A 42-year-old woman presents to the emergency department with severe epigastric pain radiating to the back that began 12 hours ago. The pain is associated with nausea and multiple episodes of vomiting. Her medical history is significant for symptomatic cholelithiasis. She does not take any medications. Temperature is 37.8°C (100.0°F), blood pressure is 104/68 mm Hg, pulse is 108/min, and respiratory rate is 20/min. Physical examination reveals epigastric tenderness to palpation without rebound or guarding. Laboratory studies demonstrate a serum lipase level of 1,800 U/L, AST of 145 U/L, ALT of 170 U/L, and total bilirubin of 1.6 mg/dL.
Which of the following is the most appropriate initial treatment?
The correct answer is:
C: Intravenous fluid resuscitation.
This patient has acute pancreatitis, likely secondary to gallstones, as evidenced by characteristic epigastric pain radiating to the back and markedly elevated serum lipase levels. Early aggressive intravenous fluid resuscitation is one of the most important components of initial management because it helps maintain pancreatic perfusion and reduces complications. Most patients improve with supportive care, including pain control and appropriate nutritional management.
Answer choice A: Broad-spectrum antibiotics, is incorrect.
Prophylactic antibiotics are not recommended in uncomplicated acute pancreatitis. Antibiotics are reserved for documented infections such as infected pancreatic necrosis.
Answer choice B: Endoscopic retrograde cholangiopancreatography, is incorrect.
The presence of gallstones makes ERCP an attractive answer. However, ERCP is generally reserved for patients with cholangitis or persistent biliary obstruction. This patient’s immediate need is supportive care and fluid resuscitation.
Answer choice D: Pancreatic enzyme replacement, is incorrect.
Pancreatic enzyme supplementation is used in chronic pancreatic insufficiency, not acute pancreatitis.
Answer choice E: Total parenteral nutrition, is incorrect.
Most patients with acute pancreatitis can resume enteral nutrition as symptoms improve. Total parenteral nutrition is reserved for selected patients who cannot tolerate enteral feeding.
Key Learning Point
Early aggressive intravenous fluid resuscitation is a cornerstone of initial management for acute pancreatitis and should be initiated promptly after diagnosis.
