DDSEP Quick Quiz

DDSEP® 8 Quick quiz - November 2017 Question 1

A 50-year-old woman with no past medical history presents to the emergency department with the acute onset of severe epigastric pain and vomiting. She is afebrile with a blood pressure of 100/50 mm Hg, and pulse of 110 bpm. Physical exam shows right upper-quadrant and epigastric tenderness to palpation without rebound. Labs demonstrate a WBC count of 17,000/mm3, hemoglobin of 16 g/dL, creatinine of 1.4 mg/dL, ALT of 215 U/L, AST of 190 U/L, a total bilirubin of 2.1 mg/dL, and triglycerides of 492 mg/dL. Right upper-quadrant ultrasound reveals gallstones and a 1.2-cm common bile duct. The following day, despite being hydrated aggressively, the patient develops a fever and becomes jaundiced with worsening abdominal pain.

What would be the next step in the patient’s management?

Abdominal CT to evaluate for pancreatic necrosis

Administration of heparin and insulin to decrease triglycerides

ERCP

HIDA scan

Initiation of antibiotics and cholecystectomy when stable

Answer: C

Rationale: The patient presents with acute gallstone pancreatitis. In patients with gallstone pancreatitis and evidence of cholangitis, ERCP with sphincterotomy and stone extraction should be performed. The patient’s fever, jaundice, and right upper-quadrant pain are sufficient to make the diagnosis of cholangitis. It is too early in the course of the disease to evaluate for pancreatic necrosis. Typically, triglyceride levels above 1,000 mg/dL are required to induce pancreatitis. Finally, while the patient has cholelithiasis, there is no evidence of cholecystitis. Therefore, a HIDA scan is not warranted.

Reference

1. Behrns K.E., Ashley S.W., Hunter J.G., Carr-Locke D. Early ERCP for gallstone pancreatitis: for whom and when? J Gastrointest Surg. 2008;12(4):629-33.

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