JUST ANOTHER CASE OF BELLY PAIN A CASE PRESENTATION. Michael Shamoon Albert Einstein College of Medicine September 10, 2013

Transcription

1 A CASE PRESENTATION Michael Shamoon Albert Einstein College of Medicine September 10, 2013

2 Mr. L 24y/o african-american man CC: abdominal pain, nausea & vomiting since 9am VS: T 98.3, HR 85, RR 18, BP 163/105, O 2 97% RA

3 Mr. L: History Woke up this morning w/ abdominal pain, crampy 8/10, radiates upwards Multiple episodes of nb/nb vomiting and was unable to tolerate PO Last BM yesterday (usually goes 2-3x per day), normal No fever, diarrhea, sick contacts, dysuria

4 Mr. L: History PMH: albinism PSH: none Meds: none NKDA Social: sexually active w/ women, uses condoms. No tobacco use. EtOH on weekends 3-4 drinks

5 Mr. L: Physical Exam VS: T 98.3, HR 85, RR 18, BP 163/105, O2 97% RA Gen: just vomited x1, in acute distress 2/2 pain HEENT: anicteric, PERRLA, EOMI. Nystagmus Abd: mild distention / tympany. Tender L, LUQ > LLQ. Hypoactive bowel sounds. No rebound / guarding. GU: uncircumcised, no discharge / swelling / erythema or masses

6 DDx (by severity) Appendicitis (perforated?) Obstruction Peptic Ulcer Disease Gastritis Others: Cholecystitis / Pancreatitis / Renal Colic?

7 Labs CBC: 1.9 / 14.7 / 39.5 / 191 / 0% bands BMP: 140 / 3.8 / 100 / 24.3 / 10 / 0.9 / 144 LFTs: 7.6 / 4.6 / 0.8 / 60 / 74 / 82 UA: normal

8 Labs Lipase: 549 (7-60) / Amylase: 373 (40-128) Lactate: 7.94 LDH: 315 ( ) Repeat CBC: 21.2 / 15.4 / 48.0 / 212 Bedside Ultrasound: no GB stones / fluid

9 Imaging

10 Imaging Mr. L

11 Imaging (Normal Pancreas)

12 Diagnosis (or Last One to the Diagnosis is a Rotten Egg) Atlanta Criteria: Abdominal pain suggestive of pancreatitis (epigastric pain often radiating to the back) Serum amylase and lipase levels 3x normal +/- Characteristic findings on CT, MRI or US

13 Diagnosis More common than you thought: Hospital admissions for acute pancreatitis increased from a low of 101,000 in 1988 to 210,000 in Acute Pancreatitis was the most common reason for hospitalization in Peter J. Fagenholz, Carlos Fernández-Del Castillo, N. Stuart Harris, Andrea J. Pelletier, Carlos A. Camargo Jr., Increasing United States Hospital Admissions for Acute Pancreatitis, , Annals of Epidemiology, Volume 17, Issue 7, July 2007, Pages 491.e1-491.e8, ISSN A. F. Peery, E. S. Dellon, J. Lund et al., Burden of gastrointestinal disease in the United States: 2012 update, Gastroenterology, vol. 143, no. 5, pp

14 Etiologies (this table not meant for reading) Mechanical Toxic Metabolic Drugs Infection Trauma Congenital Vascular Miscellaneous Genetic Gallstones, biliary sludge, ascariasis, periampullary diverticulum, pancreatic or periampullary cancer, ampullary stenosis, duodenal stricture or obstruction Ethanol, methanol, scorpion venom, organophosphate poisoning Hyperlipidemia (types I, IV, V), hypercalcemia Didanosine, pentamidine, metronidazole, stibogluconate, tetracycline furosemide, thiazides, sulphasalazine, 5-ASA, L-asparaginase, azathioprine, valproic acid, sulindac, licylates, Viruses-mumps, calcium, coxsackie, estrogen hepatitis B, CMV, varicella-zoster, HSV, HIV Bacteriamycoplasma, Legionella, Leptospira, salmonella Fungi-aspergillus Parasites-toxoplasma, cryptosporidium, Blunt or penetrating Ascaris abdominal injury, iatrogenic injury during surgery or ERCP (sphincterotomy) Cholodochocele type V,? pancreas divisum Ischemia, atheroembolism, vasculitis (polyarteritis nodosa, SLE) Post ERCP, pregnancy, renal transplantation, alpha-1-antitrypsin deficiency CFTR and other genetic mutations

15 Etiologies +1 Idiopathic Up to 30% of patients! So consider the diagnosis even if the history doesn t include one of the classic risk factors

16 Predicting Mortality Severity can affect disposition, treatment & mortality Ranson's Criteria: Well-known, fewer components, easier to calculate Meta-analysis of 110 studies found to be poor predictor APACHE II Score: Not perfect but good NPV and ok PPV Others: Balthazar (CT Severity Index), SIRS, etc.

17 To CT or Not to CT? Lots of studies Balthazar EJ, Ranson JHC, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: prognostic value of CT. Radiology 1985; 156: Arvanitakis M, Delhaye M, De Maertelaere V, et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004;126: Simchuk EJ, Traverso LW, Nukui Y, et al. Computed to- mography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg 2000;179: Uhl W, Roggo A, Kirschstein T, et al. Influence of contrast- enhanced computed tomography on course and outcome in patients with acute pancreatitis. Pancreas 2002;24: Lankisch PG, Struckmann K, Assmus C, et al. Do we need a computed tomography examination in all patients with acute pancreatitis within 72 h after admission to hospital for the detection of pancreatic necrosis? Scand J Gastroenterol 2001;36: Talamini G, Uomo G, Pezzilli R, et al. Renal function and chest x-rays in the assessment of 539 acute pancreatitis patients (abstr). Gut 1997; 41(suppl 3):A136. Mendez G, Jr, Isikoff MB, Hill MC. CT of acute pancreatitis: interim assessment. AJR Am J Roentgenol 1980; 135:

18 To CT or Not to CT?

19 To CT or Not to CT? Reasons for: CT is the best at evaluating for pancreatic necrosis Presence & extent of pancreatic necrosis correlate with complications and the mortality rate May influence the selection of management methods (i.e. prophylactic abx, drainage, etc.)

20 To CT or Not to CT? Reasons against: When is important CT within the first 24h may underestimate severity of disease as full necrosis takes at least 2-3days to develop At least one study shows CT dye can worsen pancreatitis (another shows it doesn t) The usual reasons not to CT, i.e. renal impairment, radiation, allergies, etc.

21 To CT or Not to CT? Bottom line: If the diagnosis is unclear If it will change your management / disposition If the benefits outweigh the risks, i.e. most often: severe pancreatitis to evaluate for presence / extent of necrosis

22 Mr. L Today SICU day 4 Persistently tachycardic, labile BP, decreased UOP Management: NPO, IVF, pain control, O 2 Slowly improving thus far...

23 Take-Home Make the diagnosis! Patients don t read the textbook Pancreatitis may be more common than you thought 30% pancreatitis is idiopathic can t rely on etiology Scoring systems useful for estimating severity Ranson s Criteria, Shmanson s Criteria (use APACHE II) Think about whether you really need that CT or not