A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain. She describes the pain as intense, constant, and radiating to the back. The pain is relieved by leaning forward and worsens with eating. The patient also reports nausea and has vomited several times. She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats. The patient has no known medical conditions and takes no prescription or over-the-counter medications. She does not use alcohol, tobacco, or illicit drugs. Her last menstrual period was 2 weeks ago and was normal. The patient is sexually active with a male partner and uses condoms. Temperature is 36.7 C (98.1 F) , blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 24 kg/m². Physical examination shows moist mucous membranes and anicteric sclera. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity. Bowel sounds are normal. Neither hepatomegaly nor splenomegaly is present. Bimanual examination reveals no adnexal masses or tenderness. Neurologic examination is within normal limits.
Laboratory results are as follows:
Pregnancy testing is negative. Abdominal ultrasound reveals a normal-appearing gallbladder and a nondilated biliary tree. The patient is admitted to the hospital; intravenous fluid, antiemetics, and pain medications are started. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman comes to the emergency department due to a 12-hour history of sudden-onset, upper abdominal pain. She describes the pain as intense, constant, and radiating to the back. The pain is relieved by leaning forward and worsens with eating. The patient also reports nausea and has vomited several times. She has no previous episodes of abdominal pain, fever, chills, weight loss, fatigue, or night sweats. The patient has no known medical conditions and takes no prescription or over-the-counter medications. She does not use alcohol, tobacco, or illicit drugs. Her last menstrual period was 2 weeks ago and was normal. The patient is sexually active with a male partner and uses condoms. Temperature is 36.7 C (98.1 F) , blood pressure is 134/72 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 24 kg/m². Physical examination shows moist mucous membranes and anicteric sclera. Lung fields are clear, and S1 and S2 are normal. The abdomen is soft and tender in the upper abdomen but without rebound, involuntary guarding, or rigidity. Bowel sounds are normal. Neither hepatomegaly nor splenomegaly is present. Bimanual examination reveals no adnexal masses or tenderness. Neurologic examination is within normal limits.
Laboratory results are as follows:

Pregnancy testing is negative. Abdominal ultrasound reveals a normal-appearing gallbladder and a nondilated biliary tree. The patient is admitted to the hospital; intravenous fluid, antiemetics, and pain medications are started. Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient meets diagnostic criteria for acute pancreatitis (AP) based on characteristic abdominal pain and a lipase level ≥3 times the upper limit of normal. Once a diagnosis of AP is made, the etiology must be determined. Gallstones and alcohol account for >65% of cases but have been excluded in this patient by ultrasound and a detailed history. Hypertriglyceridemia causes up to 14% of AP cases and usually occurs in patients with triglyceride levels >1,000 mg/dL; therefore, a lipid panel, including a serum triglyceride level, should be ordered in this patient. Other causes (eg, autoimmune pancreatitis, medications [eg, furosemide, didanosine], infections [eg, HIV, Ascaris]) are less common but should be considered in select circumstances. (Choices A and D) Clinical findings to suggest gallstone-induced pancreatitis include abnormal liver chemistries (eg, elevated alanine aminotransferase, bilirubin, and alkaline phosphatase) and dilated biliary ducts (suggesting obstruction at the ampulla of Vater). Endoscopic retrograde cholangiopancreatography (ERCP) and MR cholangiopancreatography should be considered in such patients but are not necessary in this woman. In addition, ERCP can worsen pancreatitis. (Choice B) Intravenous antibiotics are not indicated in the routine management of AP but are needed in patients with extrapancreatic infections (eg, pneumonia) and in those who develop infected pancreatic necrosis. An infection warranting antibiotics is unlikely because this patient is afebrile and does not have leukocytosis. (Choice E) Although certain infections (eg, Salmonella, Cryptosporidium, Ascaris) can cause AP, they are significantly less common than hypertriglyceridemia, and stool studies would not be ordered until more common causes have been eliminated. Educational objective: When alcohol or gallstones do not cause acute pancreatitis, patients should be evaluated for hypertriglyceridemia with a serum lipid panel. References: American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/29409760) Acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25368923) Early phase of acute pancreatitis: assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/25133018)

A 34-Year-Old Woman Comes to the Emergency Department Due to a 12-Hour