history of personal or familial GI
disease
9. Pancreatitis
The patient has early signs of severe
acute peritonitis
Severe disease occurs in about 15% of
patients with pancreatitis
10. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
At presentation
Age > 55 years
Leukocyte count > 16000/mL
Blood glucose > 200 mg/dL
Lactate dehydrogenase > 350 U/L
Aspartate aminotransferase > 250 U/L
11. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
At presentation
Age > 55 years
Leukocyte count > 16000/mL
Blood glucose > 200 mg/dL
Lactate dehydrogenase > 350 U/L
Aspartate aminotransferase > 250 U/L
12. Patient possessing three or more of these
criteria have a worse prognosis
This patient had:
Hyperglycemia (Blood glucose 204 mg/dL)
Elevated Lactate dehydrogenase (453 U/L)
Leukocytosis (18,000/mL )
13. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
At 48 hours
Hematocrit – decrease by 10%
Blood urea nitrogen – increase by 5 mg/dl
Calcium < 8mg/dl
PaO2 < 60 mmHg
Base deficit > 4 meq/L
Fluid sequestration > 6000 mL
14. He also had:
Hypoxemia (PaO2 59 mmHg; oxygen saturation of
90%)
Examination signs of possible noncardiogenic
pulmonary edema (The cardiac examination is
normal, but the patient has mild bibasilar rales)
Tachycardia (pulse rate of 130/min)
Oliguria (urine output 120 mL/4 hours) – despite
vigorous intravenous hydration (patient received 4
liters of fluid)
These factors also portend a worse prognosis
15. QUESTION 1
The most likely reason for this patient’s
pancreatic symptoms is:
Gallstone pancreatitis
Alcoholic pancreatitis
Infectious pancreatitis
autoimmune pancreatitis
16. Pancreatitis
The most common causes of acute pancreatitis are
Alcohol ingestion
Biliary tract disease
In this patient the lack of
dilated ducts
Cholelithiasis
elevated alkaline phosphatase
as well as
normal bilirubin
Makes gallstone pancreatitis unlikely
17. Pancreatitis
Infectious pancreatitis can be caused by viral illnesses
or bacteria such as
Mycoplasma
Campylobacter
Mycobacterium avium complex
(In this patient) without a history of antecedent
infection, this would be unlikely
Although connective tissue disease with vasculitis,
such as systemic lupus erythematosus, can cause
pancreatitis, this patient has no symptoms, examination
findings, or laboratory studies making this diagnosis
unlikely
18. QUESTION 1
The most likely case of this patient’s
problem is:
Gallstone pancreatitis
Alcoholic pancreatitis
Infectious pancreatitis
autoimmune pancreatitis
19. QUESTION 2
The most appropriate therapy for this patient
would be:
1. Aggressive fluid resuscitation, bowel rest,
monitoring in the intensive care unit, and analgesics
2. Aggressive fluid resuscitation, nasogastric
suction, bowel rest, and ward hospitalisation
3. Analgesic mediaction and outpatient follow-up the
next day
4. Immediate gastroenterology consultation for
endoscopic retrograde cholangiopancreatography
(ERCP)
20. Admission to the intensive care unit
is appropriate because of the high
likelihood of multiorgan dysfunction