History
A 45-year-old lady with a history of bipolar affective disorder on long- term valproate presents to the emergency department with a 1-day history of severe epigastric pain radiating to the back. She describes the pain as sharp in nature with a pain score of 8 out of 10. She is a non-drinker.
•Temperature 37.5°C, pulse 115 bpm, BP 120/70mmHg, SaO2 98-100% on RA.
•Moderate dehydration.
•Examination of the hands reveals no clubbing, normal-appearing palmar creases and warm peripheries.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with moderate epigastric tenderness and no pulsatile mass. Murphy’s sign is negative.
•No signs of oedema.
Investigations
•CBC:
–WBC 17 x 109/L;
–haemoglobin 12g/dL;
–platelets 286 x 109/L.
•Total bilirubin 20μmol/L.
•ALP 47 IU/L.
•ALT 22 IU/L.
•Albumin 36g/L.
•Amylase 2130 IU/L.
•Creatinine 230μmol/L.
•Urea 15mmol/L.
What is your differential diagnosis?
•Acute pancreatitis (most likely).
•Ruptured/dissecting abdominal aortic aneurysm (AAA).
•Mesenteric ischaemia or infarction.
•Perforated gastric or duodenal ulcer.
•Biliary colic/cholecystitis.
What are the causes of elevated serum amylase 1?
•Acute pancreatitis.
•Other pancreatic disease:
–pancreatic pseudocyst;
–pancreatic carcinoma.
•Biliary tract disease:
–cholecystitis;
–cholangitis.
•Intestinal obstruction, ischaemia or perforation.
•Acute appendicitis.
•Renal failure.
•Macroamylasaemia.
•Gynaecological disease: ovarian tumour, ectopic pregnancy.
•Diabetic ketoacidosis.
How would you make a diagnosis of acute pancreatitis?
The diagnosis of acute pancreatitis is made with any two out of the three following criteria 2:
•Abdominal pain consistent with the disease.
•Serum amylase or lipase >3x upper limit.
•Characteristic findings from abdominal imaging.
What are the causes of acute pancreatitis 1?
•Biliary:
–gallstones;
–microlithiasis.
•Alcohol.
•Anatomic variants:
–pancreas divisum;
–choledochal cyst;
–duodenal duplication;
–duodenal diverticula.
•Mechanical obstructions to the flow of pancreatic juice:
–ampullary: benign and malignant tumours, stricture or dysfunction of the sphincter of Oddi;
–ductal: stones, strictures, masses (including tumours), mucus (e.g. in intraductal papillary mucinous neoplasms), parasites (Ascaris).
•Metabolic:
–hypercalcaemia;
–hypertriglyceridaemia.
•Drugs (including valproate 3).
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