CPC 8Bekah Syverson, Kyle McKenzie, Ashley Thorson, Cody McCorkle, Steve Olson

Chief Complaint

My stomach hurts!

Present History

40 year old male Upper abdominal/lower chest pain

Onset 4 hours after eating porketta sandwich

Pressure-like pain Nauseated No fever/chills No prior hx of abdominal or chest pain No exertional pain

Past Medical History

Appendectomy (age 12) Inguinal hernia repair (age 22) Smoking: 20 pack years Alcohol: 3 beers/week Family Hx

Father died of MI (age 42) Brother had coronary angioplasty (age 44) No cancer, HTN, diabetes or CVAs

Past Medical History, continued Social History

Married 2 children Lives in Duluth

Occupational History Golf course superintendent

Mowing, fertilizing and supervising golf course upkeep

Review of Systems – Pertinent Positives

Decreased exercise tolerance SOB after walking 2 blocks

Leg cramps when walking Relieved with rest

Physical Exam

Vital BP: 170/110 HR: 86 RR: 14 Temp: 37.2° C

HEENT White yellow scales around orbits but not

involving the eyes

Physical Exam, continued

Neck Faint left carotid bruit

Heart Pedal pulses are faint bilaterally

Abdomen RUQ tenderness with rebound and guarding Right mid-abdominal bruit Bilateral femoral bruits

G-U: Stool hem negative

Class Differential Diagnosis

Our Differential Diagnosis

MI AAA Hepatitis Ischemic Colitis Acute Cholecystitis Acute Pancreatitis

Differential: MI

Upper abdominal/lower chest pressure-like pain

20 pack year history of smoking Family History

Father: died of MI at age 42 Brother: coronary angioplasty at age 44

Decreased exercise tolerance/SOB Leg cramps when walking, relieved by rest

Claudication/peripheral artery disease Abundant bruits

Ruling Out MI

ECG: normal Cardiac enzymes: normal

Troponin 0.16 ng/ml CPK 66.4 IU/L CK MB 4.5 ng/ml

Differential: AAA

Abrupt onset of upper abdominal/lower chest pain

Smoking: 20 pack year history Family history of vascular disease Claudication

Ruling Out AAA

Abdominal CT: normal Abdominal Ultrasound: normal

Differential: Hepatitis

Upper abdominal pain Tenderness to light palpation in RUQ with

rebound and some guarding Nausea

Ruling Out Hepatitis

Liver Panel AST 50 (normal: 10-40 IU/dl) ALT 14 (normal: 5-40 IU/dl) Alk. Phos 72 (normal: 25-125

mg/dl) GGT 18 (normal: 0-51 U/L) Total Bilirubin 0.14 (normal: 0.1-1.2

mg/dl) Hepatitis Serology

negative

Differential: Ischemic Colitis

Peripheral vascular disease Smoking: 20 pack year history Presents as diffuse abdominal pain

Upper abdominal/lower chest pain

Ruling Out Ischemic Colitis

Abdominal CT Normal

Fecal Occult Stool Test negative

Differential: Acute Cholecystitis Upper abdominal/lower chest pain

following a fatty porketta sandwich RUQ pain with rebound tenderness

Nausea Sedentary lifestyle

Ruling Out Acute Cholecystitis Liver Panel

AST 50 (normal: 10-40 IU/dl) ALT 14 (normal: 5-40 IU/dl) Alk. Phos 72 (normal: 25-125

mg/dl) GGT 18 (normal: 0-51 U/L) Total Bilirubin 0.14 (normal: 0.1-1.2

mg/dl) Abdominal Ultrasound

negative

Differential: Acute Pancreatitis Upper abdominal/lower chest pain

RUQ with rebound pain and some guarding

Ruling IN Pancreatitis

Liver Panel AST 50 (normal: 10-40 IU/dl) - H Amylase 520 (normal: 25-125 U/L) – H Calcium 7.8 (normal: 8.4-10.2 mg/dl) – L Glucose 220 (normal: <200mg/dl) - H

Lipid Panel Total Cholesterol 220 (normal: <200 mg/dl) - H Triglycerides 1250 (normal: <150 mg/dl) - H

Lipase Test 630 (normal: 0-160 U/L) - H

Causes of Pancreatitis

EtOH Causes an increase in ductule permeability

allowing the enzymes to reach the parenchyma Causes an intracellular accumulation of

pancreatic digestive enzymes and early release/activation

Causes formation of protein plugs which block outflow due to Increase protein content in pancreatic juice Decrease bicarbonate levels Decrease trypsin inhibitor concentrations

Causes of Pancreatitis, continued Cholelithiasis

Stone in the pancreatic duct or ampulla of Vater leading to obstruction and enzymatic release

Elevated Triglycerides Serum levels over 1000 mg/dl are typically

required to cause acute pancreatitis Familial Hyperlipidemia

Xanthomas on the extensor tendons of the hands, around the eye, on the Achilles tendons and at insertion of the patella tendon

Treatment of Acute Pancreatitis General

Aggressive fluid resuscitation Oxygen supplementation Pain relief with IV morphine or fentanyl Multidisciplinary team involvement

Nutrition Parenteral administration to avoid stimulation of

the pancreas More recently, enteral nutrition has shown to

prevent intestinal atrophy Prevention of Pancreatic Infection

Usually occurs 10 days or more after onset of AP

Ranson’s Criteria

At Admit Age> 55 yr WBC > 16,000 mm³ Glucose > 200 mg/dl LDH > 350 IU/L AST > 250 IU/L

Predicts mortality after 48 hours Each positive finding from above is worth 1 point

<2 points: mortality <1% 3-4 points: mortality = 16% 5-6 points: mortality = 40% 7-8 points: mortality ~ 100%

After 48 Hours Hct drops > 10% BUN increases > 5

mg/dl PO2 < 60 mmHg Base deficit > 4

mEq/L Fluid deficit > 6 L

How much did we spend?

Cardiac Enzymes - $88

CBC - $41 Lipids - $82 Liver Panel - $98 CRP - $73 Abdominal CT -

$618

ECG - $78 Hepatitis Ab –

free!! Lipase - $58 Abdominal

Ultrasound - $370 Abdominal Xray -

$115

$1621 – yikes!

Questions

What is the best way to rule out cholecystitis? A) Lab B) Intuition C) Abdominal Ultrasound D) Have patient eat porketta sandwich.

Questions

Which of the following is NOT common causes of acute pancreatitis? A) Elevated Triglycerides B) Alcohol C) Cholelithiasis D) Eating Porketta Sandwich

Questions

What are common signs of acute pancreatitis? A) Mid-epigastric pain B) Nausea/vomiting C) Progressive and constant pain D) Moderately rapid (~30 min) onset of

pain E) all of the above