A 54 year old woman was referred to the emergency department by her GP with a 3 day history of vomiting accompanied by upper abdominal pain. On examination she was obese, appeared restless and confused, GCS 13, febrile 38.6 C, heart rate of 100 /min, BP 90/40 mm Hg. She has Spo2 of 88% on oxygen via a non-rebreather bag. There was diffuse abdominal tenderness on palpation in particular in the upper abdomen. Bowel sounds were sluggish. Blood tests taken in a private laboratory the preceding day had revealed a lipase of 400 U/l (normal < 70).
23.1) What are the differential diagnoses of this patient’s presentation?
23.2) What are the causes of hypotension in acute pancreatitis?
23.3) List 3 causes of a raised A-a gradient in acute pancreatitis?
23.4) What do you understand is the role for prophylactic antimicrobial therapy in sterile pancreatic necrosis?
23.1) What are the differential diagnoses of this patient’s presentation?
1) Pancreatitis
2) Perf DU
3) Intestinal obstruction
4) Acute cholecystitis with sepsis
5) Aspiration and sepsis
6) Gut ischaemia
23.2) What are the causes of hypotension in acute pancreatitis?
a) sequestration (3rd spacing) of protein rich fluids in and around the pancreas and abbdominal cavity, retroperitoneum
b) compounded by pre existing fluid depletion.c) direct myocardial depression
d) SIRS / sepsis
e) Intra-abd hypertensionf) Bleeding
23.3) List 3 causes of a raised A-a gradient in acute pancreatitis?
Pulmonary dysfunction - Aspiration, pleural effusions, ARDS, atelectasis.
23.4) What do you understand is the role for prophylactic antimicrobial therapy in sterile pancreatic necrosis?
a) Antibiotic use in SAP without overt infection controversial and trial data are conflicting.
b) Antibiotics have been given either IV or IV plus orally/rectally via SDD.
c) Early trials - underpowered, mostly non blinded and included patients with differing disease severity suggested a reduction in both infections and improved outcome with early use of prophylactic antibiotics (Cefuroxime and imipenem) in necrotising SAP when compared with placebo. Subsequent meta analyses including a Cochrane review also suggested that antibiotics reduced infections and mortality and need for surgery in necrotic pancreatitis.
d) 2 recent RCTs (Isenmann 2004 and Dellinger 2007) have however demonstrated no effect on outcome or infection rate when prophylactic antibiotics were used in necrotic pancreatitis. The SCCM (2004) consensus conference on severe pancreatitis recommends against the use of routine prophylactic antibiotics.
23.1) What are the differential diagnoses of this patient’s presentation?
An obese hypoxic woman presents in a state of shock, febrile, and with this story of vomiting and abdominal pain. A systematic approach is called for, even though the lipase is high and the obvious single diagnosis is pancreatitis.
Vascular causes:
Infectious causes: sepsis from any origin, but more likely the gut,
Neoplastic causes
Drug-induced causes
Autoimmune causes eg. inflammatory bowel disease with perforation
Traumatic causes eg. Boerhaave's syndrome due to excessive vomiting
Endocrinological cause of abdo pain and SIRS, eg. pacreatitis due to any number of causes
23.2) What are the causes of hypotension in acute pancreatitis?
Again, there are several mechanisms:
23.3) List 3 causes of a raised A-a gradient in acute pancreatitis?
23.4) What do you understand is the role for prophylactic antimicrobial therapy in sterile pancreatic necrosis?
Again, thank you to Rajkumar (you know who you are) for pointing out the error in this answer. There was a duplication of content from Question 22 of the same paper. Well spotted!
Pederzoli, Paolo, et al. "A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem." Surgery, gynecology & obstetrics 176.5 (1993): 480-483.
Wilmer, Alexander. "ICU management of severe acute pancreatitis." European journal of internal medicine 15.5 (2004): 274-280.
Villatoro, Eduardo, Mubashir Mulla, and Mike Larvin. "Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis."Cochrane Database Syst Rev 5.5 (2010).