A 67-year-old man comes to the hospital with acute-onset upper abdominal pain associated with nausea and vomiting. The patient was discharged 24 hours earlier after he underwent elective coronary angiography and stent placement due to left circumflex artery stenosis. He has been taking his prescribed medications and reports no chest pain, shortness of breath, or flank pain. His other medical problems include type 2 diabetes, hypertension, hypercholesterolemia, and peripheral vascular disease. The patient does not use tobacco, alcohol, or illicit drugs. His temperature is 37.7 C (99.9 F), blood pressure is 134/88 mm Hg, pulse is 92/min, and respirations are 18/min. The abdomen is tender to palpation in the epigastric area. Bowel sounds are decreased. The skin over the lower extremities and toes appears mottled, reddish-blue, and reticulated but blanches on pressure. Laboratory results are as follows: CT scan of the abdomen reveals diffuse enlargement of the pancreas. Abdominal ultrasonogram reveals normal-sized gallbladder and common bile duct without gallstones. The patient's pain is improved with a dose of intravenous morphine. Which of the following is the best therapy for this patient?

Question

A 67-year-old man comes to the hospital with acute-onset upper abdominal pain associated with nausea and vomiting.  The patient was discharged 24 hours earlier after he underwent elective coronary angiography and stent placement due to left circumflex artery stenosis.  He has been taking his prescribed medications and reports no chest pain, shortness of breath, or flank pain.  His other medical problems include type 2 diabetes, hypertension, hypercholesterolemia, and peripheral vascular disease.  The patient does not use tobacco, alcohol, or illicit drugs.  His temperature is 37.7 C (99.9 F), blood pressure is 134/88 mm Hg, pulse is 92/min, and respirations are 18/min.  The abdomen is tender to palpation in the epigastric area.  Bowel sounds are decreased.  The skin over the lower extremities and toes appears mottled, reddish-blue, and reticulated but blanches on pressure.  Laboratory results are as follows:  CT scan of the abdomen reveals diffuse enlargement of the pancreas.  Abdominal ultrasonogram reveals normal-sized gallbladder and common bile duct without gallstones.  The patient's pain is improved with a dose of intravenous morphine.  Which of the following is the best therapy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d19e_9316_bc81_7da8d0530b8f_MD0003_00 This patient's abdominal pain, nausea, and elevated lipase are consistent with acute pancreatitis. He has no history of alcohol use, and his ultrasound reveals no gallstones. His pancreatitis is likely due to cholesterol emboli. Patients with risk factors for aortic atherosclerosis (eg, hypercholesterolemia, diabetes, peripheral vascular disease) who undergo cardiac catheterization or a vascular procedure are at increased risk for cholesterol emboli as a result of vascular manipulation. These emboli can occlude blood vessels and cause the following: Skin manifestations: Livedo reticularis (reticulated, mottled, discolored skin), blue toe syndrome Kidney manifestations: Acute kidney injury Gastrointestinal manifestations: Pancreatitis, mesenteric ischemia Supportive care (eg, pain control, intravenous fluids, bowel rest) is recommended for uncorrectable causes of acute pancreatitis (eg, hypotension, ischemia, viruses, atheroembolism). Most acute pancreatitis attacks are self-limiting and improve in 4-7 days with conservative management. This patient should receive nothing by mouth except essential medications (ie, antiplatelet therapy to prevent stent thrombosis); early refeeding can be considered if the patient's condition improves (eg, decreasing pain). (Choices A and B) Elective cholecystectomy is generally indicated for patients with gallstones and biliary colic or cholecystitis. Endoscopic retrograde cholangiopancreatography is indicated for sphincterotomy and stone removal in patients with gallstone pancreatitis and cholangitis or in those who have high surgical risk for cholecystectomy. This patient has no gallstones or common bile duct dilation on ultrasound. (Choice C) Prophylactic antibiotics are not routinely used in patients with acute pancreatitis unless there is evidence of necrotizing pancreatitis with local infection (which is not seen on this patient's CT scan). (Choice D) Glucocorticoids have no role in management of uncomplicated acute pancreatitis. Educational objective: Cholesterol embolism can occur after a vascular procedure (eg, cardiac catheterization) and may lead to skin (eg, livedo reticularis, blue toe) or gastrointestinal (eg, mesenteric ischemia, acute pancreatitis) complications. Acute pancreatitis from uncorrectable causes (eg, ischemia, atheroembolism) can be conservatively managed with analgesics and intravenous fluids. References: The cholesterol emboli syndrome in atherosclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/23423524) Cholesterol embolization syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21993354)

A 67-Year-Old Man Comes to the Hospital with Acute-Onset Upper