A 42-year-old man comes to the emergency department with sudden-onset severe abdominal pain and 2 episodes of vomiting. He rates his pain as 9/10 in severity with radiation to the back. He has never experienced these symptoms before and has no other medical problems. The patient admits to binge drinking last night while watching a football game on television. His temperature is 37.7 C (99.9 F), blood pressure is 112/70 mm Hg, pulse is 102/min, and respirations are 16/min. There is epigastric tenderness on palpation of the abdomen but no rigidity. There is no evidence of hematemesis, and a guaiac smear is negative. Initial laboratory findings include a normal hemoglobin and leukocytosis. A chest radiograph and electrocardiogram are normal. Which of the following is the best next step in management of this patient?

Question

A 42-year-old man comes to the emergency department with sudden-onset severe abdominal pain and 2 episodes of vomiting.  He rates his pain as 9/10 in severity with radiation to the back.  He has never experienced these symptoms before and has no other medical problems.  The patient admits to binge drinking last night while watching a football game on television.  His temperature is 37.7 C (99.9 F), blood pressure is 112/70 mm Hg, pulse is 102/min, and respirations are 16/min.  There is epigastric tenderness on palpation of the abdomen but no rigidity.  There is no evidence of hematemesis, and a guaiac smear is negative.  Initial laboratory findings include a normal hemoglobin and leukocytosis.  A chest radiograph and electrocardiogram are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d19d_f6d4_bc81_c502c882f4b0_MD0003_00 This patient's recent binge drinking, severe epigastric pain radiating to his back and leukocytosis suggest acute pancreatitis. Diagnosis of acute pancreatitis requires 2 of the following criteria: acute onset of severe epigastric pain radiating to the back, increased amylase or lipase >3 times the upper limit of normal, and characteristic abdominal imaging findings (eg, focal or diffuse pancreatic enlargement). Early in pancreatitis, the pancreas synthesizes digestive enzymes but cannot secrete them. These enzymes leak out of the acinar cells into the systemic circulation. Amylase rises within 6-12 hours of symptom onset and may remain elevated for 3-5 days. Lipase rises within 4-8 hours of symptom onset but remains elevated longer than amylase (8-14 days). As a result, lipase is more useful and sensitive than amylase for diagnosis (especially in alcoholics and patients presenting later in the disease course). Imaging is not required for diagnosis in patients with typical abdominal pain and significantly elevated amylase and/or lipase. Contrast-enhanced computed tomography scan of the abdomen may be performed in patients with unclear diagnosis or in those who fail to improve with conservative management (to identify infection or necrosis). This patient has characteristic abdominal pain and would first need laboratory testing. If the diagnosis is still unclear, he may require imaging such as abdominal computed tomography scan (Choice A). (Choice B) Abdominal ultrasound may reveal a classic diffusely enlarged and hypoechoic pancreas in acute pancreatitis. However, nearly 30% of patients have an ileus with bowel gas that prevents full visualization of the pancreas and may not clearly identify inflammation or necrosis. Once the diagnosis of pancreatitis is confirmed, ultrasound may be useful to identify certain causes (eg, gallstones). (Choice C) Abdominal x-rays may be normal in mild pancreatitis or show nonspecific ileus in severe disease. In either case, they are not as useful for diagnosing acute pancreatitis. An upright chest x-ray, however, might be useful in this patient as it could show air under the diaphragm if there were suspicion for bowel perforation. (Choice D) Endoscopic retrograde cholangiopancreatography (ERCP) is not indicated for the routine diagnosis of acute pancreatitis. However, early ERCP for suspected biliary pancreatitis may decrease morbidity and mortality. ERCP is also effective for evaluating patients with recurrent pancreatitis or draining pancreatic pseudocysts. Educational objective: Uncomplicated patients with acute onset of severe epigastric pain radiating to the back and increased amylase or lipase (>3 times normal) do not need confirmatory imaging for diagnosing acute pancreatitis. Contrast-enhanced computed tomography scan of the abdomen may be performed in patients with unclear diagnosis or those who fail to improve with conservative management. Abdominal ultrasound may identify gallstones as the cause of pancreatitis. References: American College of Gastroenterology guideline: management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23896955)

A 42-Year-Old Man Comes to the Emergency Department with Sudden-Onset