Drinking yourself to death
An unfortunate young man presented with 12 hours of severe upper abdominal pain and vomiting. He was quite obese but otherwise without medical history. He initially admitted to only occasional alcohol use, although he later confessed to consuming around 20 drinks per weekend, with a lesser degree of daily use. He reported one similar episode of pain a month before which had responded to antacids.
He was afebrile, tachycardic to about 120, actively vomiting, and moderately tender over the upper abdomen. His WBC was 24,000, and his amylase and lipase were markedly elevated (around 10 times normal). His serum glucose level was 220, his LDH was 750, and his transaminases were around 100 with normal bilirubin. His triglycerides were 1300, and his blood was notably lipemic. His CT scan revealed marked pancreatic edema with impressive surrounding inflammatory changes and peripancreatic fluid collections. There were no gallstones, pseudocysts, hemorrhage, or other abnormalities seen on the study.
Because of the rapid progression of his illness and his high Ranson score suggesting the potential for serious complications, he was admitted to the ICU. The following day, he became hypoxemic requiring intubation, and he developed acute renal failure and mild rhabdomyolysis. His serum calcium was 6.0, his creatinine had increased from 1.4 to 3.0, and the predicted mortality for this 26 year old man was well over 50%.
Acute pancreatitis can be a killer.
And in this case, it was. RIP.
He was afebrile, tachycardic to about 120, actively vomiting, and moderately tender over the upper abdomen. His WBC was 24,000, and his amylase and lipase were markedly elevated (around 10 times normal). His serum glucose level was 220, his LDH was 750, and his transaminases were around 100 with normal bilirubin. His triglycerides were 1300, and his blood was notably lipemic. His CT scan revealed marked pancreatic edema with impressive surrounding inflammatory changes and peripancreatic fluid collections. There were no gallstones, pseudocysts, hemorrhage, or other abnormalities seen on the study.
Because of the rapid progression of his illness and his high Ranson score suggesting the potential for serious complications, he was admitted to the ICU. The following day, he became hypoxemic requiring intubation, and he developed acute renal failure and mild rhabdomyolysis. His serum calcium was 6.0, his creatinine had increased from 1.4 to 3.0, and the predicted mortality for this 26 year old man was well over 50%.
Acute pancreatitis can be a killer.
And in this case, it was. RIP.
posted by scalpel at 11:26 AM
7 Comments:
Sounds like a typical admission from my MICU days, except he is about 2 decades too young.
Outcome = NG
Bet he thought drinking a 12 pack on the weekends was of no consequence.
That blood sample looks like leftover Thanksgiving gravy with that congealed fat layer on top.
Mmmmm....gravy.... ;)
In a rational world nature would take its course and he would drop out of the gene pool. But I am sure they will probably be able to "save" him. Likely, he will continue to be an alcoholic and be admitted many more times at the expense of the taxpayer. Just my cynical guess, but I bet I am right.
That's for sure! Pancreatitis in all its forms is a huge challenge for surgeons, and has represented some of my most difficult patients and procedures. Come to think about it, I should get around to posting on it myself.
I thought of you, Dr. Schwab, when I admitted this man to my favorite general surgeon. I had gradually been "influenced" by many of the surgeons at my facility to admit only patients with clear indications for urgent surgery to the surgery service; otherwise patients with nonspecific (or even specific) abdominal pain but inconclusive CT scans, pancreatitis/diverticulitis without perforation/abscess, "partial" bowel obstructions, etc. would have to go to Medicine with a surgery consult.
Fortunately, I have since found a few surgeons like yourself who enjoy the challenge of more "cognitive" work as well (wink), and I appreciate their willingness to help me out with such patients. So I refer patients to them preferentially.
As an ER doc, I really have little idea how skilled a particular surgeon is in comparison to their colleagues. The only way I can really differentiate between them is how thoughtful and receptive they seem to be when they respond to my consultations.
It has been my experiance that patients with pancreatitis due to the bottle, typically do not chnge their distructive behavoir, thus, making surgery something in vane. Many people drink because they can not deal with reality. When you have a bad pancreas, the reality of that is very real, all of the time. The surgeries are hard core and you need oxy, etc to get through it. So, if you administer those kinds of narcs to alcoholic or a drinker, then I think you have 2 issues. 1- You have a patient whom maybe become a narc adict and 2- a person who needs to be healthy in every way to recover from the magnitude of that type of procedure...though I don't think you should ever give up on people, in cases where a person dies from pancreatitis brought on by the bottle, I think , forgive me for saying this, is a good thing.
Maybe he wanted to die, perhaps he realized his worthlessness to the gene pool, or had something hanging of his head he never did but was being punished for anyway.
Maybe he successfully drank himself to death despite every hippie in the world trying to save people who don't want saving
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