A patient presenting with epigastric pain and vomiting.
A 54 years gentle man presents with epigastric pain and vomiting for 7 hours. He gives h/o heavy meal and alcohol intake last night. He also complains dizziness.
What are the diagnoses striking in your mind?
- Acute pancreatitis
- Peptic ulcer disease
- Acute myocardial infarction (inferior)
What key questions would you ask?
Pain– High epigastric severe constant pain with radiation to back, relieved by sitting
up or stooping forward- Acute pancreatitis.
Epigastric discomfort or burning or gnawing pain with anorexia and vomiting,
no radiation- peptic ulcer.
Epigastric heaviness or constricting pain, vomiting, sweating and dizziness.
h/o IHD, HTN, DM- suspect MI.
Vomiting– content of vomitus
History of NSAIDS- peptic ulcer
History of alcohol- acute pancreatitis
What will you examine?
General examination- pallor, sweating may be present.
Abdominal examination- Inappropriate tenderness in high epigastrium (e.g. severe tenderness with little guarding and rigidity) – acute pancreatitis.
Tenderness in epigastrium on palpation- peptic ulcer
Epigastric pain without tenderness, Angor animi (feeling of impending death), hypotension, cardiac arrhythmias- myocardial infarction.
Clinical diagnosis-History of alcohol intake, epigastric pain with inappropriate high epigastric tenderness clinches the diagnosis of acute pancreatitis.
Investigation-
ECG-to exclude MI
Serum amylase- raised (more than 3 fold of upper normal limit is significant)
USG of pancreas- swollen pancreas but may be normal upto 24 hours.
RBS- hyperglycaemia.
CBC- Leucocytosis (10,000–30,000/cmm).
Other investigations- urea and electrolytes, serum calcium, arterial blood gas analysis (to assess severity and complications) and endoscopy of upper GI tract-usually not available at primary and secondary level.
Treatment-
Initial management-
All patients with acute pancreatitis should be hospitalized.
The pancreas is “rested” by a regimen of
- withholding food and liquids by mouth,
- bed rest, and,
- nasogastric suction if patients with moderately severe pain or ileus and abdominal distention or vomiting,.
- Parenteral nutrition
Pain is controlled with pethidine or tramadol
Correction of hypovolaemia using normal saline and/or colloids.
Referral to tertiary level hospital as all severe cases should be managed in a
high-dependency or intensive care unit.