Acute Pancreatitis — DCE Clinical Case

Long case

Patient scenario

Mr RT is a 58-year-old man who was admitted 12 days ago with 24 hours of severe constant epigastric pain radiating to the back, with repeated vomiting. He had a low-grade fever. On admission his lipase was 2400 U per litre (ULN 60), ALT 220 IU per litre, bilirubin 45 micromol per litre, and abdominal ultrasound showed multiple gallstones with a normal-calibre common bile duct. He was diagnosed with acute gallstone pancreatitis. Over the first 48 hours he developed acute kidney injury (creatinine rising from 95 to 210 micromol per litre, oliguria) and respiratory compromise (oxygen saturation 90 per cent on room air requiring 4 litres of nasal specs), meeting criteria for severe pancreatitis per the Revised Atlanta Classification (persistent organ failure beyond 48 hours). A contrast-enhanced CT on day 5 showed extensive pancreatic and peripancreatic necrosis with gas bubbles within the collection, consistent with infected necrosis. He was commenced on a carbapenem and underwent EUS-guided endoscopic cystgastrostomy and drainage of the walled-off necrosis on day 8, with two sessions of endoscopic necrosectomy. His organ failure is now resolving: creatinine 145 micromol per litre, saturating at 95 per cent on 2 litres nasal specs. His blood glucose has been labile, with readings between 4 and 22 mmol per litre, and he has been commenced on a basal-bolus insulin regimen by the endocrinology team. He is on nasojejunal feeding at 60 mL per hour and has intermittent steatorrhoea. He drinks 60 to 80 grams of alcohol daily and smokes 15 cigarettes per day. He works as a truck driver. He has hypertension (on perindopril 5 mg daily) and has no known diabetes prior to this admission. He is keen to return home and is frustrated by the prolonged admission. ^[1]

Examination findings

The patient is in bed, comfortable but visibly deconditioned. He is afebrile, heart rate 88, blood pressure 132 over 78, respiratory rate 18, oxygen saturation 95 per cent on 2 litres nasal specs. He has mild scleral icterus. The abdomen is soft with mild epigastric tenderness, a palpable fullness in the epigastrium (consistent with the residual walled-off collection), and sparse bowel sounds. There is no guarding, rigidity, or Cullen or Grey Turner sign. He has a nasojejunal tube in situ and a triple-lumen central line in the right internal jugular vein. He has mild bilateral basal crackures. There is no peripheral oedema. ^[1]

Candidate's opening statement (SASPOP)

"Doctor, my patient is Mr RT, a 58-year-old man and truck driver, now on day 12 of an admission for severe acute gallstone pancreatitis complicated by persistent organ failure (acute kidney injury and respiratory compromise, both resolving), infected walled-off necrosis managed with endoscopic step-up drainage, new-onset diabetes of the pancreas, and malnutrition on nasojejunal feeding. He drinks 60 to 80 grams of alcohol daily. His problems are: severe necrotising gallstone pancreatitis with infected walled-off necrosis; resolving multi-organ failure; new-onset diabetes of the pancreas; malnutrition; alcohol use disorder; hypertension; and deconditioning requiring rehabilitation." ^[1]

Problem list

1. Severe necrotising gallstone pancreatitis with infected walled-off necrosis (managed with endoscopic drainage and antibiotics that penetrate necrosis).
2. Resolving multi-organ failure (acute kidney injury recovering, respiratory compromise improving).
3. New-onset diabetes of the pancreas (pancreoprivic, on basal-bolus insulin).
4. Malnutrition and ongoing catabolism (nasojejunal feeding at 60 mL per hour).
5. Alcohol use disorder (60 to 80 grams daily; withdrawal risk, need for cessation).
6. Smoking (15 cigarettes per day).
7. Hypertension (on perindopril).
8. Deconditioning and the need for rehabilitation. ^[1]

Integrated management plan

Source control for the infected necrosis. Continue endoscopic drainage of the walled-off necrosis via the established cystgastrostomy; repeat endoscopic necrosectomy if the collection re-accumulates or clinical parameters deteriorate. Continue a carbapenem or piperacillin-tazobactam, with a plan to de-escalate and stop once source control is achieved. The PANTER trial established the step-up approach as the standard — primary open necrosectomy is not indicated ^[4].

Organ support. Lactated Ringer's, WATERFALL moderate (10 mL per kg bolus only if hypovolaemic then 1.5 mL per kg per hour), reassessed at 12, 24, 48, and 72 hours (aggressive bolus resuscitation causes harm). Renal replacement therapy is on standby if the acute kidney injury worsens. Wean high-flow to low-flow oxygen as tolerated ^[3].

