Pancreatitis, another patient. - Forum

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Priya

Pancreatitis, another patient. - Ärzteforum

Post#1 »

A 35 year old male patient with previously diagnosed cholelithiasis was admitted in a district hospital with features of acute chlecystitis. The attending surgeon did laparatomy with the intention to do cholecystectomy. It turned out to be a case of acute pancreatitis. The surgeon did not do the cholecystectomy and kept a drain in the region of pancreas. He was refered to my hospital 10 days after laparatomy. To day is the 15th post op day. The patient is having high fever (103-105 F) twice or thrice a day which subsides on cold sponging. Thick white pus is coming through the drain at a rate of 700-800cc/day. Interestingly the pus is replaced by frank blood during the bouts of fever. He initially had loose motion which have now subsided.

Suspecting an abscess I asked for an ultrasonogram which doesnot show any abscess despite being repeated several times.

What to do next? Should I do laparatomy and look for an abscess? Will a CT give a better information? Thank you all in advance.


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Surgeon

Re: Pancreatitis, another patient. - Ärzteforum

Post#2 »

Leaving the gallbladder in this patient will only prevent his recovery, especially in his septic state! Not seeing an abscess on US may just indicate an efficient drainage but the clinical state of the patient is more important than morphological evidence (that is why I also do not think a CT would affect my decision in this patient!).

John Dissector

Re: Pancreatitis, another patient. - Ärzteforum

Post#3 »

The case you describe of lap for GB disease and find pancreatitis
happens all too often--it was pretty well shown over 15 years ago
that there is no rationale for "draINING" a case of
pancreatitis--serves no purpose and also is extremely dangerous as it
greatly increases the risk of introducing bacteria INTO this rich
soup of inflamed friable tissue and creating peripancreatic infection
where none would otherwise have occurred--Your colleague should have
removed the gallbladder (assuming it had stones--if a flat normal
gallbladder was found then leave it alone) and closed--Now a very
predictable and avoidable event happens--almost certainly an abscess
or infected necrosis, with a drastically increased risk of maortality
and morbidity.
A CT is the standard modality to look for the EARLY
indications of infection requiring surgery--I am unaware of any data
proving any benefit of U/S for this purpose. I'm not sure a CT is
worthwhile here though(recognizing however it is like moving a
mountain to keep surgeons from getting the CT in an attempt to find
any crutch--God forbid clinical judgement should come into play!)
because you are still left with a patient showing clear signs of
sepsis regardless of what it shows--there is NO role in my opinion
for considering percutaneous drainge here--so I would just reoperate
(note--no big deal--the incision is already there--just look and
fix!) You are like an ostrich with its head in the sand if you even
consider thinking this is not pancreatic infection.

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