CBL9: A PATIENT WITH ABDOMINAL PAIN AND JAUNDICE Flashcards
Mrs RA, a 57-year old obese woman presents to Emergency Department with a two
day history of generalized abdominal pain radiating to the back with associated
vomiting.
On examination, she appears jaundiced. Her temperature is 38.2, blood pressure
78/45 mmHg, with a heart rate 132 bpm. Her abdomen is generally tender with
involuntary guarding throughout.
Q1. What are the abnormal findings you identified on general physical
examination and abdominal examination?
- Abdomen pain
- Radiates to the back
- Vomiting
- Jaundice
- High temp
- Low BP
- Tachycardic
- Invol guarding
What are the differential diagnoses for abdominal pain, vomiting, shock,
fever and peritonism in this patient?
Gastroenteritis
Acute cholecystitis
Peptic ulcer disease
Perforated ulcer
Pancreatitis
Appendicitis
Bowel obstruction
Mesenteric ischaemia
Ruptured AAA
Myocardial infarction
Which other pathology can sometimes cause pain at the back [1]
GORD
Describe the presentations & history comon to each
Gastroenteritis
Acute cholecystitis
Peptic ulcer disease
Describe the typical presentations / histories of those with:
Perforated ulcer
Pancreatitis
Appendicitis
Bowel obstruction
Describe the typical presentations / histories of those with:
Mesenteric ischaemia
Ruptured AAA
Myocardial infarction
Q3. What are the abnormal findings on the blood tests and what do these
indicate?
Haemoglobin 169 g/L (115 -155): raised due to dehydation / vomiting
WCC 18.7 x10 9/L (4-11) & CRP 324 mg/L (0-10) - indicates infection
Potassium 3.0 mmol/L (3.5-5.5) - low because of the vomiting
Calcium 2.02 mmol/L (2.12-2.65) - Low in AP (unknown reason)
Urea 18 mmol/ L (2.5-3.4) & Creatinine 220 μmol/L (70-120) - Elevated levels suggest dehydration/hypovolaemia - AKI and increased risk for development of severe disease
Bilirubin 68 μmol/L (3-17) - due to the jaundice
ALT 112 U/L (3-35) - high ALT indicates gallstones
AST 290 U/L (3-35)
ALP 379 U/L (30-35) - indicates biliary picture causing the pancreatic damage
Amylase 2120 U/L (30-100): indicates pancreatic cause
Which serum markers have a strong assocation with mortality in acute pancreatitis? [2]
Blood urea nitrogen levels predict mortality risk in acute pancreatitis
High serum creatinine is a well-known unfavorable prognostic parameter in acute pancreatitis
What would indicate a biliary aetiology for acute pancreatitis? [2]
Biliary etiology for the acute pancreatitis (AP) is suspected when patients meet one or both of the following criteria:
* A) elevated liver enzymes (>3X increase of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) on day 1 of AP
* B) presence of gallstones/sludge on abdominal ultrasound.
Which score is used to determine level of pancreatitis? [1]
What are the the scores? [3]
The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present:
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
CRP >200 mg/L indicates a high risk of developing pancreatic []
CRP >200 mg/L indicates a high risk of developing pancreatic necrosis
Patients with acute pancreatitis are at high risk of hypoxia because of one or more of [4]
Patients with acute pancreatitis are at high risk of hypoxia because of one or more of
* abdominal splinting
* atelectasia
* pulmonary oedema
* acute respiratory distress syndrome.
Elevated alanine aminotransferase (ALT) levels strongly suggest [] as the cause of acute pancreatitis?
Elevated alanine aminotransferase (ALT) levels strongly suggest gallstones as the cause.
