Review Question - QID 107183

This alcoholic patient is presenting with epigastric pain, a low platelet count (with petechiae), an elevated INR, and schistocytes on peripheral smear which is concerning for disseminated intravascular coagulation (DIC) caused by pancreatitis.

Pancreatitis occurs when there is inflammation/injury to the pancreas from gallstones, alcohol ingestion, or infection. It can present with epigastric pain, nausea, vomiting, Grey-Turner sign (flank ecchymosis), Cullen sign (umbilical ecchymosis), and an elevated lipase level. The management of pancreatitis is to keep the patient nil per os (NPO), administer IV fluids, and control the pain. A severe complication of pancreatitis is disseminated intravascular coagulation (DIC). Pancreatic enzymes can pathologically activate the coagulation cascade leading to a depletion of coagulation factors (an elevated PT/PTT), depletion of platelets, and schistocytes from the shearing of the red blood cells from the microvasculature thrombi created from activation of the coagulation cascade.

Figure/Illustration A is a peripheral smear demonstrating schistocytes (blue arrows) or helmet cells which are commonly seen in DIC.

Incorrect Answers:
Answer 1: Cirrhosis would present with jaundice, scleral icterus, abdominal ascites, esophageal varices, caput medusae, and hemorrhoids. While liver failure may impair the synthesis of coagulation factors and increase this patient's INR, it would not lead to a decreased platelet count in the setting of schistocytes, which is seen in DIC.

Answer 2: Immune thrombocytopenic purpura occurs secondary to the autoimmune destruction of platelets. Patients will present with petechiae and a low platelet count. Treatment involves observation in stable/non-bleeding patients with a platelet count > 50,000 cells/uL, or IVIG/steroids in more severe cases.

Answer 4: Rattlesnake bite is a classic but rare cause of DIC. A rattlesnake bite would present with 2 parallel bite marks that are actively oozing with erythema, edema, tenderness, and swelling of the bitten extremity. Rattlesnake venom can activate the coagulation cascade leading to DIC.

Answer 5: Septic shock can cause DIC and would present with a fever, hypotension, and tachycardia. This patient may have an occult infection; however, his response to fluids with a normal heart rate and a normal blood pressure by definition makes this not septic shock (though it could be sepsis). Sepsis is a possible cause of DIC, though no localizing infectious symptoms are found in this patient.

Bullet Summary:
Pancreatitis can lead to pathologic activation of the coagulation cascade causing disseminated intravascular coagulation.