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A 42-year-old man comes to the hospital after a day of severe abdominal pain and
vomiting. He describes the pain as constant and nagging, localizing to the upper
abdomen, and radiating to the back. The patient has not been to a physician In years
and has no previous medical conditions or surgeries. He takes no medications. He
drinks large amounts of alcohol, but does not use tobacco or illicit drugs. His
temperature is 36.r C (98° F), blood pressure is 110/80 mm Hg, pulse is 90/mln. and
respirations are 14/mln. The patient Is admitted to the hospital and given oploid
analgesics and Intravenous fluids. On day 2 of his hospitalization, his blood pressure
drops to 80/60 mm Hg and his pulse Increases to 120/min and regular. His oxygen
saturation is 92% on 2 l nasal canula oxygen. Examination shows normal jugular
venous pressure. Bilateral crackles are heard on lung auscuHation. The patient's
abdomen is mildly distended, and there is tenderness in the epigastrium. His urine
output is 8 mllhr. He has received a total of 4 LIV fluids over the last 24 hours.
Laboratory results are as follows:

Hemoglobin 14.9 g/dL

Leukocytes 16,500/mm'
Platelets 120, 000/mm'

Sodium 138 mEq/L

Potassium 4.9 mEq/L
Chloride 97 mEqll
Bicarbonate 21 mEqll
Glucose 210 mg/dl
Creatinine 1.9 mg/dl
Blood urea nitrogen 45 mg/dl

Which of the following Is the most likely cause of this patienf s hypotension?

0 A. Increased vascular permeability

0 B. Myocardial infarction
0 c . Oplold overdose
0 D. Occult bleeding v

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 drinks large amounts of alcohol, but does not use tobacco or illicit drugs. His
temperature is 36.7" C (98" F), blood pressure is 110/80 mm Hg, pulse is 90/mln, and
respirations are 14/mln. The patient Is admitted to the hospital and given opioid
analgesics and intravenous nuids. On day 2 of his hospitalization, his blood pressure
drops to 80/60 mm Hg and his pulse increases to 120/m in and regular. His oxygen
saturation is 92% on 2 l nasal canula oxygen. Examination shows normal jugular
venous pressure. Bilateral crackles are heard on lung a uscultation. The patienrs
abdomen is mildly distended, and there is tenderness in the epigastrium. His urine
output is 8 mllhr. He has received a total of 4 liV fluid s over the last 24 hours.
l aboratory results are as follows:

Hemoglobin 14.9 g/dl

l eukocytes 16,500/llllll'

Platelets 120,000/mm•

Sodium 138 mEq/l

Potassium 4.9 mEq/l

Chloride 97 mEq/l
Bicarbonate 21 mEq/L

Glucose 210 mg/dl

Creatinine 1.9 mg/dl

Blood urea nitrogen 45 mg/dl

Which of the following Is the most likely cause of this patienrs hypotension?

0 A Increased vascular permeability

0 B. Myocardial infarction
0 C. Opiold overdose
0 D. Occult bleeding
0 E. Pericardia! effusion
0 F. Pseudocyst formation

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Item :
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A 42-year-old man comes to the hospital after a day of s evere abdominal pain and
vomiting. He describes the pain as constant and nagging, localizing to the upper
abdomen, and radiating to the back. The patient has not been to a physician in years
and has no previous medical conditions or surgeries. He takes no medications. He
drinks large amounts of alcohol, but does not use tobacco or illicit drugs. His
temperature is 36.7° C (98° F), blood pressure is 110/80 mm Hg, pulse is 90/min, and
respirations are 14/min. The patient is admitted to the hospital and given opioid
analgesics and intravenous fluids. On day 2 of his hospitalization, his blood pressure
drops to 80/60 mm Hg and his pulse increases to 120/min and regular. His oxygen
saturation is 92% on 2 L nasal canula oxygen. Examination shows normal jugular
venous pressure. Bilateral crackles are heard on lung auscultation. The patient's
abdomen Is mildly distended, and there Is tenderness in the epigastrium. His urine
output is 8 mL/hr. He has received a total of 4 L IV fluids over the last 24 hours.
Laboratory results are as follows:

Hemoglobin 14.9 g/dL

Leukocytes 16,500/mm'
Platelets 120,000/mm'

Sodium 138 mEq/L

Potassium 4.9 mEq/ L

Chloride 97 mEq!L
Bicarbonate 21 mEq!L
Glucose 210 mg/dL
Creatinine 1.9 mg/dL
Blood urea nitrogen 45 mg/dL

Which of the following Is the most likely cause of this patient's hypotension?

