Surgery II (MED 5024)

Title: Acute pancreatitis secondary to choledocholithiasis

Name: Aliah binti Mohd Tarmizi Matric no: 0808 0869 Group: 3 (A1) Rotation: Surgery 2

1.0 Aim of write up 1.1 To discuss on fluid resuscitation and oxygen supplement in managing acute pancreatitis 1.2 To explain the role endoscopic retrograde cholangiopancreatography (ERCP) in improving the outcome of acute pancreatitis 2.0 Clinical case summary ZZ, a 42 year old Malay gentleman presented to emergency department with 6 days history of abdominal pain, vomiting and yellowish discolouration and history of 1 day fever prior to admission. I clerked this patient on 26/9/12 a day after admission. Abdominal pain was sudden onset, continuous, pricking in nature, started at epigastric region and then radiates to the back, aggravated by food intake and relieved by lying down or leaning forward. It is associated with vomiting and yellowish discolouration of the eye and over the body. He vomits each time taking meals for 2 to 4 times per day, contains of fluid particles and clear fluids. No bile or blood. Yellowish discolouration was noticed by his wife. Previously patient had similar complain of epigastric pain and was admitted to this hospital in 12th July for one week and 17th September for 2 days. At that time was treated as acute pancreatitis and discharge with analgesics. The current symptoms of epigastric pain, vomiting and jaundice had started after discharge from 2nd admission, unresolved up until now. He denies any shortness of breath, chest pain, palpitations, upper respiratory tract infection (URTI) or urinary tract infection (UTI) symptoms, pruritis, haematemesis, or passing out blackish stool. One day prior to admission, patient develop fever, low grade, no documented temperature at home, no chills or rigors. Fever was associated with pale stool and tea coloured urine. Wife noted patient became weaker and restless thus was straight away brought to the hospital for further management. On examination, patient was alert and conscious, well hydrated, not tachypnoeic, pink, and looks lethargy. Capillary refill time was less than 2 seconds. Vital signs are all stable. Conjunctiva was not pale but jaundice noted. Abdomen moves with respiration, soft, tender at right hypochondrium region. No hepatosplenomegaly. Murphys sign was negative. Others system were unremarkable. Laboratory tests were done and significant findings shows highly elevated Serum Amylase of 9453 u/L, liver function test (LFT) shows elevated total serum bilirubin of 237.7 and elevated Alkaline Phosphatase (ALP) of 494. This indicates prolem of

obstructive jaundice this patient had. Ultrasound (US) of the abdomen was done in 6/7/12 and CT scan of pancreas on 25/9/12, ERCP on the day of admission. The impression for US of the abdomen stated features are consistent with pancreatitis, free fluid in the abdomen and pelvis and gallbladder calculus. CT scan impression stated that the lesion in the distal common bile duct (CBD) need further evaluation (ERCP was suggested for correlation) and acute pancreatitis. After ERCP done, patient was told to have gallstone in CBD. Patient is having Ranson score 2. Current management on admission is arrange for urgent CT abdomen, to allow clear fluid prior to CT scan, input/ output (I/O) chart, hourly urine output monitoring, continue intravenous (IV) drip 6 pints (3 normal saline and 3 dextrose 5%), trace urine diastase, continue subcutaneous morphine 5 mg 6 hourly and IV pantropazole 40 mg BD. Patient was arranged for urgent CT abdomen on 27/9/12. Post ERCP, patient was stable and ambulated well. They checked and recorded the vital signs 2 hourly and keep patient NBM, on IVD 6 pints and on CBD (intact). 3.0 Learning issues 3.1 Fluid resuscitation and oxygen supplement in managing acute pancreatitis The early prognostic factors that can be used to determine whether the clinical course is likely to be severe are three or more signs of organ failure according to the Ranson or Imrie scores, the presence of nonpancreatic complications, and the detection of pancreatic necrosis by imaging techniques Although no causal treatment exists, replacing the dramatic fluid loss that takes place in the early disease phase is critical and determines the patients prognosis. Adequate pain relief with opiates is another therapeutic priority. In patients with pancreatic necrosis, the high mortality rate between the third and fourth week after the initial episode is determined largely by the development of pancreatic infection, and can therefore be reduced by early antibiotic treatment. Early enteral nutrition for the treatment of acute pancreatitis has been shown to be superior and much more cost-effective than parenteral nutrition. Infected pancreatic necrosis or pancreatic abscesses are two of the few remaining indications for open surgery in acute pancreatitis. Even when indicated, surgery is frequently delayed or even replaced by minimally invasive surgical techniques According to a study, maintaining an adequate intravascular volume is probably the most essential therapeutic measure in the treatment of acute pancreatitisif not achieved, it is also the most consequential mistake. Patients with acute pancreatitis can sequester large amounts of fluid not only into the retroperitoneal space and the intraperitoneal cavity (pancreatic ascites), but also into the gut and the pleural space.

