A 43-year-old woman comes to the emergency department due to midepigastric abdominal pain. The pain is sharp, radiates to her back, and is accompanied by nausea, vomiting, and malaise. Her symptoms started approximately 24 hours earlier. For the past 6 months she has had intermittent, colicky abdominal pain that occurs after meals. The patient's medical problems include hypertension, depression, and recurrent urinary tract infections. Medications include lisinopril, amlodipine, and fluoxetine. She has no known drug allergies and does not use tobacco, alcohol, or illicit drugs. Family history is notable for ovarian cancer in her mother. Temperature is 37.1 C (98.8 F), blood pressure is 146/92 mm Hg, pulse is 85/min, and respirations are 14/min. Physical examination reveals moist mucous membranes, no lymphadenopathy, clear lung fields, and normal S1 and S2. The abdomen is soft and tender in the midepigastrium without rigidity or rebound tenderness. Bowel sounds are normoactive. The remainder of the examination is normal. Laboratory results are as follows: The patient is hospitalized and treated with supportive care. Abdominal ultrasound reveals multiple gallstones that are 3-5 mm in diameter, but no abnormalities are seen in the common bile duct. Lipid panel shows triglycerides of 150 mg/dL. On the third day of hospitalization, the patient is symptom-free, she tolerates oral feeding, and liver enzymes have normalized. Which of the following treatment options is most appropriate to prevent further episodes of pancreatitis?

Question

A 43-year-old woman comes to the emergency department due to midepigastric abdominal pain.  The pain is sharp, radiates to her back, and is accompanied by nausea, vomiting, and malaise.  Her symptoms started approximately 24 hours earlier.  For the past 6 months she has had intermittent, colicky abdominal pain that occurs after meals.  The patient's medical problems include hypertension, depression, and recurrent urinary tract infections.  Medications include lisinopril, amlodipine, and fluoxetine.  She has no known drug allergies and does not use tobacco, alcohol, or illicit drugs.  Family history is notable for ovarian cancer in her mother.  Temperature is 37.1 C (98.8 F), blood pressure is 146/92 mm Hg, pulse is 85/min, and respirations are 14/min.  Physical examination reveals moist mucous membranes, no lymphadenopathy, clear lung fields, and normal S1 and S2.  The abdomen is soft and tender in the midepigastrium without rigidity or rebound tenderness.  Bowel sounds are normoactive.  The remainder of the examination is normal.  Laboratory results are as follows:  The patient is hospitalized and treated with supportive care.  Abdominal ultrasound reveals multiple gallstones that are 3-5 mm in diameter, but no abnormalities are seen in the common bile duct.  Lipid panel shows triglycerides of 150 mg/dL.  On the third day of hospitalization, the patient is symptom-free, she tolerates oral feeding, and liver enzymes have normalized.  Which of the following treatment options is most appropriate to prevent further episodes of pancreatitis?

Quizplus · Accepted Answer

Explanation: This patient with acute-onset epigastric pain radiating to the back, nausea, vomiting, and an elevated lipase has acute pancreatitis. The patient lacks a history of alcohol use and has normal triglycerides and calcium levels. Given this and evidence of cholelithiasis with elevation of alkaline phosphatase, gallstone pancreatitis (GP) is the most likely diagnosis. The management of GP depends on its severity. Patients with mild disease, which is characterized by the lack of both organ failure and local or systemic complications (eg, acute necrotic collection, heart failure), should undergo cholecystectomy within 7 days of clinical improvement; this is usually performed during the same hospitalization (eg, this patient could be scheduled for surgery the next day). Patients who do not have their gallbladders removed have a 25%-30% risk of recurrent acute pancreatitis, cholecystitis, or cholangitis during the next 6-18 weeks. Delayed cholecystectomy should be considered for patients with severe GP, which is characterized by persistent failure of one or more organ systems (eg, hypotension not responsive to fluid resuscitation) (Choice B). Waiting allows for the resolution of active inflammation and complications (eg, walled-off necrosis), facilitating surgical management. In addition to having a cholecystectomy, patients should also undergo evaluation of the biliary system to ensure no gallstones remain. This can be performed through intraoperative cholangiogram in low-risk patients; alternatively, endoscopic retrograde cholangiopancreatography can be obtained prior to cholecystectomy in patients with evidence of persistent biliary obstruction (eg, elevated alkaline phosphatase, hyperbilirubinemia) (Choice C). (Choice D) Although a low-fat diet is recommended for patients with acute pancreatitis, cholecystectomy is the most important intervention to decrease the risk of recurrent pancreatitis, cholecystitis, and cholangitis. (Choice E) Ursodeoxycholic acid treatment can be considered as a second-line option for patients with symptomatic cholelithiasis (eg, biliary colic) who do not desire surgery, but it does not have a role in the treatment of patients with GP. Educational objective: The management of gallstone pancreatitis depends on its severity. Patients with mild disease should undergo cholecystectomy within 7 days of clinical improvement. Those with more severe disease should delay cholecystectomy until the resolution of inflammation and complications. References: Gallstone disease: diagnosis and management of cholelithiasis, cholecystitis and choledocholithiasis. (http://www.ncbi.nlm.nih.gov/pubmed/25473723) Acute biliary pancreatitis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19636174)

A 43-Year-Old Woman Comes to the Emergency Department Due to Midepigastric