A Increased vascular permeability [58%)

B. Myocardial infarction [2%]
c. Opioid overdose [5%]
D. Occult bleeding [14%] v
Which of the following Is the most likely cause of this patient's hypotension?

I., A. Increased vascular permeability [58%]

B. Myocardial Infarction (2%)
c. Opioid overdose (5%]
D. Occult bleeding [14%)
E. Pericardia! effusion [5%)
F. Pseudocyst formation (16%)
- . -. ...
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Explanation: User

Clinical f eatures of severe pancreatitis

• Fever, tachycardia, hypotension

• Dyspnea, tachypnea &for basilar crackles
• Abdominal tenderness &for distension
Clinical
presentation • Cullen sign: Periumbilical bluish coloration indicating
hemoperitoneum
• Grey-Turner sign: Reddish-brown coloration around flanks
Indicating retroperitoneal bleed

• Age >75
• Obesity
• Alcoholism
A ssociated w ith • C-reacbve protein >150 mgtdl at 48 hours after presentation
I risk o f severe • RISing blood urea n1trogen & creatinine 1n the first48 hours
pan creatitis
• Chest x-ray With pulmonary infiltrates or pleural effus1on
• Computed tomography scantmagnebc resonance
chotang1opancreatogmphy with pancreatic necros1s
& extrapancreatic inflammation

• Pseudocyst
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Clinical features of severe pancreatitis

• Fever, tachycardia, hypotension

• Dyspnea, tachypnea &/or basilar crackles
• Abdomlnaltendemess &/or d istension
Clinical
presentation • Cullen sign. Penumbilical bluish coloration 1ndlcatmg
hemoperitoneum
• Grey-Turner sign: Reddish-brown coloration around Hanks
1nd1cating retropentoneai bleed

• Age >75
• ObeSity
• Alcoholism
Associated w it h • C-reeclive protein >150 mg/dl at 48 hours after presentat1on
t risk of severe • Rising blood urea nitrogen & creatinine in the first 46 hours
p ancreatitis
• Chest x-ray with pulmonary infiltrates or pleural effusion
• Computed tomography scan/magnetic resonance
cholanglopancreatography with pancreatic necrosis
& extra pancreatic inflammation

• Pseudocyst
• Penpancreatic fluid collection
• NecrohZlng pancreatitis
Complications
• Acute respiratory distress syndrome
• Acute renal failure
• Gastromtestinat bleeding

This patient's presentation Is consistent with acute severe pancreatitis that has
progressed to multisystem organ dysfunction (eg. shock, renal failure, early respiratory
failure). Most patients with acute pancreatitis have mild disease and recover with
conservative management (eg, fluids, bowel rest, pain medication) in 3-5 days. However,
nearly 15%-20% of patients can develop severe acute pancreatitis. defined as
pancreatitis with failure of at least 1 organ. Clinical markers associated with increased
risk for severe pancreatitis Include age > 75, alcoholism. obesity, C-reactive protein > 150
mg/dl at 48 hours, and Increased blood urea nitrogen (B UN)/creatinine in the first 48
hours. Abdominal imaging (computed tomography scan or magnetic resonance
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• Gastrointest inal bleeding

ClUWo<!d

This patient's presentation Is consistent with acute severe pancreatitis that has
progressed to multisystem organ dysfunction (eg, shock, renal failure, early respiratory
failure). Most patients with acute pancreatitis have mild disease and recover with
conservative management (eg, fluids , bowel rest, pain medication) in 3-5 days. However,
nearly 15%-20% of patients can develop severe acute pancreatitis, defined as
pancreatitis with failure of at least 1 organ. Clinical markers associated with increased
risk for severe pancreatitis include age >75, alcoholism, obesity, C-reactive protein >150
mg/dl at 48 hours, and Increased blood urea nitrogen (BUN)Icreatinine in the first 48
hours. Abdominal Imaging (computed tomography scan or magnetic resonance
cholangiopancreatography) Is Indicated for suspected severe pancreatitis to look for
pancreatic necrosis and extrapancreatic inflammation, which also indicate severe acute
pancreatitis.

