Acute abdominal pain station

Presenting Complaint:

Severe upper abdominal pain and vomiting

Symptoms (SOCRATES):

Site: Epigastric region - “It’s right in the middle of my upper belly”

Onset: Sudden, since this morning - “It started suddenly out of nowhere when I got up”

Character: Severe, constant, burning - “It feels like a knife is inside of me”

Radiation: Radiates to back - “The pain moves to my back”

Associated symptoms: Multiple vomiting episodes, unable to eat or drink with ongoing nausea. Pain not related to eating - “I’ve thrown up so many times. I feel really sick and can’t keep anything down” 

Time: Progressive worsening - “It’s just been getting worse since this morning”

Exacerbating/Alleviating factors: Worse when lying flat, slightly better sitting forward - “It’s worse when I lie down, it’s a tiny bit better if I sit forward”

Severity: Severe - “It’s definitely one of the worst pains I have ever felt”

Systemic Symptoms (answer only if specifically asked for):

• Urinary: Concentrated urine (not dark), reduced frequency, no obvious blood
• Bowels: No bowel movements today, normal coloured stools noted previously, mild bloating
• Fever: Had a temperature since pain started
• Eyes: No scleral icterus
• Weight loss: None unintentional, been trying to lose weight for diabetes 
• Night sweats: None
• Vomiting and nausea: Multiple vomiting episodes, persistent nausea
• Pruritus: None
• Reflux: None

Past Medical History:

• Type II Diabetes
• Hyperlipidaemia
• Hypertension
• If asked specifically: no history of H.pylori infection

Past Surgical History:

• Laparoscopic cholecystectomy (2 years ago)
• C-section with first child

Drug History:

• Metformin
• Atorvastatin
• Ramipril

Allergies:

• NKDA

Family History:

• Father has type II diabetes 
• Mother had gallstones
• No family history of pancreatic cancer

Social History:

• BMI 35 (obese)
• Smoker: 10 cigarettes a day
• Alcohol: One bottle of wine a day, was binge drinking one day prior 
• Occupation: Office administrator - sedentary work 
• Diet: Struggles with portion control, admits diet often includes fatty foods
• Two children, both teenagers

Ideas, Concerns, and Expectations:

• Think it could be food poisoning 
• Worried she might need an operation
• Wants strong pain relief

Observations

• Respiratory rate: 24
• Oxygen sats: 96% on room air
• Pulse: 110
• Blood pressure: 100/65
• Alert
• Temperature: 38.0

NEWS: 5

Examination

General Inspection:

- Appears in pain and slightly anxious

- Large body habitus

- No jaundice

Hands:

- No clubbing, pallor, or tremor

- Capillary refill time 3 seconds

- Peripheries cool

- Regular pulse, tachycardic

- No palmar erythema or Dupuytren’s contracture

Face:

- No scleral icterus present

- Dry mucous membranes

Neck:

- JVP not raised

- No scars or palpable lymphadenopathy

Chest:

- No spider naevi 

Abdomen:

Inspection

- No distension 

- Small port scars from previous cholecystectomy

- Grey turner’s sign visible on flanks

Grey Turner’s sign. Authors: Herbert L. Fred, MD and Hendrik A. van Dijk. Via Wikimedia Commons, CC-BY-2.0.

Palpation

- Severe tenderness in epigastrium with voluntary guarding

- Abdomen soft and mildly tender on palpation of the right/left lower quadrants

- No hepatomegaly or splenomegaly palpable

- No palpable renal or aortic/pulsatile masses

- No suprapubic tenderness or distension

Percussion

- Not tolerated due to percussion tenderness in the epigastrium

Auscultation

- Bowel sounds present though reduced on auscultation

Special tests:

- Fluid thrill -> negative

- If performed or asked for, DRE, examination of external hernial orifices and external genitalia normal

Other:

- No peripheral or sacral oedema

Laboratory tests:

• • Lipase 590 U/L (Normal lipase range: 10–140 U/L)

Examiner questions:

