A 58-Year-Old Man in Severe Abdominal Pain
A 58-year-old man presents to the clinic with severe abdominal pain that has been ongoing for several days. The pain is in his upper abdomen and radiates to his back. The patient describes the pain as “boring and unrelenting,” but he is not crampy or colicky. There is little he can do to ameliorate the pain, although he finds that lying on his side with legs flexed is the most comfortable position for him. He is unable to keep most foods or liquids down since symptom onset due to the increased pain. Emesis occurs when he tries to eat. Upon questioning, he recalls several instances of similar pain but of much milder nature in the last year or so, resulting in a day or two of drinking clear liquids only. He related no other symptoms and has not been febrile.
The patient has little past medical history, with only the occasional use of acetaminophen and ibuprofen for minor muscle and joint symptoms. The patient works in construction and says when he was younger, he sporadically used illicit drugs but has not used any for many years. He is and has been a heavy drinker since his teenage years with particularly heavy alcohol intake of both spirits and beer on weekends.
On physical examination, he presents as non-icteric but manifests a profound dehydration with dry mouth, tachycardia of 108 beats/min at rest, and a blood pressure of 95/60 mm Hg in the supine position. There are no spider telangiectasias or ascites. The only major physical finding is a quiet abdomen with significant guarding. There is exquisite tenderness to any direct palpation to his mid and upper epigastrium with radiation to his back. There is no tremor or fasciculation of the tongue, and he is oriented.
His basic laboratory tests confirm a profound hypovolemia state with change to sodium lactate solution 132 mg/L, creatinine 2.1 mg/dL, and blood urea nitrogen 40 mg/dL. His hemoglobin (Hb) is 15 gm/dL, white blood cell (WBC) count of 17,000/mm3, and serum lipase 670 u/L (normal <160 u/L). His abdominal ultrasound is negative for gallstones but otherwise noninformative.
After 6 hours of aggressive fluid resuscitation using lactated Ringer’s solution there is improvement in his volume status and metabolics such that he could safely undergo a thin slice abdominal computed tomography (CT) scan, which demonstrates severe pancreatic stranding with areas of pancreatic hypoperfusion (necrosis) and several areas of fluid collection estimated to be about 25%. He is acutely managed with continued hydration and improves clinically with diminished pain and analgesic requirements. Enteral feeding began on day 3 and small oral feedings are tolerated by day 5.
However, on day 7, his progress stalls with continuing episodes of abdominal pain. Additional laboratory tests show Hb 12.0 gm/dL, WBC 21 K/dL, Na 136 mg/L, creatinine 1.6 mg/dL, serum lipase 399 u/L (normal < 160 u/L). A thin slice CT scan again shows pancreatic necrosis and fluid collections, with little change from admission. His management regimen is continued until day 16 with a noted fever (39° C), tachycardia of 108 beats/min, and WBC of 24 K/dL with a left shift.
Fine needle aspiration specimens showed the presence of gram-negative rods on gram stain with culture and sensitivity pending. The fever and leukocytosis persist into day 19.
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- Boxhorn L, van Dijk SM, van Grinsven J, Verdonk RC, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Eng J Med. 2021;385:1372-1381. doi:10.1056/NEJMoa2100826
- Besselink MG, Vermer TJ, Schoenmaekers EJ, et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg. 2007;142:1184-2001. doi:10.1001/archsurg.142.12.1194
- Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173:71-75.doi:10.1016/S0002-9610(96)00425-4
- Van Brunscot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step up approach for infected necrotizing pancreatitis: A multicenter randomized trial. Lancet. 2018;391:51-58. doi:10.1016/S0140-6736(17)32404-2
- Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step up approach or open necrostomy for necrotizing pancreatitis. N Eng J Med. 2010; 362: 1491-1502. doi:10.1056/NEJMoa0908821
- Bradley EL III, Dexter ND. Management of severe acute pancreatitis: A surgical odyssey. Ann Surg. 2010;25:6-17. doi:10.1097/SLA.0b013e3181c72b79
- Barron TH. Drainage for infected pancreatic necrosis – Is the waiting the hardest part? N Eng J Med. 2021;385:1433-1435. doi:10.1056/NEJMe2110313