Severe pancreatitis causes local release of activated pancreatic enzymes that enter the
vascular system and Increase vascular permeability within and around the pancreas.
This leads to large volumes of fluid migrating from the vascular system to the surrounding
retroperitoneum. Systemic Inflammation also ensues as the inflammatory mediators enter
the vascular system. The net effect Is widespread vasodilation, capillary leak, shock,
and associated end-organ damage. Treatment usually involves supportive care with
several liters of IV fluid to replace the lost intravascular volume.

(Choice B) Hypotensive episodes seen in severe pancreatitis could incite an underlying

myocardial infarction. However, this patient has no signs or symptoms (eg, chest pain)
suggesting myocardial Infa rction.

(Choice C) Narcotics (eg, meperidine) are often given for analgesia in acute
pancreatitis. Narcotic overdose can cause respiratory depression, hypotension, and
bradycardia. This patient's tachycardia, crackles, abdominal distention, worsening BUN,
and low urine output make severe pancreatitis with early multiorgan failure more likely.

(Choice D) Occult bleeding is unlikely to cause significant hypotension without resulting

in anemia.

(Choice E) Pericardia! effusion can be a complication of pancreatitis, but tamponade

severe enough to cause cardiac failure would cause jug ular venous distention (not seen
in this patient's physical examination).

(Choice F) Acute pancreatitis can be complicated by a peripancreatic pseudocyst, a

fluid collection (containing pancreatic enzymes, blood, fluid , and tissue debris)
surrounded by a necrotic or fibrous capsule. Pseudocysts typically take 3-4 weeks to v
 causes enzymes
vascular system and Increase vascular permeability within and around the pancreas.
This leads to large volumes of fluid migrating from the vascular system to the surrounding
retroperitoneum. Systemic inflammation also ensues as the inflammatory mediators enter
the vascular system. The net effect is widespread vaso dilation, capillary leak, shock,
and associated end-organ damage. Treatment usually involves supportive care with
sev eral liters of IV fluid to replace the lost intravascular volume.

(Choice B) Hypotensive episodes seen in severe pancreatitis could incite an underlying

myocardial infarction. However, this patient has no signs or symptoms (eg, chest pain)
suggesting myocardial infarction.

(Choice C) Narcotics (eg, meperidine) are often given for analgesia in acute
pancreatitis. Narcotic overdose can cause respiratory d epression, hypotension, and
bradycardia. This patient's tachycardia, crackles, abdominal distention, worsening BUN,
and low urine output make severe pancreatitis with early multiorgan failure more likely.

(Choice 0 ) Occult bleeding Is unlikely to cause significant hypotension without resulting

in anemia.

(Choice E) Perlcardial effusion can be a complication of pancreatitis, but tamponade

severe enough to cause cardiac failure would cause jugular venous distention (not seen
in this patient's physical examination).

(Choice F) Acute pancreatitis can be complicated by a peripancreatic pseudocyst, a

fluid collection (containing pancreatic enzymes, blood, fl uid, and tissue debris)
surrounded by a necrotic or fibrous capsule. Pseudocysts typically take 3-4 weeks to
develop after acute pancreatitis and would be a less likely cause of acute hypotension in
this patient.

Educational objective:
Acute pancreatitis complicated by hypotension is thought to arise from intravascular
volume loss secondary to local and systemic vascular e ndothelial injury. This causes
vasodilation, Increased vascular permeability, and plasma leak into the retroperitoneum,
resulting in systemic hypotension.

References:
1. Elevated serum creatinine as a mar1<er of pancreatic necrosis In acute
pancreatitis
2. Management of fluid collections and necrosis in acute pancreatitis

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