FRIDAY CONFERENCE

MEDICINE
JUNE 17TH,2022
Ext. Chulalux Limpanawat
Ext. Warongkorn Lakanawiwat
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Information
Admission date : 4/6/65
Attending date : 7/6/65
Information source : ผู้ป่วยและเวชระเบียนผู้
ป่วยใน
Patient profile : หญิงไทยคู่อายุ 44 ปี อาชีพ
รับจ้าง ภูมิลำเนา อ.บ้านโคก จ.อุตรดิตถ์
Status : มาเปลนอนที่ ER

Friday Conference
June 17th,2022
6th year medical student
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ผู้ป่วยหญิง อายุ 44 ปี
CC : ปวดท้องบริเวณลิ้นปี่
5 ชั่วโมงก่อนมาโรงพยาบาล

Friday Conference
June 17th,2022
6th year medical student
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HISTORY TAKING
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HISTORY TAKING
Timeline

มีอาการปวดท้องบริเวณลิ้นปี่ ไม่ร้าว มีอาการปวดท้องบริเวณลิ้นปี่ ปวดขึ้นมาทันที ลักษณะตื้ อๆแน่นๆ ร้าว

ไปไหน ปวดประมาณ 1 ชั่วโมง ทะลุหลัง PS 10/10 ไม่มีช่วงที่บรรเทา ไม่ได้ทานยาเพื่อบรรเทาอาการ
อาการหายไปได้เอง เป็นๆหายๆมา นอนราบแล้วเจ็บมากขึ้น แต่โน้มตัวไปข้างหน้าแล้วดีขึ้น อาเจียน 1
ตลอด ครั้งเป็นน้ำลาย อาการปวดไม่ดีขึ้น

4 M 1 M 5 HR

มีอาการปวดท้องบริเวณลิ้นปี่ ไม่ร้าวไปไหน ปวดเป็นๆ

หายๆ ตัวเหลือง ปัสสาวะสีเข้ม จึงไปหาหมอที่รพ. จึงพบ
Friday Conference
ว่า มีโรคท่อน้ำดีผิดรูปแต่กำเนิด
June 17th,2022
6th year medical student
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History taking
Past history :
ไม่มีประวัติแพ้ยาแพ้อาหาร
ท่อน้ำดีผิดรูป choledochal cyst
วินิจฉัยเมื่อ 29/4/65 (1 เดือน PTA) จากอาการปวดท้องใต้ลิ้นปี่ เป็นๆหายๆ ตัวเหลือง ปัสสาวะสี
เข้ม แพทย์นัดทำ CT whole abdomen
ส่งตัวไปรักษาต่อที่ มอ. ล่าสุดยังไม่ได้ไปตามนัด
ยังไม่ได้รับการผ่าตัดแก้ไข

Personal history :
ปฏิเสธประวัติโรคประจำตัวอื่น
ไม่ดื่มสุรา
ไม่สูบบุหรี่
ไม่มียาที่กินประจำ
Friday Conference
ไม่มีประวัติใช้ยาต้ม ยาหม้อ ยาสมุนไพร
June 17th,2022
ไม่เคยมีประวัติผ่าตัดหรืออุบัติเหตุ 6th year medical student
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History taking

Family history :
ไม่มีประวัติโรคทางพันธุกรรมหรือโรคมะเร็งในครอบครัว

Friday Conference
June 17th,2022
6th year medical student
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PHYSICAL
EXAMINATION
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Physical Examination
Vital signs : BT 36.6 °c ,BP 146/71 mmHg,PR 59 bpm, RR 20/min ,O2sat
98%
General appearance : A middle-aged Thai female, good consciousness,
normosthenic built
Measurement : Weight 59 kg, Height 163 cm, BMI 22 kg/m2
Skin and appendage : not pale, no jaundice, no rash, no ecchymosis
HEENT : Not pale conjunctiva, anicteric sclera, pharynx and tonsils not
injected, no thyroid gland enlargement
Pulmonary system : Clear and equal breath sounds both lungs, no
adventitious sounds
Cardiovascular system : Full pulse, regular rhythms,normal S1S2, no
murmur Friday Conference
June 17th,2022
6th year medical student
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Physical Examination
Abdominal examination :
mild distension, no scar, no superficial vein dilate
normoactive bowel sound
soft, tender at epigastrium
no guarding, no rebound tenderness
liver and spleen can not be palpated
Murphy's sign : negative, FIST test : negative
No CVA tenderness
Musculoskeletal system : no deformities
Lymph nodes : superficial lymph node can't palpable
Neurological system : E4V5M6, pupil 2 mm BRTL, intact sensory system,
Motor power grade V all extremities Friday Conference
June 17th,2022
6th year medical student
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PERTINENT
SUBJECTIVE
 PERTINENT 13

