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