David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Both discussants recommend a goal-directed fluid resuscitation strategy for a patient with acute pancreatitis, monitoring clinical variables (i.e., urine output and hemodynamics) to avoid complications of under- or overresuscitation. They also advocate for early nutrition, resuming oral nutrition after 24 to 48 hours.
Both discussants recommend ultrasonography as the initial test of choice in acute pancreatitis, to identify gallstones or choledocholithiasis. Both advise against routine computed tomography at the time of admission, noting that necrosis and fluid collection typically take several days to develop. They also advise against magnetic resonance cholangiopancreatography, unless another cause of pancreatitis is suspected or there is continued concern for choledocholithiasis. Endoscopic retrograde cholangiopancreatography is reserved for treatment of biliary obstruction or cholangitis.
Both discussants agree that cholecystectomy should be done during the index admission in cases of gallstone pancreatitis, although the surgeon notes that it is appropriate to delay surgery until systemic findings of pancreatitis resolve and necrosis and fluid collections stabilize. If surgery is not performed during the index hospitalization, there should be a clear plan in place to expedite surgery after discharge.
The MEESSI-AHF score predicts 30-day mortality with excellent discrimination, accurately assigning patients to groups of low, intermediate, high, and very high risk.
This score may be useful in distinguishing low-risk patients (who may be safely discharged from the ED) from higher-risk patients (who may benefit from inpatient care).
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Wesorick DH, Chopra V. Annals for Hospitalists - 19 February 2019. Ann Intern Med. ;170:HO1. doi: 10.7326/AWHO201902190
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Published: Ann Intern Med. 2019;170(4):HO1.
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