A 45-year-old man is evaluated in the emergency department for severe, constant abdominal … — USMLE Step 2 CK

A 45-year-old man is evaluated in the emergency department for severe, constant abdominal pain that began 12 hours ago. He states the pain is located in the upper abdomen and radiates directly to his mid-back. He has had three episodes of non-bilious emesis since the pain started. The patient has a history of alcohol use disorder, consuming approximately six beers daily for the past decade. Vital signs show a temperature of $37.6^\circ\text{C}$ ( $99.7^\circ\text{F}$ ), blood pressure of $142/88\text{ mm Hg}$ , heart rate of $112/\text{min}$ , and respiratory rate of $18/\text{min}$ . Physical examination reveals a diaphoretic man in acute distress. The abdomen is non-distended but exquisitely tender to palpation in the epigastric region; there is no guarding or rebound tenderness. Bowel sounds are sluggish. Laboratory studies reveal:

Laboratory Test	Result
Leukocyte count	$11,200/\text{mm}^3$
Lipase	$1,850\text{ U/L}$
Aspartate aminotransferase (AST)	$45\text{ U/L}$
Alanine aminotransferase (ALT)	$38\text{ U/L}$
Thyroid-stimulating hormone (TSH)	$5.5\text{ mU/L}$ (normal: $0.4-4.0\text{ mU/L}$ )
Free T4	$1.2\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$ )

An abdominal ultrasound demonstrates a normal-appearing gallbladder without cholelithiasis, a normal common bile duct diameter, and obscured views of the pancreas due to overlying bowel gas.

Which of the following is the most appropriate next step in management?

Initiation of vigorous intravenous fluid hydrationAnswer
B
Administration of intravenous imipenem-cilastatin
C
Immediate surgical consultation for exploratory laparotomy
D
Initiation of oral levothyroxine therapy
E
Administration of intravenous furosemide

Answer

Initiation of vigorous intravenous fluid hydration

This patient presents with a classic clinical picture of acute pancreatitis: severe acute-onset epigastric pain radiating to the back, nausea, vomiting, a significant history of alcohol use, and a serum lipase level markedly elevated above three times the upper limit of normal. The most critical initial step in the management of acute pancreatitis is early and aggressive intravenous fluid resuscitation (typically with crystalloids such as lactated Ringer solution). Acute pancreatic inflammation results in profound systemic vasodilation, increased capillary permeability, and massive third-spacing of fluids. If not rapidly corrected with intravenous fluids, this intravascular volume depletion can lead to hypoperfusion of the pancreas (increasing the risk of pancreatic necrosis) and progression to multisystem organ failure.

Step-by-Step Solution

Analyze the patient's clinical presentation and laboratory results.

The patient has severe epigastric pain radiating to the back, a history of heavy alcohol use, and a serum lipase level greater than three times the upper limit of normal.

These findings fulfill the diagnostic criteria for acute pancreatitis.

Determine the most appropriate initial management for acute pancreatitis.

The first-line therapy is aggressive supportive care, primarily consisting of vigorous intravenous fluid hydration.

Severe pancreatic inflammation leads to massive third-spacing of fluids, intravascular volume depletion, and potential organ failure if perfusion is not maintained.

Key Concept

The primary initial management for acute pancreatitis is aggressive intravenous fluid resuscitation to correct intravascular volume depletion caused by third-spacing and to prevent pancreatic necrosis.

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