Worsening Abdominal Pain in Man With History of Alcohol Abuse

Forty-eight hours earlier, a 39-year-old man presented to the emergency department with emesis and severe upper abdominal pain of semi-acute onset, which radiated slightly to the back. He was admitted and has been managed conservatively with intravenous fluids, analgesics, and nothing to eat or drink.

In the past several hours, however, his condition has significantly deteriorated. He has assumed a fetal position but still seems unable to get comfortable. He now complains of thirst, is quite agitated, and is becoming confused.

HISTORY

The patient has had similar episodes in the past and was told they resulted from pancreatic inflammation. He has a long history of alcohol abuse and has been drinking at least half a bottle of vodka daily during the week before his admission. He also had been hospitalized previously for heart failure and atrial fibrillation that were thought to be alcohol-related.

PHYSICAL EXAMINATION

Temperature is 38.3°C (101°F); heart rate, 150 beats per minute; and respiration rate, 20 breaths per minute. The mucosae are dry, but there is no scleral icterus. Chest is clear. Bowel sounds are markedly diminished, and the abdomen is diffusely tender, with the greatest tenderness in the upper mid-epigastrum; rebound tenderness is noted as well.

LABORATORY AND IMAGING STUDIES

Hematocrit is 50 mL/dL (on admission it was 39 mL/dL); leukocyte count is 19,000/µL (on admission, 16,700/µL). Blood glucose level is 253 mg/dL, which is essentially unchanged from the level on admission. Serum amylase and lipase levels are both significantly elevated at 906 U/L and 2011 U/L, respectively. Lactate dehydrogenase level is 510 U/dL. The C-reactive protein level in a sample obtained the morning after admission is 191 mg/dL.

The admission CT scan revealed significant streaking and necrosis of the pancreas and a single small fluid collection near the tail. The extent of pancreatic necrosis was estimated at between 30% and 50% with a high severity index of 8. Gas formation was suspected in the area of the fluid collection. Abdominal ultrasonography shows no gallstones or dilation of the bile ducts.

Which of the following would be least beneficial for the patient at this time?

A. Transfer the patient to an ICU for fluid resuscitation and monitoring.

B. Empirically initiate broad-spectrum antibiotics such as ciprofloxacin and metronidazole.

C. Arrange for immediate open surgical debridement of necrotic pancreatic tissue.

D. Initiate a protocol of phased intervention including percutaneous drainage and
video-assisted retroperitoneal debridement (VARD) with postoperative lavage.

Answer on next page

Correct Answer: C

This patient has acute pancreatitis that is evolving into severe, morbid disease. Acute pancreatitis is common; in the United States, those affected tend to be either elderly (older than 60 years), predominantly female patients with (small) gallstone pancreatitis or younger, predominantly male patients with alcohol-related pancreatitis. In disease of either origin, inappropriate activation of trypsinogen into trypsin is involved, with subsequent activation of digestive enzymes within the pancreas that causes local injury and an intense, body-wide inflammatory response. The latter produces its own tissue damage and systemic effects that can culminate in multi-organ failure and even death.¹

Severe disease develops in roughly 20% of patients with acute pancreatitis; about 10% to 30% of these patients die (2% to 6% of all patients with pancreatitis). Despite advances in ICU medicine and medical care generally, these percentages have changed little in the past 30 years.² Still, certain management maneuvers are more effective than others at reducing the morbidity and mortality associated with acute, severe pancreatitis.

IDENTIFYING PATIENTS AT RISK FOR SEVERE ACUTE PANCREATITIS

Various time- and data-tested markers can accurately quantitate the risk of severe disease in patients with acute pancreatitis. These include specific laboratory values that indicate the systemic inflammatory response, scoring systems that assess the same response as well as organ failure, and imaging scores.^1-3

This patient fulfills several sets of criteria for severe pancreatitis:

•The traditional Ranson criteria.

•C-reactive protein level.

•CT severity index.

He also displays several other markers not included in traditional risk profiles but reported to be prognostic (eg, rising hematocrit, progressive tachycardia, agitation, and confusion).¹ In addition, his history of ill-defined cardiac disease introduces enough doubt about his hemodynamic stability to make it prudent to transfer him to the ICU for monitoring of the aggressive and complicated volume resuscitation he obviously will require (choice A).

MANAGEMENT OF SEVERE DISEASE

When a patient’s condition fails to improve within 48 hours (and this man’s condition is actually worsening), further diagnostic and therapeutic maneuvers need to be considered. Most experts suggest a second imaging study (eg, CT with contrast) to detect new necrosis, fluid collections, or other pertinent findings.

Antibiotics. The use of antibiotics in severe acute pancreatitis (choice B) remains controversial. Infection of pseudocysts or pancreatic necrosis are dreaded complications that increase mortality to about 50%.^1,4 However, several randomized trials of prophylactic antibiotic therapy have produced conflicting results.⁵ Here, the use of antibiotics would not be strictly “prophylactic” and is essentially a uniform trigger for some form of invasive approach. This man has a fever, and although the fever has other possible causes (eg, delirium tremens), most experts would consider using antibiotics, possibly in conjunction with fine-needle aspiration to confirm infection. In addition, his CT scan suggests the presence of gas in the fluid collections, which most authorities would consider a criterion for infection even if initial cultures are not positive.

Timing of surgery. Drainage of infected pseudocysts and debridement of infected necrotic pancreatic tissue are indicated and potentially life-saving. However, the timing of surgery is crucial to the outcome. Surgery early in the course of severe acute pancreatitis (first 48 to 96 hours) is associated with increased mortality—as high as 65%.⁶ Most authorities agree that even in disease complicated by infection, postponement of surgery for about 4 weeks permits demarcation of necrotic/infected tissue to occur and allows for optimization of the patient’s medical condition. Thus, choice C is least likely to benefit this patient. Immediate surgery would be too early and would likely be counterproductive. In fact, as will be discussed, even when delayed, open surgery may not be the optimal surgical approach in these patients.

A variety of less aggressive alternatives to open pancreatectomy, whether acute or delayed, have been recently used and include percutaneous drainage, transgastric endoscopic drainage, and minimally invasive (video-assisted) retroperitoneal necrosectomy procedures.⁷ A recent Dutch study with accompanying editorial randomized patients to either open pancreatic necrosectomy or a “step up” approach using first a percutaneous or endoscopic drainage followed by a minimally invasive retroperitoneal procedure if the former did not result in improvement.^7,8 Of note, more than 90% of the patients eventually were shown to have documented infection, which indicated that the study group was indeed at serious risk. Although no mortality difference was seen (8 deaths in the “step up” approach group versus 7 deaths in the open procedure group), a very substantial difference (9 complications in the “step up” group versus 23 in the open group) in a variety of predetermined major morbidities was demonstrated, including pancreatic fistulas, incisional hernias, and development of diabetes as well as acute organ failure and repeated admissions to the ICU. The authors concluded, as did the editorialist, that from an overall clinical view, the preferred treatment strategy for severe, necrotizing pancreatitis and secondary infection is the “step up approach” (choice D) rather than laparotomy, even if delayed, in most patients.^7,8

OUTCOME OF THIS CASE

On day 6 a repeated CT scan confirmed the presence of gas, and on the following day a blood culture was positive for Escherichia coli. The patient underwent percutaneous drainage—culture of the fluid also grew E coli—and eventual debridement by a video-assisted retroperitoneal procedure. He was discharged on day 19 and is alive at 6 months without further complications.