Case 29


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.

Physical examination

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.



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:



Intestinal obstruction, ischaemia or perforation.

Acute appendicitis.

Renal failure.


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?





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).




Drugs (including valproate 3).

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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 29
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