Surgery Case

astric pain and vomiting

History
A 50-year-old man presents to the emergency department with vomiting and severe
epigastric
pain, which radiates through to the back. The pain was of gradual onset, coming on over
the past 2 days. He denies any previous episodes. He is not on any regular medication, but
admits to drinking in excess of eight cans of lager a day. He is a heavy smoker, but denies
any
recreational drug use. He is homeless and relates his heavy drinking to depression.
Examination
The patient is sweaty and agitated. He says he is unable to lie flat for the examination and
vomits persistently. His blood pressure is 150/80 mmHg and he has a pulse rate of 120/min.
Palpation of his abdomen reveals tenderness in the epigastrium. The abdomen is not
distended
and he has normal bowel sounds. Rectal examination is unremarkable.
INVESTIGATIONS
Normal
Haemoglobin 12 g/dL 11.5–16.0 g/dL
Mean cell volume 102 fL 76–96 fL
White cell count 13.3 109/L 4.0–11.0 109/L
Platelets 310 109/L 150–400 109/L
Sodium 132 mmol/L 135–145 mmol/L
Potassium 4.2 mmol/L 3.5–5.0 mmol/L
Urea 5 mmol/L 2.5–6.7 mmol/L
Creatinine 72 mol/L 44–80 mol/L
Amylase 4672 IU/dL 0–100 IU/dL
AST 30 IU/L 5–35 IU/L
GGT 212 IU/L 11–51 IU/L
Albumin 25 g/L 35–50 g/L
Bilirubin 12 mmol/L 3–17 mmol/L
Glucose 5 mmol/L 3.5–5.5 mmol/L
Lactate dehydrogenase (LDH) 84 IU/L 70–250 IU/L
Total serum calcium 2.35 mmol/L 2.12–2.65 mmol/L
Questions
• What is the most likely diagnosis?
• Which important differential diagnosis should be excluded?
• How will you grade the severity of the condition?
• What are its causes?
• What are the other causes of the elevated serum marker of this condition?
• How will you manage the condition?
• Give four potential complications.

ANSWER 22
The most obvious abnormal result is the raised amylase, giving a diagnosis of acute
pancreatitis.
The history and macrocytosis would suggest this is of alcoholic aetiology, but it is
important to ultrasound the abdomen to exclude gallstones as the cause. The pain is
typically
severe and radiates through to the back, due to the retroperitoneal position of the pancreas.
Vomiting is also a common feature, as a result of gastric stasis caused by the local
inflammation.
The severity of the attack has no relation to the rise in serum amylase. Twenty per cent
of cases of pancreatitis have a normal serum amylase, particularly when there is an
alcoholic
aetiology.
It is important to exclude a perforated peptic ulcer in this patient by requesting an erect
chest
x-ray, which would show free subphrenic air in 90 per cent of cases. The serum amylase can
be elevated in a patient with gastric perforation due to the systemic absorption of pancreatic
enzymes from the abdominal cavity. An amylase rise of over 1000 IU/dL, however, is usually
diagnostic of acute pancreatitis.
Ranson’s criteria are used to grade the severity of alcoholic pancreatitis, but it takes 48 h
before the score can be used. Each fulfilled criterion scores a point and the total indicates
the
severity.
• On admission:
• Age 55 years
• White cell count >16 109/L
• LDH >600 IU/L
• AST >120 IU/L
• Glucose >10 mmol/L
• Fluid sequestration >6 L
• Within 48 h:
• Haematocrit fall >10 per cent
• Urea rise >0.9 mmol/L
• Calcium <2 mmol/L
• Partial pressure of oxygen (pO2) <60 mmHg
• Base deficit >4
Estimates on mortality are based on the number of points scored: 0–2 = 2 per cent; 3–4 =
15 per cent; 5–6 = 40 per cent; >7 = 100 per cent.
! Causes of acute pancreatitis
• Common (80 per cent): gallstones, alcohol
• Rare (20 per cent): idiopathic, infection (mumps, coxsackie B virus), iatrogenic
(endoscopic retrograde cholangiopancreatography [ER CP]), trauma, ampullary or
pancreatic tumours, drugs (salicylates, azathioprine, cimetidine), pancreatic structural
anomalies (pancreatic divisum), metabolic (hypertriglyceridaemia, raised Ca 2),
hypothermia

! Causes of hyperamylasaemia
• Perforated peptic ulcer
• Mesenteric infarction
• Cholecystitis
• Generalized peritonitis
• Intestinal obstruction
• Ruptured ectopic pregnancy
• Diabetic ketoacidosis
• Liver failure
• Bowel perforation
• Renal failure
• Ruptured abdominal aortic aneurysm
The aim of treatment is to halt the progression of local inflammation into systemic
inflammation,
which can result in multi-organ failure. Patients will often require nursing in a
highdependency
or intensive care unit. They require prompt fluid resuscitation, a urinary catheter
and central venous pressure monitoring. Early enteral feeding is advocated by some
specialists.
If there is evidence of sepsis, the patient should receive broad-spectrum antibiotics. An
ultrasound may demonstrate the presence of gallstones, biliary obstruction or a pseudocyst.
Computerized tomography (CT) is used to confirm the diagnosis a few days after the onset
of
the symptoms, and can be used to assess for pancreatic necrosis.
! Complications of pancreatitis
Local Systemic
Pancreatic pseudocyst Renal failure
Abscess formation Respiratory failure
Biliary obstruction Septic shock
Fistula formation Electrolyte disturbance
Thrombosis Multi-organ failure and death
KEY POINTS
• Ranson’s criteria are used to grade the severity of acute alcoholic pancreatitis.
• Patients should be managed aggressively and may require treatment in a highdependency
or in intensive care unit.