SUBJECTIVE
Female 44 years old
Sudden epigastrium pain relieved with leaning
forward position
Vomiting
History of choledochal cyst (1 M. PTA)

Friday Conference
June 17th,2022
6th year medical student
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PERTINENT
OBJECTIVE
 PERTINENT 15

OBJECTIVE
Vital signs : BT 36.6 °c ,BP 146/71 mmHg,PR 59 bpm, RR 20/min
,O2 sat 98%
Abdominal examination :
mild distension
soft, tender at epigastrium
no guarding, no rebound tenderness
liver and spleen can not be palpated
Murphy's sign : negative, FIST test : negative
Friday Conference
June 17th,2022
6th year medical student
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PROBLEM LIST
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PROBLEM LIST

acute epigastrium pain

Friday Conference
June 17th,2022
6th year medical student
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DIFFERENTIAL
DIAGNOSIS
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PERTINENT SUBJECTIVE

Female 44 years old

Sudden epigastrium pain relieved with leaning
forward position
Vomiting
History of choledochal cyst (1 M. PTA) PROBLEM LIST

PERTINENT OBJECTIVE acute epigastrium pain

Vital signs : BT 36.6 °c ,BP 146/71 mmHg,PR 59 bpm, RR 20/min

,O2 sat 98%
Abdominal examination :
mild distension
soft, tender at epigastrium
no guarding, no rebound tenderness
liver and spleen can not be palpated
Murphy's sign : negative, FIST test : negative
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Acute pancreatitis
Perforated viscus

DIFFERENTIAL Acute cholecystitis

Acute intestinal obstruct
Mesenteric vascular occlusion

DIAGNOSIS Dissecting Aortic aneurysm

Inferior MI
Renal colic
Dyspepsia

Friday Conference
June 17th,2022
6th year medical student
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INVESTIGATION
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CBC
WBC 11,600 /ul Neutrophil 84.0 %
RBC 5.90 x10^6/ul Lymphocyte 15.0 %
HGB 12.9 g/dl Monocyte 1.0 %
HCT 39.4 % hypochromia few
MCV 67 fl microcyte few
MCH 22 pg
MCHC 33 g/dl
PLT 400,000 /ul
RDW 16.7 % 4/6/65
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Electrolyte
BUN 7 mg/dL
Cr 0.68 mg/dL
eGFR 106.986 mL/min/1.73 m2
Sodium 140 mmol/L
Potassium 4.3 mmol/L
Chloride 108 mmol/L
CO2 17 mmol/L
Anion Gap 15 mmol/L
4/6/65
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LFT
Total protein 7.4 g/dL
Albumin 4.1 g/dL
Total Bilirubin 1.9 mg/dL
Direct Bilirubin 0.69 mg/dL
AST 111 U/L
ALT 112 U/L
ALP 301 U/L
Amylase 1677 U/L
Lipase 8 429 U/L 4/6/65
CXR
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Progression
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LFT
Total protein 5.6 g/dL
Albumin 3.4 g/dL
Total Bilirubin 1.43 mg/dL
Direct Bilirubin 0.32 mg/dL
AST 51 U/L
ALT 74 U/L
ALP 197 U/L

5/6/65
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Lipid profile
Cholesterol 250 mg/dL
Triglyceride 72 mg/dL
HDL-C 65 mg/dL
LDL-C 166 mg/dL
Calcium 8.1 mg/dL

5/6/65
Progression
28
Progression
29
Progression
30
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ACUTE PANCREATITIS
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Definition
An acute inflammatory process of the pancreas with
variable involvement of other regional tissues or remote
organ systems , Associated with raised pancreatic enzyme
levels in blood and/or urine

Friday Conference
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by
international consensus. Gut 2013; 62:102.
June 17th,2022
6th year medical student
 Common Causes
33
Etiology 1.Gallstones (including microlithiasis) 80-90%

2. Alcohol (acute and chronic alcoholism) 15-30%

3. Endoscopic retrograde cholangiopancreatography

5-10%
(ERCP), especially after biliary manometry

4. Hypertriglyceridemia 1.8-3.8%

5. Drugs (azathioprine, 6-mercaptopurine, sulfonamides,

estrogens, tetracycline, valproic acid, anti-HIV medications, 0.1-2%
5-aminosalicylic acid [5-ASA)

6. Trauma (especially blunt abdominal trauma)

Darwin L. Conwell.Acute and Chronic
pancreatitis.In : Jameson LA,Kasper
L.,Lomgo arrison's principle. internal 7. Postoperative (abdominal and nonabdominal operations) Friday Conference
medicine Ed.20th Graw Hill:2020. p.2437-51 June 17th,2022
6th year medical student
 Pathogenesis 34

Initial phase : intrapancreatic digestive enzyme activation and acinar cell

injury

Second phase : Leukocytes and macrophages in the pancreas result in

enhanced intrapancreatic inflammatory reaction.

