presents a case of pancreatitis with pics and values in addition to the treatment

1. CASE PRESENTATION
Supervised by
Dr . Muhannad Sarminy
Presented by
Dana Sultan

3.  A 42-year-old woman presents to the
emergency department complaining of 24
hours of severe, steady epigastric abdominal
pain, radiating to her back, with several
episodes of nausea and vomiting.
 She has experienced similar painful episodes
in the past, usually in the evening following
heavy meals, but the episodes always resolved
spontaneously within an hour or two.
 This time the pain did not improve, so she
sought medical attention. She has medical
history significant for hyperlipedimia and
hypertention treated with simvastatin and
furosemide and metprolol . She is married, has
three children, and does not drink alcohol or
smoke cigarette.

4. What is the next step ?

5.  ON EXAMINATION,
 she is afebrile ,
 tachycardic with a heart rate of 104 bpm ,
 blood pressure 115/74 mm Hg,
 shallow respirations of 25 breaths per
minute. She is moving uncomfortably on
the stretcher,,
 she has scleral icterus .
 Her abdomen is soft, mildly distended with
marked right upper quadrant and epigastric
tenderness to palpation,
 hypoactive bowel sounds, and no masses
or organomegaly appreciated.

6. What is the next step ?

7. labratory study
(9.2 g/dL)total bilirubin
285 IU/Lalkaline phosphatase
50%HCT
16,500/mmleukocyte count
45 mg/dlUrea
90 IU/Laspartate aminotransferase (AST),
160 IU/Lalanine aminotransferase (ALT,
1900 IU/Lelevated amylase level.
= 0.7 mgdlcreatine
6742 U/LLipase

8. What is the next step ?
ECG
Abdominal Xray
Cxr
ULTRASONOGRAP
HY

10. A plain film of the abdomen shows a
Sentinel Loop Sign and no
pneumoperitoneum.

12. What is the most likely diagnosis?
A. A-acute pancreatitis
B. b-acute cholecystitis
C. c- biliary colic
D. d- ascending cholangitis
E. E- Perforation Peritonitis
F. F- Gastritis
G. G- Mesenteric Ischemia
H.
T- Myocardial Infarction

13. What is your next diagnostic step
??
 A-CT Abdomen
 b- Right upper quadrant abdominal
ultrasonography.
 C-MRI

15. Summary
 A 42-year-old woman with a prior history
consistent with symptomatic cholelithiasis now
presents with epigastric pain and nausea for
24 hours, much longer than would be
expected with uncomplicated biliary colic. Her
symptoms are consistent with acute
pancreatitis. She also has hyperbilirubinemia
and an elevated alkaline phosphatase level,
suggesting obstruction of the common bile
duct caused by a gallstone, which is the likely
cause of her pancreatitis ..

16.  ➤ Most likely diagnosis:
 Acute pancreatitis.
 ➤ Most likely etiology:
 Choledocholithiasis
 (common bile duct stone).

17. Severity of pancreatitis

18. BISAP
 (B) Blood urea nitrogen (BUN) >22 mgdl
 (I) Impaired mental status
 (S) SIRS: 2/4 present
 (A) Age >60 years
 (P) Pleural effusion
SIRS
 temperature >38° or <36°C (>100.4° or
96.8°F), Pulse >90, Tachypnea >24, WBC
>12,000
Lower mortality (<2
percent)
0-2 Points:

21. Management
 Pain relief.
 Fluid resuscitation ,, maintain adequate urine
output and blood pressure
 Invasive monitoring of vital signs
 NPO : Suppression of pancreatic function ,,
Fluids and diet are withheld until nausea and
vomiting settle
 Antibiotic >?? prophylaxis can be considered
(imipenem, cefuroxime)

22. ERCP
Early endoscopic retrograde cholangiogram (ERCP) with
papillotomy or surgical intervention to remove bile duct
stones may lessen the severity of gallstone pancreatitis

23. With routine follow up
Up to 10 days after being hospitalized the
patient , temperature is 38.2 and continued to
have severe mid-epigastric pain that radiates
to the back, nausea, and. She has not been
able eat or drink and has not had a bowel
movement since being admitted.

24. Pancreatic pseudocyst

25. CT for pancreatitis
Patients with clinical and biochemical features
of acute pancreatitis who:
do not improve with initial conservative
therapy
who are suspected of having complications
or other diagnoses should undergo CT
scan of the abdomen

26. PANCREATIC
COMPLICATIONS
 Sterile and infected pancreatic necrosis
 Pancreatic abscess
 Pancreatic ascites
 Pancreatic effusion
 Haemorrhage
 Portal or splenic vein thrombosis
 Pseudocyst

27. Treatment of pancreatitis
 Percutaneous CT-guided aspiration — CT-guided percutaneous
aspiration with Gram's stain and culture is recommended when infected
pancreatic necrosis is suspected .We do this when there is >30 percent
pancreatic necrosis and there are clinical signs of infection without another
obvious site of infection.
 . If there is bacterial infection, we consider performing a necrosectomy
(Surgical debridement of infected necrosis)
 Cholecystectomy should be performed after recovery in all patients with
gallstone pancreatitis prior to hospital discharge
 ERCP should be performed within 72 hours in those with a high
suspicion of persistent bile duct stones (ie, visible common bile duct stone
on noninvasive imaging, persistently dilated common bile duct, jaundice)
 Surgical drainage — Surgical management is still considered the
gold standard of pancreatic pseudocyst management,

28. Thank U