General Surgery · Year 3 · from General Surgery

Case 1: Acute Pancreatitis

Patient Demographics

  • Age: 48 years
  • Sex: Male
  • Occupation: Sales manager

Chief Complaint

"I have severe pain in my upper abdomen that goes through to my back."

History of Present Illness

The patient presents with a 12-hour history of severe, constant epigastric pain radiating straight through to his back. The pain began after a business dinner where he consumed several alcoholic drinks. He has had multiple episodes of vomiting. The pain is somewhat relieved by leaning forward. He admits to heavy alcohol consumption over the past several years (6-8 drinks daily). He has had similar but milder episodes in the past that he attributed to "stomach upset."

Past Medical History

  • No formal medical history (does not see physicians regularly)
  • Alcohol use disorder (undiagnosed)

Social History

  • Heavy alcohol use: 6-8 drinks daily for 15 years
  • Smokes 1 pack/day
  • Works in sales with frequent client dinners

Physical Examination

  • Vitals: BP 108/68 mmHg, HR 112 bpm, RR 22/min, Temp 37.8°C, SpO2 96%
  • General: Distressed male, restless, leaning forward
  • Abdomen:
  • Tender epigastrium with guarding
  • Decreased bowel sounds
  • No rebound
  • No ecchymosis (Cullen's or Grey Turner's signs)
  • Skin: Mildly diaphoretic

Laboratory Results

  • WBC: 15,600/μL
  • Hemoglobin: 16.2 g/dL (hemoconcentrated)
  • Platelets: 168,000/μL
  • BUN: 32 mg/dL
  • Creatinine: 1.6 mg/dL
  • Glucose: 186 mg/dL
  • Lipase: 2,840 U/L (markedly elevated, normal <60)
  • AST: 86 U/L
  • ALT: 52 U/L (not significantly elevated - argues against biliary etiology)
  • Total bilirubin: 1.4 mg/dL
  • Calcium: 8.2 mg/dL
  • LDH: 340 U/L
  • Triglycerides: 180 mg/dL (normal)
  • Lactate: 2.4 mmol/L

Severity Assessment

APACHE II Score: 12 (moderate severity)

BISAP Score: 3

  • BUN >25: +1
  • Impaired mental status: 0
  • SIRS criteria: +1 (HR >90, WBC >12,000)
  • Age >60: 0
  • Pleural effusion: +1 (on chest X-ray)

Predicted mortality: 5-10%

Imaging

CT Abdomen/Pelvis with IV contrast:

  • Enlarged, edematous pancreas
  • Peripancreatic fat stranding
  • Peripancreatic fluid collections
  • No pancreatic necrosis (enhancement preserved)
  • No gallstones visible
  • Balthazar Score: D (moderate)

Right Upper Quadrant Ultrasound:

  • No gallstones
  • No biliary dilation
  • Consistent with alcoholic etiology

Diagnosis

Acute alcoholic pancreatitis, moderately severe

Initial Management

  1. Aggressive IV fluid resuscitation (Lactated Ringer's, goal-directed)
  2. NPO initially
  3. Pain control (IV hydromorphone)
  4. Anti-emetics
  5. Monitor for organ dysfunction
  6. No role for prophylactic antibiotics

Hospital Course

Days 1-3:

  • Continued IV fluids (250-500 mL/hr initially, then adjusted)
  • Pain improving
  • No respiratory distress
  • Renal function improved with hydration

Day 4:

  • Attempted clear liquids - tolerated
  • Pain well controlled with oral analgesics

Day 5:

  • Advanced to low-fat solid diet
  • Tolerated well

Nutritional Management

  • Early enteral nutrition preferred (within 24-72 hours if feasible)
  • If not tolerating oral, nasojejunal feeding superior to TPN

Alcohol Counseling

  • Addiction medicine consultation
  • Patient agreed to alcohol rehabilitation program
  • CIWA protocol for alcohol withdrawal monitoring (not needed)

Discharge

  • Day 6
  • Oral analgesics
  • Low-fat diet instructions
  • Alcohol cessation resources
  • Follow-up with GI and addiction medicine

Teaching Points

  1. Lipase is highly sensitive and specific for acute pancreatitis
  2. Severity scoring (APACHE II, BISAP) guides ICU admission
  3. Goal-directed fluid resuscitation is critical in first 12-24 hours
  4. Early enteral nutrition when feasible
  5. CT with contrast should be delayed 48-72 hours (to assess necrosis)
  6. Address underlying etiology (alcohol, gallstones)
  7. Prophylactic antibiotics not recommended

Clinical Image

Image Description: CT scan demonstrating acute pancreatitis with diffuse pancreatic enlargement, peripancreatic fat stranding, and peripancreatic fluid collections. The pancreatic parenchyma shows preserved enhancement indicating absence of necrosis.

Attribution: Image from Wikimedia Commons, Category:Pancreatic cancer. Source: https://commons.wikimedia.org/wiki/Category:Pancreatic_cancer

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