LOKUN! I got stomach ache!
Mr L is a 67year old Chinese gentleman who is a non smoker, social drinker. He has a medical history significant for Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus, Chronic Kidney Disease with a previous Left Nephrectomy for Renal Cell Carcinoma. He presents to the ED at 10am for abdominal pain that started at 7am. This started in the epigastrium, which was constant and woke him from sleep, radiating to the back, pain score 7 out of 10. This was associated with diaphoresis but no shortness of breath or palpitations. There was nausea but not vomiting. There was no fever, chills or rigors. Vital signs: Temperature 36.0degC BP 160/87 HR 73 SpO2 100% on Room Air On Examination: Alert, In Pain, Not Jaundiced Heart S1+S2 no murmur, no rub Lungs Clear Abdomen Soft, Epigastric Tenderness Bowel Sounds Active, No Guarding, No Rebound, Murphy's negative, no palpable organomegaly DRE No Malena
Question ONE: Which would be your top three differentials for this gentleman? 1. Acute Coronary Syndrome 2. Aortic Dissection 3. Peptic ulcer disease 4. Biliary Colic 5. Cholangitis 6. Pancreatitis 7. Pancreatic Cancer 8. Acute Cholecystitis 9. Perforated Viscus 10.Gastroenteritis 11.Liver abscess
Question TWO: What are the TWO most important investigations that you would do in the Emergency Department 1. Full blood count 2. Renal Panel + Glucose 3. Liver Panel 4. Lipase 5. Amylase 6. Procalcitonin 7. Troponin T 8. Arterial Blood Gas 9. Electrocardiogram 10.Chest Radiograph 11.Contrasted Computed Tomography of the Abdomen
Initial Investigations Haemoglobin 14.1 (13.0-17.0) WBC 11.0 (4.0-10.0 Platelet 290 (150-450) Urea 11.5 (2.8-7.7) Sodium 137 (135-145) Potassium 4.9 (3.5-5.0) Chloride 98 (96-108) Bicarbonate 21 (19-31) Glucose 13.9 (4.0-7.8) Creatinine 140 (65-125) Troponin T 23 (0-29) Total Bilirubin 3.9 (5.0-30.0) Alkaline Phos. 57 (32-103) Alanine Transam. 25 (10-55) Aspartate Transam. 21 (10-45) Gamma-Glutamyl T. 27 (5-50) Amylase 227 (30-100) Lipase 162 (14-40)
Initial Investigations
Diagnosis? Acute Pancreatitis Diagnostic Criteria of Acute Pancreatitis? Two out of Three: (1) Acute onset of severe Epigastric pain, often radiating to the back (2) Serum Amylase or Lipase three times the upper limit of normal (3) Characteristic Findings of Acute Pancreatitis on Imaging (CT contrasted, MRI, US Abdomen)
Question THREE: What would you initiate emergently? (Can pick up to four) 1. Close Monitoring with Hourly Parameters 2. Strict Intake-Output charting with an Indwelling Catheter 3. Nil by mouth strictly 4. Allow Diet of Choice 5. Call a senior for urgent transfer to a High Dependency Unit 6. Aggressive Intravenous Fluid Rehydration 7. Blood cultures and to start Intravenous Antibiotics 8. Analgesia 9. Urgent Referral for Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Pancreatography (ERCP) 10.Urgent Referral to General Surgery 11. Urgent CT AP (Contrast)
Basic Principles of Pancreatitis Management (a) Frequent assessment of haemodynamicstatus - Patients with organ failure should be monitored in a High Dependency/ICU setting (b) Aggressive fluid rehydration (250-500ml/hr) dependent on co-morbidities - Hartmann s solution (c) Antibiotics - Only indicated if there is presence of extrapancreaticinfection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia - Prophylactic antibiotics is not indicated, even in severe pancreatitis (d) Abdominal imaging (MRI/CT AP) in the acute setting - Only if the diagnosis is unclear or patient fails to improve after 48-72hrs (e) Feeding - Mild Acute Pancreatitis, can start oral feeding immediately - Severe Acute Pancreatitis, enteral feeding should be initiated
Question FOUR: What other investigations would you order? 1. Full Blood Count at 48hours 2. Calcium Levels 3. Calcium Levels at 48 hours 4. Renal Panel at 48 hours 5. Arterial Blood Gas 6. Arterial Blood Gas at 48 hours 7. Lactate Dehydrogenase 8. C-reactive Protein 9. Lipase at 48hours 10. Amylase at 48hours 11. Lipid Panel
Scoring Systems in Acute Pancreatitis
Question FIVE: What is the most likely cause of Acute Pancreatitis in this gentleman? 1. Alcohol related 2. Autoimmune 3. Gallstones 4. Hypertriglyceridemia 5. Post Procedure 6. Smoking 7. None of the above/others
16hours after you saw Mr L, he develops an acute shortness of breath. SpO2 checked is 78% on Room Air. His oxygen supplementation is escalated to 100% Non rebreather mask, and his SpO2 maintains at 92%. There is no associated chest pain, cough or phlegm Question SIX: The most likely cause for this acute desaturation is: 1. Hospital Acquired Pneumonia 2. Pulmonary Embolism 3. Congestive Cardiac Failure 4. Acute Respiratory Distress Syndrome 5. Acute Myocardial Infarction
Early complications of Acute Pancreatitis Early complications are usually systemic - Can mimic a SIRS response - May result in multi-organ failure - Other scoring systems for Multi-organ failure (APACHE II, Modified Marshall s)
Mr L is intubated and transferred to the Intensive Care Unit. His ventilation is supported and subsequently weaned down. He is extubated uneventfully on D6 of his admission. He is transferred to the General Ward and undergoes some rehabilitation in view of deconditioning. On Day 15 of admission, he reports to his therapist that there is mild abdominal discomfort and distension. That evening, he develops a fever of 38.9degC, with a HR of 106 and a BP of 102/76. His saturations maintain well on Room Air. On examination of his abdomen, it is soft with no guarding or rebound.
Question SEVEN: What is the most likely cause of his new fever? 1. Hospital Acquired Pneumonia 2. Clostridium Difficile Diarrhoea 3. Cholangitis 4. Acute Cholecystitis 5. Sterile Pancreatic Necrosis 6. Infective Necrosis 7. Bacterial Translocation
Early vs Late Complications World J Gastroenterol. 2007 Oct 14; 13(38): 5043 5051.
Early vs Late Complications Late complications are usually local - Peri-pancreatic collections (infected vs non infected) - Pancreatic Necrosis - Pancreatic Psuedocysts - Decision to drain will depend on clinical condition