59 yo Male with

Abdominal Pain and

SOB

Case Conference 3/18/08

Roman Melamed, MD

History

59 y.o. male with acute onset of severe

constant abdominal pain after eating a

turkey sandwich and some popcorn 1.5 h

prior to presentation to ED

Nausea, vomiting

PMH

HTN

COPD

Hyperlipidemia

Chronic knee pain

Alcoholism, quit in 1999

Stopped smoking several weeks ago

Meds

Albuterol

Viagra

Buspar

Zocor

Glucosamine

Naproxen

Ibuprofen

Exam and Initial Labs

BP 145/86 HR 96 T 99.5

Abdomen distended, diffusely tender to

palpation, negative peritoneal signs

WBC 16 Hgb 13 Hct 41.2 BUN 27Cr 1.1

CO2 27 Ca 7.8 AST, ALT, bili wnl

Diagnostic Studies

Lipase 13273

Abd. CT: inflammatory changes anterior to

the pancreas

RUQ US: no gallstones. CBD wnl.

Day 2

Called by RN at 11 pm to evaluate for

respiratory distress

RR 44

SpO2 93% on 95% FiO2 via FM

CXR: LLL infiltrate or atelectasis,

unchanged from the previous study

ABG: 7.28/46/98/21

Day 3

Persistent respiratory distress despite

Zosyn, nebs, steroids and BiPAP

No response to diuretics

Repeat abd. CT: worsening pancreatitis;

no abscess or necrosis; some ascitis

Paracentesis attempted: minimal return

Day 3

Creatinine 4.4 K 5.5

Hypotension despite total fluid balance 10

liters positive

WBC 21 Lipase 794 INR 1.4 Ca 5.1 CO2

20

Intubated

Day 4

Hypotensive

Elevated bladder pressures

OR: severe necrotizing pancreatitis, ischemic colon with areas of full thickness necrosis involving cecum, descending colon, and sigmoid colon.

Procedure: Expl lap, total abdominal colectomy, pancreatic débridement and

end ileostomy

Day 9

Remains vasopressor dependent

Elevated bladder pressures

Intubated

OR: ongoing fat necrosis and peritonitis from pancreatic fluid with marked necrosis of tissue in the pelvis, pancreas has adjacent black necrotic tissue, central 12 cm of fascia left open to reduce intra abdominal pressure

Day 18

OR: closure of midline incision and

tracheostomy

Subsequent Course

Fevers

CRRT

Gradually improved

D/c’d to Bethesda on Day # 54 with

abdominal drains

Several readmissions

2 years later: at home; regular diet; still

with some functional impairment

Case Presentation #1

Robert Haung, MD

3/18/2008

59 yo woman with abd pain

• CC- mid epigastric pain.

• MMP

1. Hematemesis- one episode in 2003, EGD

and colonoscopy negative

2. H.O. cholecystectomy

3. Meniere’s disease

4. Hypothyroidism- levothyroxine

5. Hyperlipidemia- niacin

6. Osteoporosis- Fosamax, calcium

• HPI –– 59 yo woman, presented to OSH with mid epigastric pain

radiating to back. Started 5pm day prior to admission.

– Initially came in waves, now sharp and constant, 6/10 without nausea/vomiting, chest pain or shortness of breath. Feels like previous gallbladder attack

– Not changed by acetaminophen, Tums, or bowel movement.

– No diarrhea/constipation, bloody/black stools/light colored stools.

– No EtoH, herbals, street drugs, sick contacts or travel.

