0071643192.pdf

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

DIFFERENTIAL

Biliary colic, cholecystitis, mesenteric ischemia, intestinal obstruction/ileus,
perforated hollow viscus, inferior MI, dissecting aortic aneurysm, ectopic
pregnancy

DIAGNOSIS

■ Elevated amylase (more sensitive) and lipase (more specific)
■ High serum glucose
■ An ALT >3 ×normal suggests biliary stones over EtOH; an AST/ALT
ratio >2 favors EtOH. CRP declines with improvement.
■ Differential for elevated amylase: Pancreatitis, pancreatic tumors, chole-
cystitis, perforation (esophagus, bowel), intestinal ischemia or infarction,
appendicitis, ruptured ectopic pregnancy, mumps, ovarian cysts, lung can-
cer, macroamylasemia, renal insufficiency, HIV, DKA, head trauma; lipase
usually normal in nonpancreatic amylase elevationsand therefore more
specific for pancreatitis
■ AXR: May show gallstones, “sentinel loop” (an air-filled small bowel in
the LUQ), and “colon cutoff sign” (abrupt ending of the transverse
colon)
■ RUQ ultrasound: Reveals cholelithiasis without cholecystitis; choledo-
cholithiasis (common duct stones) often missed or have passed
■ CT: Performed initially to exclude abdominal catastrophes; at 48–72 hours,
exclude necrotizing pancreatitis; an ↑risk of renal failure from contrast dye

TREATMENT

■ NPO with nasojejunal tube feeds or total parenteral nutrition with severe
disease and anticipated NPO status for >3–5 days
■ Aggressive IV hydration
■ Pain control with narcotics; avoid morphine, as it ↑sphincter of Oddi
tone
■ Broad spectrum IV antibiotics (imipenem) for severe necrotizing pancre-
atitis
■ Forgallstone pancreatitis (elevated serum bilirubin, signs of biliary sepsis),
perform ERCP for stone removal and cholecystectomy following recovery
but prior to discharge.

COMPLICATIONS

■ Necrotizing pancreatitis
■ Suspected in the setting of a persistently elevated WBC count (7–10 days),
high fever, and shock (organ failure)
■ Has a poor prognosis (up to 30% mortality and 70% risk of complications)
■ If infected necrosis is suspected, perform percutaneous aspiration. If
organisms are present on smear, surgical debridement is indicated.
■ Pancreatic pseudocyst: A collection of pancreatic fluid walled off by
granulation tissue; occurs in approximately 30% of cases but resolves
spontaneously in about 50%; drainage not required unless the pseudocyst
is present >6–8 weeks and is enlarging and symptomatic
■ Other:Pseudoaneurysm, renal failure, ARDS, splenic vein thrombosis
(which can →isolated gastric varices)
■ Hypocalcemia

CT is prognostic in severe

pancreatitis and is used to

evaluate for necrotizing

pancreatitis. Necrotizing

pancreatitis warrants empiric

antibiotics (eg, imipenem).