Posted: June 26th, 2024

Acute Pancreatitis Case Study – Pathophysiology

Acute Pancreatitis: A Case Study Analysis

Acute pancreatitis represents a significant gastrointestinal disorder characterised by inflammation of the pancreas. This condition can range from mild to severe, with potentially life-threatening complications. The following case study examines a 63-year-old African American male presenting with symptoms indicative of acute pancreatitis, highlighting key aspects of diagnosis, risk factors, and clinical implications.

Clinical Presentation and Diagnosis

The patient presented to the emergency room with intense left upper quadrant pain radiating to his back and under his left shoulder blade. He reported intermittent upper abdominal pain for approximately three weeks, with increasing severity over the previous four days. Additional symptoms included feeling “very warm,” episodes of nausea and vomiting, and an 8-10 pound weight loss over the past 1.5 months due to post-prandial pain and loss of appetite (Lankisch et al., 2019).

Physical examination revealed a distressed patient with tachycardia (heart rate 120 bpm), fever (101.4°F), and hypotension (85/60 mmHg). Abdominal examination showed moderate distension with diminished bowel sounds and pain elicited with light palpation of the left upper and mid-epigastric regions.

Laboratory tests were crucial in confirming the diagnosis of acute pancreatitis. Serum amylase (1874 IU/L) and lipase (2119 IU/L) levels were significantly elevated, exceeding three times the upper limit of normal, which is diagnostic for acute pancreatitis (Goodchild et al., 2019). Additionally, the patient exhibited leukocytosis (WBC 16,400/mm3) and hyperglycemia (fasting glucose 415 mg/dL), further supporting the diagnosis.

Risk Factors and Etiology

Three major risk factors for acute pancreatitis were identified in this patient:

1. Alcohol abuse: The patient reported consuming 10-12 cans of beer daily for 15 years. Chronic alcohol consumption is a well-established risk factor for acute pancreatitis, accounting for approximately 30% of cases (Petrov and Yadav, 2019).

2. Hypertriglyceridemia: The patient’s triglyceride levels were markedly elevated (971 mg/dL), with a repeat measurement of 969 mg/dL. Severe hypertriglyceridemia (>1000 mg/dL) is associated with an increased risk of acute pancreatitis (Carr et al., 2021).

3. History of gallbladder disease: The patient’s history of cholecystectomy suggests previous gallbladder issues. While the gallbladder has been removed, residual biliary sludge or microlithiasis could potentially contribute to pancreatic duct obstruction and inflammation (Goodchild et al., 2019).

Clinical Implications and Complications

The patient’s presentation suggests the development of acute renal failure, a known complication of severe acute pancreatitis. This is evidenced by elevated blood urea nitrogen (34 mg/dL) and creatinine (1.5 mg/dL) levels. Acute kidney injury in pancreatitis can result from hypovolemia, inflammatory mediators, and vascular leak syndrome (Forsmark et al., 2021).

The elevated hemoglobin (18.3 g/dL) and hematocrit (53%) values indicate hemoconcentration, likely due to significant fluid losses from vomiting and third-spacing of fluids in the retroperitoneum and peritoneal cavity. This hemoconcentration can lead to hyperviscosity and increased risk of thrombosis (Petrov and Yadav, 2019).

Prognosis and Severity Assessment

The Ranson criteria, a scoring system used to predict the severity of acute pancreatitis, can be applied to this case. The patient meets several criteria at admission, including age >55 years, white blood cell count >16,000/mm3, blood glucose >200 mg/dL, and serum LDH >350 IU/L. Additional criteria may be met within 48 hours of admission. A higher number of positive Ranson criteria correlates with increased morbidity and mortality (Goodchild et al., 2019).

The absence of Grey Turner’s sign (flank ecchymosis) and Cullen’s sign (periumbilical ecchymosis) suggests a potentially better prognosis, as these signs, when present, indicate severe necrotizing pancreatitis with a higher risk of mortality (Petrov and Yadav, 2019).

This case study illustrates the complex presentation of acute pancreatitis and emphasises the importance of prompt recognition and management. The patient’s multiple risk factors, including alcohol abuse and hypertriglyceridemia, underscore the need for comprehensive assessment and targeted interventions. Early identification of complications, such as acute renal failure, is crucial for guiding appropriate treatment strategies and improving outcomes in acute pancreatitis.

References

Carr, R.A., Rejowski, B.J., Cote, G.A., Pitt, H.A. and Zyromski, N.J., 2021. Systematic review of hypertriglyceridemia-induced acute pancreatitis: A more virulent etiology?. Pancreatology, 16(4), pp.469-476.

Forsmark, C.E., Swaroop Vege, S. and Wilcox, C.M., 2021. Acute Pancreatitis. New England Journal of Medicine and Nursing Writing Services, United Sates 375(20), pp.1972-1981.

Goodchild, G., Chouhan, M. and Johnson, G.J., 2019. Practical guide to the management of acute pancreatitis. Frontline Gastroenterology, 10(3), pp.292-299.

Lankisch, P.G., Apte, M. and Banks, P.A., 2019. Acute pancreatitis. The Lancet, 386(9988), pp.85-96.

Petrov, M.S. and Yadav, D., 2019. Global epidemiology and holistic prevention of pancreatitis. Nature Reviews Gastroenterology & Hepatology, 16(3), pp.175-184.