– Went to OSH ER 0200 day of admission

• Home MedsLevothyroxine, niacin, aspirin, Fosamax, calcium

• EXAM131/69 81 99.7F 20 93% RA

HEENT - normal, no icterusCor - normalChest - mild tenderness inferior right ribsResp - normalAbd - soft, lap chole healed incisions, nontender, no massesBack - no CVA tendernessDerm - normal, no jaundiceNeuro - normal and nonfocal

• OSH Test Results

Na 141, K 3.6, BUN 16, Cr 1.1

WBC 4.6, Hgb 14.7

Total Bili 1.4, Direct Bili 0.8, Alk phos 121

ALT 694, AST 1267, Amylase 38

UA unremarkable

CT abd/pelvis- very small non-obstructive stone in right kidney, o/w normal

EKG- NSR, no Q waves, ST changes. Possible LAD and LAE o/w normal

• Assessment/Plan

ABD PAIN - hepatocellular injury

– DDX infection, toxins, obstructive, hepatic

congestion, ischemia, pancreatitis

– NPO, lipase, LFTs, hold niacin, hepatitis

serologies

– Acetaminophen level, INR

• Results

– Lipase 6, acetaminophen 1.5

Day 2 Day 3 Day 4

• BILIRUBIN,T 3.2 1.3 1.6

• BILIRUBIN,D 2.0 0.6 0.9

• BILIRUBIN,I 1.2 0.7 0.7

• ALK PHOS 85 91 121

• ALT (SGPT) 687 478 414

• AST (SGOT) 473 244 229

• Recurrent midepigastric abd pain day 4

• GI consult given worsening Tbili, and recurrent pain

• “Episodic abd pain associated with LFT abnormality (improving) in a pt with h/o gallstones suggests choledocholithiasis. If confirmatory evidence on US would proceed to ERCP but EUS if US not helpful before ERCP.”

• US– Cholecystectomy with mild to borderline moderate

dilatation of the common bile duct ranging up to 9 mm in diameter. No intrahepatic bile duct dilatation. If desired, MRCP would be the best test to further evaluate for obstructive process of the common bile duct.

– Moderate diffuse fatty infiltration of the liver.

• ERCP Day 6– Single small CBD stone

– Successful sphincterotomy and removal of stone

Day 6 Day 7

• BILIRUBIN,T 2.6 1.5

• BILIRUBIN,D 1.5 0.5

• BILIRUBIN,I 1.1 1.0

• ALK PHOS 177 144

• ALT (SGPT) 422 298

• AST (SGOT) 249 123

• Hepatitis serologies negative

• Discharged home Day 7

Biliary Physiology

• Bile secretion by liver 0.5-1 L per day

• Gallbladder holds 50 mL

– Has capacity to concentrate bile via

electrolyte and water absorption

• CBD diameter 2-4 mm

– 18+ yo patients, fasting, measured by US

– Radiology. 2001;221:411-414

CBD obstruction

• Intrinsic obstruction

– Gallstones

– Malignancy

– Infection

– Biliary cirrhosis

• Extrinsic obstruction

– Extrinsic compression

• Mass

• Inflammation

• pancreatitis

Cholangitis

• Charcot’s Triad 50-75%

– Fever

– RUQ pain

– Jaundice

• Reynold’s Pentad

– Confusion

– Hypotension

• Diagnosis

– Abd US

Cholangitis

• Diagnosis (cont.)

– ERCP

– MRCP

– Blood cultures

• Treatment

– Relieve obstruction

– Antibiotics• Unasyn, Zosyn, Timentin

• Flagyl + ceftriaxone, Flayl + Cipro/Levaquin

• Imipenem, Meropenem, or Ertapenem

Niacin Toxicity

• Crystalline vs. sustained release

formulations

• Sustained release higher incidence of

hepatotoxicity

• Cases are rare but usually associated with

higher dose >1.5g/day

• Unpredictable onset

– Need to monitor LFTs

75 yo Female with

Abdominal Pain and

Vomiting

Case conference 3/18/08

Amber Paddock, MD

HPI

75 yo F admitted to OSH with c/o sudden

onset of severe bilateral upper quadrant

abd pain, radiating to back

nonbloody emesis and 1-2 loose stools.

No clear fever

No hx of similar symptoms

No trauma.

