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June 2015: Abdomen

A 46 year old safety officer presents to the sick bay with a complaint of intermittent epigastric pain for the past week which has now become constant. The pain at times radiates through to his back and when it is severe it is associated with nausea and vomiting. The patient had a similar episode approximately one year ago although pain was more localized to the right upper quadrant, which resolved on its own at that time. He is on day 17/21 of his hitch.

 

On review of systems he denies fever, chills, joint or muscle pains, but has noticed general weakness.  The patient denies chest pain, shortness of breath, dizziness or vision changes.

 

  • Past History: cholelithiasis (gallstones), mild hypertension
  • Past Surgical History: Hernia repair, tonsillectomy
  • Current Medications: Prinivil (lisinopril) 40mg/d, multivitamin
  • Allergies: NKDA
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Social drinker, smokes ½ a pack a day
  • Family History: Mother had gallbladder removed; father had peptic ulcer disease and coronary artery disease (CAD)

Vitals

  • Temp 99.1
  • Pulse 96
  • Respirations 22 (shallow)
  • Blood pressure 146/100
  • Pulse Ox 98% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress although patient appears to be very uncomfortable however sitting up with knees flexed or on his side in a knee/chest position seems to alleviate some discomfort, skin cool and dry
  • HEENT: AT/NC, eyes anicteric, TMs clear, Nose clear, mucus membranes somewhat dry, no lesions appreciated
  • Cardio: regular rhythm and rate, no murmurs appreciated
  • Lung: clear to auscultation bilaterally
  • Back: no CVAT although patient appears uncomfortable from the percussion
  • Abdomen: soft, mildly distended, bowel sounds diminished in all 4 quadrants, generalized tenderness noted with rebound and voluntary guarding
  • Extremities: no clubbing, cyanosis or edema
  • Skin: Cool and dry, no rashes, anicteric

Lab Work

  •  Orthostatics: Positive
  •  Rapid Flu: Negative
  • UA:
    • Specific gravity >1.030
    • pH 6
    • Blood trace
    • WBCs negative
    • Bilirubin small
    • Urobilinogen trace
    • Protein small
    • Ketones large

 

 

How would you approach this patient?

 

Differential Diagnosis

  • Cholecystitis
  • Peptic Ulcer Disease (PUD)
  • Pancreatitis
  • Appendicitis
  • Hepatitis
  • Angina Pectoris
  • Renal Cholic (Kidney Stone)
  • Abdominal Aortic Aneurism
  • Duodenitis
  • Colitis
  • Pyelonephritis

 

Diagnosis: Pancreatitis secondary to biliary stones

 

Treatment

  • NPO
  • IV Fluids
  • Morphine titrate 2mg increments for pain control while monitoring blood pressure and respiratory rate
  • MEDEVAC for further work-up, definitive diagnosis and treatment

 

Discussion

Abdominal pain is one of the most challenging presentations in the remote environment. Looking at the differential diagnosis above, all of these entities must be considered and ruled in/out. The list should go from highest index of suspicion to lowest. This patient’s presentation gives the remote practitioner certain clues leading him/her to the most likely entity on the differential diagnosis.

 

Pancreatitis can stem from a number of etiologies with the most common being biliary stones which become trapped in the pancreatic duct. This accounts for ~35-40% of all cases. The second most frequent cause is alcohol related.

 

The features in this case which pointed to the diagnosis included a previous history of similar colicky like pain. The pain is colicky in nature due to “a ball valve effect” of stones obstructing and then migrating from the pancreatic duct. The constant pain comes from a completely obstructed duct. The net effect of the obstruction is severe pain, chemical peritonitis causing an ileus manifested by decreased bowel sounds, abdominal distention, nausea and vomiting. The patient will also “3rd space” fluid into the abdomen which along with decreased intake and vomiting giving us positive orthostatics due to volume depletion. Lastly we will notice decreased urine output with a urine that is concentrated and may also demonstrate as ours does other abnormalities either associated or not associated with this disease.

 

Definitive treatment typically includes keeping the patient NPO, IV hydration, pain control, hyperalimentation. It can also require IV antibiotics, surgical intervention and can become a chronic problem with repeated episodes depending on the etiology.

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