A 65-year-old man is being evaluated in the hospital due to altered mental status and fever. He was admitted 10 days ago for acute pancreatitis secondary to alcohol use. On admission, the patient was afebrile, and CT scan revealed pancreatic edema and necrosis. He has been receiving intravenous fluids and intravenous opioid pain control since then. Today, the patient appears confused and requests more pain medication. Temperature is 38.9 C (102 F), blood pressure is 90/64 mm Hg, pulse is 120/min, and respirations are 22/min. The pupils are 2 mm and symmetric, and the neck is supple. The lungs are clear to auscultation, and heart sounds are normal. Bowel sounds are decreased, but the abdomen is nondistended; there is tenderness to palpation in the epigastrium. The flanks are tympanic to percussion, without any fluid wave. Neurologic examination shows no focal findings. Which of the following is the best next step in management?

Question

A 65-year-old man is being evaluated in the hospital due to altered mental status and fever.  He was admitted 10 days ago for acute pancreatitis secondary to alcohol use.  On admission, the patient was afebrile, and CT scan revealed pancreatic edema and necrosis.  He has been receiving intravenous fluids and intravenous opioid pain control since then.  Today, the patient appears confused and requests more pain medication.  Temperature is 38.9 C (102 F), blood pressure is 90/64 mm Hg, pulse is 120/min, and respirations are 22/min.  The pupils are 2 mm and symmetric, and the neck is supple.  The lungs are clear to auscultation, and heart sounds are normal.  Bowel sounds are decreased, but the abdomen is nondistended; there is tenderness to palpation in the epigastrium.  The flanks are tympanic to percussion, without any fluid wave.  Neurologic examination shows no focal findings.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

This patient with signs of sepsis (eg, fever, hypotension, tachycardia, confusion) 10 days after being admitted with acute necrotizing pancreatitis has likely developed infected pancreatic necrosis. Acute necrotizing pancreatitis is thought to occur when pancreatic inflammation (ie, pancreatitis) causes uncontrolled release of pancreatic enzymes, leading to autodigestion of the pancreatic parenchyma and peripancreatic tissues (eg, pancreatic edema and necrosis on CT). Initially, the resulting necrotic collection is sterile; however, infection with enteric pathogens (eg, Escherichia coli, Pseudomonas, Enterococcus) occurs in approximately a third of patients, typically 7-10 days after onset of acute necrotizing pancreatitis. When this occurs, patients can decompensate clinically (eg, fever, confusion, sepsis), and a CT scan of the abdomen should be ordered (even if an initial CT scan was obtained). Gas (produced by microorganisms) within the necrotic collection on CT scan is diagnostic for infected pancreatic necrosis and prompts initiation of intravenous antibiotic therapy. If CT findings are equivocal, aspiration and culture of the necrotic pancreatic material may be necessary to confirm the diagnosis. Débridement (eg, endoscopic, surgical) is often required but is ideally delayed until the patient has stabilized on antibiotic therapy and the necrotic collection has become encapsulated (ie, walled off), which facilitates débridement. (Choices A and C) Opioid overdose (which naloxone treats) and stroke (which CT scan of the head can evaluate) are possible causes of acute confusion. However, opioid overdose does not cause fever and typically causes bradypnea (vs tachypnea). Stroke classically causes focal neurologic deficits, which are absent in this patient. (Choice D) Intravenous benzodiazepines (eg, lorazepam) are used to treat severe alcohol withdrawal (eg, delirium tremens), which can cause autonomic hyperactivity with confusion, hyperthermia, and tachycardia; however, hypertension (vs hypotension) would be expected. (Choice E) Lumbar puncture can help diagnose meningitis, which may cause fever and mental status changes. However, meningitis is unlikely in the absence of nuchal rigidity or severe headache. (Choice F) Hepatic encephalopathy (which increases serum ammonia) can cause confusion in patients with alcoholic cirrhosis, often in response to a trigger (eg, infection, opioids). However, this patient exhibits no signs of cirrhosis, such as ascites (eg, flanks dull [vs tympanic] to percussion with fluid wave) or splenomegaly. In addition, hepatic encephalopathy does not typically cause fever or unstable vital signs. signs of cirrhosis Educational objective: Infected pancreatic necrosis should be suspected in patients who develop worsening abdominal pain, unstable vital signs, or signs (eg, fever, leukocytosis) of infection 7-10 days after onset of acute necrotizing pancreatitis. CT scan of the abdomen demonstrating gas within the pancreatic necrotic collection is diagnostic. References: American College of Gastroenterology guideline: management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23896955) Managing infected pancreatic necrosis. (http://www.ncbi.nlm.nih.gov/pubmed/29981660)

A 65-Year-Old Man Is Being Evaluated in the Hospital Due