A 45-year-old man comes to the clinic for follow-up 8 weeks after an episode of acute pancreatitis due to alcohol abuse. The patient initially presented with abdominal pain radiating to his back, nausea, and vomiting. His condition improved with supportive care, and the hospital course was uncomplicated. Since discharge, he reports occasional mild abdominal discomfort but otherwise feels well. His abdominal discomfort is not associated with food. He has no vomiting, diarrhea, or early satiety. The patient has stopped drinking since his last admission, but continues to smoke a pack of cigarettes a day and has done so for the last 30 years. Temperature is 36.7 C (98.2 F), blood pressure is 125/70 mm Hg, pulse is 72/min, and respirations are 16/min. On physical examination, oropharynx is without lesions, lungs are clear, and there are normal S1 and S2 without murmurs. Abdominal examination reveals fullness and mild tenderness over the epigastric area. Bowel sounds are present. There is no hepatomegaly, splenomegaly, guarding, or rebound tenderness. The remainder of the examination is normal. Laboratory results are as follows: Which of the following is the most likely cause of this patient's persistent abdominal pain?

Question

A 45-year-old man comes to the clinic for follow-up 8 weeks after an episode of acute pancreatitis due to alcohol abuse.  The patient initially presented with abdominal pain radiating to his back, nausea, and vomiting.  His condition improved with supportive care, and the hospital course was uncomplicated.  Since discharge, he reports occasional mild abdominal discomfort but otherwise feels well.  His abdominal discomfort is not associated with food.  He has no vomiting, diarrhea, or early satiety.  The patient has stopped drinking since his last admission, but continues to smoke a pack of cigarettes a day and has done so for the last 30 years.  Temperature is 36.7 C (98.2 F), blood pressure is 125/70 mm Hg, pulse is 72/min, and respirations are 16/min.  On physical examination, oropharynx is without lesions, lungs are clear, and there are normal S1 and S2 without murmurs.  Abdominal examination reveals fullness and mild tenderness over the epigastric area.  Bowel sounds are present.  There is no hepatomegaly, splenomegaly, guarding, or rebound tenderness.  The remainder of the examination is normal.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's persistent abdominal pain?

Quizplus · Accepted Answer

Explanation: This patient with mild abdominal pain, tenderness, and a slightly elevated serum lipase in the setting of recent acute pancreatitis (AP) likely has an inflammatory fluid collection (IFC). These collections occur in approximately 10% of patients after an episode of AP. The symptoms of pancreatic IFCs are largely due to their mass effects and location. As they expand they can cause abdominal pain, biliary and pancreatic duct obstruction, or fistulization into adjacent organs. They can also erode into adjacent blood vessels and result in pseudoaneurysms and gastrointestinal hemorrhage. In addition, IFCs can become superinfected, leading to signs and symptoms of intraabdominal infection (eg, fever, leukocytosis). IFCs are classified by timing (early: <4 weeks, late: >4 weeks) and the presence of a defined wall. Late, walled-off IFCs include pancreatic pseudocysts and walled-off necrosis, whereas peripancreatic fluid collections and acute necrotic collections are their early, wall-less counterparts. Given the timing since this patient's episode of AP and the uncomplicated course, pancreatic pseudocyst is the most likely cause of his condition. Management for asymptomatic or mildly symptomatic IFCs is supportive, but patients with significant symptoms should undergo surgical or endoscopic drainage.(Choice A) Although patients with pancreatic IFCs can develop biliary obstruction, stricture usually presents with postprandial epigastric pain and nausea, which this patient lacks. In addition, many patients also develop hyperbilirubinemia and elevated alkaline phosphatase. (Choice B) This patient lacks a history of complicated or necrotizing AP and has no fever or leukocytosis to suggest intraabdominal infection, which makes infected necrosis less likely than a simple pancreatic pseudocyst. (Choice C) Smoking is a significant risk factor for pancreatic adenocarcinoma, which most commonly presents with anorexia, weight loss, and fatigue, but not isolated abdominal pain. (Choice E) Splenic vein thrombosis, which frequently occurs in association with pancreatitis, may be asymptomatic or present with variceal bleeding due to isolated gastric varices, the disease's hallmark. Other manifestations include portal hypertension, ascites, and congestive splenomegaly. Educational objective: Pancreatic inflammatory fluid collections (eg, pancreatic pseudocysts) occur in approximately 10% of patients after an episode of acute pancreatitis. Symptoms are largely determined by the mass effects and location of these collections and can include abdominal pain, biliary and pancreatic duct obstruction, fistulization into adjacent organs, and gastrointestinal hemorrhage. References: Treatment of severe acute pancreatitis and its complications. (http://www.ncbi.nlm.nih.gov/pubmed/25320523) Surgical and interventional management of complications caused by acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25309073)

A 45-Year-Old Man Comes to the Clinic for Follow-Up 8