NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Q: What condition do you suspect, and how do you manage it? A: The most likely diagnosis is erosion of the catheter or abscess into a major artery such as the splenic, gastroduodenal, or superior mesenteric arteries or a pancreatic vessel. Diagno- sis involves angiography; control consists of embolization in most cases. Case Variation 7.15.1. A severe case of pancreatitis occurs in a 70-year-old patient ◆ ◆ In older patients with abdominal pain and increased amylase levels, it is necessary to consider diagnoses other than pancreatitis. Abdominal catastrophes such as mesenteric ischemia and volvulus could manifest similarly. The pain pattern of mesenteric ischemia may be less local- ized to the epigastric region, but in obtunded patients, this could be difficult to determine. A serum amylase elevation by itself is not a reliable enough marker of pancreatitis in severely ill patients. CT with CT angiogram is very useful in assessing the intra-abdominal process. ◆ ◆ In practice, any patient who is severely ill with suspected pancreatitis warrants close exam- ination to rule out some other cause. CT is one good way to reassure oneself of the presence of pancreatitis because it shows edema of the pancreas and surrounding tissue. If that is not present, then one should be suspicious of the diagnosis. If after the CT the diagnosis remains uncertain, exploratory laparotomy may be appropriate. Q: What is the expected course of a patient with severe pancreatitis? A: The sicker the patient, the more likely the development of serious complications involving other organs and tissues. The mortality of severe pancreatitis remains high. Case 7.16 Acute Epigastric Pain with Continued Pain A34-year-old alcoholic patient who has developed acute pancreatitis initially improves, but the symptoms fail to resolve completely. Instead, the patient continues to have moderate abdominal pain, anorexia, persistent elevation of serum amylase, and inability to eat due to early satiety. Q: What is the suspected diagnosis? A: The presumptive diagnosis is a “ pancreatic pseudocyst ,” which is a collection of fluid near the pancreas presumably due to leakage of pancreatic fluid and edema. It can cause pain due to a local compressive effect, especially on the posterior wall of the stomach, which causes the early satiety. Q: How would you confirm this diagnosis? A: This is best visualized by CT of the abdomen , although an abdominal ultrasound study can also be useful (Fig. 7-24). Small pseudocysts are common with pancreatitis and do not usually cause this picture. You institute this therapy, and the patient improves over the next 10 days. The pain resolves, the amylase returns to normal, and the pseudocyst shrinks to 2 cm. SAMPLE The CT shows a pseudocyst in the lesser sac that is 8 cm in diameter. Q: What is the next step? A: The common practice would be NPO feeding, TPN, and observation , as long as no signs of infection are present.