A male aged 45 years who is a known case of Acute Necrotizing Pancreatitis (Etiology- Biliary) on conservative management suddenly developed Pain Abdomen since 2 hrs and non passage of flatus... comment on his Xray Abdomen and discuss the findings and treatment

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Ac.int.obst

Ac int obstruction

Ac int Obst. Req Emergency Lap after correting the Basics.

Likely on looking to xaray Acute Intestinal obdtruction

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Paralytic ileus in a patient of acute pancreatitis can be due to inflammation itself or can be due to electrolyte imbalance. Manage with RT/NPO/IVF Ideally this patient should undergo a CT abdomen to look for development of necrotic collections, any splanchnic venous thrombosis or gallstone in bowel. If necrotic collections + and are infected then better to go for percutaneous drainage. Similarly if splanchnic thrombosis, start anticoagulation. If no definite site of obstruction could be identified then the patient should improve with conservative management

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Multiple air fluid level Suggestive of Acute intestinal obstruction Watch for abdominal girth Antibiotics cefotaxine + metro + amikacine for SABP RT,Foley's

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X ray abdomen shows multiple air fluid level involving predominantly ileal loops More in upper abdomen This fits in to - localised peritonitis in upper abdomen in a known case of acute necrotising peritonitis Impression Sudden deterioration is likely to be because of infection of pancreatic necrosis Adv Serum Procalcitonin - raised value will indicate infection CT guided aspiration of necrosis and culture sensitivity, administration of specific Antibiotic to treat infection Surgery - pancreatic necrosectomy should be avoided in early phase. It should be considered after 4 - 5 weeks of pancreatitis , after that time there is adequate separation of necrosed tissue and necrosectomy can be carried out Until then conservative treatment with vital support and Antibiotics

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Acute intestinal obstruction as multiple air fluid levels are seen on X- ray abdomen- standing and right dome of diaphragm is raised . Obstruction can be due to 1.Sequelae of acute necrotising Pancreatitis with secondary haemrrhagic peritonitis 2.A gall stone slipping in the intestines and causing bolus Obstruction 3.Adhesion Obstruction- secondary to Pancreatitis 4.Volvulus Treatment- remains mainly conservative with 1.Nil orally 2.RT aspiration 3.IV fluids 4.Parenteral antibiotics- 3rd generation cephalosporins + Amikacin ( if creatinine level is normal ) A CT abdomen or MRI abdomen can help on location of obstruction

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