A 68-year-old woman comes to the emergency department due to epigastric abdominal pain. The pain began suddenly, is severe and unremitting, and radiates to the back. The patient also has nausea and frequent nonbloody emesis. She was seen in the office 3 months ago for hypertension management. Medications include hydrochlorothiazide and amlodipine. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.1 C (100.6 F), blood pressure is 149/89 mm Hg, pulse is 95/min, and respirations are 18/min. Physical examination reveals anicteric sclera and moist mucous membranes. Heart and lung sounds are unremarkable. The abdomen is tender to palpation diffusely with mild distension but no rebound or guarding. Laboratory results are as follows: The patient is admitted to the hospital for intravenous fluids and pain control. Ultrasound of the right upper quadrant shows a normal gallbladder without stones; the size of the common bile duct is normal. Which of the following is the best next step in management of this patient?

Question

A 68-year-old woman comes to the emergency department due to epigastric abdominal pain.  The pain began suddenly, is severe and unremitting, and radiates to the back.  The patient also has nausea and frequent nonbloody emesis.  She was seen in the office 3 months ago for hypertension management.  Medications include hydrochlorothiazide and amlodipine.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.1 C (100.6 F), blood pressure is 149/89 mm Hg, pulse is 95/min, and respirations are 18/min.  Physical examination reveals anicteric sclera and moist mucous membranes.  Heart and lung sounds are unremarkable.  The abdomen is tender to palpation diffusely with mild distension but no rebound or guarding.  Laboratory results are as follows:  The patient is admitted to the hospital for intravenous fluids and pain control.  Ultrasound of the right upper quadrant shows a normal gallbladder without stones; the size of the common bile duct is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d3d6_5ae8_bc81_59da46ef8906_MD0003_00 The diagnosis of acute pancreatitis requires ≥2 of the following 3 criteria: Severe epigastric pain Elevated serum lipase >3 times the upper limit of normal CT scan findings suggestive of pancreatic inflammation Gallstones and alcohol abuse account for approximately 75% of all cases of acute pancreatitis. Hypertriglyceridemia, the third most common cause, typically occurs only when the triglyceride level exceeds 1,000 mg/dL. When these common etiologies have been ruled out, less common causes, including drug-induced pancreatitis (DIP), should be considered. Recognizing DIP can be challenging because it may develop months after drug initiation and many medications have been implicated. Diuretics, including thiazides (eg, hydrochlorothiazide) and most loop diuretics (eg, furosemide), are among the most common offenders. These drugs may trigger pancreatitis via hypersensitivity to the sulfonamide molecule (a structural component of thiazides and most loop diuretics), pancreatic ischemia due to reduced blood volume, and/or increased viscosity of pancreatic secretions. Other medications associated with DIP include ACE inhibitors (eg, enalapril), statins (eg, simvastatin), and certain antibiotics (eg, isoniazid, trimethoprim-sulfamethoxazole), which may act through similar or other pathophysiologic mechanisms (eg, direct toxicity). In addition to discontinuation of the offending agent, management of DIP is identical to that of other causes of acute pancreatitis, involving aggressive intravenous hydration, pain control, and diet advancement as tolerated. (Choices A and C) Patients with gallstone pancreatitis should undergo timely cholecystectomy to help prevent additional episodes. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to remove gallstones obstructing the biliary tract, and it is indicated in patients with gallstone pancreatitis complicated by cholangitis. This patient has no laboratory evidence (eg, hyperbilirubinemia, elevated transaminases) or ultrasound findings (eg, gallstones, common bile duct dilation) to suggest gallstone pancreatitis, and no evidence of cholangitis (eg, jaundice, right upper quadrant pain). Endoscopic retrograde cholangiopancreatography (Choice D) Glucocorticoids are used to treat autoimmune pancreatitis, a relatively rare IgG4 mediated disorder. These drugs should not be initiated prior to diagnostic confirmation, which typically requires pancreatic biopsy in addition to a serum IgG4 level. (Choice E) HIDA scan can demonstrate cystic duct obstruction in acute cholecystitis, which presents with fever, leukocytosis, and right upper quadrant pain. This test has minimal use in evaluating acute pancreatitis. Educational objective: Most cases of acute pancreatitis are related to gallstones or alcohol abuse, and hypertriglyceridemia is the third most common cause. Drug-induced pancreatitis should be considered once these more common etiologies are ruled out, especially in patients taking a known offending agent (eg, furosemide, hydrochlorothiazide). References: Drug-induced acute pancreatitis: a review (http://www.ncbi.nlm.nih.gov/pubmed/25829880)

A 68-Year-Old Woman Comes to the Emergency Department Due to Epigastric