2 A 65‐year‐old man was admitted with acute pancreatitis and has been stable with intermittent tachycardia on the floor since his admission 2 days ago. Admission CT scan of the abdomen and pelvis showed edema and fat stranding around his pancreas. On the third day, he was noted to be more tachycardic, febrile with an increase of his leukocytosis. An interval CT scan demonstrates hypoattenuation of the pancreas, a large peri‐pancreatic retroperitoneal fluid collection with air and surrounding fat stranding. The next best course of treatment is:Start antibiotics with piperacillin‐tazobactam.Start antibiotics and percutaneously drain the collection.Start antibiotics and surgery for emergent necrosectomy.Start antifungals and percutaneously drain the collection.Continue current treatment with IV fluid resuscitation.This patient has infected necrotizing pancreatitis based on the physiologic and laboratory changes and new findings on CT scan. Broad‐spectrum antibiotics should be started since the fluid collection appears to be infected on clinical exam and on CT scan. In general, there is no indication to start antibiotics in necrotizing pancreatitis unless there is a culture‐proven infection or a strong suspicion for infection (gas in collection, sepsis, and clinical deterioration). Prophylactic antibiotics should not be used for sterile necrosis. For infected pancreatic necrosis, a multicenter trial showed that a minimally invasive step‐up approach (percutaneous drainage followed by minimal invasive retroperitoneal necrosectomy if needed) reduced major complications and death when compared to open necrosectomy. Answer A is incorrect because patient has indications for the need of drainage of the fluid collection. Answer C is not optimal as necrosectomy is now suggested to be reserved for failure of a step approach method. Answer D is incorrect because antifungals are not yet indicated. Answer E is incorrect because there is evidence of infection.Answer: BDa Costa DW, Boerma D, Van Santvoort HC, et al. Staged multidisciplinary step‐up management for necrotizing pancreatitis. Br J Surg. 2014; 101(1). doi:10.1002/bjs.9346Baron TH, DiMaio CJ, Wang AY, et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020; 158(1):67–75.e1. doi:10.1053/j.gastro.2019.07.064van Santvoort HC, Besselink MG, Bakker OJ, et al. A step‐up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 362(16):1491–1502. doi:10.1056/nejmoa0908821
3 A 68‐year‐old woman was injured in MVC and had exploratory laparotomy, small bowel resection, and splenectomy. She is now three weeks post‐operative, and she has developed copious green fluid extruding from a newly opened wound on the superior aspect of her incision. Her abdomen is soft but exquisitely tender to palpation around the wound. A CT scan of the abdomen with oral contrast shows extravasation of the contrast through the abdominal wall. All of the following are important and necessary in the initial management of an enterocutaneous fistula except:Treatment and control of sepsisFluid resuscitationElectrolyte repletionEffluent control and wound careOral toleration of dietThis patient has an enterocutaneous fistula, a very morbid complication after open surgery. Mortality is associated with sepsis, malnutrition, and fluid and electrolyte disturbances. It is important to control and treat sepsis as well as resuscitate the patient first. Effluent control and wound care are necessary to control output and prevent worsening and infection of any soft tissue wound. Nutrition is important for successful management of an EC fistula and can be a combination of enteral and parenteral, depending on nutritional needs and characteristics of the fistula. Oral toleration is not important initially and definitely not necessary. Characteristics of the fistula should be used to determine the appropriate nutrition source.Answer: EEvenson AR, Fischer JE . Current management of enterocutaneous fistula. J Gastrointest Surg. 2006; 10(3):455–464. doi:10.1016/j.gassur.2005.08.001Rosenthal MD, Brown CJ, Loftus TJ, et al. Nutritional management and strategies for the enterocutaneous fistula. Curr Surg Reports. 2020; 8(6):1–10. doi:10.1007/s40137‐020‐00255‐5Gribovskaja‐Rupp I, Melton GB . Enterocutaneous fistula: proven strategies and updates. Clin Colon Rectal Surg. 2016; 29(2):130–137. doi:10.1055/s‐0036‐1580732
4 A 32‐year‐old man with HIV is brought to the hospital post‐ictal after a seizure while at home. He is now complaining of a stiff neck, nausea, and a constant headache. His temperature is 102.3°F, heart rate is 98, and blood pressure is 100/58. His ophthalmic exam reveals bilateral papilledema. What are the next steps for management after blood cultures, antibiotics, and fluids?Lumbar puncture and place an ICP monitorDexamethasone and lumbar punctureDexamethasone and obtain a CT scan of headCT scan of head and place an ICP monitorDCT scan of head and mannitolThis immunocompromised patient has signs and symptoms concerning bacterial meningitis. After blood cultures and broad‐spectrum antibiotics are started, dexamethasone should be given to adult patients. A trial that evaluated outcomes in adult patients with bacterial meningitis found that negative outcomes, including death, were significantly lower in the group that received dexamethasone versus placebo; the group with streptococcus meningitis saw the most benefit. Hence, current recommendations state starting dexamethasone for any patients with possible streptococcal meningitis and continuing it only if culture results confirm the diagnosis. CT scan of the head should be obtained before a lumbar puncture since this patient has physical exam findings of elevated intracranial pressure (ICP), is immunocompromised, and had a new onset seizure within 1 week of presentation (choice A, B). There is a small (~1%) chance of herniation in adults with elevated ICP. A lumbar puncture is eventually necessary to identify the exact organism causing meningitis but is not done immediately (choice D). Mannitol may eventually be used to lower ICP prior to performing lumbar puncture. Initial