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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

low grade. He denies any shortness of breath. On examination. not tachypnoeic. upper respiratory tract infection (URTI) or urinary tract infection (UTI) symptoms.7 and elevated Alkaline Phosphatase (ALP) of 494. The current symptoms of epigastric pain. Capillary refill time was less than 2 seconds. I clerked this patient on 26/9/12 a day after admission.2 To explain the role endoscopic retrograde cholangiopancreatography (ERCP) in improving the outcome of acute pancreatitis 2. pink. Abdominal pain was sudden onset. Abdomen moves with respiration. chest pain. no documented temperature at home. Yellowish discolouration was noticed by his wife. a 42 year old Malay gentleman presented to emergency department with 6 days history of abdominal pain. This indicates prolem of . 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. He vomits each time taking meals for 2 to 4 times per day. Murphy’s sign was negative.1 To discuss on fluid resuscitation and oxygen supplement in managing acute pancreatitis 1. soft.1. contains of fluid particles and clear fluids. and looks lethargy. tender at right hypochondrium region. Others system were unremarkable. patient was alert and conscious. liver function test (LFT) shows elevated total serum bilirubin of 237. At that time was treated as acute pancreatitis and discharge with analgesics. Vital signs are all stable. no chills or rigors. well hydrated. pricking in nature. One day prior to admission. aggravated by food intake and relieved by lying down or leaning forward. Conjunctiva was not pale but jaundice noted. vomiting and yellowish discolouration and history of 1 day fever prior to admission. or passing out blackish stool. It is associated with vomiting and yellowish discolouration of the eye and over the body. vomiting and jaundice had started after discharge from 2nd admission. No bile or blood. haematemesis. continuous. patient develop fever. palpitations.0 Aim of write up 1. No hepatosplenomegaly. pruritis. Laboratory tests were done and significant findings shows highly elevated Serum Amylase of 9453 u/L. Fever was associated with pale stool and tea coloured urine.0 Clinical case summary ZZ. Wife noted patient became weaker and restless thus was straight away brought to the hospital for further management. unresolved up until now. started at epigastric region and then radiates to the back.

Patients with acute pancreatitis can sequester large amounts of fluid not only into the retroperitoneal space and the intraperitoneal cavity (pancreatic ascites). After ERCP done. Patient was arranged for urgent CT abdomen on 27/9/12. . surgery is frequently delayed or even replaced by minimally invasive surgical techniques According to a study. but also into the gut and the pleural space. continue intravenous (IV) drip 6 pints (3 normal saline and 3 dextrose 5%). it is also the most consequential mistake. Post ERCP. free fluid in the abdomen and pelvis and gallbladder calculus. the presence of nonpancreatic complications. continue subcutaneous morphine 5 mg 6 hourly and IV pantropazole 40 mg BD. Even when indicated. patient was stable and ambulated well. The impression for US of the abdomen stated features are consistent with pancreatitis. replacing the dramatic fluid loss that takes place in the early disease phase is critical and determines the patient’s prognosis. 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. 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. input/ output (I/O) chart. Adequate pain relief with opiates is another therapeutic priority. and can therefore be reduced by early antibiotic treatment. patient was told to have gallstone in CBD. Early enteral nutrition for the treatment of acute pancreatitis has been shown to be superior and much more cost-effective than parenteral nutrition. hourly urine output monitoring. to allow clear fluid prior to CT scan. Patient is having Ranson score 2. Ultrasound (US) of the abdomen was done in 6/7/12 and CT scan of pancreas on 25/9/12. They checked and recorded the vital signs 2 hourly and keep patient NBM. maintaining an adequate intravascular volume is probably the most essential therapeutic measure in the treatment of acute pancreatitis—if not achieved.0 Learning issues 3. ERCP on the day of admission. Infected pancreatic necrosis or pancreatic abscesses are two of the few remaining indications for open surgery in acute pancreatitis. the high mortality rate between the third and fourth week after the initial episode is determined largely by the development of pancreatic infection.obstructive jaundice this patient had. trace urine diastase. and the detection of pancreatic necrosis by imaging techniques Although no causal treatment exists. on IVD 6 pints and on CBD (intact). Current management on admission is arrange for urgent CT abdomen. In patients with pancreatic necrosis.

