Case Presentation: A 24 year-old man presented with one day of mid-epigastric abdominal pain with radiation to his back. He reported an episode of binge drinking the night before. On admission, pulse was 107, blood pressure 141/73, respiratory rate 21, and oxygen saturation 100% on room air. He was fully alert and oriented, and had mid-epigastric tenderness to deep palpation without rigidity, guarding, or rebound tenderness. Labs were notable for a lipase of 13,304, white blood cell count 19,000, hematocrit 47, blood urea nitrogen (BUN) 12, and creatinine (Cr) 0.9. CT scan revealed an edematous pancreas and an acute non-encapsulated peripancreatic fluid collection, with no evidence of pancreatic necrosis. His BISAP score was 1. He was given 2 L of saline and admitted to the medicine floor for pain control and additional IV fluids.
After 24 hours the patient’s abdominal pain and distention worsened, and he became tachycardic and tachypneic. BUN was 21 and Cr 2.6 on repeat labs. He was initially stabilized with aggressive fluid resuscitation and noninvasive supplemental oxygen, but eventually required intubation, mechanical ventilation, and paralysis. At 36 hours into admission and upon arrival to the intensive care unit (ICU), APACHE II score was 16 (estimates a 22% risk of mortality). Bladder pressure was found to be 25 mmHg, surgery was consulted, and the patient was taken emergently to the operating room for abdominal compartment syndrome (ACS). Laparotomy revealed 1.5 L of abdominal free fluid and acute hemorrhagic necrotizing pancreatitis.
Discussion: Acute pancreatitis (AP) is a common problem encountered by the hospitalist. While some hospitalists may be reassured by this patient’s initial presentation, it is important to remain vigilant in all cases of AP given the wide spectrum of severity and the risk of rapid deterioration. Despite the absence of organ failure on admission, this patient met revised Atlanta criteria for moderately severe AP given the local complication of an acute peripancreatic fluid collection, and he eventually progressed to severe AP.
ACS is more commonly seen in ICU and trauma patients, but needs to be on the clinical radar of all hospitalists. Defined as intra-abdominal hypertension causing organ failure, ACS occurs in about 4% of patients with severe AP and those who receive aggressive fluid resuscitation are at highest risk. ACS is associated with significant morbidity and mortality and can present a diagnostic dilemma, as both ACS and severe AP alone can be associated with abdominal distention/ileus, and both can lead to renal failure, respiratory failure, and cardiovascular collapse. Early recognition of ACS is imperative, as surgical decompression improves outcomes.
Conclusions: Acute pancreatitis is a clinical entity that warrants close observation even when the initial presentation is seemingly mild. Abdominal compartment syndrome is a complication all hospitalists need to be wary of and know how to recognize.