Nutrition. Continue nasojejunal enteral feeding and advance to target rate as tolerated; early enteral feeding reduces infectious complications and mortality compared with NPO and parenteral nutrition. Plan to transition to an oral low-fat diet as ileus resolves. Add pancreatic enzyme replacement for the steatorrhoea from exocrine insufficiency. ^[4]

Diabetes. Continue the endocrinology-guided basal-bolus insulin regimen. Pancreoprivic diabetes is often brittle (loss of glucagon counter-regulation makes hypoglycaemia dangerous). Educate the patient about hypoglycaemia recognition and management. Monitor HbA1c in 3 months. ^[1]

Alcohol and smoking. Thiamine replacement (Wernicke prevention). Addiction medicine consultation for cessation counselling and supervised detoxification planning. Counsel that continued drinking will cause recurrent pancreatitis and progression to chronic pancreatitis. Smoking cessation counselling (smoking increases the risk of pancreatic cancer in chronic pancreatitis). ^[1]

Definitive biliary management. Laparoscopic cholecystectomy once the patient has fully recovered from the acute episode. A 3 to 6 month delay after severe disease is exam convention, not a Moody interval — Moody and BSG apply to mild disease (index admission or within 2 weeks). ^[9]

Rehabilitation. Early mobilisation, physiotherapy, and functional recovery. Deconditioning after a prolonged ICU and hospital stay is a major contributor to length of stay. ^[1]

Discussion questions

Examiner: "How would the fluid strategy differ if this patient had presented today, given the WATERFALL trial?" The 2024 ACG guideline recommends moderately aggressive, goal-directed fluid resuscitation with Ringer lactate — NOT the old approach of aggressive 250 to 500 mL per hour. The WATERFALL trial stopped early because aggressive resuscitation (20 mL per kg bolus, then 3 mL per kg per hour) caused significantly more fluid overload without improving disease-specific outcomes. The practical approach is WATERFALL moderate: 10 mL per kg bolus only if hypovolaemic, then 1.5 mL per kg per hour, reassessed at 12, 24, 48, and 72 hours — not 5 to 10 mL per kg per hour. ^[3]

Examiner: "Why was ERCP not performed at admission despite the gallstone aetiology?" ACG 2013: patients with AP and concurrent acute cholangitis should undergo ERCP within 24 hours of admission. ACG 2024: early ERCP if biliary pancreatitis is complicated by cholangitis. This patient had no cholangitis (no fever, no rigors, no ongoing jaundice beyond the initial bilirubin of 45). Do not invent a 24 to 72 hour obstruction-without-cholangitis clock from these abstracts. ^[10][2].

Examiner: "What is the BISAP score and why is it useful?" The Bedside Index of Severity in Acute Pancreatitis (BISAP) was derived from a population of nearly 18,000 patients to provide early risk stratification using data available within 24 hours. One point each for: Blood urea nitrogen above 8.9 mmol per litre, Impaired mental status, SIRS, Age above 60, and Pleural effusion. Wu: mortality more than 20 per cent in the highest-risk group to less than 1 per cent in the lowest-risk group; AUC 0.82 versus APACHE II 0.83. The advantage over Ranson (48 hours) and APACHE II (complex) is that it is simple, early, and bedside-available ^[6].

Examiner: "Why does he have diabetes and what makes pancreoprivic diabetes different from type 2?" Necrotising pancreatitis destroys the endocrine pancreas. The resulting type 3c (pancreoprivic) diabetes is different from type 2 because it involves the loss of both insulin-secreting beta cells and glucagon-secreting alpha cells. Without glucagon counter-regulation, hypoglycaemia is more dangerous and the diabetes is brittle — wide glucose excursions, difficult to control, and prone to severe hypoglycaemia. Treatment requires insulin, but with education about hypoglycaemia. Pancreatic enzyme replacement improves glycaemic control by restoring nutrient absorption and reducing the mismatch between insulin and absorbed glucose. ^[1]

Examiner: "When would you perform the cholecystectomy?" Because this is severe necrotising pancreatitis with ongoing walled-off necrosis and organ failure recovery, I would defer cholecystectomy until recovered from the acute episode. A 3 to 6 month interval is exam convention, not a Moody or ACG 2024 abstract number. For mild gallstone pancreatitis, Moody/BSG is index admission or within 2 weeks (recurrent biliary readmissions OR 0.17). ^[9]