34 yo M with fever and abdominal pain

Original case by Brandon Fainstad, MD
Edits and graphics by Yilin Zhang, MD


OBJECTIVES:


CASE:

34 year old man presents to the ED with fever and abdominal pain.  The abdominal pain is episodic, worse after meals, initially epigastrium but now most intense in the LLQ. This pain has been worsening over the past month. The fever first developed three days ago. He denies any change in his stools, his urine output has been low the past couple days but no dysuria or hematuria.  He has a  history of severe necrotizing EtOH pancreatitis 1 year prior complicated by a self resolving pseudocyst (as of 10 months ago) and chronic intermittent abdominal pain and insulin dependent diabetes. His medications include gabapentin and insulin.  He denies any ongoing EtOH use.

On exam he is febrile 38.4C, HR 130, BP 110/70 and SpO2 98% on RA.  He is uncomfortable and diaphoretic.  His abdomen is diffusely tender, but most severe in the LLQ with voluntary guarding but no rebound tenderness.  Labs are significant for Cr 0.8, WBC 15k, Hct 42%, lipase 11, INR 1.2 with otherwise normal LFTs.

CT A/P #1

What options are there to manage a pancreatic pseudocyst? 


CASE CONTINUED:
CT A/P #2 

OUTCOME:

At 6 weeks, he underwent a follow-up CT.

CT A/P #3

Repeat imaging showed resolution of peripancreatic fluid collections (IR drains still in place on CT above). He underwent removal of IR placed drains.


TAKE HOME POINTS:

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