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.
The patient is diagnosed with hypertriglyceridemia-induced acute pancreatitis, and intravenous insulin is started. Although the triglyceride levels improve in response to therapy, her abdominal pain remains unchanged by day 8 of hospitalization. The patient tolerates minimal nutritional intake despite the use of a nasogastric tube. Temperature is 38.6 C (101.5 F) , blood pressure is 90/50 mm Hg, pulse is 107/min, and respirations are 22/min. Oxygen saturation is 98% on room air. Physical examination reveals tenderness in the upper abdomen to deep palpation without involuntary guarding, rebound, or rigidity. Repeat laboratory analysis reveals leukocytosis with a left shift, whereas hemoglobin and liver function tests remain unchanged. Which of the following would be the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Despite appropriate treatment for hypertriglyceridemia-induced acute pancreatitis (AP) with intravenous insulin and supportive care, this patient's condition is deteriorating (eg, fever, leukocytosis, hypotension), and she has ongoing abdominal pain. She should be evaluated for infected pancreatic necrosis. Mild to moderate AP usually resolves with supportive management, but pancreatic necrosis can develop in severe cases. The necrosis is initially sterile but can become secondarily infected (usually gram-negative enteric bacteria) typically >7 days after initial presentation. Infected pancreatic necrosis should be considered in patients with persistent abdominal pain and in those whose condition initially improves but then deteriorates (eg, leukocytosis, fever, unstable vital signs). Gas within pancreatic necrosis is diagnostic, which is best identified by an abdominal CT scan with intravenous contrast. Initial management requires the use of intravenous antibiotics capable of penetrating pancreatic necrosis (eg, meropenem, fluoroquinolone + metronidazole). Debridement of the necrotic material is sometimes considered for patients whose condition fails to improve with conservative management. (Choice A) Corticosteroids can be used to treat autoimmune pancreatitis but not hypertriglyceridemia-induced AP or infected pancreatic necrosis, so they would not be recommended in this patient. (Choice C) Patients whose condition fails to improve with antibiotics are sometimes treated with antifungals (eg, fluconazole), but these agents would not be administered before confirming the diagnosis with CT scan. (Choice D) MR cholangiopancreatography is more time-consuming and costly than CT scan. Infected pancreatic necrosis is a life-threatening condition, and rapid diagnosis with CT scan is preferred. (Choice E) Nasogastric (NG) or nasojejunal (NJ) tube feedings are used for patients who cannot tolerate oral nutrition for an extended time. This patient's NG tube feeding has already failed, and she is unlikely to benefit from an NJ tube; instead, parenteral nutrition should be considered. Educational objective: Infected pancreatic necrosis should be considered in patients with acute pancreatitis who have persistent abdominal pain or have initial improvement followed by clinical deterioration (eg, leukocytosis, fever). CT scan showing gas within pancreatic necrosis is diagnostic. Management includes intravenous antibiotics. References: Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. (http://www.ncbi.nlm.nih.gov/pubmed/23100216) American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/29409760) Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23786708)

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