A 45-year-old man comes to the emergency department due to a 2-day history of progressively increasing epigastric pain that radiates to the back. He also has had nausea, an episode of vomiting, and anorexia. The patient has no chronic medical conditions and takes no medications. Temperature is 38.3 C (101 F), blood pressure is 116/78 mm Hg, pulse is 104/min, and respirations are 22/min. BMI is 27 kg/m². Mucous membranes are moist. Breath sounds are decreased at both lung bases. The abdomen is mildly distended, and bowel sounds are decreased; there is epigastric tenderness with voluntary guarding. No rebound tenderness or rigidity is noted. Laboratory results are as follows: Which of the following findings in this patient is associated with the worst prognosis?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d8d7_7b8f_bc81_f321833f3115_MD0003_00 This patient with epigastric pain radiating to the back, nausea, vomiting, leukocytosis, and elevated serum amylase and lipase has acute pancreatitis. Approximately 15%-25% of patients with acute pancreatitis develop severe acute pancreatitis (SAP), defined as pancreatitis that causes failure of ≥1 organ systems (eg, renal, respiratory, cardiovascular) lasting >48 hours. Important clinical predictors of SAP, associated with a worse prognosis, include: Signs of the systemic inflammatory response syndrome (SIRS) (eg, temperature >38 C [100.4 F], leukocytes >12,000/mm³) Elevated blood urea nitrogen (BUN) (>20 mg/dL), creatinine (>1.8 mg/dL), and/or hematocrit (>44%), which reflect intravascular volume depletion (with hemoconcentration) due to third spacing of fluid caused by the inflammatory response and increased capillary permeability Radiologic findings demonstrating third spacing of fluid, such as pulmonary infiltrates or pleural effusions (eg, decreased breath sounds at the bases) Patient characteristics that predict a worse prognosis include older age (>55) and medical comorbidities, particularly obesity (BMI >30 kg/m²) (Choice C). ² These factors are incorporated into clinical prediction scores (eg, SIRS score, bedside index of severity in acute pancreatitis [BISAP], Ranson criteria), which can help guide management. BUN levels are particularly reliable in predicting mortality, and fluid resuscitation rates can be adjusted to ensure decreases in these levels. Because patients with SAP have increased morbidity and mortality, they typically require admission to the intensive care unit. (Choice A) Epigastric tenderness, voluntary guarding (ie, muscle contraction during palpation to minimize pain), and ileus (eg, mild abdominal distension, decreased bowel sounds) are relatively common findings in acute pancreatitis. These examination findings do not indicate severe disease, unlike rebound tenderness, involuntary guarding (ie, muscle rigidity regardless of palpation), or diffuse abdominal tenderness. (Choice D) Elevated hematocrit (eg, >44%) is associated with increased disease severity in acute pancreatitis. In contrast, normal or low levels (eg, 37% in this patient) are usually predictive of a milder disease course. (Choice E) An elevated lipase level (>3 times normal limit) is part of the initial diagnostic criteria for acute pancreatitis (classic epigastric pain radiating to back; elevated amylase/lipase; characteristic imaging findings). However, neither the absolute lipase value nor the trend (serial measurements) predict SAP. Educational objective: Severe acute pancreatitis (SAP) occurs in 15%-25% of patients with acute pancreatitis and causes failure of ≥1 organ systems lasting >48 hours. Predictors of SAP include signs of the systemic inflammatory response syndrome and evidence (eg, elevated blood urea nitrogen or hematocrit) of intravascular volume depletion. Patients with SAP have increased risk of morbidity and mortality and usually require intensive monitoring. References: American College of Gastroenterology guideline: management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23896955)

A 45-Year-Old Man Comes to the Emergency Department Due to a 2-Day