Q5. What additional history would you like to seek? [3]
Typical symptoms of acute pancreatitis include:
* Epigastric pain: typically severe, sudden onset and may radiate through to the back
* Ask about stool - greasy; floating
* Nausea and vomiting
* Pain - constant & severe
* Decreased appetite
* If pain worsens with movement
* Dysopnoea if ARDS or pleural effusion
Other important areas to cover in the history include:
* Past medical history: history of gallstones, biliary disease or previous episodes of pancreatitis
* Past surgical history: recent surgical procedures (e.g. ERCP)
* Drug history: regular medications and over the counter medications
* Social history: alcohol intake and smoking
* Family history: hereditary pancreatitis is a rare cause of pancreatitis
Which imaging would likely be provided for this patient? [1]
NICE - US
(In reality & hospital medicine most likely to give CT)
Q6. What will be the key goals of immediate management of this patient?
1st line: Fluid resuscitation
- reduces risk of organ failure and death
consider: analgesia
- pain is the predominant symptom
- ibuprofen
- codeine phosphate
consider: oxygen
consider: anti-emetic
- ondansetron
- Nausea and/or vomiting is a presenting symptom in 70% to 80% of patients
consider: empirical IV abx
- Only give antibiotics if pancreatic or extra-pancreatic infection is proven or strongly clinically suspected
- fever, leukocytosis, and signs of organ dysfunction.
- imipenem/cilastatin
plus:nutrional support
- enteral feeding
- paraenteral feeding
plus severity assessment
- Use SIRS criteria along with patient risk factors to assess severity in the first 48 hours.
BMJ BP
Why don’t give Abx in all cases of AP? [1]
When would Abx be indicated in AP ptx?
Research suggests that Abx doesn’t actually improve outcomes unless extra-pancreatic infection:
- pneumonia
- cholangitis
-
What is the additional managment plan for acute pancreatitis:
- gallstone pancreatitis: with cholangitis [1]
- gallstone pancreatitis: without cholangitis or bile duct obstruction [1]
- gallstone pancreatitis: with bile duct obstruction [1]
- alcohol related pancreatitis [2]
Gallstone pancreatitis: with cholangitis:
- PLUS ERCP
- Arrange emergency ERCP within 24 hours for any patient with acute gallstone pancreatitis who has concurrent cholangitis - jaundice; fevers & rigors; RUQ pain
Gallstone pancreatitis: without cholangitis or bile duct obstruction
- cholecystectomy
Gallstone pancreatitis: with bile duct obstruction:
- ERCP with sphincterotomy
Alcohol related pancreatitis
- vitamin replacement
- alcohol abstinence
Describe the treament plan for a patient with AP who is deteriorating or failing to improve after 5-7 days [4]
1ST LINE – contrast-enhanced computed tomography (CECT)
PLUS – ongoing supportive treatment
PLUS – ongoing nutritional support
CONSIDER – fine needle aspiration (FNA) and culture
Which minerals might need replacement therapy in AP? [2]
Calcium
Magnesium:
- Low magnesium is common in alcoholic and malnourished patients
- Magnesium is necessary for the secretion of parathyroid hormone (PTH), therefore low levels will reduce the action of PTH on calcium homeostasis.
Q7. Are antibiotics indicated in this clinical condition for all cases? What are
the issues to be considered while prescribing antibiotic in any unwell patient
and this patient in particular?
Antibiotics indicated due to shock and high WBC, lactate and CRP. May be pancreatic abscess or necrotic pancreas
Which Abx may contribute to causing AP? [2]
Some antibiotics can cause acute pancreatitis such as septrin and tetracyclines
Q8. How do the blood tests help in assessing the severity of her medical
problem?
Blood tests can be used in the risk stratification of AP and can ID life threatening features i.e. SIRs
Place into the Glasgow-Imre Score:
Pancreas
P: PAO2 < 8 kpA
A: age >55 years
N: neutrophilia (WBC >15 x 109 / L)
C: calcium < 2 mmol/L
R: renal (urea >16 mmol/L)
E: enzymes (LDH >600 IU/L and AST >200 IU/L)
A: albumin (serum) < 32 g/L
S: sugar (blood glucose) >10 mmol/L
LEARN
Patient has score of 4
