Examkin

Question

Difficulty: MediumGastroenterology and Hepatology

A 42-year-old woman is admitted to the hospital with a 1-day history of severe, unrelenting epigastric pain that radiates to her back. She also reports nausea and multiple episodes of nonbilious vomiting. Her temperature is 37.8°C (100°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 18/min. Physical examination shows marked epigastric tenderness with guarding but no rebound tenderness. Bowel sounds are decreased. Laboratory studies show:

TestValue
Hemoglobin14.5 g/dL
Leukocyte count14,000/mm³
Platelet count250,000/mm³
Serum aspartate aminotransferase (AST)120 U/L
Serum alanine aminotransferase (ALT)145 U/L
Serum total bilirubin1.1 mg/dL
Serum alkaline phosphatase95 U/L
Serum lipase3,200 U/L

Right upper quadrant ultrasound shows a distended gallbladder with multiple small echogenic foci and posterior acoustic shadowing. The common bile duct measures 4 mm in diameter, and no choledocholithiasis is visualized. Which of the following is the most appropriate next step in management?

  1. Aggressive intravenous fluid resuscitationAnswer
  2. B
    Intravenous administration of broad-spectrum antibiotics
  3. C
    Endoscopic retrograde cholangiopancreatography
  4. D
    Contrast-enhanced computed tomography of the abdomen
  5. E
    Urgent laparoscopic cholecystectomy

Answer

Aggressive intravenous fluid resuscitation
The correct answer is aggressive intravenous fluid resuscitation. This patient presents with classic signs and symptoms of acute gallstone pancreatitis: severe epigastric pain radiating to the back, elevated serum lipase greater than three times the upper limit of normal, and ultrasound evidence of cholelithiasis. In patients with acute pancreatitis, significant third-spacing of fluids occurs due to severe systemic inflammation. Therefore, the cornerstone of early management is aggressive goal-directed intravenous fluid resuscitation (typically with lactated Ringer solution) to maintain intravascular volume and prevent pancreatic necrosis. This should be combined with pain control and bowel rest.

Step-by-Step Solution

1
Diagnose the patient's condition based on the clinical presentation.
The patient has acute gallstone pancreatitis, diagnosed by severe epigastric pain, a serum lipase level >3 times the upper limit of normal, and ultrasound evidence of gallstones.
Establishing the correct diagnosis is essential for determining the initial management.
2
Evaluate for any immediate complications such as biliary obstruction or ascending cholangitis.
The patient's normal serum total bilirubin and normal common bile duct diameter (4 mm) indicate that there is no ongoing biliary obstruction or concurrent cholangitis.
The presence of cholangitis would necessitate immediate procedural intervention (ERCP).
3
Determine the most appropriate initial management step for uncomplicated acute pancreatitis.
The most important initial step is supportive care with early, aggressive goal-directed intravenous fluid resuscitation.
Acute pancreatitis causes significant third-spacing of fluids and systemic inflammation; adequate hydration is crucial to prevent necrosis and hypovolemia.

Key Concept

Initial management of acute pancreatitis
Rate this question

Topics

Gastroenterology and Hepatology

More questions from this topic