A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and malaise. Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and subsequent cholecystectomy. Her maternal grandfather died of pancreatic cancer. She does not smoke. She drinks 1–2 beers daily. Her temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg. Abdominal examination shows epigastric tenderness and three well-healed laparoscopy scars. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 15,800/mm3 Serum Na+ 140 mEq/L Cl− 103 mEq/L K+ 4.5 mEq/L HCO3- 25 mEq/L Urea nitrogen 18 mg/dL Creatinine 1.0 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 22 U/L Alanine aminotransferase (ALT, GPT) 19 U/L γ-Glutamyltransferase (GGT) 55 U/L (N = 5–50) Bilirubin 1 mg/dl Glucose 105 mg/dL Amylase 220 U/L Lipase 365 U/L (N = 14–280) Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas. Which of the following is the most likely diagnosis?
APancreatic cancer
BAcute cholangitis
CPancreatic abscess
DPancreatic pseudocyst
EERCP-induced pancreatitis
A 37-year-old man presents to the emergency department with rapid onset epigastric pain that started 4 hours ago. He describes the pain as severe, localized to the epigastric region and radiating to the back, which is partially relieved by leaning forward. He admits to binge drinking this evening at a friend’s party. He is nauseated but denies vomiting. Vital signs include: blood pressure 90/60 mm Hg, pulse 110/min, temperature 37.2°C (99.0°F), and respiratory rate 16/min. Physical examination shows tenderness to palpation over the epigastric region with no rebound or guarding. The bowel sounds are decreased on auscultation. The laboratory findings are significant for the following: Laboratory test Leukocyte Count 18,000/mm³ Neutrophils 81% Serum amylase 416 U/L Serum lipase 520 U/L Which of the following would be the most helpful in determining the prognosis in this case?
AAcute Physiology and Chronic Health Examination (APACHE) II score
BRanson's criteria
CBedside Index of Severity in Acute Pancreatitis (BISAP) score
DModified Glasgow Score
EC-reactive protein level
A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?
AOral gabapentin every 24 hours
BTransdermal fentanyl every 72 hours
COral acetaminophen every 6 hours
DPatient-controlled intravenous hydromorphone
ETransdermal bupivacaine on request
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