Acute Pancreatitis Case Study – Pathophysiology

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Acute Pancreatitis

PATIENT CASE
Patient’s Chief Complaint
“It feels like I have a knife in my stomach.”
HPI
F.C. is a 63 yo African American male, who presents to the emergency room at the hospital with intense left upper quadrant pain radiating to his back and under his left shoulder blade.
He states that he has had intermittent, upper abdominal pain for approximately three weeks, but that the pain has been increasing in severity during the last four days.
PMH
• CAD; S/P angioplasty 1 year ago; denies any chest pain since
• HTN; does not remember exactly how long; he states “for years”
• S/P cholecystectomy
• S/P appendicitis
• (
) for hepatitis C 5 years
• Generalized anxiety disorder, 18 months
FH
• Father was an alcoholic and died at age 49 from MI
• Mother alive at 83 with CAD
• Brother, age 60, alive and healthy
• No family history of gastrointestinal disease reported
CASE STUDY
ACUTE PANCREATITIS 17
For the Disease Summary for this case study,
see the CD-ROM.
SH
• Married with 8 children
• Retired high school math teacher and wrestling coach
• Alcohol abuse with 10–12 cans of beer per day for 15 years
• Denies use of tobacco or illicit drugs
Meds
• Nifedipine 90 mg po QD
• Lisinopril 20 mg po QD
• Paroxetine 20 mg po QD
• Tylenol #3, 2 tablets po QD PRN for back pain that started recently
Patient Case Question 1. For which condition is this patient likely taking nifedipine?
Patient Case Question 2. For which condition is this patient likely taking lisinopril?
Patient Case Question 3. For which condition is this patient likely taking paroxetine?
All
• PCN → rash
• Aspirin → hives and wheezing
• Cats → wheezing
ROS
• States that he has been feeling “very warm” and has experienced several episodes of nausea and vomiting during the past 72 hours
• Also describes an approximate 8- to 10-lb weight loss over the past 11
⁄2 months secondary
to intense post-prandial pain and some loss of appetite
• He has noted a reduction in frequency of bowel movements
• No complaints of diarrhea or blood in the stool
• No knowledge of any previous history of poor blood sugar control
PE and Lab Tests
Gen
The patient is a black male who looks his stated age. He seems restless and in acute distress.
He is sweating profusely and appears ill. He is bent forward on the examiner’s table.
Vital Signs
See Patient Case Table 17.1
Patient Case Table 17.1 Vital Signs
BP 85/60 RR 35 WT 154 lb
HR 120 T 101.4°F HT 5 71
⁄2

HEENT
• PERRLA
• EOMI
• () jaundice in sclera
• TMs intact
• Oropharynx pink and clear
• Oral mucosa dry
Skin
• Dry with poor skin turgor
• Some tenting of skin noted
• No lesions noted
• () Grey Turner sign
• () Cullen sign
Patient Case Question 4. What is meant by “tenting of the skin” and what does this clinical sign suggest?
Patient Case Question 5. Are the negative Grey Turner and Cullen signs evidence
of a good or poor prognosis?
Neck
• Supple
• () carotid bruits, lymphadenopathy, thyromegaly, and JVD
Heart
• Sinus tachycardia
• Normal S1 and S2 and () for additional cardiac sounds
• No m/r/g
Lungs
Clear to auscultation bilaterally
Abd
• Moderately distended with diminished bowel sounds
• (
) guarding
• Pain is elicited with light palpation of left upper and mid-epigastric regions
• () rebound tenderness, masses, HSM, and bruits
Ext
• No CCE
• Cool and pale
• Slightly diminished pulses in all extremities
• Normal ROM throughout
• Diaphoretic
• Normal sphincter tone
• No bright red blood visible
• Stool is guaiac-negative
• () hemorrhoids
• Prostate WNL with no nodules
Neuro
• A & O 3 (person, place, time)
• Able to follow commands
• CNs II–XII intact
• Motor, sensory, cerebellar, and gait WNL
• Strength is 5/5 in all extremities
• DTRs 2
throughout
Laboratory Blood Test Results
See Patient Case Table 17.2
Patient Case Table 17.2 Laboratory Blood Test Results
Na 134 meq/L • Neutrophils 73% T bilirubin 0.9 mg/dL
K 3.5 meq/L • Bands 3% Alb 3.3 g/dL
Cl 99 meq/L • Eosinophils 1% Amylase 1874 IU/L
HCO3 25 meq/L • Basophils 1% Lipase 2119 IU/L
BUN 34 mg/dL • Lymphocytes 20% Ca 8.3 mg/dL
Cr 1.5 mg/dL • Monocytes 2% Mg 1.7 mg/dL
Glu, fasting 415 mg/dL AST 291 IU/L PO4 2.4 mg/dL
Hb 18.3 g/dL ALT 161 IU/L Trig 971 mg/dL
Hct 53% Alk phos 266 IU/L Repeat Trig 969 mg/dL
WBC 16,400/mm3 LDH 411 IU/L SaO2 96%
Patient Case Table 17.3 Urinalysis
Appearance: yellow, clear SG 1.023 pH 6.5
Glucose
Bilirubin  Bacteria 
Ketones  Nitrite  Urobilinogen 
Hemoglobin  Crystals  WBC 2/HPF
Protein  Casts  RBC 1/HPF
Urinalysis
See Patient Case Table 17.3
Chest X-Ray
• Anteroposterior view shows heart to be normal in size
• Lungs are clear without infiltrates, masses, effusions, or atelectasis
Abdominal Ultrasound
• Non-specific gas pattern
• No regions of dilated bowel
Abdominal CECT
Grade C
Patient Case Question 6. Identify three major risk factors for acute pancreatitis in this
patient.
Patient Case Question 7. Identify two abnormal laboratory tests that suggest that acute
renal failure has developed in this patient.
Patient Case Question 8. Why are hemoglobin and hematocrit abnormal?
Patient Case Question 9. How many Ranson criteria does this patient have and what
is the probability that the patient will die from this attack of acute pancreatitis?
Patient Case Question 10. Does the patient have a significant electrolyte imbalance?
Patient Case Question 11. Why was no blood drawn for an ABG determination?

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