P2922 - Necrotizing Pancreatitis Complicated by ARDS and GI Bleeding: A Case Report

Tuesday, October 24, 2023

10:30 AM – 4:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

Ahmad Thunaibat, MD

Hamilton Health Care System
Dalton, Georgia

Ahmad Thunaibat, MD¹, Haya Omeish, MD², Mohammed Rashid, MD³
¹Hamilton Health Care System, Dalton, GA; ²Henry Ford Health Hospital, Detroit, MI; ³Istishari Hospital, Amman, 'Amman, Jordan

Introduction: Acute necrotizing pancreatitis, though relatively rare comprising 10% of acute pancreatitis cases, carries high mortality and morbidity rates. This condition occurs when more than 30% of the pancreas is affected by necrosis. Additionally, acute respiratory distress syndrome (ARDS) in pancreatitis can lead to respiratory failure and increased mortality risk. Although gastrointestinal bleeding (GIB) is uncommon, it can be fatal.

Case Description/Methods: A 54-year-old patient with presented with severe abdominal pain, fatigue, nausea, vomiting, loss of appetite, and weight loss. An abdominal CT scan confirmed necrotizing pancreatitis, and conservative therapy with Carbapenem was initiated. However, on the fifth day, the patient experienced bloody diarrhea and deteriorated rapidly. Hemoglobin dropped, chest X-ray revealed ARDS, and the patient was transferred to the ICU. Despite intubation attempts, the patient developed bradycardia, irregular beats, and ultimately went into cardiac arrest.

Discussion: Acute pancreatitis is an inflammatory disease of the pancreas that triggers the release of pro-inflammatory mediators, causing systemic inflammation, endothelial dysfunction, and organ failure. Causes include gallstones, alcohol, trauma, infection, malignancy, and autoimmune factors. Complications include necrotizing pancreatitis, abscess formation, pseudocysts, hemorrhage, and ARDS. Bleeding can result from ulcers, erosions or direct vascular involvement. Hemorrhagic transformation, though rare, has high mortality and can be managed with angiography and embolization. Severity, necrosis, and mortality can be predicted using scoring systems, radiological scores, and biochemical markers. Acute necrotizing pancreatitis accounts for 5-10% of cases and has varying prognosis based on sterile/infected necrosis. ARDS occurs in 0.2% of cases and is diagnosed based on a specific criteria of bilateral pulmonary infiltrates, PaO2/FiO2 ratio less than 300 mmHg, and a p/f ratio of less than 100 mmHg. Management involves strategies such as high PEEP, muscle relaxants, recruitment maneuvers, and ECMO. Mortality rates for ARDS in acute pancreatitis range from 30% to 40%. Prediction scores like LIPS, APACHE II, IL-6, and IL-8 help anticipate ARDS. This case emphasizes the rare lethality and rapid rate with which these complications develop and the need for a multidisciplinary approach in managing severe acute necrotizing pancreatitis and its complications, such as hemorrhagic shock and ARDS.

Figure: Figure 1: "Abdominopelvic CT scan highlighting significant findings in the region of the pancreas: a large fluid collection (ascites) indicated by the black arrow, diffusely enlarged pancreas with cystic changes and inflammatory alterations in the pancreatic and peripancreatic regions, extensive pancreatic necrotic changes (hypoattenuation) exceeding 50% as indicated by the orange arrow, presence of gas bubbles denoted by the blue arrow, and misty mesentery with fat stranding suggestive of an inflammatory process with phlegmons in the pancreatic area."

Figure 2: "Chest X-ray revealing a suboptimal inspiratory film demonstrating bilateral atelectasis changes, bilateral pleural effusion with greater involvement on the left side, and consolidation in the lower right lung zone."

Labs	Result	Normal Range
Hemoglobin	9.6	13.5-17.5 g/dL
Amylase	189	25-125 IU/L
Lipase	490	10-140 IU/L
C-reactive protein	133.9	>100 mg/L
Arterial pH	7.54	7.35-7.45
PCO2	28.8	35-45 mmHg
PO2	149.8	80-110 mmHg
HCO3	26.8	22-26 mmol/L
Alkaline Phosphatase	69	0-40 U/L
Alanine Aminotransferase	14	11-44 U/L
Gamma-glutamyl transferase	46	0-37 U/L
Aspartate aminotransferase	34	70-150 U/L
Potassium	3.1	3.5-5.3 mEq/L
Calcium	7.8	8.5-10.2 mg/dL
Magnesium	1.5	1.7-2.6 mg/dL
Troponin T	122.4	0-14 ng/L
White Blood Cells	18.92	4.5-11.0 × 10^3 cells/µL
Neutrophils	9200	2500-7500 cells/µL
Lymphocytes	7000	1500-3500 cells/µL
IGG4	105	0.052-1.250 g/L

Disclosures:

Ahmad Thunaibat indicated no relevant financial relationships.

Haya Omeish indicated no relevant financial relationships.

Mohammed Rashid indicated no relevant financial relationships.

Ahmad Thunaibat, MD¹, Haya Omeish, MD², Mohammed Rashid, MD³. P2922 - Necrotizing Pancreatitis Complicated by ARDS and GI Bleeding: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.