A 55-year-old male who is POD # 3 status post a Whipple procedure suddenly begins to have worsening tachycardia, tachypnea, and destruction with abdominal distention. Surgically placed intra- abdominal drains are in place. Chest X-ray shows bilateral patchy infiltrates, PaO2 /FiO2 ratio is 150, and he has sinus tachycardia with heart rate 130 bpm and stable blood pressures.
How would you diagnose and confirm a pancreatic leak in a post Whipple patient?
Correct Answer: D
Acute postoperative pancreatic leak can lead to signs of SIRS, abdominal pain, and respiratory insufficiency. A CT abdomen and pelvis may show postoperative free fluid, but it does not give the physician a definitive diagnosis as the free fluid can be nonspecific. The diagnostic test of choice for the diagnosis of postoperative pancreatic leak or fistula is diagnosed when the amylase content of the intra-abdominal fluid from the surgical drain on or after post-operative day 3 is greater than three times the upper limit of normal serum amylase content based on the International Study Group of Pancreatic Fistulas. These pancreatic leaks/fistulas postoperatively occur at an incidence of 20% but become clinically significant in 5% to 10 % of the patients. Patients with higher body mass index and preoperative comorbidities such as jaundice, soft pancreas, and smaller pancreatic duct are at higher risk of postoperative pancreatic leak.
A 64-year-old male with no significant past medical history has recently immigrated to the United States from Peru and now presents with severe abdominal pain and sinus tachycardia, with otherwise stable vital signs. CT of the abdomen and pelvis shows a 14-cm liver cyst in the right lobe with multiple daughter cysts, intermittent minute calcifications, and small pockets of gas. Liver enzyme tests show a slight elevation of AST and ALT but no elevation of alkaline phosphatase or total and direct bilirubin. No evidence of biliary obstruction is noted. Owing to concerns for impending rupture, the patient is sent to the ICU for close monitoring.
What is the BEST next step?
Correct Answer: C
Cystic Hydatidosis is a significant public health problem in South America, the Middle East and eastern Mediterranean regions, some subSaharan African countries, western China, and the former Soviet Union territories. In the United States, transmission has been seen in California, Arizona, New Mexico, Utah, and Alaska. CT has higher overall sensitivity (95%-100%) compared to ultrasound in this diagnosis. It is superior to ultrasonography for evaluation of complications such as infection and intrabiliary rupture and fistula. Intrahepatic biliary rupture and fistula can lead to severe cholangitis and septic shock. Among the serological testing for the diagnosis of Cystic Hydatidosis, ELISA is accepted as the most sensitive and specific test. Liver and lungs are the most common sites for this disease process and the prevalence of liver and pulmonary hydatic cysts increase with age. Surgery or puncture, aspiration, injection, and reaspiration otherwise known as PAIR are the treatments of choice. The choice between surgery or PAIR will depend on specific criteria and the complexity of the cyst and disease process. Albendazole is generally started one week before the operation and/or procedure and continued at least 4 weeks postoperatively. Metronidazole is the agent of choice for Amebic liver abscesses not Echinococcal cysts.
Which is the BEST test to detect the gastrointestinal bleeding rate of 0.3 to 0.5 mL/min in a hemodynamically labile patient in the ICU?
Correct Answer: A
Colonoscopy and upper endoscopy have certain advantages and disadvantages compared to any other test for lower gastrointestinal bleeding. Colonoscopy can localize the bleeding site specifically no matter the etiology or the rate of bleeding and it can be therapeutic at the same time. In this question, capsule endoscopy is a type of endoscopy however, not the ideal test for a hemodynamically labile patient in the ICU and generally used in the outpatient setting. Radionuclide imaging can detect bleeding at the lowest rate of 0.1 to 0.5 mL/min. It is considered the most sensitive radiographic test for gastrointestinal bleeding. This test is also not the ideal test for a patient with concerns of labile hemodynamics in the ICU as it can take from 90 minutes to 24 hours and perhaps multiple visits to the nuclear medicine department and away from close hemodynamic monitoring. CT angiography is an appealing diagnostic modality as it is fast and minimally invasive. It can detect bleeding at rates of 0.3 to 0.5 mL/min but offers no therapeutic benefit. A formal angiography requires active blood loss of 0.5 to 1.0 mL/min. This test is reserved for patients for whom endoscopy cannot be done or with severe bleeding causing hemodynamic instability. The question above is specifically focused on which test would be ideal for a patient with hemodynamic concerns detecting a slow rate of bleeding of 0.3 to 0.5 mL/min. CT angiography is the ideal test for this patient.
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