Postpartum Gallstone Pancreatitis Leads to Patient Death

Case Overview

This case involves a 27-year-old postpartum patient who initially presented to the Emergency Department (ED) with severe abdominal pain radiating to the back. The patient was diagnosed with Chololithiasis, a condition involving gallstones in the gallbladder.

Despite prolonged waiting times for further consultations, the patient left Against Medical Advice (AMA), only to return later with continued complaints of abdominal pain.

The patient’s condition worsened over time, developing into acute pancreatitis and hemodynamic instability. A sepsis alert was initiated, and an empiric Zosyn was administered. Further complications arose when a CT scan revealed a pulmonary embolism and venous thrombosis extending through the Inferior Vena Cava (IVC).

Despite transitioning to Heparin treatment and stabilization from a laboratory standpoint, the patient’s health continued to deteriorate. After being discharged, the patient returned to the ED with worsening abdominal pain.

An extensive workup revealed mild leukocytosis, non-obstructing gallstones, and an iliac vein Deep Vein Thrombosis (DVT) along with right-sided Pulmonary Embolism (PE). During subsequent surgical procedures, the patient became hypotensive, leading to an aborted cholecystectomy and placement of chest tubes due to injury to the Superior Vena Cava (SVC).

Despite attempts at stabilization and management in the Surgical Intensive Care Unit (ICU), the patient passed away following the administration of a tissue Plasminogen Activator (tPA).

Questions to the expert and their responses

Do you have experience in similar postpartum cases?

As a board-certified internist practicing hospital medicine, I frequently evaluate patients with acute pathologies such as pulmonary emboli and gallstone pancreatitis.

What is the protocol for a similar patient?

Common recommendations for newly diagnosed patients with PE involving the left lower lung lobe, iliac veins, and IVC include anticoagulation therapy, close monitoring of vital signs, and consideration of more aggressive treatments such as catheter-directed thrombolysis or interventional thrombectomy in cases of hemodynamic instability.

What is the standard discharge protocol following PE?

When discharging a patient with a Pulmonary Embolism, transitioning from a Heparin drip to a Novel Oral Anticoagulant (NOAC) typically involves ensuring therapeutic anticoagulation levels are maintained. This often requires overlap of the two medications until the NOAC reaches its full therapeutic effect.

What significance does a delay in PE treatment hold?

Any interruption or delay in treatment of a pulmonary embolism can significantly impact an adverse outcome. Rapid diagnosis and initiation of appropriate therapy are crucial to prevent further clot propagation and potential life-threatening complications.

About the expert

This expert is a seasoned professional in hospital medicine with over two decades of experience. They are board-certified by the American College of Osteopathic Internists and have held significant roles such as medical director of various hospitalist programs, section chief of internal medicine at multiple hospitals, and battalion surgeon for the United States Army. Currently, they serve as an associate professor of medicine at a renowned osteopathic medicine school and hold leadership positions at a university-affiliated hospital network in Pennsylvania.