A woman with acute upper abdominal pain

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Problem 14 A woman with acute upper abdominal pain

Duncan J. Stewart, Roger Ackroyd

A 57-year-old woman is admitted with a 2-day history of increasingly severe upper abdominal pain, radiating through to the back. Although initially colicky in nature, the pain is now constant. She has lost her appetite and has vomited on several occasions. Over the preceding months she has suffered with intermittent bouts of colicky upper abdominal pain that have lasted a few hours at a time. She has no allergies and is a non-smoker. She has no other significant past medical history, including no previous abdominal surgery. On examination she is overweight and looks unwell and dehydrated, although she is apyrexial. Her heart rate is 115 bpm and regular and her blood pressure is 130/90 mmHg. Respiratory examination reveals decreased air entry and dullness to percussion at the left base. Her abdomen is mildly distended and tender in the epigastrium and peri-umbilically. There are no palpable masses and although present, bowel sounds are infrequent.

Q.1

Based on the history and examination, briefly discuss the differential diagnoses.

To refine your list of differential diagnoses you order some investigations.

Q.2

Which initial investigations would you order and why?

The patient’s ECG reveals a sinus tachycardia and no other changes. Her chest X-ray is shown in Figure 14.1 and her blood test results are shown in Investigation 14.1. Her BMI is calculated to be 34 kg/m².

Figure 14.1

Investigation 14.1 Summary of results

Q.3

What do the investigations show, what is the likely diagnosis and what other investigations would you like at this point?

The results of the arterial blood gas analysis on inspired room air and the C-reactive protein (CRP) are shown in Investigation 14.2.

Investigation 14.2 Summary of results

Q.4

How would you initially manage this patient? How would you assess potential disease severity?

Overnight, she remains stable and begins to feel better.

Q.5

What is the likely underlying cause of the pancreatitis and what investigation should be performed to investigate this?

An ultrasound scan shows gallstones in a distended gallbladder, with dilatation of the intrahepatic bile ducts. The extrahepatic biliary tree and the pancreas are obscured by bowel gas.

Over the next 24 hours the patient deteriorates. She develops a pyrexia of 38.8°C and becomes jaundiced. She is transferred to the high dependency unit and her repeat blood results are shown in Investigation 14.3.

Investigation 14.3 Summary of results

Q.6

What radiological investigation(s) would now be appropriate?

The magnetic resonance cholangiopancreatogram is shown in Figure 14.2. The MRCP shows dilated intra- and extrahepatic ducts and a solitary stone (arrow) impacted at the bottom of the common bile duct. The pancreatic duct is also visible passing to the right of the picture.

Figure 14.2

Q.7

Given the clinical deterioration and the radiological findings, what is the next management step?

She has a successful sphincterotomy, duct clearance and stent insertion at ERCP and makes a prolonged, but otherwise uneventful recovery over the next 10 days.

Q.8

What are the remaining steps in the management of this patient?

Answers

A.1 The diagnoses to consider include acute pancreatitis, perforated peptic ulcer and acute cholecystitis. It is possible that she has been suffering with attacks of biliary colic for some time and, given the progressive nature of her pain and its radiation through to the back, acute pancreatitis would be the most likely clinical diagnosis. Although not always the case, you may expect the patient to have a rigid abdomen if the cause were a perforated peptic ulcer. It is important to consider the possibility of a myocardial infarction or a lower lobe pneumonia giving rise to similar symptoms, especially considering the findings on respiratory examination.

Other diagnoses to consider are ischaemic gut and intestinal obstruction. Ischaemic gut is a difficult diagnosis to make but may be more likely in those with pre-existing vascular disease or cardiac dysrythmias, particularly atrial fibrillation. There are few, if any, features to suggest the possibility of intestinal obstruction.

• Full blood count – an elevated white cell count would support the hypothesis of an inflammatory or infective process.

• Serum biochemistry – to gauge the degree of electrolyte disturbance from vomiting and also assess renal function and degree of dehydration. With upper abdominal pain and the possibility of biliary disease or obstruction, liver function tests are also important.

• Chest X-ray – to evaluate the findings on respiratory examination and to look for free sub-diaphragmatic gas.

• 12-lead electrocardiogram – the patient has what clinically appears to be a sinus tachycardia – and further evaluate the possibility of a cardiac cause for the pain.

• Serum amylase and lipase – grossly elevated levels would confirm acute pancreatitis.

A.3 The chest X-ray shows a small left-sided pleural effusion. The white cell count is elevated, as are the serum lipase and amylase estimations. Given the degree of hyperamylasaemia and hyperlipasaemia this patient almost certainly has acute pancreatitis. The clinical picture and the raised white cell count and blood glucose are certainly in keeping with this. A rise in the serum amylase to at least three times the upper limit of normal would be expected. Hyperamylasaemia to a lesser degree can, however, be associated with alternative intra-abdominal conditions such as acute cholecystitis and intestinal ischaemia. In situations of diagnostic difficulty, measurement of the serum lipase has a higher sensitivity and specificity than serum amylase.

She has deranged liver function tests, with an elevated alkaline phosphatase and a slightly raised bilirubin, although this is unlikely to be detectable clinically. It would be prudent to check the clotting profile in this circumstance.

She needs arterial blood gas analysis and a C-reactive protein measurement.

A.4 This patient needs careful management. Initially, she should be fluid resuscitated with intravenous crystalloids. She may require a considerable volume of fluid over the next few days because of the acute inflammatory response leading to fluid sequestration around the inflamed pancreas, within bowel loops and in the interstitial fluid compartment. She needs close monitoring of fluid input and output and will need a urinary catheter connected to an hourly drainage bag.