To determine the required fluid volume to be resuscitated, the central venous pressure should be closely monitored and hourly urine excretion rates and daily hematocrit measurements taken. All of these had been done in the plan of management of this patient. Besides fluid resuscitation, there is also increasing evidence that oxygen supplementation to maintain an arterial saturation of 95% is associated with the resolution of organ failure [1]. As for my patient, the main principle is resuscitation with IV fluid and early oxygen supplements. On admission, patient is kept nil by mouth (NBM) with intravenous drip (IVD) 6 pints (3 normal saline and 3 Dextrose 5%). Input and output (I/O) charting also had been monitored. 3.2 The role of Endoscopic retrograde cholangiopancreatography (ERCP) to improve the outcome of acute pancreatitis

The role of early endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) in patients with acute pancreatitis is controversial [2,3], My patient was arranged for ERCP in Hospital Selayang on the 2nd day of admission. Result came back showing gallstone in the CBD (choledocholithiasis). ERCP was done after results of US and CT abdomen did not prove of any presence of calculus. ERCP within 72 hours of admission to hospital may improve outcome, but there are concerns that this policy may aggravate the severity of the disease. However, the results of a number of clinical trials examining the role and potential benefits of ERCP and ES suggest that this policy in gallstone associated pancreatitis is beneficial, and that clearance of gallstones from papilla or common bile duct can prevent exacerbation of the pancreatitis by persistent or recurrent impaction of stones. ERCP is still the gold standard for detection and treatment of biliary ductal stones. The ERCP, in experienced hands and dedicated centre, has been shown to be a safe, accurate and effective diagnostic and therapeutic tool for treatment of bile duct stones and biliary pancreatitis [4,5]. Early ERCP offers several advantages over early surgery, especially in severe pancreatitis: lower morbidity and mortality rates, unnecessary laparotomy and in most cases no general anaesthesia is needed [4,6].

4.0 Conclusion In conclusion, my patient a 42 year old Malay gentleman was having history of epigastric pain that radiates to the back associated with jaundice, vomiting and low grade fever that started after his latest discharge from hospital. He had similar presentation before and was admitted twice and being treated as acute pancreatitis. However along the two admissions, the causal of the acute pancreatitis still yet has not been identified after US was done. For the current admission CT scan of abdomen and ERCP were done. They suggested ERCP for further evaluation after findings of CT scan shows lesion in the distal CBD. Early ERCP plays role in detecting any biliary tract disease (i.e presence of gallstone) that can be one of the causes of this patient problem. Result of ERCP shows this patient is having gallstone in the CBD. As stated above, maintaining an adequate intravascular volume is probably the most essential therapeutic measure in the treatment of acute pancreatitis. My patient had been managed well along admission including monitoring the hydration and oxygen status other than pain management, etc. This support the study quoted above when the same management applied in my patients management.

5.0 References 1. Brown A et al. (2002) Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology 2: 104107 2. NEOPTOLEMOS JP, CARR-LOCKE DL, LONDON NJM, BAILEY IA, JAMES D, FOSSARD DP. Controlled trial of urgent endoscopic retrograde colangiopancreotography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet 1988; 2: 979-983. 3. NOVAK A, NOWAKOWSKA-DULAWA E, MAREK TA, KACZOR R. Timing of endoscopic sphincterotomy for acute biliary pancreatitis-a prospective study. Gastrointest Endosc 1996; 143: 401 (Abstract). 4. ROSCHER R, BERGER HG. Bacterial infection of pancreatic necrosis. Heidelberg Springer 1987; 314-317. 5. CLASSEN M, OSSENBERG W, WURBS D, DAMMERMAN R, HAGENMULLER F. Pancreatitis-An indication for endoscopic papillotomy? Endoscopy 1978; 10: 223. 6. NEOPTOLEMOS JP, CARR-LOCKE DL, LONDON NJM. ERCP findings and the role of endoscopic sphincterotomy an acute gallstones pancreatitis. Br J Surg 1988; 75: 954-960.