Review Question - QID 107669

This patient with a history of alcohol abuse is presenting with acute epigastric tenderness, vital sign instability, and Gray Turner's sign suggestive of hemorrhagic acute pancreatitis. Management with IV fluids and supportive therapy in the intensive care unit is appropriate.

Acute pancreatitis is a potentially fatal condition most commonly caused by alcohol ingestion or obstruction of the pancreatic duct by a gallstone (gallstone pancreatitis). Pathogenesis involves inflammation of the pancreatic parenchyma and activation of trypsinogen into trypsin resulting in auto-digestion of pancreatic and surrounding tissue. Other causes of pancreatitis include blunt abdominal trauma, auto-immune mediated pancreatitis, infection, and drug induced.

Carroll et al. discuss the management of acute pancreatitis, including risk stratification of patients. Stratification through APACHE II Scale or CT Severity Index can provide invaluable insight into patient morbidity and mortality and help guide escalation of care. In the U.S. just over 200,000 hospitalizations occur yearly due to acute pancreatitis, while mortality remains low in moderate uncomplicated cases, those with necrosis can be as high as 10-30% depending on super infection.

An area of controversy in the management of acute pancreatitis is the approach of nutrition for the patient. Mirtallo et al. discuss the evidence for enteral nutrition on patients with acute pancreatitis. Mounting evidence supports the use of nutritional support in patients with acute pancreatitis, with enteral nutrition. Even with this evidence, there remains a prevailing clinical practice to withhold enteral nutrition, in the belief that bowel rest is advantageous. However, a number of recommendations support the use of enteral nutrition over parenteral nutrition, unless there is a contraindication to enteral feeds.

Figure A shows a photograph of a patient with blood tracking along the intercostal space, a sign known as Gray Turner's sign, indicative of hemorrhage in the retroperitoneal space.

Incorrect Answers:
Answer 1: ERCP is appropriate if obstruction is suspected, this patient's disease is likely alcohol mediated.
Answer 3: This is an appropriate approach to a patient presenting with alcohol withdrawal.
Answer 4: This patient has no evidence of cirrhosis or stigmata of portacaval anastomosis.
Answer 5: PTC is appropriate in patients with biliary obstruction who fail ERCP.