3. ERCP is still the gold standard for detection and treatment of biliary ductal stones. ERCP was done after results of US and CT abdomen did not prove of any presence of calculus.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].5]. . ERCP within 72 hours of admission to hospital may improve outcome. My patient was arranged for ERCP in Hospital Selayang on the 2nd day of admission. All of these had been done in the plan of management of this patient. However. patient is kept nil by mouth (NBM) with intravenous drip (IVD) 6 pints (3 normal saline and 3 Dextrose 5%). Early ERCP offers several advantages over early surgery. Result came back showing gallstone in the CBD (choledocholithiasis). unnecessary laparotomy and in most cases no general anaesthesia is needed [4. 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. has been shown to be a safe. in experienced hands and dedicated centre. On admission.6]. but there are concerns that this policy may aggravate the severity of the disease. 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. and that clearance of gallstones from papilla or common bile duct can prevent exacerbation of the pancreatitis by persistent or recurrent impaction of stones. especially in severe pancreatitis: lower morbidity and mortality rates. Input and output (I/O) charting also had been monitored. The ERCP. the central venous pressure should be closely monitored and hourly urine excretion rates and daily hematocrit measurements taken. the main principle is resuscitation with IV fluid and early oxygen supplements. Besides fluid resuscitation.To determine the required fluid volume to be resuscitated. accurate and effective diagnostic and therapeutic tool for treatment of bile duct stones and biliary pancreatitis [4.

75: 954-960. LONDON NJM. My patient had been managed well along admission including monitoring the hydration and oxygen status other than pain management. 314-317. JAMES D. BERGER HG. . 6. 2: 979-983. maintaining an adequate intravascular volume is probably the most essential therapeutic measure in the treatment of acute pancreatitis. MAREK TA. Gastrointest Endosc 1996. 10: 223. NEOPTOLEMOS JP. However along the two admissions. WURBS D. DAMMERMAN R. (2002) Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology 2: 104–107 2. NOWAKOWSKA-DULAWA E. He had similar presentation before and was admitted twice and being treated as acute pancreatitis.4.0 References 1. Controlled trial of urgent endoscopic retrograde colangiopancreotography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. This support the study quoted above when the same management applied in my patient’s management. NOVAK A. As stated above. 5. etc.0 Conclusion In conclusion. Bacterial infection of pancreatic necrosis. 5. KACZOR R. For the current admission CT scan of abdomen and ERCP were done. ROSCHER R. CARR-LOCKE DL. the causal of the acute pancreatitis still yet has not been identified after US was done. FOSSARD DP. Timing of endoscopic sphincterotomy for acute biliary pancreatitis-a prospective study. CARR-LOCKE DL. Early ERCP plays role in detecting any biliary tract disease (i. 3. Heidelberg Springer 1987. BAILEY IA. 4. CLASSEN M. NEOPTOLEMOS JP. Pancreatitis-An indication for endoscopic papillotomy? Endoscopy 1978. Result of ERCP shows this patient is having gallstone in the CBD. LONDON NJM. HAGENMULLER F.e presence of gallstone) that can be one of the causes of this patient problem. Lancet 1988. vomiting and low grade fever that started after his latest discharge from hospital. Brown A et al. OSSENBERG W. my patient a 42 year old Malay gentleman was having history of epigastric pain that radiates to the back associated with jaundice. Br J Surg 1988. 143: 401 (Abstract). They suggested ERCP for further evaluation after findings of CT scan shows lesion in the distal CBD. ERCP findings and the role of endoscopic sphincterotomy an acute gallstones pancreatitis.