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    Case Presentation: Family Medicine Team C Gerry Martin, MD Christie Prendergast, MS3 Annie Lim, MS3

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    Aditya Sonal Mahajan
    The document presents a case of a 46-year-old female who presented to the emergency room with epigastric and back pain diagnosed with acute pancreatitis secondary to alcohol abuse based on elevated lipase and amylase levels, and history of alcohol binge drinking. Her hospital course involved pain management, IV fluids, monitoring of pancreatic enzymes, and counseling on diabetes control and cessation of alcohol and tobacco use before discharge with clinic follow up.

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    Case Presentation: Family Medicine Team C Gerry Martin, MD Christie Prendergast, MS3 Annie Lim, MS3

    Uploaded by

    Aditya Sonal Mahajan
    417 views24 pages
    The document presents a case of a 46-year-old female who presented to the emergency room with epigastric and back pain diagnosed with acute pancreatitis secondary to alcohol abuse based on elevated lipase and amylase levels, and history of alcohol binge drinking. Her hospital course involved pain management, IV fluids, monitoring of pancreatic enzymes, and counseling on diabetes control and cessation of alcohol and tobacco use before discharge with clinic follow up.

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    Acute Pancreatitis Presentation

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    The document presents a case of a 46-year-old female who presented to the emergency room with epigastric and back pain diagnosed with acute pancreatitis secondary to alcohol abuse based on elevated lipase and amylase levels, and history of alcohol binge drinking. Her hospital course involved pain management, IV fluids, monitoring of pancreatic enzymes, and counseling on diabetes control and cessation of alcohol and tobacco use before discharge with clinic follow up.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    417 views24 pages

    Case Presentation: Family Medicine Team C Gerry Martin, MD Christie Prendergast, MS3 Annie Lim, MS3

    Uploaded by

    Aditya Sonal Mahajan
    The document presents a case of a 46-year-old female who presented to the emergency room with epigastric and back pain diagnosed with acute pancreatitis secondary to alcohol abuse based on elevated lipase and amylase levels, and history of alcohol binge drinking. Her hospital course involved pain management, IV fluids, monitoring of pancreatic enzymes, and counseling on diabetes control and cessation of alcohol and tobacco use before discharge with clinic follow up.

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    Case Presentation

    Family Medicine Team C Gerry Martin, MD Christie Prendergast, MS3 Annie Lim, MS3

    Case Presentation
    CC: Epigastric pain HPI: 46 YO AA female presented to ER with 2 day Hx of abdominal pain. Pain is epigastric & periumblical, constant, 10/10, and radiates to back. Pain is worse with food, improved in fetal position. Denies NV, +diarrhea, +night chills. Precipitated by EtOH binge 2 days prior.

    Case Presentation Continued


    PMHx: HTNx13 yrs, DMII x13yrs, hyperlipidemia, major depressive d/o (Hx of 5150), hx of acute pancreatitis. Pt also states BS have been in 400s and has not f/u in clinic since 3/07

    Case Presentation Continued


    PSurgHx: lumpectomy FamHx: mother HTN, father DM, mother CAD SocHx: 5-pack year hx, EtOH abuse (2-3 large drinks/day) Meds: DM: Metformin 100mg, Glipizide 10mg, Pioglitazone 30 mg, Gabapentin 600 mg HTN: HCTZ 25mg, Simvastatin 40mg, ASA 81 mg, Losartan 50 mg Depression: Citalopram 40 mg, Risperdal 6 mg Allergies: NKDA

    Physical Exam

    Case Presentation Continued

    Vitals: BP:163/109 P:91 T:96 R:18 Gen: pleasant, mildly distressed, obese female HEENT: non-icteric sclera CV: RRR, no murmurs appreciated Resp: CTAx2, no wheezing, rales, rhonchi GI: epigastric & RUQ tenderness, no rebound tenderness, negative Murphys, neg Cullens & Turners sign, +BSx4 Ext/MSK: 5/5 bilateral UE, 5/5 bilateral LE, 2/4 posterior tibal, 2/4 dorsalis pedis, 2/4 popliteal + monofilament test

    Case Presentation Continued


    Labs:
    133 4.4 99 21 11 0.8 441

    8.8

    13.9 40.2 221

    Cardiac enzymes neg x2 Accucheck: 363 216 HgA1c = 13.9 Lipids (3/07) TG 64 Chol 250 LDL 161 Lipase on admission 333 AST/ALT = 13/12

