RT is a 54 y/o male with a PMHx of HTN, HLD and depression who presents with abdominal pain x1 day
History Elements:
- Onset: pain began suddenly and rapidly around 1:00 pm yesterday while patient was sitting on his couch
- Location: epigastric abdominal pain
- Duration: pain is constant and persistent
- Character: sharp, severe pain
- Alleviating/Exacerbating: sitting up and bending forward helps slightly but only temporarily. Patient took advil for the pain but his sx were barely alleviated
- Radiating: pain is mainly in the upper abdomen and radiates around to the back
- Timing: pain came on yesterday and has gradually gotten worse since it began
- Severity: patient states the pain is 10/10
- Patient has never experienced anything like this before
- Patient admits to nausea x1 day and 1 episode of non-bilious non-bloody vomiting this morning, admits to passing gas
- Patient denies a relationship between eating and the onset of abdominal pain
- Patient denies diarrhea, constipation any bleeding or appetite changes although he can’t eat since the pain came on
- Patient denies fever, urinary symptoms, discharge or pain anywhere else
- Medications: Patient is taking Amlodipine 5mg for his HTN, Simvastatin 10 mg for his HLD and Prozac 20 mg for his depression. Pt is quick to take advil whenever he feels pain anywhere.
- Patient admits to compliance with medications, denies any new medications or change in doses of current medications
- Family history: non-contributory
- Social history: patient is married and sexually active with his wife, works as an accountant, admits to smoking ½ a pack per day for the past 5 months due to work stress, admits to drinking “socially” which he defines as a couple of beers a day and hard liquor on the weekends with friends when asked, denies recent travel.
Physical Exam:
- Vitals: BP – 138/86, Pulse – 108, Respiratory rate – 20, temperature – 99.8 F, SpO2 – 97% on room air
- General: A&O x3, in severe pain and distress
- Heart: regular rhythm, tachycardic, S1 and S2 heard, no murmurs gallops or rubs
- Lungs: clear to auscultation bilaterally, normal respiratory effort
- Abdomen: soft, non-distended, tympanic throughout. No masses, hernias. Bowel sounds slightly diminished, tender to palpation in the epigastrium, no rebounding, + guarding. Murphy’s sign, McBurney’s point, Rovsing sign are all negative.
- Genitourinary: uncircumcised penis with no erythema, discharge or blood at the urethral meatus. No lesions, masses on penis or scrotum, testes are nontender
Differential Diagnosis:
- Acute pancreatitis – severe epigastric pain radiating to the back, hx of alcohol use
- Acute cholecystitis (secondary to cholelithiasis) – epigastric pain radiating to the back. Less likely with constant (as opposed to intermittent) pain negative Murphy’s sign, and pain on palpation of the gallbladder specifically
- Peptic ulcer disease – epigastric pain, hx of NSAID use. Less likely as this pain is usually intermittent and pain does not radiate to the back
- Small bowel obstruction – abdominal pain with vomiting and anorexia. Less likely as patient is not constipated, is passing gas, no surgical history
- Perforated viscus – sudden onset abdominal pain, peritoneal signs including guarding, fever, tachycardia. Less likely as patient’s abdomen is not rigid, there’s no rebound tenderness.
Tests:
Labs –
- CBC: WBC 16.26, HgB 16.4, HCT 48.5, PLT 410
- BMP: Na 135, K 3.7, Cl 104, CO2 16, BUN 6, Cr 0.66, Glu 147, Ca 8.1, Mg 1.90
- LFTs:
- CHEM: Amylase 245 U/L, Lipase 1,814 U/L
- LFT: Alb 4.0, Alkphos 121, ALT <24, AST <23
Imaging – (not required with clinical presentation + serum lipase 3x greater upper limit of normal)
- Abdominal radiograph/xray – no acute findings/unremarkable
- Abdominal RUQ ultrasound – pancreas appears diffusely enlarged, hypoechoic. Negative for gallstones
- CT abdomen and pelvis with contrast – diffuse enlargement of pancreas with extensive fat stranding. No peripancreatic fluid collections.
Dx: acute (uncomplicated) pancreatitis
Treatment:
- Aggressive IV hydration 5-10 mL/kg per hour of LR
- Pain control with IV hydromorphone or fentanyl bolus 20-50 mcg with 10-min lock-out period
- Zofran for nausea
- Close monitoring in the first 24-48 hours including vitals, Is & Os, electrolytes
- Advance diet as tolerated – if can’t tolerate enterally after a few days, consider parenteral feeding through NG tube
Patient education:
- Educate patient on zero alcohol tolerance. Educate on the risk of recurrent acute pancreatitis and possible development of chronic pancreatitis with continued alcohol use.
- Advance diet with no or very low fat foods
- Routine follow-up care with primary care physician
- Patient should return to the ED if symptoms return
