Examination: Acute Pancreatitis

Casebank Combined
1

Key points: Consider these groups of questions to:

To reach Diagnosis (Symptoms) To reach Causes (Risk Factors) To reach if there are any Complications
1. Pain in the abdomen refers to back. 1. Gall stones (ask about Hx of gall stones or Hx of procedure to remove stones). 1. Necrosis.
2. Tenderness on abdomen 2. Alcohol. 2. Respiratory failure (ARDS) (v. common).
3. Feeling or being sick (vomiting). 3. Others:
4. Diarrhea. GET SMASHED → Side effects. → Virus mumps. →Auto-immune.
5. Fever.
6. Jaundice.

To reach diagnosis → Investigations

  1. Blood tests:
  • Bilirubin - Liver
  • ALT - Liver
  • AST - Liver
  • ALP - Obstruction or bone
  • Amylase - Pancreas
  • Lipase - Pancreas
  • GGT - Alcohol
  1. USS → Picture of gall bladder (stone).
  2. CT on abdomen.

At any case where there is Jaundice → you must ask about (Clinical picture of Obstructive Jaundice).

  1. Dark urine.
  2. Pale stool.
  3. Itching.

Who you are:
You are an FY2 in the emergency department

Who the patient is:
45 year old Rachel Fernandez came to A&E with severe abdominal pain.

What you should do:
Talk to her, take relevant history, discuss plan of management and address her concerns.

D: Hello Rachel, I am one of the doctors in the emergency department. Can I get your full name and age please.
P: Rachel Fernandez, I am 45 years old doctor.
(The patient might be in pain keeping a specific position so please don’t forget to acknowledge and reflect at once)
D: I can see you’re holding your tummy Rachel, are you in any pain now? How can I help you?
P: Yes, doctor I have severe pain in my upper tummy it’s very bad doctor.

P1: SOCRATES
D: Site: Where is the pain exactly?/ Can you point with one finger?
P: Epigastrium (all over tummy if Peritonitis)
D: Onset: How did it start?
P: Started Suddenly
D: Character: Can you describe the pain for me?
P: Severe, agonising pain.
D: Radiation: Does it go anywhere else?
P: It’s going to my back doctor.
D: Is it continuous or comes and goes?
P: It is continuous doctor.
D: Duration (time): when did it start exactly?
P: …… yesterday but got really bad today.
D: Alleviating factors: Does anything make it better ?
P: When I lean forward like this doctor (she might or might not be leaning forward with her chest)
D: Exacerbating Factors: Anything that makes it worse?
P: It’s always bad.
D: Severity: Can you score the pain for me on a scale from 1 to 10, 1 being the least and 10 being the highest pain possible?
P: 10 its very severe doctor.

You can reflect with one or two words here and show empathy with your facial expressions “Oh it sounds very painful, just a few more questions and I will do my best to help with the pain”

REMEMBER TO ACT :smiling_face:
D: Have you tried anything for the pain?
P: No doctor.
D: Anything else with the pain? Open Q before asking about DDx.
D: Have you got any nausea or vomiting, fever or diarrhoea?
D: Have you noticed any change in your skin colour lately?
P: No.

Remember any tummy pain means: Chest, Bowels, Urine & Genitals (maximum 1 or 2 Qs each)

DDx
D: Any cough or chest pain with it that goes to your left side? (If old age you must exclude MI.)
D: Any problems with your bowels recently like constipation?
D: Any pain while passing urine or change in its colour or smell ?
D: Any discharge from your front passage.
D: Any appetite change or weight loss lately? FLAWS

ICE:
D: Any idea what might be the cause? Were you doing anything specific before the pain started?
D: Do you have any specific concerns regarding this pain?
D: Apart from the pain are you expecting anything in particular today?

P2:
D: Have you ever had this pain before?
D: Do you have any medical conditions? Like any stones?
D: Have you ever been hospitalised or had any procedures like stone removal before?

MAFTOSA:
D: Are you currently on any medications?
D: Do you have any allergies?
D: Any similar tummy problems in your family?

DESA:
D: Do you smoke or drink alcohol? (It’s an emergency so only ask about these)

Examination:
D: Thank you for bearing with me so far. If you can bear with me a bit longer, I would like to take your observations BP, temperature, pulse and breathing rate, examine your tummy and do a general physical examination, if you don’t mind.

Provisional Diagnosis
From the information that you have given me, I suspect that you have inflammation called Acute pancreatitis. It is an inflammation that causes one of the major organs that shares in food digestion called the pancreas to become painful and swollen.

Management:
Most people with this condition start to feel better within about a week and have no further problems. But some people with severe acute pancreatitis can go on to develop serious complications.
Therefore we will need to take some urgent steps right now to confirm the diagnosis and start management as well.

  1. We will need to Admit you to the hospital ( v. important).
  2. I will involve my Senior as we will need to run some Investigations.
  3. Investigations:
  • Blood → All blood + Special Pancreatic markers called Amylase + Lipase. (Infection markers and blood sugar)
  • X-ray → erect on chest and abdomen (must exclude perforation).
  • US → to have a good visualisation of gall bladder to exclude stones and AA Aneurysm.
  • CT → Better picture of abdomen (and to exclude pancreatic necrosis). By senior.
  1. Mainly supportive + TTT Cause.
  • Painkillers: immediately
  • Fluids through your veins to prevent dehydration.
  • Oxygen through face mask or nasal cannula to make sure your body gets enough O2.
  • You may need Antibiotics if you have infection on top like chest or urine infection.

Nutrition:

  • If not feeling too sick we can encourage you to eat and drink normally.
  • But if the condition is more severe, better not to eat solid foods for a few days or longer to avoid too much strain on your pancreas. You will then be given a special liquid food mixture, with the nutrients you need, through a tube to your nose that reaches your tummy called a nasogastric tube (or NasoJejunal tube)

We will continue to monitor your observations, tummy symptoms, blood sugar and pancreatic markers.

  1. Managing the cause:
  • Advice against excessive alcohol consumption, discuss DESA advice at a later appointment when you feel better. (May be with the GP)
  • Discuss statins if high cholesterol.
  • If stones: Refer to specialist who will do further investigations and will give you options to remove the stones by a special camera test called ERCP or removing the gall bladder by a surgery.

  1. Safety net: Please ring this bell if you feel you’re getting worse or persistent pain, or if you feel drowsy, fever or not passing urine.

  2. Follow up: it improves within a few days or a week in most situations unless complications develop. Complications include:

  • Pseudocyst (resolves on its own).
  • Infection/necrosis which is treated by antibiotic according to hospital protocol and surgery.
  • Chronic pancreatitis.

IN A NUTSHELL:
1- ANALYSE PAIN VERY WELL (LEANING FORWARD)
2- STONES OR ALCOHOL AND FAMILY
3- PANCREATIC MARKERS (AMYLASE AND LIPASE)
4- MANAGEMENT ADMIT SUPPORTIVE
5- NUTRITION: EAT OR NG TUBE

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