Acute Necrotizing Pancreatitis
Patient presentation:
N.D. is a 24 y/o male who presented to a local ER on a Sunday with severe abdominal pain radiating to his back and was unable to localize the pain. The patient rated his pain consistently as 10/10 and described the pain as piercing and “knifelike” with no relief. The patient was also experiencing nausea and vomiting with no diarrhea. The patient stated that the pain came on suddenly, late the previous night. Pt. reports that he felt like he has a fever and chills, but has not taken his temperature. Pt. reports that he is an alcoholic and has been drinking heavily for the last week. Pt. reports that over the weekend he was drinking “a lot” of vodka, but was unsure of precisely how much. Pt. is agitated and diaphoretic. Abdomen is distended and firm. VS- HR 120-NSR w/12 lead, BP- 90/56, RR-29, Temp-38.8 oral, Pulse 88, with no O2. Pt. was placed on 2L O2, ABG obtained, CMP, Amylase, Lipase, CBC, Liver Panel ordered. A CT of the abdomen was also ordered.
Differential list:
Acute Pancreatitis, Bowel obstruction, Acute Cholecystitis, Peptic Ulcer disease, MI
Diagnosis:
Serum amylase 625 U/L, serum lipase 1295. In addition, blood work revealed leukocytosis, hyperglycemia, elevated alkaline phosphatases, conjugated bilirubin, and GGT. CT scan revealed pancreatic fluid collection and suggested pancreatic necrosis. CT scan results revealed mild to severe acute necrotizing pancreatitis.
Acute pancreatitis is a severe inflammation of the pancreas and the cause can be varied. The most common causes of acute pancreatitis is gallstones and toxins - specifically ETOH. The exact mechanism of acute pancreatitis is not well understood, however it is commonly explained that there is a disruption of pancreatic cells that leads to leakage of pancreatic enzymes, causing autodigestion of pancreatic tissue. The release of the enzymes causes tissue damage leading to inflammation, edema, hemorrhage, necrosis and fibrosis.
Treatment:
N.D. was admitted to the ICU where he was monitored closely for signs of sepsis. His hypotension and respiratory status were also closely monitored. Treatment is often supportive and focuses on stopping the process of autodigestion and systemic complications. N.D’s pain was managed with morphine. NG tube was placed to low continuous wall suction to prevent paralytic ileus. The pt. was NPO for a significant period of time to decrease stimulation of the pancreas. He was placed on parenteral nutrition and IVF of normal saline was initiated to maintain hydration and prevent kidney damage. IV antibiotics Imipenem 500 mg IV q 6 hr for phrophylaxis. Serial labs, including ABG, were ordered every 8 hours to assess the need for electrolyte replacement and to monitor hemodynamic and respiratory status. The patient was placed on alcohol withdrawal protocol to manage his symptoms and increased agitation.
Outcome:
The patient left the ICU within 3 days after stabilizing and completing withdrawal. He was discharged from the hospital with no need for surgical intervention after a 12 day hospital stay.
Case created by Nadine Zakhour Diliberto, 2010.