Intern Report Case 3.6

Case Presentation by Dr. John Wilburn

Pt. E.R. is a 25 Y.O Hispanic female presenting to the emergency Department with a 4 day history of stomach pain in the periumbilical and epigastric area radiating around the right side to the back.  Patient describes the pain as Constant 8/10 sharp cramping that is aggravated with food and water. Alleviated by sitting up, patient did take Tylenol but it did not help her pain. She reports nausea and has had four episodes of non bloody emesis the night before after eating some bread, the emesis was described as “yellow with food in it”. She denies any change in the color or consistency of her bowel movements. LMP was 2 week ago and was a normal cycle. Her abdominal pain has been worsening over the past 4 days and it woke her up from her sleep at 4 am, at which time she decided to seek medical attention.  She denies any trauma or ever having pain like this before. Denies any recent travel and reports that her kids at have had a cold but no GI illnesses. The patient feeling feverish denies any chest pain, shortness of breath or rashes.

ROS:  Negative except as noted per HPI
Past medical history: Denies Diabetes or asthma
Past surgical history: C-section x2
Allergies: Penicillin (rash)
Medication: None
Family history: Father has HTN and Diabetes
Social History: Denies Tobacco, Drinks alcohol socially, denies any illicit drug use. She is currently employed as a waitress and lives at home with her two children ages 3 and 1.
Physical Exam:
VS: 37.5 pulse 106 Bp 128/86 RR 16  99% Room air
General: Laying on her side holding her epigastric area appears uncomfortable but in NAD
HEENT: NC/AT Perrl sclera mildly icteric. EOMI No nasal Discharge no pharyngeal erythema Mucous membranes are dry sublingual has a yellowish color to it.
Neck: Supple No tenderness Trachea is midline. No thyromegaly or Lymphadenopathy
Respiratory: CTAB no W/R/R
Cardiovascular: Tachycardia regular rythm, S1S2 no M/R/G good pulses
Chest: No visible rashes/scars/ no reproducible chest wall tenderness
Abdomen: No lesions or rashes on inspection, Obese, +BS, ST/Tender to Palpation in Epigastric area and RUQ +Murphys sign, No Rebound tenderness, – Rovsings – rigidity. No Guarding.
Extremities: Strength 5/5 b/l upper and Lower ext. Full AROM and PROM palpable radial and dp pulses, SILT and symmetric.
GU: Wnl on inspection no erythema or discharge – No CMT or Adnexal tenderness. Slide shows epithelial cells
Rectal: No Hemorrhoids good tone, no palpable masses. Guaic Negative
Laboratory Results:
Electrolytes: Na 140, K 3.9, Cl 104, HCO3 24, BUN/Cr 14/0.8, Glucose 125, Ca 8.8
CBC:  Wbc 10.9, H/H 12.3/39.2, Platelets 427
ALT 193, AST 159, Alk Phos 288, Tbili 2.8, Dbili 1.3, Lipase 8005, Amylase 800
Urine hCG: Negative
U/A: 3+bili, 3+ ketones, Sp Gravity 1.025, trace blood, trace LE, Nitrite negative, rbc 2-5
Wbc 5-10, epithelial cells 5-10, trace bacteria
Ultrasound Demonstrates
  
