NMS. Casos Clínicos

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Part II ♦ Specific Disorders

rule out other common disorders such as a perforated ulcer with free air. CT of the abdo- men is not mandatory for patients with uncomplicated pancreatitis. The usual treatment for pancreatitis involves NPO feeding, IV hydration, pain control, and observation. Many patients recover quickly as a consequence of this therapy. If a particular patient does not improve rapidly, it may be necessary to administer total parenteral nutrition (TPN) to maintain good nutrition.

Digging Deep

It is important to diagnose the cause of the acute pancreatitis to guide therapy and pre- vent future recurrence.

Q: How would the presence of gallstones influence the proposed management? A: Gallstone pancreatitis is generally managed in a similar way. The serum amylase level is monitored. The bile duct should be monitored for the presence of stones with intraopera- tive cholangiogram, MRCP, or ERCP. When the amylase decreases and the patient improves clinically, laparoscopic cholecystectomy is warranted.

Case 7.15 Acute Epigastric Pain in Severely Ill Patient A 34-year-old has severe abdominal pain that has been progressively increasing over the past several hours. The patient amylase value is elevated. You admit the patient and begin therapy. Over the next hour, you note that the patient appears severely ill; hypotension, hypoxemia, and multiorgan failure develop rapidly. Q: What is the most likely diagnosis? A: The patient most likely has severe necrotizing pancreatitis with massive third-space fluid loss due to local pancreatic inflammation. In addition, there is systemic inflammatory re- sponse syndrome, resulting in multiorgan system failure. It is hypothesized that this syn- drome is mediated by cytokine release, resulting in acute respiratory distress syndrome (ARDS), multiorgan system failure, and hemodynamic instability. Q: What steps are necessary next? A: Major resuscitation in a critical care unit is essential. CT of the abdomen is useful to as- sess the extent of local inflammation and search for additional causes of decompensation, including bowel necrosis and perforation, abscess formation, or biliary obstruction with infection (Fig. 7-22). After receiving 3 L of normal saline over 4 hours, the patient remains hypotensive with a very low urine output—10 mL/hr in the past 4 hours. Q: What is your plan for fluid resuscitation? A: The adequacy of resuscitation should still be a concern. The patient may need more IV fluids for adequate resuscitation. Pressor support could increase organ perfusion and prevent fur- ther organ injury. Septic shock is associated with vasodilation and hypovolemia. Adequate fluid resuscitation is necessary to restore organ perfusion. Vasoconstriction with pressors SAMPLE