Gastrointestinal · Year 2 · from Gastrointestinal
Case 1: Acute Gallstone Pancreatitis
Patient Presentation
Demographics: 52-year-old female
Chief Complaint: Severe epigastric pain radiating to the back for 12 hours
History of Present Illness: The patient developed severe, constant epigastric pain after eating dinner last night. The pain is "boring" in quality and radiates straight through to her back. She reports that leaning forward provides some relief. She has had multiple episodes of nausea and vomiting. She notes that she has had similar but milder episodes of right upper quadrant pain after fatty meals over the past year that typically resolved within a few hours.
Past Medical History: Obesity, hyperlipidemia, type 2 diabetes mellitus, known gallstones (found incidentally 2 years ago)
Social History: Non-smoker, occasional alcohol (1-2 glasses of wine weekly)
Physical Examination
- Vital Signs: Temperature 38.2C, BP 105/68 mmHg, HR 108 bpm, RR 20/min
- General: Uncomfortable female lying still, appears distressed
- Abdomen: Significant epigastric tenderness with voluntary guarding; no rebound tenderness; hypoactive bowel sounds; no palpable masses
Workup and Results
- CBC: WBC 15,200 with 82% neutrophils
- BMP: Glucose 245 mg/dL, BUN 28 mg/dL, Creatinine 1.2 mg/dL
- Liver Function Tests: AST 186 U/L, ALT 312 U/L (elevated, suggesting biliary etiology), ALP 185 U/L, Total bilirubin 2.8 mg/dL
- Lipase: 1,842 U/L (greater than 3x upper limit of normal)
- Triglycerides: 180 mg/dL (normal)
- Right Upper Quadrant Ultrasound: Multiple gallstones; gallbladder wall thickening; common bile duct 8 mm (mildly dilated); no definite choledocholithiasis visualized
- CT Abdomen with IV Contrast (obtained at 72 hours): Diffuse pancreatic enlargement with peripancreatic fat stranding and small peripancreatic fluid collection; pancreas enhances uniformly without evidence of necrosis
CT scan demonstrating diffuse pancreatic enlargement with loss of normal lobular contour ("sausage pancreas" appearance), consistent with pancreatic inflammation. While this particular image shows autoimmune pancreatitis, similar diffuse enlargement can be seen in acute pancreatitis of various etiologies.
Image Source: Wikimedia Commons. Hellerhoff, CC BY-SA 3.0
Diagnosis
Acute Gallstone Pancreatitis - Mild (Revised Atlanta Classification)
Clinical Correlation
This case illustrates classic gallstone pancreatitis, the most common cause of acute pancreatitis (40% of cases). The diagnosis is established when two of three criteria are met: (1) characteristic epigastric pain radiating to the back, (2) serum lipase greater than 3 times the upper limit of normal, and (3) characteristic imaging findings. This patient meets all three criteria.
Several features point to gallstones as the etiology: the classic "4 F's" risk factors (Female, Forty-plus, Fertile, Fat), known cholelithiasis, and elevated ALT (an ALT greater than 3 times normal has a positive predictive value exceeding 85% for gallstone pancreatitis). The mechanism involves transient obstruction of the pancreatic duct at the ampulla of Vater by a passing stone, causing premature activation of pancreatic enzymes and autodigestion.
The BISAP score helps risk-stratify patients at presentation: BUN > 25 (present), Impaired mental status (absent), SIRS criteria (present - fever, tachycardia, tachypnea), Age > 60 (absent), Pleural effusion (absent). This patient's BISAP score of 2 indicates moderate risk.
Treatment
- NPO initially; early enteral nutrition when pain improves (within 24-48 hours)
- IV fluid resuscitation with Lactated Ringer's (250-500 mL/hour initially), goal-directed to urine output 0.5-1 mL/kg/hour
- Pain management with IV opioids (morphine or hydromorphone)
- No prophylactic antibiotics - sterile necrosis does not benefit from antibiotics
- MRCP or endoscopic ultrasound to evaluate for retained CBD stones given elevated liver enzymes
- Cholecystectomy during the same admission (after clinical improvement) to prevent recurrent pancreatitis
- ERCP only if concurrent cholangitis or persistent biliary obstruction