1. What is your main differential diagnosis and why is this more likely than other differentials?

Answer: Acute pancreatitis with retroperitoneal haemorrhage

• Severe epigastric pain radiating to the back, with nausea and vomiting, is suggestive of acute pancreatitis
• Likely caused by excess alcohol consumption (significant in the history), which is one of the most common causes of acute pancreatitis
• Presence of Grey-Turner’s sign is indicative of retroperitoneal haemorrhage
• Diagnosis of acute pancreatitis is confirmed with raised serum amylase or lipase (3x the upper normal limit) and/or imaging confirmation

• Acute coronary syndrome can present with epigastric pain and needs to be ruled out with ECG and troponin due to the patient’s cardiac risk factors including raised BMI, PMH hyperlipidaemia and hypertension, and smoking status.
• Bowel or hollow viscus obstruction or perforation - has had previous abdominal surgery carrying risk of adhesions. Imaging with AXR or CT can provide further confirmation, however significantly raised lipase here points towards pancreatitis
• Less likely to be appendicitis due to pain localisation, however cannot be completely ruled out, raised lipase points towards pancreatitis
• Cholecystitis ruled out as gallbladder is removed in previous cholecystectomy
• Less likely to be peptic ulcer as pain not associated with eating, no PMH of reflux, dyspepsia or NSAID use

• Less likely to be a malignancy due to absence red flag symptoms (weight loss, night sweats, abdominal mass) and acute rather than chronic/subacute onset of symptoms
• Less likely ruptured AAA as no palpable pulsatile abdominal mass, patient is haemodynamically relatively stable, no history of connective tissue disorder or aneurysm, patient is relatively young.

2. State two blood results that are likely to be raised with this condition and why this is the case

Possible answer: Serum amylase or lipase and any inflammatory markers (count as one point) 

• Rise in amylase and lipase is indicative of pancreatic inflammation and enzyme leakage into the bloodstream
• Rise in inflammatory markers is due to acute inflammation/infection

3. Name three risk factors that a patient may have that can predispose them to this condition

Possible answers: 

• Alcohol excess
• Gallstones/cholelithiasis (cholecystectomy reduces this possibility)
• Hyperlipidemia and obesity
• Type II diabetes mellitus
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Trauma
• Steroid use
• Drugs (e.g. azathioprine, mercaptopurine)
• Autoimmune conditions
• Family history
• Infection (mumps, EBV, HIV) 
• Hypercalcaemia
• Scorpion venom

4. Describe the management of this condition

Possible answer: 

• Initial A-E assessment, including ECG, full set of bloods including amylase/lipase troponin (if required), FBC, U&Es, LFTs, Lactate, CRP, Glucose, Calcium profile, Coagulation screen and G&S, IV access, erect CXR to look for subdiaphragmatic air or lung consolidation, ABG/VBG
• CTAP/CT angiogram to rule out differentials and characterise retroperitoneal haemorrhage on imaging
• Discussion between interventional radiology and surgical teams to decide on management of retroperitoneal haemorrhage i.e. conservative vs radiological vs surgical
• Supportive care including providing strong analgesia, goal-directed care with aggressive IV fluid resuscitation and circulatory optimisation, antiemetics, blood transfusion if required for anaemia or blood loss, correction of any underlying coagulopathy
• Suspend medications (metformin, atorvastatin, ramipril) in acute period and especially if evidence of AKI
• Monitor U&Es, CRP, glucose, calcium and lactate
• Strict fluid balance and urine output monitoring with catheterisation
• Dietician input with nutritional support if prolonged NBM e.g. enteral feeding with NJ tube, TPN
• Treat underlying cause, e.g. ERCP/cholecystectomy if caused by choledocholithiasis or cholelithiasis; referral to alcohol services if ETOH excess.
• Escalate to ITU if severe (e.g. >= 3 Glasgow-Imrie score, signs of SIRS/sepsis or organ dysfunction, severe retroperitoneal bleeding)
  

5. Name some possible complications of acute pancreatitis

Possible answer:

Local complications:

• Pancreatic necrosis
• Pseudocysts
• Pancreatic abscess
• Hemorrhage
• Splenic or portal vein thrombosis

Systemic complications:

• ARDS
• AKI
• SIRS or sepsis
• DIC 
• Chronic pancreatitis (long term)
• Hypocalcaemia 
• Hyperglycemia