Cardiac tamponade in acute pancreatitis.

A 37-year-old woman was admitted to hospital with severe epigastric pain. She gave a four-month history of intermittent epigastric discomfort aggravated by fats. This had proved unresponsive to cimetidine, carbenoxolone, and diazepam. She did not drink alcohol. She was distressed, mildly jaundiced, and had marked abdominal tenderness. Her blood pressure was 130/70 mmHg and her heart rate 80/min. No abnormal cardiac signs were present on admission. Her chest and plain abdominal radiographs were normal. The haemoglobin was 14-3 g/100 ml and the white cell count 13 100/cu mm. Biochemical investigations were as follows (normal results in brackets): serum amylase 4800 Somogyi units/100 ml (<160); serum alkaline phosphatase 13-5 KA units (4-13); serum bilirubin 60-2 mol/l (5-17); SGPT 74 IU/I (<40). Her serum calcium, blood glucose and blood urea were normal. A diagnosis of acute pancreatitis was made. She was treated with analgesics and intravenous fluid. She developed pyrexia and paralytic ileus on the third day. A repeat chest radiograph revealed shadowing at the left base and she was treated with gentamicin and ampicillin. Chest pain and a pericardial friction rub developed on the fourth day. She became distressed and her systolic blood pressure fell to 80 mmHg with pulsus paradoxus and a raised venous pressure. Chest radiograph now revealed an enlarged cardiac shadow and a left pleural effusion, but her ECG was normal. Pericardial paracentesis was performed and 120 ml of turbid amber fluid was removed. This produced rapid clinical improvement. The fluid contained a mixture of neutrophils and lymphocytes. Its protein concentration was 4x7 g/100 ml. Culture was sterile and examinati6n for malignant cells and LE cells was negative. Amylase was not measured. Recovery was uneventful after pericardial paracentesis. A subsequent cholecystogram showed no concentration of dye by the gall bladder, but an intravenous cholangiogram revealed non-opaque gall stones in a contracted gall bladder.