Case 7: Management

Choose the next best steps in management:

Now that we have made our diagnosis, which of the following treatments should be initiated to appropriately manage this patient’s condition? (more than one answer might apply). 
Lactated ringers at 250 cc/hour
Correct! Weak evidence favors the use of Lactated Ringer’s as the preferred type of fluid and in a patient without contraindications such as ESRD or heart failure 250cc-500cc/hour is the appropriate initial rate of hydration. Hydrating aggressively in the first 6 hours, to ensure downtrend in the hematocrit and BUN levels, has shown improved outcomes in patients.
Incorrect. Acute pancreatitis is an inflammatory state but there is no need for antibiotics. If there were concern for cholangitis (would require an elevation in bilirubin) then this would be an appropriate choice.
Ibuprofen for pain management
Incorrect. NSAIDS should be avoided given the potential increased risk of renal failure associated with pancreatitis. Opiate agents are the preferred analgesics in pancreatitis patients with severe pain.
Incorrect. This is not the preferred choice of nutrition in patients with pancreatitis. Patients without features of complicated pancreatitis, and those able to tolerate oral intake are permitted to take a low fat diet. If the patient remains unable to tolerate an oral diet beyond 24 hours, then a nasojejunal tube should be placed to initiate enteral feeding.
CT Abdomen/Pelvis
Not necessary currently for multiple reasons. 1) The diagnosis has already been made based on patient meeting the pain and lipase criteria and other etiologies are currently unlikely. 2) Features such as pancreatic necrosis and fluid collections are often not revealed in early imaging (<48 hours of onset). A CT scan can be considered in the future if the patient shows worsening symptoms despite 48hours of conservative management or there is concern for development of complications of pancreatitis.
RUQ Ultrasound
Correct! Our patient reports preceding abdominal pain triggered by fatty foods, and currently has elevated transaminases in the setting of pancreatitis. So a biliary etiology is very likely. RUQ US is the recommended imaging modality for suspected gallstone disease.
Magnetic Resonance Cholangiopancreatography (MRCP)
Not warranted currently. If the RUQ US raises intermediate likelihood for choledocholithiasis (check out Case 6 to learn more!) or if the patient’s condition deteriorates raising concern for development of complications (pancreatic necrosis, peri-pancreatic fluid collection) then MRCP maybe considered for better delineation of the pancreatio-biliary system.

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Case 7 Index:
Physical Exam
Differential Diagnosis
Diagnostic Testing

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