PMHx

MR s/p Carbomedics ring repair 2000

Chronic afib

HTN

COPD

Hx of intestinal fistula/diverticulitis with

partial bowel resection and ileostomy with

takedown. 2005

Rectocele repair 1999

MEDS

Warfarin

Digoxin

Diltiazem

Diovan

Toprol XL

Triamterene/HCTZ

Zoloft

Calcium plus D

Evista

Glucosamine

Vit C

Magnesium oxide

Potassium

Protonix daily

Social and Family Hx

Married, retired

Quit tobacco 1980

Reported 2 drinks per

day, family reports at

least 6 shots per day

Mother and brother

with CVAs

Exam

148/64, 68, 97.6, 12, 94% RA

Moderate distress

HEAD and NECK: normal

CV: irreg, irreg. systolic murmer, no edema

CHEST: normal

ABD: soft, +BS, diffuse upper abd tenderness without rebound/guarding

BACK: nontender

NEURO: normal

SKIN: normal

DATA

Lipase 5673, alb 4.4, tbili 1.0, ALT 27, AST 50, alkphos 53

INR 2.5

Sodium 134, K 3.7, bicarb 30,BUN 13, cr 0.7, gluc 148

WBC 12.1, Hemoglobin 14.6, platelet 227

CXR: no free air or infiltrate

EKG: afib, trop negative

DATA

RUQ US: sludge and innumerable small stones in GB, markedly thickened GB wall at 1.6 cm, mild CBD dilation at 9 mm, no definite obstructing stone, no intrahepatic biliary dilation, pancreas somewhat swollen

CT abd/pelvis with IV con: extensive peripancreatic fluid, no pseudocyst or abscess. Distended GB without biliary dilation. Fluidextending into GB fossa and right pericolic gutter. No bowel distention with prior colon resection.

Assessment

Acute pancreatitis – likely gallstone,

consider ETOH

Acute cholecystitis – doubt

choledolcholithiasis given LFTs

Elevated AST likely due to ETOH

Coagulopathy on warfarin

Chronic afib

PLAN

NPO, IVF, pain control, antiemetics

Flagyl and avelox

5 units FFP for anticipated procedures

OSH Surgery consult rec: GI consult, lap

chole when pancreatitis resolved

OSH GI consult rec: consider MRCP

Transfer to Abbott

Hospital Day 2

Pain improved some

Afebrile, VSS

Lipase 764, tbili 1.4, alkphos 41, ALT 20, AST 41

WBC 6.8, hemoglobin stable, creatinine 0.9, INR

1.9

ANW surgical consult: antibiotics, repeat RUQ US

in am, favor perc cholecystostomy tube rather

than almost certainly open chole

Hospital Day 3

Dyspneic, abd more distended

Oliguric

ARF - Cr up 2.1, felt contrast nephropathy and ATN

lipase 443, AST 87, ALT 23, tbili 1.8, alkphos 35, INR 1.7

RUQ US: multiple gallstones, GB wall borderline at 2.9 mm with pericholecystic fluid, borderline CBD at 8.9 mm, right pleural effusion, ascites

Day 3 continued

Transferred to ICU, consult intensivists

Exam: distended with periumbilical and flank ecchymosis. Normal bladder pressure

Stat CT chest/abd/pelvis: bilateral effusions, increased free fluid, marked peripancreatic fat stranding, anasarca, mod dilation small bowel loops, no definite pseudocyst

Assess: hemorrhagic pancreatitis without abdominal compartment syndrome

Day 4

Right thoracentesis with 450 cc bloody, foamy fluid – 6700 RBC, 2.6 g protein, 1219 amylase, LDH 1644

Cr up to 3.3 -> Renal consulted

Intubated

Distal duodenal tube feeds started at 5 cc/h

Hemoglobin dropped to 9.4

Surgery: nonoperative management

Day 5

Lipase 84, WBC 6.5, platelets 88, INR 1.3,

bicarb 17, Cr 4.2

Dialysis initiated

Surgery rec perc cholecystostomy tube. IR

unable to place after multiple attempts.