Questions
  1. Although there is no gold standard for this diagnosis which of the following is considered by most experts to be the most sensitive and specific test available?
    1. CRP
    2. Lipase
    3. Trypsin
    4. Amylase
    5. ALT
       2.  Which of the of the following Liver Enzymes is the single best marker for biliary     etiology of this diagnosis
a.     ALT
b.     LDH
c.     Total Bilirubin
d.     AST
e.     Alkaline Phosphatase
  3. Which of the following complications of this diagnosis has the highest mortality?
a.     Acute Renal Failure
b.     Myocardial Infarction
c.     Infected Pancreatic Pseudocyst
d.     ARDS
e.     Splenic Vein Thrombosis
4. Which of the following is the definitive treatment?
a.     Cholecystectomy
b.     ERCP
c.     Lexipafant
d.     ERCP with sphincterotomy and stone extraction
e.     Conservative management
Discussion
Answers: 1.b   2.a   3.d   4.a
Discussion:
This patient is suffering from gallstone pancreatitis. Gallstones are the major cause of acute pancreatitis accounting for 40% of cases. Other causes of pancreatitis include alcohol, ERCP induced, medications, metabolic, and idiopathic. Gallstone pancreatitis takes place when a stone impacts and obstructs the ampulla of vater or the pancreatic duct resulting in early activation of exocrine enzymes and auto digestion of the pancreas.  Prognosis is generally good if pancreatitis is mild and appropriately treated. Mortality of mild to moderate gallstone pancreatitis is around 10% which is a decrease in 10-15% over the past 30 years.
Severe pancreatitis is defined by local complications (pseudocyst, hemorrhage, and infection), or signs of organ damage (hypoxia, ARF, DIC, hypocalcemia <7.5). The overall mortality of severe pancreatitis is 30% which has not changed over the past 30 years.
Risk factors for gallstone pancreatitis include: female, advanced age, obesity, multiparous women, high cholesterol, alcoholism, and smoking.
Most patients have the cardinal symptom of abdominal pain in the epigastric region, but can be in the left or right upper quadrants. Patients usually describe the pain as rapid in onset, constant steady, or boring pain increasing in intensity till it reaches a maximum. When the pain reaches pinnacle with no relief most patients seek medical attention. Patients can present with tachycardia, febrile, and elevation or depression of blood pressure.  This pain can be associated with nausea and emesis and anorexia. Patients can appear jaundiced as obstruction of the ducts causes back up in the biliary system. Most patients on physical exam are tender in the epigastric region and may have a positive Murphy sign.
Pancreatitis should always be in the differential for any patient with upper abdominal pain. The work up for pancreatitis includes cbc, metabolic panel, LFT, and lipase. There is no gold standard diagnosis of pancreatitis most experts agree that lipase is just as sensitive as amylase and has more specificity at 3x normal values. Recently experts in the United Kingdom recommend that lipase should be used for the diagnosis of pancreatitis. Amylase can still be used to diagnose pancreatitis; however it is not as specific at 3x the normal values. ALT above the level of 150IU/L is the most sensitive and specific liver enzyme for gallstone pancreatitis. If pancreatitis is diagnosed ultrasound should be conducted within the first 24 hours to either confirm or rule out gallstones as the cause. CT may also be indicated in severe pancreatitis to rule out peripancreatic complications such as pseudocyst, hemorrhage, and necrosis of pancreas.
Medical management:
Medical management of pancreatitis is usually supportive and tailored to the cause of pancreatitis with emphasis on avoiding complications.  Patients should be admitted to the hospital for intravenous fluids, pain control, antiemetic, and made NPO in the initial phase.  There should be a consult to general surgery for management, ERCP, and cholecystectomy the same hospital admission. Intravenous fluids are the most important intervention in the initial setting, some patients may require up to 6L of fluid as the inflammation leads to sequestration of fluid out of the intravascular space. Give 2-3L bolus of .9ns initially and reassess, if sufficient; place the patient on infusion at 250ml/hr normal saline. Pain control with morphine, no evidence has shown clinical difference or outcome when compared to meperidine.  Nasogastric tube is only indicated in patients with intractable emesis, severe abdominal distention and ileus. Routine use has shown no clinical benefit and has increased the number of days hospitalized. ERCP with sphincterotomy and stone extraction is indicated after the initial pain has subsided and patient clinically improves. This is usually 24-48 hours after admission; early ERCP is only indicated in severe episodes of pancreatitis not responding to conservative management or cholangitis. ERCP may actually induce pancreatitis 5% of the time and is not the definitive treatment for gallstone pancreatitis. Studies have shown a 30-50% recurrence of gallstone pancreatitis with ERCP alone. Cholecystectomy is the definitive treatment and should be performed on the same hospital admission. Patients with severe pancreatitis require ICU admission.
There are cardiopulmonary, renal, metabolic, infectious, and hematologic complications of pancreatitis. All complications are caused by the inflammatory reaction of pancreatitis. Usually cardiopulmonary collapse due to hypotension or ARDS is the cause of death within the first week. Patients who develop ARDS have a mortality of 50-60% which is the highest of the complications in pancreatitis.
  References
Rosen’s Emergency Medicine, seventh edition, 2010, pages 1172-1183, Marx
Tintinalli’s Emergency Medicine, sixth edition, 2004, pages 573-577, Tintinalli
Uptodate, Clinical manifestation and diagnosis of acute pancreatitis, 2010, Vege
Pancreatitis, Acute, eMedicine http:emedicine.medscape.com/article/181364
Pancreatitis in Emergency Medicine, eMedicine http://emedicine.medscape.com/article/775867
Dhir, R. et al: Drug-induced pancreatitis: A practical review

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