A 27-year-old woman is brought to the emergency department with severe epigastric pain, nausea, and vomiting. The pain radiates to her back and is exacerbated by eating. The patient was recently diagnosed with functional biliary sphincter of Oddi dysfunction for which she underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy 24 hours ago. She has no other chronic medical conditions. She does not drink alcohol. Temperature is 38.7 C (101.7 F), blood pressure is 124/82 mm Hg, pulse is 95/min, and respirations are 19/min. There is no scleral icterus. Cardiopulmonary examination shows no abnormalities. The abdomen is tender to palpation in the epigastrium, soft, and without rebound or guarding. Which of the following is the most appropriate next step in management of this patient?

Question

A 27-year-old woman is brought to the emergency department with severe epigastric pain, nausea, and vomiting.  The pain radiates to her back and is exacerbated by eating.  The patient was recently diagnosed with functional biliary sphincter of Oddi dysfunction for which she underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy 24 hours ago.  She has no other chronic medical conditions.  She does not drink alcohol.  Temperature is 38.7 C (101.7 F), blood pressure is 124/82 mm Hg, pulse is 95/min, and respirations are 19/min.  There is no scleral icterus.  Cardiopulmonary examination shows no abnormalities.  The abdomen is tender to palpation in the epigastrium, soft, and without rebound or guarding.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Endoscopic retrograde cholangiopancreatography (ERCP), a minimally invasive endoscopic technique used to visualize and intervene upon the biliary and pancreatic ducts, is widely used for stone removal, tissue sampling, stent placement, and sphincterotomy. In some patients, ERCP with manometry can confirm the diagnosis of sphincter of Oddi dysfunction (SOD), which typically causes biliary-type pain with no obvious etiology. Post-ERCP complications can occur; postprocedural abdominal pain is relatively common and may be due to infection (eg, ascending cholangitis), perforation, or pancreatitis. The most common complication is post-ERCP pancreatitis, which occurs in up to 10% of patients and is particularly prevalent in those with SOD. Classic symptoms of pancreatitis include nausea, vomiting, and epigastric pain that radiates to the back and worsens with eating. Fever may occur due to inflammation. Acute pancreatitis is diagnosed in patients meeting ≥2 of the following criteria: Severe epigastric pain (often radiating to the back) Amylase or lipase ≥3 times the upper limit of normal Characteristic findings of acute pancreatitis on imaging (eg, CT, MRI, ultrasound) Because the first 2 criteria are sufficient to confirm the diagnosis, serum amylase and lipase should be obtained as part of the initial workup in all patients with suspected pancreatitis. These enzymes rise within several hours of the development of symptoms whereas CT findings may remain normal for up to 48 hours. (Choice A) CT scan of the abdomen is the most sensitive method for diagnosing perforation (eg, bowel wall, pancreatic/biliary duct), and it demonstrates intra-abdominal or retroperitoneal free air. Significant perforations can cause abdominal pain and fever; however, abdominal distension, rigidity, rebound, and guarding would be expected. CT scan is less useful in the evaluation of post-ERCP pancreatitis as findings may initially be normal. (Choices B and D) A HIDA scan is used to diagnose acute cholecystitis by demonstrating cystic duct obstruction whereas a right upper quadrant ultrasound may be used to identify cholecystitis or biliary dilation due to cholangitis. These complications can cause fever, nausea, and vomiting, but pain is typically located in the right upper quadrant. In addition, patients with cholangitis are typically jaundiced and acutely ill (eg, hypotension). (Choice C) MR cholangiopancreatography (MRCP) is used to evaluate the biliary and pancreatic ducts for stones, structural abnormalities (eg, biliary duct perforation), and pancreatitis. However, MRCP is expensive and timely, and these complications may be more easily assessed with CT, ultrasound, or laboratory tests. Educational objective: Acute pancreatitis is the most common complication after endoscopic retrograde cholangiopancreatography, and typically presents with abdominal pain with radiation to the back, nausea, and vomiting. Lipase and amylase levels will rise several hours after symptom onset whereas CT scans can be normal for up to 48 hours. References: Adverse events associated with ERCP. (http://www.ncbi.nlm.nih.gov/pubmed/27546389) Imaging of acute pancreatitis and its complications. Part 1: acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/24512896)

A 27-Year-Old Woman Is Brought to the Emergency Department with Severe