A 50 year-old-female with a history of coronary artery disease, hypertension, and alcohol dependence presented to our ED with complaints of chest pain.  She had been drinking heavily with friends when she started to complain of chest pain. About an hour after the onset of the pain, she was brought in by EMS. She was a poor historian and quite intoxicated.

 

Breath alcohol on arrival was 0.27.

 

Initial VS: BP 127/97, Pulse 101, T 36.4 °C (97.5 °F), RR 20, SpO2 94%

 

The team taking care of the patient initiated a work up with an ECG and troponin.

 

Here is the ECG:

 Minimal ST depression was noted, but was thought to be non-specific and non-diagnostic for ACS, acute ischemia or pericarditis.

 

The troponin returned normal, and the team planned to obtain a serial troponin and reassess the patient when she was sober.

 

The second troponin, drawn three hours after the first, was also normal.

 

The patient had several episodes of emesis, and as she sobered, began to complain more of epigastric and right upper quadrant abdominal pain than of chest pain. The team then decided to add on some additional lab tests.

 

WBC: 18

Lactate: 4

Lipase: 4460

LFTs: normal

 

The patient had never had pancreatitis before and was starting to look more ill. She was now breathing at a rate of about 35 breaths per minute. The team decided to do a BSUS to look for gallstones as a cause of pancreatitis.

 

The gallbladder was compressed and hard to visualize, but something else was noticed:

 

There is a stripe of fluid near the tip of the liver, but is it intraperitoneal?

 

The sonographer thought not because the fluid seems to follow the kidney more than the liver making this fluid collection seem retroperitoneal.

 

The sonographer also tried to look for the pancreas, but was having a hard time visualizing it and instead found this:

 

What do you think is going on here?

 

If you do not know, you are not alone because the sonographer was not sure what was going on either, but knew this looked like bowel surrounded by something hypoechoic that looked somewhat like fluid.

 

The ultrasound along with a worsening clinical picture prompted a CT scan of the abdomen.

 

It seems as though the outlined loop of bowel correlates to what was seen on the ultrasound below:

 

 

Here is another image from the CT scan:

 

The CT showed severe pancreatitis with a large amount of fat stranding and fluid throughout the peritoneal cavity.

 

As would be expected, she became very ill. She was intubated and developed ARDS and was quite difficult to ventilate. She also developed renal failure requiring dialysis. She remained in the ICU for 24 days total and was discharged to a Long Term Acute Care facility with a tracheostomy in place, but with normal mental status and returned renal function.