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Acute necrotising pancreatitis — MRCEM SBA MCQ

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HardGastrointestinal and surgical emergenciesAcute necrotising pancreatitisMRCEM SBA

A 59-year-old woman was admitted 50 hours ago with acute pancreatitis. Her abdominal pain began four days ago. Despite analgesia and antiemetics, she has taken almost no food since admission. She is now haemodynamically stable, is not vomiting and has no ileus. Contrast-enhanced CT shows pancreatic non-enhancement and an acute necrotic collection, without gastric outlet obstruction. She has no fever, new organ dysfunction or other evidence of infection. She remains under the care of the local surgical team. Which plan is most appropriate now?

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Correct answer: D — Begin nasogastric feeding; discuss with a pancreatic centre; continue inpatient observation.

The CT establishes pancreatic necrosis, a complication requiring advice from a specialist pancreatic centre and discussion of whether transfer is needed. It does not establish infected necrosis. Meanwhile, this patient cannot meet her nutritional needs orally, but she is stable and has no apparent barrier to gastric feeding. NICE recommends enteral nutrition for moderately severe or severe acute pancreatitis, started within 72 hours of presentation. Nasogastric feeding is a suitable route when there is no upper gastrointestinal dysfunction. She still needs supportive inpatient care while specialist advice is obtained. A leaves her substantial nutritional deficit unaddressed; continuing oral intake would be reasonable if she could eat enough. B is tempting because necrosis can become infected, but antibiotics are not indicated prophylactically; they would be appropriate if infection were suspected or confirmed. C supplies nutrition but bypasses a usable gastrointestinal tract. Parenteral nutrition becomes appropriate if enteral feeding fails or is contraindicated. E anticipates a procedure that the findings do not currently justify. An endoscopic approach may be appropriate for infected or suspected infected necrosis when anatomically possible, but even then the need for prompt intervention must be weighed against the advantages of delay.

Reference: NICE NG104: Pancreatitis — recommendations (Published 5 September 2018; last updated 16 December 2020) — https://www.nice.org.uk/guidance/ng104/chapter/Recommendations NICE NG104: Pancreatitis — managing complications and specialist referral (Published 5 September 2018; last updated 16 December 2020) — https://www.nice.org.uk/guidance/ng104/chapter/Recommendations NICE CG32: Nutrition support for adults — enteral tube feeding (Published 22 February 2006; last updated 4 August 2017) — https://www.nice.org.uk/guidance/cg32/chapter/Recommendations