A 42-year-old man comes to the hospital after a day of severe abdominal pain and vomiting. He describes the pain as constant and nagging, localizing to the upper abdomen, and radiating to the back. The patient has not been to a physician in years and has no previous medical conditions or surgeries. He takes no medications. He drinks large amounts of alcohol, but does not use tobacco or illicit drugs. His temperature is 36.7° C (98° F), blood pressure is 110/80 mm Hg, pulse is 90/min, and respirations are 14/min. The patient is admitted to the hospital and given opioid analgesics and intravenous fluids. On day 2 of his hospitalization, his blood pressure drops to 80/60 mm Hg and his pulse increases to 120/min and regular. His oxygen saturation is 92% on 2 L nasal canula oxygen. Examination shows normal jugular venous pressure. Bilateral crackles are heard on lung auscultation. The patient's abdomen is mildly distended, and there is tenderness in the epigastrium. His urine output is 8 mL/hr. He has received a total of 4 L IV fluids over the last 24 hours. Laboratory results are as follows: Which of the following is the most likely cause of this patient's hypotension?

Question

A 42-year-old man comes to the hospital after a day of severe abdominal pain and vomiting.  He describes the pain as constant and nagging, localizing to the upper abdomen, and radiating to the back.  The patient has not been to a physician in years and has no previous medical conditions or surgeries.  He takes no medications.  He drinks large amounts of alcohol, but does not use tobacco or illicit drugs.  His temperature is 36.7° C (98° F), blood pressure is 110/80 mm Hg, pulse is 90/min, and respirations are 14/min.  The patient is admitted to the hospital and given opioid analgesics and intravenous fluids.  On day 2 of his hospitalization, his blood pressure drops to 80/60 mm Hg and his pulse increases to 120/min and regular.  His oxygen saturation is 92% on 2 L nasal canula oxygen.  Examination shows normal jugular venous pressure.  Bilateral crackles are heard on lung auscultation.  The patient's abdomen is mildly distended, and there is tenderness in the epigastrium.  His urine output is 8 mL/hr.  He has received a total of 4 L IV fluids over the last 24 hours.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's hypotension?

Quizplus · Accepted Answer

11ec25c8_d3d5_7086_bc81_6dff075ad163_MD0003_00 This patient's presentation is consistent with acute severe pancreatitis that has progressed to multisystem organ dysfunction (eg, shock, renal failure, early respiratory failure). Most patients with acute pancreatitis have mild disease and recover with conservative management (eg, fluids, bowel rest, pain medication) in 3-5 days. However, nearly 15%-20% of patients can develop severe acute pancreatitis, defined as pancreatitis with failure of at least 1 organ. Clinical markers associated with increased risk for severe pancreatitis include age >75, alcoholism, obesity, C-reactive protein >150 mg/dL at 48 hours, and increased blood urea nitrogen (BUN)/creatinine in the first 48 hours. Abdominal imaging (computed tomography scan or magnetic resonance cholangiopancreatography) is indicated for suspected severe pancreatitis to look for pancreatic necrosis and extrapancreatic inflammation, which also indicate severe acute pancreatitis. Severe pancreatitis causes local release of activated pancreatic enzymes that enter the vascular system and increase vascular permeability within and around the pancreas. This leads to large volumes of fluid migrating from the vascular system to the surrounding retroperitoneum. Systemic inflammation also ensues as the inflammatory mediators enter the vascular system. The net effect is widespread vasodilation, capillary leak, shock, and associated end-organ damage. Treatment usually involves supportive care with several liters of IV fluid to replace the lost intravascular volume. (Choice B) Hypotensive episodes seen in severe pancreatitis could incite an underlying myocardial infarction. However, this patient has no signs or symptoms (eg, chest pain) suggesting myocardial infarction. (Choice C) Narcotics (eg, meperidine) are often given for analgesia in acute pancreatitis. Narcotic overdose can cause respiratory depression, hypotension, and bradycardia. This patient's tachycardia, crackles, abdominal distention, worsening BUN, and low urine output make severe pancreatitis with early multiorgan failure more likely. (Choice D) Occult bleeding is unlikely to cause significant hypotension without resulting in anemia. (Choice E) Pericardial effusion can be a complication of pancreatitis, but tamponade severe enough to cause cardiac failure would cause jugular venous distention (not seen in this patient's physical examination). (Choice F) Acute pancreatitis can be complicated by a peripancreatic pseudocyst, a fluid collection (containing pancreatic enzymes, blood, fluid, and tissue debris) surrounded by a necrotic or fibrous capsule. Pseudocysts typically take 3-4 weeks to develop after acute pancreatitis and would be a less likely cause of acute hypotension in this patient. Educational objective: Acute pancreatitis complicated by hypotension is thought to arise from intravascular volume loss secondary to local and systemic vascular endothelial injury. This causes vasodilation, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension. References: Elevated serum creatinine as a marker of pancreatic necrosis in acute pancreatitis (http://www.ncbi.nlm.nih.gov/pubmed/19098865) Management of fluid collections and necrosis in acute pancreatitis (http://www.ncbi.nlm.nih.gov/pubmed/10980941)

A 42-Year-Old Man Comes to the Hospital After a Day