Aspirated 1 cc nonpurulent bile and 10 cc

ascitic fluid

Day 6-10

All cultures negative

Developed DIC

Repeat CT abd/pelvis with moderate bilateral pleural effusions, anasarca, marked inflammation about pancreas, new large amount hyperdensity in dependent portion on ascites with a hematocrit level, moderately dilated SB loops

Steadily increasing leukocytosis and new fever, increasing FIO2 requirement

Day 6-10 continued

Dyssynchronous on vent -> atracurium

Pressors started, changed to CRRT

ID consulted -> imipenem

Repeat CT without abscess, likely multiple

pseudocysts, necrotic change of pancreas

Became hypothermic unresponsive to

warming efforts

Day 6-10 continued

Electrically cardioverted to try to increase

BP without real improvement

Requiring 100% FIO2

Weight up 20 kg since admission

Family conference -> comfort cares.

Extubated and died 7 minutes later

Acute pancreatitis

Case Conference 3/18/08

Two Broad Categories

Edematous or mild acute pancreatitis:

self limited disease with minimal organ

dysfunction; mortality < 1%

Necrotizing or severe acute pancreatitis:

mortality 30%

Overall mortality for hospitalized patients

with acute panc is 10% (2-22%)

Etiology

Alcohol

Gallstones

Trauma

Triglycerides >1000 mg/dL

High Ca++

Congenital ductal abnormalities

Infection

Meds

Malignancy

Vasculitis

idiopathic

Pathogenesis

Blockade of secertion of pancreatic enzymes while synthesis continues

Generation and release of large amounts of active trypsin within the pancreas

Subsequent activation of more trypsin and other pancreatic enzymes

Pancreatic autodigestion and spread of destruction into the peripancreatic tissue

Failure of pancreatic microcirculation leads to edema and tissue ischemia

Pathogenesis

SIRS mediated by activated pancreatic enzymes and inflammatory mediators

ARDS

Myocardial depression

Acute renal failure

Metabolic complications (low Ca, high or low BG)

Bacterial translocation from the gut resulting in infection of pancreatic tissue

Diagnosis

Upper abdominal pain and tenderness; radiates

to the back; relief on bending forward

Nausea, vomiting

Restlessness, agitation

Fever, tachycardia

Dyspnea due to diaphragmatic irritation; pleural

effusions

Shock, coma

Cullen and Grey-Turner signs in 1%

Labs

Amylase: rises within 6 – 12h, ½ life of 10 h,

relatively nonspecific, returns to normal 3-5 d

Lipase: more specific, rises in 4- 8 h, returns to

normal after 8 – 14 days

Combination doesn’t improve diagnostic

accuracy

Levels of enzymes do not correlate with severity

of disease

ALT > 150 suggests gallstones

Imaging

US: GB/biliary tree, fluid. poor for pancreas

EUS: CBD stones, head of pancreas

Contrast-enhanced CT: gold standard for dx

pancreatic necrosis, peripancreatic fluid

collections, and for grading

Necrosis may not be fully established for 3 – 4

days – no CT in the first 72 h unless diagnostic

uncertainty

MRI/MRCP-as sensitive as CT, delineates ducts

Predicting the Severity

Several systems to predict severity to allow

targeted interventions

None ideal or proven consistently accurate

Main predictor: extended pancreatic

necrosis

Predictors of Severity

Age > 55 – 60

Obesity

Comorbidities

Presence of organ failure

Pleural effusion or pulmonary infiltrates

Scoring systems: low sensitivity and specificity. Limited use.

