Abdominal Pain

Question 1

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

Besides alcohol, list three other causes of pancreatitis.

Answer 1

Gallstones
Hypertriglyceridemia
Genetic causes
Drugs
Autoimmune causes 

Ref: CFPC Self Learning Vol 32.3 (June 2017)

I GET SMASHED 
Idiopathic 
Gallstones
Ethanol 
Trauma 
Steroids 
Mumps virus 
Autoimmune disorders 
Scorpion stings
Hypertriglyceridemia 
ERCP
Drugs

Question 2

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

Accurate diagnosis of pancreatitis requires the presence of two out of three diagnostic features. What are these three features?

Answer 2

Abdominal pain consistent with acute pancreatitis
Serum lipase or amylase levels that are at least three times the upper limit of the normal range
Findings of acute pancreatitis on cross-sectional imaging (computed tomography or magnetic resonance imaging).

Note: The degree of elevation of the serum amylase or lipase level has no prognostic value (only required for diagnosis)

Question 3

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

List two clinical factors that increase the risk of complications or death among patients with acute pancreatitis.

Answer 3

Advanced age (>/=60 years)
Numerous and severe co-existing conditions
Obesity
Long-term, heavy alcohol use.

Question 4

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

Testing confirms the diagnosis and alcohol consumption is the only cause identified. You decide to admit the patient and provide fluid resuscitation. What type and volume of fluid should be provided over the first 24 hours?

Answer 4

Administration of a balanced crystalloid solution has been recommended at a rate of 200-500 ml per hour, or 5-10 ml per kilogram of body weight per hour, which usually amounts to 2,500-4,000 ml within the first 24 hours.

Question 5

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

Three days later his symptoms have improved and he is anxious to go home. What two lifestyle interventions will help to prevent recurrence?

Answer 5

A structured, consistent intervention to encourage abstinence and interventions directed at smoking cessation.

Question 6

JB, a 44-year-old man with type 2 diabetes, presents to the emergency room with a two-hour history of upper abdominal pain. He recently separated from his partner and admits to “smoking more cigarettes and drinking a lot more beer for the past couple of weeks.” You suspect he has acute pancreatitis.

When you visit the patient later the same day, he is feeling much better and is asking for something to eat. He has some mild abdominal pain but no nausea, vomiting, or signs of ileus. What do you recommend?

Answer 6

Low fat soft or solid diet

Note:
In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started. A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods. Most patients with mild acute pancreatitis can be started on a low-fat diet soon after admission, in the absence of severe pain, nausea, vomiting, and ileus (all of which are unusual in mild cases of acute pancreatitis).