A 40-year-old man comes to the emergency department with a week of progressive abdominal discomfort, abdominal distension, and nausea. Over the last 2 days, he has also had several episodes of vomiting. Six weeks ago, he was hospitalized for an episode of acute pancreatitis. The patient used to drink heavily before the hospitalization but has been abstinent since then. He also has a history of emergency department visits due to alcohol intoxication and street fights. The patient does not use tobacco or illicit drugs. His temperature is 37 C (98.6 F), blood pressure is 117/84 mm Hg, pulse is 86/min, and respirations are 16/min. Examination shows epigastric fullness and tenderness. Bowel sounds are present. There is no rebound tenderness or rigidity. Cardiopulmonary examination shows no abnormalities. There is no peripheral edema. Complete blood count and serum chemistries are within normal limits. CT scan of the abdomen with intravenous contrast is shown below. Which of the following is the most appropriate next step in management?

Question

A 40-year-old man comes to the emergency department with a week of progressive abdominal discomfort, abdominal distension, and nausea.  Over the last 2 days, he has also had several episodes of vomiting.  Six weeks ago, he was hospitalized for an episode of acute pancreatitis.  The patient used to drink heavily before the hospitalization but has been abstinent since then.  He also has a history of emergency department visits due to alcohol intoxication and street fights.  The patient does not use tobacco or illicit drugs.  His temperature is 37 C (98.6 F), blood pressure is 117/84 mm Hg, pulse is 86/min, and respirations are 16/min.  Examination shows epigastric fullness and tenderness.  Bowel sounds are present.  There is no rebound tenderness or rigidity.  Cardiopulmonary examination shows no abnormalities.  There is no peripheral edema.  Complete blood count and serum chemistries are within normal limits.  CT scan of the abdomen with intravenous contrast is shown below.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d8d5_7fba_bc81_89e39c784f27_MD0003_00 This patient with a history of alcohol use and a recent episode of pancreatitis now has progressive abdominal distension, nausea, and vomiting, with a CT scan showing a round, well-circumscribed, encapsulated fluid collection in the pancreatic bed, consistent with a pancreatic pseudocyst. Pseudocysts are mature walled-off pancreatic fluid collections (usually no necrosis or solid material) surrounded by a thick fibrous capsule and containing enzyme-rich fluid, tissue, and debris. They can leak amylase-rich fluid into the circulation and increase serum amylase. Complications include spontaneous infection, duodenal or biliary obstruction, pseudoaneurysm (due to digestion of adjacent vessels), pancreatic ascites, and pleural effusion. Abdominal imaging usually confirms the diagnosis. In patients with minimal or no symptoms and without complications (eg, pseudoaneurysm), expectant management (eg, symptomatic therapy, nothing by mouth) is preferred initially. Endoscopic drainage is typically reserved for those (such as this patient) with significant symptoms (eg, abdominal pain, vomiting), infected pseudocyst, or evidence of pseudoaneurysm (usually embolized before drainage procedure). (Choice A) Cholecystectomy is performed (usually following endoscopic retrograde cholangiopancreatography) in patients who have recovered from gallstone pancreatitis, which typically presents with elevated liver function studies, amylase, lipase, and (often) serum bilirubin. This patient's normal serum chemistries make gallstone pancreatitis unlikely. (Choice C) Intravenous antibiotics are typically given for an infected pseudocyst. The absence of fever and leukocyte count elevation in this patient makes infection less likely. (Choice D) This patient has worsening distension, nausea, and vomiting, likely due to pseudocyst compression of surrounding structures; he would benefit from endoscopic drainage. (Choice E) Pancreatic enzyme supplementation is usually given to patients with chronic pancreatitis and exocrine pancreatic insufficiency (eg, steatorrhea due to fat malabsorption). Although this patient has chronic alcohol use and a recent episode of acute pancreatitis, the absence of diarrhea makes pancreatic insufficiency less likely. Educational objective: Pancreatic pseudocyst is an encapsulated area (comprised of enzyme-rich fluid, tissue, and debris) that causes an inflammatory response. Diagnosis is confirmed by abdominal imaging. Expectant management is preferred initially in patients with minimal or no symptoms and without complications. Endoscopic drainage is typically reserved for patients with significant symptoms (eg, abdominal pain, vomiting), infected pseudocyst, or evidence of pseudoaneurysm. References: Classification and management of pancreatic pseudocysts (http://www.ncbi.nlm.nih.gov/pubmed/26091462) Conservative treatment as an option in the management of pancreatic pseudocyst. (http://www.ncbi.nlm.nih.gov/pubmed/14594534)

A 40-Year-Old Man Comes to the Emergency Department with a Week