Third phase : activated proteolytic enzymes and cytokines, released by the

inflamed pancreas, on distant organ

Friday Conference
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine June 17th,2022
Ed.20th Graw Hill:2020. p.2437-51 6th year medical student
 35
Physical
Symptoms examination
Abdominal pain Low-grade fever, tachycardia, and
Characteristic : hypotension
- the pain, which is steady Abdominal tenderness and muscle
- boring character rigidity (variable degree)
- located epigastrium and periumbilical Bowel sound are diminished or
region, and radiate to back, chest, flanks absent
and lower abdomen palpable mass in upper abdomen
Nausea and vomitting (later 4-6 weeks)
Abdominal distension faint blue discoloration arond
Systemic inflammatory response umbilicus (Cullen's sign)
blue-red-purple or green-brown
discoloration of flanks (Turner's sign)
Friday Conference
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine Ed.20th Graw June 17th,2022
Hill:2020. p.2437-51 6th year medical student
 36
Physical examination

Friday Conference
June 17th,2022
6th year medical student
A: Cullen sign B:Grey Turner’s sign
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Laboratory
Amylase or Lipase >3X UNL
Leukocytosis ( 15,000-20,000 leukocytes/microlitres)
Hyperglycemia
Hemoconcentration (Hct >44% or BUN >22 mg/dL from 3rd space
loss)
Hypocalcemia (25%)
Hyperbilirubinemia (10%)
elevated AST and ALT (transiently elevated)
Hypertriglyceridemia (5-10%)
Hypoxemia (PaO2 <= 60 mmHg ; ARDS)
Friday Conference
June 17th,2022
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal 6th year medical student
medicine Ed.20th Graw Hill:2020. p.2437-51
 38
Amylase vs Lipase

https://pubmed.ncbi.nlm.nih.gov/28720341
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US abdomen
 Diagnosis
40

Requires two of the following three features

acute onset of a
constant, severe,
Serum imaging finding :
epigastric pain with
Lipase or Amylase CT/ MRI/ US
tenderness, often
rising > 3 times
radiates through to
mid back

Friday Conference
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification
June 17th,2022
and definitions by international consensus. Gut 2013; 62:102. 6th year medical student
 41
Phases of Acute Pancreatitis

Early phase (<2 wks) : severity is defined by clinical findings.

Three organ system define organ failure (Respiratory, Cardiovascular,
and Renal) by using modified Marshall scoring system

Friday Conference
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut June 17th,2022
2013; 62:102. 6th year medical student
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Phases of Acute Pancreatitis
Late phase (>2 wks) :
protracted course of illness
and may require imaging to
evaluate for local
complication.

CT imaging best evaluated 3-5

days when patients not respond
to supportive care to look for
local complication such as
necrosis

Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
 43
Phases of Acute Pancreatitis
Morphologic
Definition CT criteria Imaging
feature

Acute inflammation of
Interstitial Iv constrast agent enhancement in pancreatic
pancreatic parenchyma
pancreatitis parenchyma
and peripancreatic tissu

peripancreatic fluid with

Acute pancreatic interstitial edematous Homogenous collection with fluid density, no definable
fluid collection pancreatitis (within first wall encapsulating fascial planes
4 weeks)

An encapsulated
collection of fluid with
Pancreatic
well-defined Well-defined wall, homogeneous fluid density
pseudocyst
inflammatory wall (> 4
weeks)

Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
 44
Imaging CT scan

IV enhancement

Friday Conference
June 17th,2022
Interstitial edematous pancreatitis 6th year medical student
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Phases of Acute Pancreatitis
Morphologic
Definition CT criteria
feature

Lack of IV constrast agent

Necrotizing inflammation associated with pancreatic parenchymal
enhancement in pancreatic
pancreatitis necrosis and peripancreatic necrosis
parenchyma

Heterogeneous and non-liquid density

Acute necrotic A collection of both fluid and necrosis associated with of varying degrees in different
collection (ANC) necrotizing pancreatitis location, no definable wall
encapsulated the collection

Heterogeneous and non-liquid density

A mature, encapsulated collection of pancreatic
Walled off necrosis of varying degrees in different
and/or peripancreatic necrosis that has developed the
(WON) location, with definable wall
wall-defined inflammatory wall (> 4 weeks)
encapsulated the collection

Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
 46
Imaging CT scan

Lack of
IV enhancement

Friday Conference
Necrotizing pancreatitis June 17th,2022
6th year medical student
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Severity
Mild : self-limited and subside spontaneously within 3-7 days
no organ failure
no local complication

Moderate : require a prolong hospitalization > 1 weeks

Trasient organ failure (resolve within 48 hr.)
Local or systemic complication without persistent organ failure

