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Case PresentationFamily Medicine Team C
Gerry Martin, MDChristie Prendergast, MS3
Annie Lim, MS3
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Case Presentation
CC: Epigastric painHPI: 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. Precipitatedby EtOH binge 2 days prior.
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Case Presentation Continued
PMHx: HTNx13 yrs, DMII x13yrs,
hyperlipidemia, major depressive
d/o (Hx of 5150), hx of acutepancreatitis.
Pt also states BS have been in
400s and has not f/u in clinic since
3/07
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Case Presentation Continued
PSurgHx: lumpectomyFamHx: mother HTN, father DM, mother CAD
SocHx: 5-pack year hx, EtOH abuse (2-3 largedrinks/day)
Meds:
DM: Metformin 100mg, Glipizide 10mg,Pioglitazone 30 mg, Gabapentin 600 mg
HTN: HCTZ 25mg, Simvastatin 40mg, ASA 81mg, Losartan 50 mg
Depression: Citalopram 40 mg, Risperdal 6 mg
Allergies: NKDA
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Case Presentation ContinuedPhysical Exam
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
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Case Presentation Continued
Labs:133 99 11
4.4 21 0.88.8
13.9
40.2221
Accucheck: 363 216
HgA1c = 13.9
Lipids (3/07)
TG 64
Chol 250
LDL 161
441
Lipase on admission 333
AST/ALT = 13/12
Urine
B-hydroxy = 2.60 ( )
+ketones + glucose
Cardiac enzymes neg x2
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Case Presentation Continued
Imaging
CT scan: acute on chronic pancreatitis
CXR: normalEKG: NSR
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Diagnosis
Acute Pancreatitis secondary
to EtOH abuse
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Assessment/Plan
1. Acute Pancreatitis 2/2 EtOH abuseRansons criteria score 1clear liquids, IV fluids, Morphine sulfateCBC/Chem, Lipid panel
2. DM II poor controlHgA1c=14.9Start Levemir 14U qHS
Hold oral hypoglycemic meds3. HTN poor control
continued current BP meds and BPmonitoring
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Assessment/Plan Continued
4. HyperlipidemiaLDL 161 (3/07)Continue ZocorRechecked 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
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Differential Diagnosis
1. Acute cholecystitis
2. Intestinal obstruction
3. Mesenteric vascular occlusion4. Renal colic
5. MI
6. Pneumonia
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Ransons Criteria/Prognosis
On admission:1. Age >55 YO
2. WBC > 16K
3. Glucose > 2004. LDH > 350
5. AST >250
At 48 hrs:1. Ca < 8
2. Hct > 10%
3. BUN > 5mg/dL4. Base deficit > 4meq/L
5. PaO2 < 60mmHg
6. Fluid seq > 6L
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Hospital Course
Patient was placed on clear liquids, IVhydration, and given morphine for paincontrol. She stayed in the hospital for 2
days. On HD#2 pain decreased,amylase/lipase levels decrease (17/86)and patient tolerated diabetic diet withoutany exacerbation of symptoms. Pt was
extensively counseled on diabetic control,and smoking/EtOH cessation. Pt was thendischarged home with follow-up in clinic.
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DISCUSSIONQuestions?
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Introduction
Definition: Acute pancreatitis is aninflammatory condition of the pancreascharacterized clinically by abdominal pain
and elevated levels of pancreatic enzymesin the blood
Prevalence in United States is79.8/100,000 per year, thus resulting in185,000 new cases of acute pancreatitisannually
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Etiology of Pancreatitis
1. Gallstones2. Alcohol3. Hypertriglyceridemia4. Hypercalcemia5. ERCP6. Trauma7. Postoperative
8. Rx (sulfas, diuretics, HIV Rx, ASA)9. Infections10.+many more uncommon causes
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Signs & Symptoms
Acute upper abdominal pain (90%)
Radiates to the back
NauseaVomiting
Relief on bending forward
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Physical Exam
Mild: epigastric tenderness
Severe:
fever, tachycardia, shock, coma
Respiratory distress
Grey turners or Cullens sign
Epigastric mass
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Laboratory/Imaging
Elevated amylase/lipase
CRP >150 mg/dl discriminates severefrom mild
Ultrasound to r/o gallstone pancreatitis
Abdominal X-ray range from unremarkableto localized ileus (sentinel loop/colon cutoff
sign) CXR to r/o pleural effusion, elevation of
diaphragm, ARDS
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Laboratory/Imaging
CT Scan assess the severity
MRI lacks nephrotoxicity, better
categorize fluid collection, necrosis,
abscess, hemorrhage and pseudocyst.
Equivocal to ERCP
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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
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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
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Treatment 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
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Treatment
Nutritional support with early enteralfeeding reduces complications
Parenteral nutrition required if enteral
feeding not tolerated Necrotizing Pacreatitis (30% of pancreas),
meropenem/imipenem
Surgical referral: unstable, failure of Rx