Ranson, Glasgow: take 48h to complete

APACHE II > or = 8: better predictive values but it is complex and cumbersome to use

Ranson Criteria

0 hours 48 hours

Age >55

WBC >16

BG >200

LDH >350

AST >250

Hct Fall > 10%

BUN Incr > 5

Ca < 8

pO2 < 60

Based def. > 4

Fluid seq. > 6 L

Ranson, JHC,

Rifkind, KM,

Roses, DF, et al,

Surg Gynecol

Obstet 1974;

139:69.

Ranson factors % Mortality

0 - 2 0.9%

3 - 4 16%

5 - 6 40%

7 - 8 100%

Glasgow System: 3 or > criteria

within the 1st 48h predict SP

WBC > 15

BG > 180 (no h/o DM)

BUN > 45 with no resp. to IVF

pO2 < 60

Ca < 8

Albumin < 3.2

LDH > 600

AST > 2000

Corfield, AP, Williamson, RCN, McMahon, MJ, et al, Lancet 1985;

24:403

Grade CT without contrast Score

A Normal pancreas 0

B Focal or diffuse enlarg., contour

irregularity, inhomog. attenuation

1

C Peripancreatic inflammation 2

D Intra- or extrapancreatic fluid collections 3

E 2 or > large collections of gas in

pancreas or retoperitoneum

4

Contrast enhanced CT0 Necrosis, percent 0

<33 2

33-50 4

>50 6

CT severity index: unenhanced CT score plus necrosis score: max

10, 6 = severe disease

Adapted from

Balthazar, EJ,

Robinson, DL,

Megibow, AJ, Ranson,

JH, Radiology 1990;

174:331.

Patients with a CT severity index >5: 8 times more likely to die, 17 times more likely to have a

prolonged hospital course, and 10 times more likely to undergo necrosectomy than pt’s with scores

<5 in a study of 268 pts.(Simchuk EJ; Traverso LW; Nukui Y; Kozarek RA SOAm J Surg 2000 May;179(5):352-5).

APACHE II

• Can be performed daily

• Decreasing values over 48 hours suggest

mild

• Uses proprietary computer technology

• Large amount of physiologic variables,

age, chronic health

• AGA rec APACHE II, cut off > or = 8

Treatment

Correction of predisposing factors (early ERCP for gallstones, treat hyperCa++, stop offending drugs)

Supportive care: pain control, IVFs, NPO, oxygen

Mild pancreatitis: recovery within 3 – 7 days

Necrotizing pancreatitis: treatment in ICU or dedicated unit

Fluid Resuscitation in Severe

Pancreatitis

Patients may accumulate large amounts of

fluid in the injured pancreatic bed

250 – 300 cc/h in the 1st 48h

Fluid depletion may result in more

pancreatic necrosis

Monitor cardiac filling pressures,

hematocrit and UO

Risk of pulmonary edema if ATN present

Infection

1/3 of patients with pancreatic necrosis develop local infection

Infected necrosis is more common late in clinical course (after 10 days)

Abx prophylaxis should be restricted to patients with 30% or more pancreatic necrosis by CT scan

CT-guided aspiration if infection suspected, deterioration, no improvement in 1 week for culture

Surgical Treatment

Late (>14 days) surgical debridement associated with lower mortality and morbidity

Viable and non-viable tissues are better defined with delayed approach

Minimally invasive necrosectomy is preferred, especially if pt has hemodynamic or respiratory instability

Nutrition

Continuous feeding into distal jejunum doesn’t

stimulate exocrine pancreatic secretion

Enteral nutrition helps maintain intestinal barrier

and prevents bacterial translocation

Improved outcomes with enteral when compared

to parenteral nutrition

Parenteral nutrition: for pts who do not tolerate

enteral feeding or nutritional goals can not be

reached

ERCP

Urgent ERCP (within 24h): pts with GS

pancreatitis and cholangitis

Early ERCP (within 72h): pts with high

suspicion of persistent bile duct stones

Cholecystectomy in all pts. with GS panc

prior to discharge