Pancreatitis

You are the general surgery CT1 asked to see a 55-year old lady complaining of central abdominal pain the morning after a heavy night of drinking alcohol at a hen party. The pain radiates through to her back and so far, only morphine has helped. She has vomited twice and had an episode of diarrhoea. Her vitals are stable. What is your differential diagnosis and how would you proceed?

Example answer introduction

In this scenario I would be most worried about acute pancreatitis. I would also consider acute gastritis, cholecystitis, myocardial infarction and pneumonia. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, triglycerides, clotting studies, Group and Save and an ABG. I would also take blood and urine cultures if spiking a temperature. 

Focused history

  • Allergies

  • Medications – Opiates, laxatives, new medications, anticoagulants

  • Past medical history: Autoimmune conditions, recent ERCP, known gallstones, mumps, metabolic disorders (hypercalcaemia/hyperparathyroidism,hyperlipidaemia) previous abdominal 

  • Last meal

  • Events leading up to this point - nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – Distention, surgical/traumatic scars

  • Auscultate – “Tinkling” bowel sounds

  • Palpate – Tenderness, hernia

  • Percussion – Normal or hyper-resonant

  • Digital rectal examination – obturator hernia, malignant masses, blood – can suggest late strangulation

  • External genitalia - hernia 

Initial Investigations

  • Urine dip – looking for blood, leukocytes, nitrites (Beta HCG in childbearing ages), glucose, ketones

  • ABG – Acute respiratory distress (Pancreatitis can cause Acute Respiratory Distress Syndrome – ARDS, a potentially fatal condition).

  • ECG – myocardial infarction

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

  • Ultrasound abdomen - gallstones

Example questions to progress the station

Q1 - Her amylase comes back raised at 450. What would you do next?

This would be in keeping with an acute pancreatitis. I would instigate treatment in the form of:

1. Analgesia according to the WHO pain ladder, with a morphine PCA if required.

2. Fluids - IV crystalloids, 3-4L in the first 24hrs and then to maintain urine output of 0.5ml/kg/hr thereafter.

3. I would keep the patient nil-by-mouth.

4. I would score the patient using the Glasgow or Ranson scores, depending on local practice. This will help determine the severity of the episode and ascertain need for higher level care.

5. Keep patient and relatives informed

6. Document carefully in the notes. Always document every reassessment.

 Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct and arrange further imaging, for example contrast abdominal CT, if indicated. At all stages I would keep the patient informed and document proceedings in the notes and on the handover. 
Useful Resources

​Working Party of the British Society of Gastroenterology, 2005. UK guidelines for the management of acute pancreatitis. 

Prognostic factors in acute pancreatitis

(Glasgow-Imrie)

Prognostic signs and the role of operative management in acute pancreatitis

(Ranson)

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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