A 42-year-old woman with a history of chronic alcoholism comes to the emergency department due to 2 days of severe abdominal pain. She describes the pain as sharp, nonradiating, and located in the center of her abdomen. The patient also reports nausea and several episodes of vomiting. Medical history is significant for type 2 diabetes mellitus and asthma. Medications include metformin, sitagliptin, and inhaled albuterol. For the last 2 years she has drunk 2 or 3 pints of alcohol at a time, several times a week. The patient smokes a pack of cigarettes a day and occasionally uses cocaine. Family history is not significant. Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, pulse is 92/min, and respirations are 16/min. Oxygen saturation is 96% on room air. BMI is 27 kg/m². Physical examination shows dry mucous membranes, normal jugular venous pressure, clear lung fields, and normal S1 and S2. The abdomen is soft and tender in the midepigastric region without hepatosplenomegaly. Bowel sounds are present. There is no rebound tenderness, rigidity, or costovertebral angle tenderness, and no peripheral edema. Neurologic examination is within normal limits. Laboratory results are as follows: Abdominal ultrasound reveals no gallstones or pericholecystic fluid collection. The pancreas is not well visualized. Which of the following is the best predictor for the severity of this patient's disease?

Question

Quizplus · Accepted Answer

Explanation: This patient's presentation is consistent with acute alcoholic pancreatitis (abdominal pain, elevated lipase, history of heavy alcohol use). The severity of acute pancreatitis (AP) can vary widely, and clinical judgment alone has been shown to be a poor predictor. As a result, a comprehensive approach to disease assessment is important, as patients with severe AP require more intensive monitoring and therapy than patients with mild disease. One of the earliest systems, Ranson criteria, involves 11 different criteria, some of which cannot be calculated until 48 hours after admission, and has been found to be a poor predictor of severity. Other systems have improved predictive characteristics, although they can also be cumbersome to apply, such as the APACHE II score, systemic inflammatory response syndrome (SIRS) score, and bedside index for severity in AP (BISAP) score. The most frequently evaluated single-item predictors that have been found to correlate with severity include older age, obesity, hematocrit, C-reactive protein, and blood urea nitrogen (BUN). An elevated hematocrit (>44%) on admission is predictive of more severe disease, as it reflects greater hemoconcentration from third-space losses. Similarly, a BUN >20 mg/dL at the time of admission is associated with an increased risk of death. In addition, increases in BUN on serial measurement are associated with worse outcomes. An elevated C-reactive protein level (>150 mg/dL), which rises more slowly than BUN or other acute markers (eg, hematocrit), has also been shown to correlate with severe AP 24-48 hours after admission. (Choice A) Aspartate aminotransferase (AST) level >250 U/L is one of the Ranson criteria for AP severity; this patient's AST level does not meet this cutoff. (Choice C) A BMI >30 kg/m² has been associated with an increased risk for severe AP, local and systemic complications, and death. (Choice D) Serum lipase is typically not used to predict severity of AP; however, levels >1,000 U/L in adults or >7 times the upper limit of normal in children have been associated with worse outcomes. (Choice E) Although an elevated serum triglyceride level >1,000 mg/dL is associated with an increased risk of AP, triglyceride levels are not associated with disease severity. Educational objective: The severity of acute pancreatitis can vary widely, and clinical judgment alone has been shown to be a poor predictor. A comprehensive approach to disease assessment is important and can include scoring systems, such as the APACHE II score and the systemic inflammatory response syndrome (SIRS) score, or single-item predictors such as hematocrit or blood urea nitrogen. References: Advances in prognostic factors in acute pancreatitis: a mini-review. (http://www.ncbi.nlm.nih.gov/pubmed/20943456) IAP/APA evidence-based guidelines for the management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/24054878)

A 42-Year-Old Woman with a History of Chronic Alcoholism Comes