Severe : CT/MRI should be obtained for assess necrosis or complication

persistent organ failure (>48 hr.)
Multiple organ failure Friday Conference
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. June 17th,2022
Gut 2013; 62:102. 6th year medical student
 Local Complications of Acute Pancreatitis 48

Involvement of contiguous organs

Necrosis (Sterile, Infected)
by necrotizing pancreatitis

Thrombosis of blood vessels

Walled-off necrosis
(splenic vein, portal vein)

Pancreatic fluid collections Pancreatic enteric fistula

Pancreatic pseudocyst Bowel infarction

Disruption of main pancreatic duct

Obstructive jaundice
or secondary branches

Involvement of contiguous organs

Pancreatic ascites
by necrotizing pancreatitis
Friday Conference
June 17th,2022
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;
6th year medical student
62:102.
 49
Systemic Complication
Pulmonary Renal
Pleural effusion Oliguria (<300 mL/d)
Atelectasis Azotemia
Mediastinal fluid Renal artery and /or renal vein thrombosis
Pneumonitis Acute tubular necrosis
Acute resoiratory distress syndrome Metabolic
Hypoxemia (unrecognized) Hyperelycemia
Cardiovascular Hypertrigyceridemia
Hypotension Hypocalcemia
Hypovolemia Encephalopathy
Nonspecific ST- changes in electrocardiogram simulating myocardial Sudden blindness [Purtscher's retinopatim)
Infarction Central nervous system
Pericardial effusion Psychosis
Hematologic Fat emboli
Disseminated intravascular coagulation Fat necrosis
Gastrointestinal hemormage Subcutaneous tissues (erythematous nodules)
Pentic Ulcer disease Bone
Erosive gastritis Miscellaneous (mediastinum, pleura, nervous system)
Hemorrhagic pancreatic necrosis with erosion into major blood vessels
Portal vein thrombosis, splenic vein thrombosis, vanceal hemorrhage Friday Conference
June 17th,2022
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine Ed.20th Graw
6th year medical student
Hill:2020. p.2437-51
 50
Initial Management
NPO to rest the pancreas
Supplement O2 cannula 2 LPM
Fluid Resuscitation
IV fluid of RLS 15-20 mL/kg, followed by 2-3 mL/kg/hr.
keep urine output >0.5 mL/kg/hr
monitor V/S q 6-8 hr
monitor BUN and Hct. q 8-12 hr for adequacy of fluid
resuscitation
cardiac,pulmonary, or renal disease
IV narcotics analgesics for pain control

Friday Conference
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine Ed.20th Graw June 17th,2022
Hill:2020. p.2437-51 6th year medical student
 51

Nutrition

A low-fat solid diet after abdominal pain has resolved in mild

acute pancreatitis
Enteral nutrition should be considered 2-3 days in severe
pancreatitis
Enteral feedings maintain gut barrier integrity, limits bacterial
translocation

Friday Conference
June 17th,2022
6th year medical student
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine Ed.20th Graw Hill:2020. p.2437-51
 52
Hospital triage
The Bedside Index of Severity in Acute Pancreatitis (BISAP)
BUN >25 mg/dL
Impaired mental status (GCS < 15)
SIRS
Age >60 years
Pleural effusion
Presence of three or more of these factors -> increased risk for in-
hospital mortality

Hct >44%
Admission BUN >22 mg/dL

Friday Conference
June 17th,2022
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal 6th year medical student
medicine Ed.20th Graw Hill:2020. p.2437-51
 53
Specific management

Gallstone Pancreatitis : undergo ERCP within 24-48 hr.

Hypertriglyceridemia : Serum triglycerides >1,000 mg/dL. Initial
therapy include insulin, heparin, or plasmapheresis. Control of
diabetes, lipid-lowering agents, weight loss
Autoimmune pancreatitis : glucocorticoid administration
Post-ERCP pancreatitis : duct stenting and rectal indomethacin
administration
Drug induced pancreatitis : discontinue

Friday Conference
June 17th,2022
Darwin L. Conwell.Acute and Chronic pancreatitis.In : Jameson LA,Kasper L.,Lomgo arrison's principle. internal medicine
Ed.20th Graw Hill:2020. p.2437-51
6th year medical student
 54

Take Home Message

The diagnosis requires two of the three criteria : Abdominal pain, Lab, Imaging

Elevated lipase levels are more specific to the pancreas than elevated amylase levels

Initial supportive care with fluid resuscitation, pain control, and nutritional support

Opioids are safe and effective at providing pain control in patients with acute pancreatitis

Enteral nutrition should be considered 2-3 days in severe pancreatitis

Basurto Ona X, Rigau Comas D, Urrútia G. Opioids for acute pancreatitis pain. Cochrane Database Syst Rev 2013; :CD009179.
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Thank You !
Imaging ERCP (Endoscopic Retrograde Cholangiopancreatography)