    Urine B-hydroxy = 2.60 () +ketones + glucose

    Case Presentation Continued


    Imaging CT scan: acute on chronic pancreatitis CXR: normal EKG: NSR

    Diagnosis

    Acute Pancreatitis secondary


    to EtOH abuse

    Assessment/Plan
    1. Acute Pancreatitis 2/2 EtOH abuse
    Ransons criteria score 1 clear liquids, IV fluids, Morphine sulfate CBC/Chem, Lipid panel 2. DM II poor control HgA1c=14.9 Start Levemir 14U qHS Hold oral hypoglycemic meds 3. HTN poor control continued current BP meds and BP monitoring

    Assessment/Plan Continued
    4. Hyperlipidemia LDL 161 (3/07) Continue Zocor Rechecked fasting lipid panel (LDL 103) 5. Major Depressive D/O stable Continue current management 6. EtOH abuse Counseled patient on EtOH complications & importance of cessation 7. Tobacco abuse Smoking cessation counseling

    Differential Diagnosis
    1. 2. 3. 4. 5. 6.
    Acute cholecystitis Intestinal obstruction Mesenteric vascular occlusion Renal colic MI Pneumonia

    Ransons Criteria/Prognosis
    On admission: 1. Age >55 YO 2. WBC > 16K 3. Glucose > 200 4. LDH > 350 5. AST >250 At 48 hrs: 1. Ca < 8 2. Hct > 10% 3. BUN > 5mg/dL 4. Base deficit > 4meq/L 5. PaO2 < 60mmHg 6. Fluid seq > 6L

    <2 mortality <5%, 3-4 mortality =15-20% 5-6 mortality =40%, >7 mortality =99%

    Hospital Course
    Patient was placed on clear liquids, IV
    hydration, and given morphine for pain control. She stayed in the hospital for 2 days. On HD#2 pain decreased, amylase/lipase levels decrease (17/86) and patient tolerated diabetic diet without any exacerbation of symptoms. Pt was extensively counseled on diabetic control, and smoking/EtOH cessation. Pt was then discharged home with follow-up in clinic.

    DISCUSSION
    Questions?

    Introduction
    Definition: Acute pancreatitis is an
    inflammatory condition of the pancreas characterized clinically by abdominal pain and elevated levels of pancreatic enzymes in the blood Prevalence in United States is 79.8/100,000 per year, thus resulting in 185,000 new cases of acute pancreatitis annually

    Etiology of Pancreatitis
    1. Gallstones 2. Alcohol 3. Hypertriglyceridemia 4. Hypercalcemia 5. ERCP 6. Trauma 7. Postoperative 8. Rx (sulfas, diuretics, HIV Rx, ASA) 9. Infections 10. +many more uncommon causes

    Signs & Symptoms


    Acute upper abdominal pain (90%) Radiates to the back Nausea Vomiting Relief on bending forward

    Physical Exam
    Mild: epigastric tenderness Severe:
    fever, tachycardia, shock, coma Respiratory distress Grey turners or Cullens sign Epigastric mass

    Laboratory/Imaging
    Elevated amylase/lipase CRP >150 mg/dl discriminates severe
    from mild Ultrasound to r/o gallstone pancreatitis Abdominal X-ray range from unremarkable to localized ileus (sentinel loop/colon cutoff sign) CXR to r/o pleural effusion, elevation of diaphragm, ARDS

    Laboratory/Imaging
    CT Scan assess the severity MRI lacks nephrotoxicity, better
    categorize fluid collection, necrosis, abscess, hemorrhage and pseudocyst. Equivocal to ERCP

    CLINICAL PREDICTORS
    Scoring systems
    APACHE II uses physiology, age and chronic health to calculate prognosis Ranson, Glasgow, Bank takes 48 hours to complete, can be used only once

    Treatment
    General Principles: Correction of
    underlying predisposing factors Gallstone Pancreatitis: Early ERCP in patients with biliary sepsis and obstructive jaundice Reversal of hypercalcemia Cessation of causative agent/drugs Administration of insulin to poorly controlled diabetics with hypertriglyceridemia

    Mild pancreatitis supportive care Severe pancreatitis


    ICU monitoring Support of pulmonary, renal, circulatory, hepatobiliary function Fluid resuscitation(250-300 cc/hr) Pain management meperidine, morphine, fentanyl Preventing infection: Selective decontamination of the gut by oral nonabsorbable abx Systemic Antiobiotics: studies evaluating its benefit and harm is still unsettled

    Treatment

    Treatment
    Nutritional support with early enteral
    feeding reduces complications Parenteral nutrition required if enteral feeding not tolerated Necrotizing Pacreatitis (30% of pancreas), meropenem/imipenem Surgical referral: unstable, failure of Rx

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