ABDOMINAL PAIN CASE 5

Posted on by Andrew Coggins

Abdominal Pain Case 5

‘Severe epigastric pain’

Janice is a 55 year old female who presents to the Emergency Department (ED) with severe epigastric pain and three episodes of vomiting over the last twelve hours. On examination she is tachycardic, diaphoretic and appears to be in significant discomfort. 

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Which of the following listed is the LEAST common cause of pancreatitis?

  1. Ethanol
  2. Gallstones
  3. Idiopathic
  4. Drugs   

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Correct answer:

“D” – though all are causes – correct answer is drugs which is the least common cause

Take Home Message:

Pancreatitis is inflammation of the pancreas and involves activation of proteolytic enzymes that may progress to haemorrhagic necrosis of the pancreatic parenchyma. Different geographic locations may report different incidences of aetiologies but universally ethanol and gallstones common causes. 

A Further Explanation:

A retrospective study of pancreatitis in Western Sydney (International Journal of Surgery 2015) found gallstones was the most common cause of pancreatitis. This was followed by idiopathic (no cause found) and alcohol. Pancreatitis is an important disease to recognise that may me be associated with significant morbidity. In a patient with severe abdominal pain always consider pancreatitis, AAA, acute myocardial infarction, visceral perforation and ischaemic colitis as immediate life threatening concerns. 

ED diagnosis of Pancreatitis is made by considering the following: 

  • 2 out of 3 criteria are met: (1) Symptoms consistent with pancreatitis (e.g. epigastric pain), (2) Elevation of serum amylase or lipase (at least 3 times normal level – see below), (3) Radiological features consistent with pancreatitis (e.g. CT or MRI)
  • The severity ranges from mild to severe (acute necrotising pancreatitis). 15-25% of pancreatitis is severe with a mortality of >15% in these cases

Here is a more extensive list of causes:

  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps and other viruses (EBV, CMV, HIV)
  • Autoimmune diseases (SLE, polyarteritis nodosa, pregnancy)
  • Scorpion stings
  • Hypercalcaemia, hyperlipidaemia, hypothermia, hypotension (ischemia)
  • ERCP, emboli
  • Drugs

NB – Of note the lipase reference ranges in many hospitals have changed – for a diagnosis the lipase should be at least 3-4 the normal reference range.

References:

  1. LITFL Review – https://lifeinthefastlane.com/ccc/pancreatitis
  2. Epidemiology, aetiology and outcomes of acute pancreatitis: A retrospective cohort study. –  https://www.ncbi.nlm.nih.gov/pubmed/26384834