If vomiting is a problem, she may benefit from a nasogastric tube, although patients with acute pancreatitis may, if tolerated, benefit from oral intake and nasogastric feeding in an attempt to reduce the incidence of septic complications.

She will require opiate analgesia.

Given the presence of a small pleural effusion at presentation and oxygen saturations of 95% on air, she should have supplemental oxygen, although at this stage nasal cannulae with 2–4 L/minute will probably suffice. She will require regular measurement of oxygen saturations by pulse oximetry.

She will need regular monitoring of serum electrolytes, calcium and blood sugar. She may require supplemental calcium and intravenous sliding scale insulin therapy.

The Atlanta classification (1992) is the most widely used clinically based scoring system that stratifies patients as having either mild or severe disease depending largely on the severity of associated organ dysfunction, combined with the presence or absence of local and systemic complications. However, numerous attempts have been made to develop scoring systems with the aim of predicting which patients will go on to develop severe pancreatitis to allow early intensive monitoring and therapy. On admission, a BMI of >30 and the presence of a pleural effusion are predictive of severe disease. The acute physiology and chronic health evaluation (APACHE) II scoring system has been used in pancreatitis and can be applied to patients with acute pancreatitis from the time of admission. A score of >8 predicts severe disease. The modified Glasgow score consists of eight variables applied after 48 hours of admission. Each positive variable scores 1, with a total of ≥3 predicting severe pancreatitis (see revision points). A CRP of >150 IU after the first 24 hours is indicative of severe disease. However, much still depends on clinical impression of severity, especially if there is persistent or deteriorating organ failure extending beyond 48 hours after admission.

A.5 The most common cause of acute pancreatitis in Western medicine is gallstones. Every patient diagnosed with acute pancreatitis should have an abdominal ultrasound scan within 24 hours.

A.6 Given the presence of gallstones and dilated intrahepatic bile ducts on ultrasound, in conjunction with a rising serum bilirubin, a rising WCC and pyrexia, the most useful investigation is magnetic resonance cholangiopancreatography (MRCP) to confirm the presence of a stone within the bile duct.

Your patient is at risk of developing severe pancreatitis. With a BMI >30, she had a left pleural effusion at presentation, her CRP has risen to >150 mg/L and her modified Glasgow score is 5 (age > 55, WCC >15 × 10⁹/L, calcium <2 mmol/L, LDH >600 U/L and albumin <32 g/L).

A.7 She needs urgent endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy and stone extraction +/− removable stent insertion to ensure relief of biliary obstruction, ideally with 72 hours.

A.8 This patient needs a cholecystectomy. This should ideally be arranged within the same hospital admission and as a laparoscopic procedure. The biliary stent should be removed endoscopically once her gallbladder has been removed.

Revision Points

Presentation

Upper abdominal pain, nausea, vomiting and anorexia. Jaundice occurs less frequently.

Diagnosis and Investigations

• Serum amylase to confirm diagnosis.

• Chest X-ray to exclude visceral perforation.

• ECG to exclude cardiac causes of pain.

• Abdominal ultrasound scan within 24 hours to look for gallstones as a cause.

• Consider CT to assess for pancreatic perfusion, necrosis and peripancreatic fluid collections. This may be of limited management value within the first 4 days of the illness.

Management

• Usually supportive only. Fluid resuscitation, monitoring electrolytes, analgesia, ensuring adequate nutrition and determining cause. May need ERCP in the acute phase if gallstones the cause, especially with jaundice or cholangitis, to ensure adequate biliary drainage.

• Surgical necrosectomy occasionally required if necrotic, non-perfusing areas of pancreas and clinically deteriorating patient. If gallstones are the underlying cause, the patient will need a cholecystectomy.

Complications

Up to 85% of cases are mild and self-limiting with few complications. However, multi-organ failure can occur, with upper gastrointestinal haemorrhage, pancreatic abscess/necrosis and formation of pseudocyst.

Prognosis

Overall mortality 5–10%, although in severe haemorrhagic pancreatitis mortality may approach 90%.

Issues to Consider

• How would the management of this patient differ if the cause of the pancreatitis was alcohol related?

• What are the symptoms and signs associated with pseudocyst formation and how is this complication treated?

Further Information

Ayub K., Slavin J., Imada R. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database of Systematic Reviews. 2004. 2004, Issue 3. Art. No.: CD003630. DOI:10.1002/14651858.CD003630.pub2. Provides the evidence base for endoscopic intervention in patients with severe acute pancreatitis due to gallstones

Banks P.A., Freeman M.L. Practice guidelines in acute pancreatitis. American Journal of Gastroenterology. 2006;101:2379-2400. DOI: 10.1111/j.1572-0241.2006.00856.x The most recent American guidelines published. Advocate abandonment of the Ranson scoring system due to unacceptably poor predictive power

Bollen T.L., van Santvoort H.C., Besselink M.G., et al. The Atlanta classification of acute pancreatitis revisited. British Journal of Surgery. 2008;95:6-21.

Mofidi R., Patil P.V., Suttie S.A., et al. Risk assessment in acute pancreatitis. British Journal of Surgery. 2009;96:137-150.

UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut, 54. 2005:1-9. DOI:10.1136/gut.2004.057026 Provide a comprehensive management strategy for patients with acute pancreatitis. Represent the most recent European guidelines published. Updates available at http://gut.bmjjournals.com/cgi/content/full/54/suppl_3/iii1.

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