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A 56-year-old man with known gallstones who drinks 60 g of alcohol daily presents with severe constant epigastric pain radiating straight through to the back, vomiting, and faint bluish flank bruising. On examination he is confused, RR 28, SpO2 90% on air, BP 84/52, with marked epigastric tenderness and absent bowel sounds. Serum lipase is 6 times the upper limit of normal, calcium 1.8 mmol/L, ALT 180 IU/L, CRP 180 mg/L. Urine output is 15 mL/h.[1]
Questions
a) Diagnosis and severity grade? (2 marks)
Acute pancreatitis by 2 of 3 criteria (typical epigastric pain radiating to the back + lipase over 3 × ULN); imaging is not required for diagnosis. Severe by Revised Atlanta if persistent organ failure over 48 h (respiratory, renal or cardiovascular). This patient already has hypotension, hypoxia, oliguria and confusion — treat as severe pending the 48-hour clock. Grey-Turner's sign (flank bruising) marks necrotising or haemorrhagic disease.[1]
b) Initial resuscitation with drug, dose, route, rationale? (3 marks)
- ABCDE — high-flow oxygen to SpO2 94 to 98%; two large-bore cannulae; urinary catheter for hourly output; ICU referral.
- Goal-directed moderate lactated Ringer's (WATERFALL) — 10 mL/kg bolus only if hypovolaemic (no bolus if normovolaemic), then 1.5 mL/kg per hour, reassessed at 12, 24, 48 and 72 hours. Avoid the aggressive regimen (20 mL/kg then 3 mL/kg per hour) — fluid overload 20.5 versus 6.3 percent without outcome benefit.[2]
- Adequate IV opioid analgesia; urinary catheter for hourly output.
- Daily weights, continuous SpO2/ECG, hourly urine output.
c) Definitive management — feeding, antibiotics, ERCP, cholecystectomy? (3 marks)
- Early enteral feeding within 24 to 48 h (oral or NG/NJ if intolerant) — no prolonged nil by mouth; reduces gut translocation and infected necrosis.
- No routine prophylactic antibiotics (Poropat 2022: no significant reduction in infected necrosis or mortality) — give only for infected necrosis (an antibiotic that penetrates necrosis, typically a carbapenem) or cholangitis.[7]
- ERCP within 24 h ONLY for cholangitis or persistent biliary obstruction (jaundice, CBD stone, worsening LFTs); NOT routine.
- Same-admission laparoscopic cholecystectomy in mild gallstone pancreatitis; in severe disease delay until resolution. ERCP + sphincterotomy if unfit.
d) Two complications and their management? (2 marks)
- Infected necrosis — diagnosed by gas in necrosis on CT or positive FNA; treat with antibiotics plus step-up drainage around 4 weeks (PANTER: composite 40 versus 69 percent; 35 percent drainage alone).[5]
- ARDS — from phospholipase-A2 destroying surfactant; manage by lung-protective ventilation in ICU.
- Hypocalcaemia (saponification) — correct only if symptomatic; splenic/portal vein thrombosis, exocrine/endocrine insufficiency long-term.
References5ShowHide
- [1]Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus Gut, 2013.PMID 23100216
- [2]de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis N Engl J Med, 2022.PMID 36103415
- [3]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis Am J Gastroenterol, 2024.PMID 38857482
- [5]van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis N Engl J Med, 2010.PMID 20410514
- [7]Poropat G, Goričanec K, Lacković A, et al. Systematic Review with Trial Sequential Analysis of Prophylactic Antibiotics for Acute Pancreatitis Antibiotics (Basel), 2022.PMID 36139970