GI3 Case C Answers

In the triage unit of your ER you find a 37 yo male with past medical h/o of primary hyperparathyroidism status post right inferior parathyroidectomy 1 year ago, hyperlipidemia, HTN, temporal(giant cell) arteritis being treated with prednisone complaining of severe midepigastric abdominal pain that radiates to the back that started a few hours ago and has not abated in intensity since its start. His pain was so severe he's had two episodes of nonbloody, nonbilious vomiting a few hours ago that scared him to come into the ER at 4am. On questioning his activities earlier in the evening, he mentioned he attended his 20 year high school reunion which had a luxurious open bar selection. 

On Physical exam you note a low grade fever, tachypnea, tachycardia, upper abdominal tenderness with guarding but without rebound. You were not able to appreciate any bowel sounds. 

Abdominal Exam of Patient

Name these two physical exam findings:

Cullen's Sign: Bluish discoloration of the periumbilicus

Grey-Turner's sign: Bluish discoloration of the flanks

What is your suspected Dx?

Acute Pancreatitis

Name the 5 risk factors this patient presented with in your initial history of present illness

Hyperlipidemia

Possible recalcitrant hypercalcemia due to an undiscovered abnormal parathyroid gland

Vasculitis

Glucocorticoid Use

Alcohol abuse

Could possibly have cholelithiasis that caused it bc of his h/o hyperlipidemia

What are the two most common causes of your patient's disease?

Alcohol Abuse and Gallstones

Describe the pathophysiology behind the Most Common Cause of your diagnosis.

Alcohol thickens duct secretions and also increases duct permeability to enzymes

What lab study do you want to order to confirm your diagnosis?

Lipase Study

What other lab study, not specific to the diagnosis, will be elevated in this patient? Name four of the five areas in the body that produce this quantifiable lab study. 

Amylase. Also found in salivary glands, small bowel, overies, testes, and skeletal muscle. 

What is the most common cause of this disease in kids?

Seatbelt trauma

What kind of shock can you go into because of this disease? How does it relate to Third Space Fluid?

Hypovolemic Shock due to third space loss of fluids. 

"Third space fluid is sequestered fluid that is unavailable for maintenance of volume in the vascular compartment. In acute pancreatitis, it refers to the peripancreatic collection of fluid that commonly occurs as the pancreas auto-digests itself." Goljam

 What is the mechanism behind acute pancreatitis induced hypoxemia?

Circulating pancreatic phopholipase destroys surfactant…ARDS may occur

Why can you go into DC during pancreatitis?

Activation of prothrombin by trypsin

(Just kidding. Did you really think I'd make you draw it?)

A highlight on histological progression...

"Progressive loss of normal acinar cells (and later islet cells – marked as “*”) as chronic inflammation and fibrosis (light colored material) replaces the normal cells." -Pancreas.org