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Case Management Presentation and Discussion and Sharing of Information on Acute Non-Surgical Abdomen

Benjamin C. Deveza, M.D.

General Data :

E.N., 525-year-old female
Tondo, Manila

Chief complaint :

abdominal pain
History of Present Illness

Past Medical History

Family History
(+) HPN – mother

Personal History
Occasional alcoholic beverage drinker

Physical Examination
Conscious, coherent, ambulatory, not in cardiorespiratory distress
BP 110/80 PR 86 RR 18 T 37
Pink palpebral conjunctiva, anicteric sclerae, supple neck, no CLAD
Symmetrical chest expansion, no retractions, clear breath sounds,
Physical Examination
Adynamic precordium, with regular rate, rhythm
Flat, normoactive bowel sounds, soft, (+) direct tenderness, epigastric area; no muscle guarding
Pulses full and equal; no edema, cyanosis
Case Discussion
Salient Features
25-year-old female
sudden onset of severe epigastric pain
boring, radiating to the back
(+) intake of alcohol
(+) direct tenderness, epigastric area

Acute Non-Surgical Abdomen

Acute Non-Surgical Abdomen

Acute Non-Surgical Abdomen

Acute Non-Surgical Abdomen

Acute Non-Surgical Abdomen

Do I need a Paraclinical Diagnostic procedure?
- Yes. To increase my degree of certainty

Paraclinical Diagnostic Procedures
Paraclinical Diagnostic Procedures

On admission, the following laboratory exams were done :

CBC Hgb 12.7
Hct 4.8
WBC 19.1
Plt 518
Lipase 1,180

Pre-Treatment Diagnosis
Goals of treatment
Relief of pain
Prevention of complications
Treatment options
Treatment options
Course in the Wards
On admission

IVF PNSS x 4 hrs
IV meds : Meperidine HCl 50 mg TIV q 8
Ranitidine 50 mg TIV q 8

Course in the Wards
On the 2nd Hospital Day
soft diet
IV meds continued
decrease in abdominal pain
Course in the Wards
On the 3rd Hospital Day

Resolution of symptoms
Patient was discharged improved

Final Diagnosis

Sharing of Information
Acute Non Surgical Abdomen

- Any abdominal condition acute in onset requiring no immediate/urgent surgical intervention or may not need surgery at all

Sharing of Information
Common acute non- surgical abdomen cases
- Acute Renal Colic
- Acute Cholecystitis
- Peptic Ulcer Disease/ Gastritis
- Pancreatitis
- Non Specific Abdominal Pain
- Acute Gastroenteritis
- Intestinal obstruction
- GI Bleeding

Sharing of Information
Acute Pancreatitis
An inflammatory disease of the pancreas that is associated with little or no fibrosisof the gland.
Initiated by several factors :

- pancreatitis begins with the activation of digective zymogens inside acinar cells which cause acinar cell injury
- the ultimate severity of the resulting pancreatitis maybe determined by the events that occur subsequent to acinar cell injury
inflammatory cell recruitment and activation
generation and release of cytokines
Sharing of Information
- Presentation
Young patients present with acute pancreatitis secondary to alcohol consumption
Estimated consumption of alcohol per day in patients with pancreatitis is about 150 g but it can occur in persons consuming only 50 g / day (approx four 12-oz servings of beer with 3-5% alcohol content.)
In contrast, biliary pancreatitis occurs in older patients
Sharing of Information
- Presentation
mild to severe epigastric pain which radiates to the back and flanks
pain is constant, dull, boring or “knifing”
worse when patient is supine
nausea and vomiting are present in 75-90% of patients

Sharing of Information
Laboratory exams :
Amylase - most widely used; levels vary depending on the severity of the disease
- starts increasing from 2-12 hrs after the onset of symptoms and peaks at 12-72 hrs
- returns to normal within one week
Sharing of Information
Laboratory exams :
Lipase - starts increasing within 4-8 hrs after the onset of symptoms and peaks at 24 hrs
- returns to normal within 8-14 days
Sharing of Information
Laboratory exams :
Trypsin – based on median sensitivities and specificities, an elevated trypsin level has a better likelihood ratio for detecting pancreatitis
- the most accurate indicator
Sharing of Information
Ultrasonography - acceptable study for initial evaluation when biliary causes are suspected
CT scan – provides the best imaging of the pancreas and surrounding structures
- helpful in assessing complications related to acute pancreatitis or as a follow-up study in patients who are clinically deteriorating

Sharing of Information
CT scan - findings are : diffuse enlargement of the pancreas with irregular contour and obliteration of peripancreatic fat, necrosis or pseudocyst

Medical management of mild acute pancreatitis is relatively straightforward :
- patient is kept NPO
- adequate hydration
- analgesics
- antibiotics are generally not indicated
Indication for Surgery
Infected pancreatic necrosis is the major risk factor with regards to morbidity and mortality in severe acute pancreatitis
Surgery for sterile necrosis can be recommended in selected cases but infected pancreatic necrosis is a well-accepted indication for surgery.
Surgery is postponed until 4 weeks after the onset of symptoms as necrosis is well demarcated at that time
Indication for Surgery
Two techniques can be performed :
necrosectomy combined with closed continous local lavage
open drainage

* selection of these techniques depends on the extent of infected peripancreatic fat necrosis
Potential Complications of Acute Pancreatitis
Acute Renal Failure
Adynamic Ileus
Circulatory Shock
Pancreatic Necrosis
Extrapancreatic necrosis

Cameron,J.L. Current Surgical Therapy 8th Ed; 2004: 663-664
Rhoads, J.E. Textbook of Surgery Principles and Practice 5th Ed; vol 1 :
Schwartz, S.I. Principles of Surgery 8th Ed 2005
Harrison’s Principles of Internal Medicine 14 th Ed 1998
McKellar, D.P. Prognosis and Outcomes in Surgical Disease. 1999
Clinical Gastroenterology – Acute Pancreatitis
Munoz, A. Diagnosis and Management of Acute Pacreatitis

MCQ : Choose the best answer

1. What is the most accurate laboratory indicator to confirm the diagnosis of acute pancreatitis?
a. amylase
b. lipase
c. trypsin
d. elastase

2. What is the preferred analgesic for treating the pain of acute pancreatitis?

a. Tramadol
b. Morphine
c. Mefenamic Acid
d. Meperidine

Direction: Write
“A” if 1, 2, and 3 are valid statements.
“B” if only 1 and 3 are valid statements.
“C” if only 2 and 4 are valid statements.
“D” if only 4 is a valid statement.
“E” if all are valid statements.

3. What are the factors that have been implicated in causation of acute pancreatitis which account for 80-90% of cases?
1. infection
2. alcoholism
3. trauma
4. biliary tract stone disease

4. What are the systems used in determining
prognosis in patients diagnosed with acute pancreatitis?
1. Ranson’s criteria
2. APACHE II scale
3. Multiple organ system failure(MOSF) scale

4. Jones criteria

5. What are the complications of acute pancreatitis ?

1. sepsis
2. shock
3. ARF
4. hypovolemia


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