Hepatic Failure/GI/Endocrine Emergencies

Patient Case

A 44-year-old woman presents to the ED with a 2-day history of diffuse abdominal pain. Amylase is 700

IU/L, and lipase is 800 IU/L. She is given intravenous fluids with lactated Ringer solution and enteral

nutrition through an NJ tube. However, after 48 hours, she has still not improved, and CT imaging reveals

pancreatic necrosis involving 40% of the pancreas. Which interventions would best be performed at this

time?

pancreatitis.

About 20% of patients with Crohn disease will develop a spontaneous fistula in their lifetime, and up to

12% of patients with diverticulitis will develop a spontaneous fistula.

type of abdominal surgery, with the rate of fistula increasing with more complex surgical procedures

and more complicated resections/anastomoses. Additional factors such as Crohn’s disease (incidence

15%–35%) increases the risk of fistula formation postoperatively.

In the past 50 years, the mortality rate associated with fistulas has decreased significantly from greater

than 40% to currently around 20%, mainly because of improvements in supportive care and the advent

of nutritional support.

GI fistulas remain a source of considerable morbidity with prolonged hospital courses, infections, and

malnutrition.

A fistula is any abnormal connection between two epithelialized surfaces. GI fistulas involve an

abnormal connection between the GI tract and the skin, another internal organ, or an internal cavity

such as the peritoneal or pleural space.

Anatomic: Describe the fistula origin and drainage point

Internal: Connection to another internal organ or internal cavity (i.e., ileocolic)

ii.

External: Connection to the skin (i.e., enterocutaneous)

Nomenclature: Typical method is from point of origin (e.g., gastro-, entero-, ileo-, etc.) followed by

point of termination (e.g., -cutaneous, -colic, etc.).

Physiologic: Classified according to daily fistula output. Daily fistula output is one of the most

important determinants of morbidity and mortality, and it generally decreases before spontaneous

closure.

High output: Greater than 500 mL/day. High-output fistulas are associated with a mortality

rate of about 35%.

ii.

Moderate output: 200–500 mL/day

iii.

Low output: Less than 200 mL/day