Presentation of case study on the presentation, etiology and management of acute pancreatitis. Slides compiled as part of medical school studies. Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.

1. CASE 2:
Acute Pancreatitis
Robert Ferris

2. History
 A 33-year-old white man presents to the
Emergency Department 4 hours ago with
acute epigastric pain and nausea and
vomiting of 24 hours durations.
 He is obviously uncomfortable, twisting
on the gurney trying to get comfortable.

3. On examination
Vitals:
 temperature 37.2oC (98.9oF)
 HR 130/min
 RR 22/min
 BP 124/72mmHg
 SpO2 90% on room air.
 The patient has epigastric tenderness on
physical examination, but no peritoneal signs.

4. On examination
 The cardiac examination is normal, but
the patient has mild bibasilar rales.
 Right upper quadrant ultrasonography
shows no biliary tract obstruction.
 He has had no recent infections.
 The patient received 4 liters of fluid before
your arrival. His urine output has been
120mL since his arrival in the emergency
department.

5. Laboratory studies show
 Hematocrit of 36%,
 Leukocyte count 18,000/mL
 Platelet count 114,000/mL
 Lactate dehydrogenase 453 U/L
 Alakaline phosphatase 97 U/L
 Total bilirubin 0.6 mg/dL
 Blood glucose 204 mg/dL
 Blood urea nitrogen of 26mg/dL
 PaO2 59 mmHg
 Amylase 600 U/L
 Calcium 9.2mg/dL

6. Pancreatitis

7. Pancreatitis
 Localised pain with nausea/vomiting
 Rapid HR (130bpm)
 Rapid RR (22/min)
 increase in urination and low BP (hypovolemia)
 No established history of personal or familial GI
disease

8. Pancreatitis
Laboratory studies show
 Hematocrit of 36%,
 Leukocyte count 18,000/mL 4,000-10,000/mL
 Platelet count 114,000/mL
 Lactate dehydrogenase 453 U/L 140-280U/L
 Alakaline phosphatase 97 U/L
 Total bilirubin 0.6 mg/dL
 Blood glucose 204 mg/dL 79-110mg/dL
 Blood urea nitrogen of 26mg/dL 7-20mg/dL
 PaO2 59 mmHg >80mmHg
 Amylase 600 U/L 23-140U/L
 Calcium 9.2mg/dL

9. Pancreatitis
 The patient has early signs of severe
acute peritonitis
 Severe disease occurs in about 15% of
patients with pancreatitis

10. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
 At presentation
 Age > 55 years
 Leukocyte count > 16000/mL
 Blood glucose > 200 mg/dL
 Lactate dehydrogenase > 350 U/L
 Aspartate aminotransferase > 250 U/L

11. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
 At presentation
 Age > 55 years
 Leukocyte count > 16000/mL
 Blood glucose > 200 mg/dL
 Lactate dehydrogenase > 350 U/L
 Aspartate aminotransferase > 250 U/L

12.  Patient possessing three or more of these
criteria have a worse prognosis
 This patient had:
 Hyperglycemia (Blood glucose 204 mg/dL)
 Elevated Lactate dehydrogenase (453 U/L)
 Leukocytosis (18,000/mL )

13. Ranson’s Early Prognostic Signs of
Severity of Acute Pancreatitis
 At 48 hours
 Hematocrit – decrease by 10%
 Blood urea nitrogen – increase by 5 mg/dl
 Calcium < 8mg/dl
 PaO2 < 60 mmHg
 Base deficit > 4 meq/L
 Fluid sequestration > 6000 mL

14.  He also had:
 Hypoxemia (PaO2 59 mmHg; oxygen saturation of
90%)
 Examination signs of possible noncardiogenic
pulmonary edema (The cardiac examination is
normal, but the patient has mild bibasilar rales)
 Tachycardia (pulse rate of 130/min)
 Oliguria (urine output 120 mL/4 hours) – despite
vigorous intravenous hydration (patient received 4
liters of fluid)
 These factors also portend a worse prognosis

15. QUESTION 1
 The most likely reason for this patient’s
pancreatic symptoms is:
 Gallstone pancreatitis
 Alcoholic pancreatitis
 Infectious pancreatitis
 autoimmune pancreatitis

16. Pancreatitis
 The most common causes of acute pancreatitis are
 Alcohol ingestion
 Biliary tract disease
 In this patient the lack of
 dilated ducts
 Cholelithiasis
 elevated alkaline phosphatase
as well as
 normal bilirubin
Makes gallstone pancreatitis unlikely

17. Pancreatitis
 Infectious pancreatitis can be caused by viral illnesses
or bacteria such as
 Mycoplasma
 Campylobacter
 Mycobacterium avium complex
 (In this patient) without a history of antecedent
infection, this would be unlikely
 Although connective tissue disease with vasculitis,
such as systemic lupus erythematosus, can cause
pancreatitis, this patient has no symptoms, examination
findings, or laboratory studies making this diagnosis
unlikely

18. QUESTION 1
 The most likely case of this patient’s
problem is:
 Gallstone pancreatitis
 Alcoholic pancreatitis
 Infectious pancreatitis
 autoimmune pancreatitis

19. QUESTION 2
 The most appropriate therapy for this patient
would be:
 1. Aggressive fluid resuscitation, bowel rest,
monitoring in the intensive care unit, and analgesics
 2. Aggressive fluid resuscitation, nasogastric
suction, bowel rest, and ward hospitalisation
 3. Analgesic mediaction and outpatient follow-up the
next day
 4. Immediate gastroenterology consultation for
endoscopic retrograde cholangiopancreatography
(ERCP)

20.  Admission to the intensive care unit
is appropriate because of the high
likelihood of multiorgan dysfunction