CC: ABDOMINAL PAIN
HPI
 42 year old male presents to the Emergency
Department with severe epigastric pain that started
3 days ago. He describes the pain as constant and
epigastric. It has been severe since its onset, and also
is described as band-like and radiating to his back.
He also complains of nausea and vomiting that
started yesterday. His wife is present and reports
increased agitation since he quit drinking alcohol
after one last binge 1 week ago. She also reports that
he has a hx of gall stones and was recently stung by
a scorpion during a trip to Arizona. Denies fever,
rash or headache. Denies diarrhea or constipation.
No hx of GI bleeding.
HPI
Past Medical Hx:
Family and Social Hx:
 Mother with hx
 Hx alcohol dependence
 Hx of choledocholithiasis tx
with ERCP
 Hx of scorpion sting 1 week
ago
 Hx of migraine headaches
 No other past surgical hx
cholecystitis, hx of HTN
and CAD.
 Father has hx of obesity
and alcohol dependence.
 2 Brothers who are healthy
 Married, lives at home with
wife, two children and dog.
Recent travel to Arizona for
a hiking trip. Works in a
beer bottling factory as a
quality assurance engineer.
DIFFERENTIAL DIAGNOSIS
 Acute cholecystitis or cholangitis
 Penetrating duodenal ulcer
 Pancreatic pseudocyst
 Ischemic colitis
 Small bowel obstruction
 Abdominal aortic aneurysm
 Kidney stone
 Nonpancreatic causes of increased amylase
PHYSICAL EXAM
VITALS: BP 115/80, T 38.0, R 16, HR 95
GEN: Appears to be in moderate distress secondary to pain.
HEENT: Normocephalic, atraumatic (NCAT), pupils equal, round and
reactive (PERRL) and extraocular movements intact (EOMI). Moist
mucous membranes. Oropharynx clear and patent, no erythema.
CV, RESP: Regular rate and rhythm, no murmurs, rubs or gallops. Breath
sounds are clear to auscultation bilaterally (CTAB), no crackles or ronchi,
and symmetrical chest rise, though breathing is noticeably shallow.
ABDOMINAL: Soft, mildly distended abdomen, voluntary guarding no
rebound tenderness. Abdominal tenderness on exam is out of proportion
to the patient’s level of discomfort. Negative Murphy’s sign.
RECTAL: DRE is negative for gross and occult blood. Perianal area is
intact without lesions.
NEURO: Alert, awake and oriented to person, place and time. (AAOx3).
CN II-VII intact. Strength 5/5 and sensation intact over all extremities.
Classic and Other Concerning Symptoms
•Grey-Turner’s Sign: ecchymotic discoloration in the flank.
•Cullen’s Sign: ecchymotic discoloration in the periumbilical
region.
•These signs occur in 1% of cases and reflect intraabdominal
hemorrhage and are associated with poor prognosis.
•Jaundice is seen in cases of pancreatitis where inflammation
is secondary to choledocholithiasis or edema at the head of
the pancreas from obstruction of the common bile duct.
•Epigastric mass may be palpable due to pseudocyst
formation.
•Subcutaneous nodular fat necrosis, thrombophlebitis in the
legs and polyarthritis are also less commonly seen.
LABORATORY TESTS
 CBC: normal
 WBC: 16,000
 CMP: normal, Calcium 2, AST 220, ALT 80,
Alk phos 150, Albumin 25, tBili 6, Amylase 320
 UA: Negative for WBC, RBC, protein,
leukocyte esterase and nitrites.
 What would you like to do next?
Acute Abdominal Series
 Abdominal Plain Film : helps to
exclude other causes of abdominal
pain, including bowel obstruction or
bowel perforation.
 Localized ileus of a segment of the
small intestine, aka “sentinal loop”
may be seen.
 Generalized ileus can occur in severe
disease.
 Ground glass appearance may
indicate ascites.
 Chest Film: May see elevation of
hemidiaphragm, pleural effusion or
basal atelectasis, left sided or
bilateral.
LOCALIZED ILEUS WITH SENTINAL
LOOP SIGN
Abdominal CT Scan

Most important imaging study for diagnosis
of acute pancreatitis, intraabdominal
complications and to assess severity.

