A 38-year-old man admitted with severe, acute alcoholic pancreatitis is evaluated in the intensive care unit for persistent fever. The patient is intubated and on mechanical ventilation. He is receiving nasojejunal tube feeding and intravenous crystalloids.
His temperature is 38.3 C (101 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 18/min. Respiratory secretions are scant. Breath sounds are decreased at the lung bases. There is epigastric tenderness on deep palpation and mild abdominal distension. 2+ presacral edema is present. A peripherally inserted central catheter in the right arm shows no surrounding skin redness or discharge.
Laboratory results are as follows:

Chest x-ray reveals bilateral, small pleural effusions. A contrast-enhanced abdominal CT scan reveals 40% pancreatic necrosis and moderate-size fluid collections in the retroperitoneum around the pancreas. The gallbladder has some sludge, the common bile duct measures 5 mm, and no intrahepatic ductal dilation is seen.
Which of the following is the best next step in managing this patient?

Question

A 38-year-old man admitted with severe, acute alcoholic pancreatitis is evaluated in the intensive care unit for persistent fever.  The patient is intubated and on mechanical ventilation.  He is receiving nasojejunal tube feeding and intravenous crystalloids.
His temperature is 38.3 C (101 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 18/min.  Respiratory secretions are scant.  Breath sounds are decreased at the lung bases.  There is epigastric tenderness on deep palpation and mild abdominal distension.  2+ presacral edema is present.  A peripherally inserted central catheter in the right arm shows no surrounding skin redness or discharge.
Laboratory results are as follows:

Chest x-ray reveals bilateral, small pleural effusions.  A contrast-enhanced abdominal CT scan reveals 40% pancreatic necrosis and moderate-size fluid collections in the retroperitoneum around the pancreas.  The gallbladder has some sludge, the common bile duct measures 5 mm, and no intrahepatic ductal dilation is seen.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_96cc_1f0f_853d_c70b00370fe7_MD0002_00 This patient with severe necrotizing pancreatitis and signs of sepsis likely has infected necrosis. Infected necrosis occurs in one-third of patients with necrotizing pancreatitis and should be suspected in those who do not improve or who deteriorate clinically after a week of hospitalization. These patients may either be treated with empiric antibiotics or first undergo CT-guided aspiration with Gram stain and culture to direct antimicrobial therapy. Carbapenems (eg, imipenem, meropenem) or a combination of a quinolone and metronidazole is a recommended empiric regimen due to the coverage of gut-derived organisms and superior penetration into the pancreatic tissue (Choice A). Patients who fail to respond to antibiotics may require percutaneous or open surgical debridement of infected necrosis (eg, necrosectomy) (Choice C). (Choice B) Endoscopic retrograde cholangiopancreatography should be performed within 24 hours of admission in patients with gallstone pancreatitis and concurrent acute cholangitis, which are not evident in this patient. (Choice D) Enteral nutrition is preferred in severe, acute pancreatitis as it prevents bacterial translocation by maintaining intestinal integrity and avoids complications associated with parenteral nutrition (eg, catheter-related sepsis, venous thrombosis, embolism). Therefore, switching to parenteral nutrition is indicated only in cases of intolerance to enteral feeding. Educational objective: Infected necrosis should be suspected in patients with necrotizing pancreatitis who do not improve or who deteriorate clinically after a week of hospitalization. These patients can either be treated with empiric antibiotics (eg, carbapenem) or first undergo CT-guided aspiration to direct antimicrobial therapy. Percutaneous/open surgical debridement may be necessary in patients who fail to respond to antibiotics. __________ References: Modern management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/22341246) American College of Gastroenterology guideline: management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23896955)

A 38-Year-Old Man Admitted with Severe, Acute Alcoholic Pancreatitis Is