The severity of acute pancreatitis based on
non-contrast CT findings:

Grade A – Normal pancreas consistent with
mild pancreatitis

Grade B – Focal or diffuse enlargement of
the gland, including contour irregularities
and inhomogeneous attenuation but
without peripancreatic inflammation

Grade C – Abnormalities seen in grade B plus
peripancreatic inflammation

Grade D – Grade C plus single fluid collection

Grade E – Grade C plus two or more
peripancreatic fluid collections or gas in the
pancreas or retroperitoneum
Non-Contrast CT with peripancreatic fat stranding.
Pancreatitis
 Although measurement of amylase and lipase are useful
for diagnosis of pancreatitis, serial measurements are
not useful to predict prognosis or to guide management.
 Important radiologic features may be seen on a plain film
of the abdomen, chest radiograph, and spiral (helical) CT
scan. CT scan is the most important imaging test for the
diagnosis of acute pancreatitis and its intraabdominal
complications and also for assessment of severity. And
CT is best utilized in patients who do not improve with
conservative management or in whom you suspect
complications.
Histological Interpretations
Acute pancreatitis morphology ranges from mild inflammation and edema to severe
extensive necrosis and hemorrhage. Findings include:
1. Microvascular leakage causing edema
2. Necrosis of fat by lipolytic enzymes
3. Acute inflammation
4. Proteolytic destruction of pancreatic parenchyma
5. Destruction of blood vessels and subsequent interstitial hemorrhage
Histological Features Cont’d

Below see regions of fat necrosis and focal pancreatic parenchymal necrosis.

Gross specimens reveal dark areas of hemorrhage in the head of the pancreas and
focal areas of pale fat necrosis
Treatment
 Acute pancreatitis can be divided into two broad categories: edematous,
interstitial or mild acute pancreatitis and necrotizing or severe acute
pancreatitisTreatment varies depending on the severity of the condition.
 Mild pancreatitis is treated for several days with supportive care including
pain control, intravenous fluids, correction of electrolyte and metabolic
abnormalities, and nothing by mouth.
 In severe pancreatitis, intensive care unit monitoring and support of
pulmonary, renal, circulatory, and hepatobiliary function may minimize
systemic sequelae.
 In patients with gallstone pancreatitis, we recommend early ERCP and
sphincterotomy for those who have a high suspicion of cholestasis and
those with cholangitis. Cholecystectomy should be performed after
recovery in all patients with gallstone pancreatitis.
 The anatomic changes of acute pancreatitis strongly suggest
autodigestion of the pancreatic substance by inappropriately activated
pancreatic enzymes.
Summary
References:

Kumar, Vinay, Abul K. Abbas, Nelson Fausto, Stanley L. Robbins, and
Ramzi S. Cotran. "Chapter 19 The Pancreas." Robbins and
Cotran Pathologic Basis of Disease. Philadelphia: Elsevier
Saunders, 2005. 893-897. Print.
 Vege, Santhi S., MD. "Clinical Manifestations and Diagnosis of Acute
Pancreatitis." Clinical Manifestations and Diagnosis of Acute
Pancreatitis. N.p., 13 Nov. 2012. Web. 20 Dec. 2012.
<http://www.uptodate.com.proxy.medlib.iupui.edu/contents/clinic
al-manifestations-and-diagnosis-of-acute-pancreatitis?source=
search_result&search=pancreatitis&selectedTitle=1~150>.
 Vege, Santhi S., MD. "Treatment of Acute Pancreatitis." Treatment of
Acute Pancreatitis. N.p., 25 Oct. 2012. Web. 20 Dec. 2012.
<http://www.uptodate.com.proxy.medlib.iupui.edu/contents/treat
ment-of-acute-pancreatitis?source=search_result&search=
pancreatitis&selectedTitle=2~150>.