58 year old Male with c/o pain abdomen since 2 days

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 Patient came to causality with c/o pain abdomen since day before yesterday evening . 

Hopi - patient was apparently alright till day before yesterday evening then he had pain in the epigastric region which is sudden in onset , gradually progressive , dragging type of pain , radiating to the umbilical region not associated with nausea and vomiting . Aggravating on taking food 

No c/o fever , cold , cough , chest pain , SOB

Past history: similar complaints in the past in jan 2023 and jul 2023 , admitted in our hospital and treated as Alcoholic liver disease .

Personal history : bowel and bladder are regular . 

Alcohol- daily 90ml since 30 yrs . Last drink day before yesterday. 

Smoking - smokes chutta since 30 yrs . Daily 16 chutta .

General examination;

No pallor ,  icterus,cyanosis, clubbing,pedal edema , no lymphadenopathy

Vitals 

Temp- afebrile 

PR - 82 bpm

BP- 140/100mmHg

RR- 16CPM

Systemic examination

CVS- S1,S2 heard,no murmurs

RS - BLAE, NVBS  

Per abdomen - Tenderness present in the epigastric region and left lumbar region 

CNS -  patient is conscious coherent and cooperative. 

No neck stiffness 

NORMAL

MOTOR SYSTEM-      

TONE    UL  LL         

RT    N   N

LT     N    N

SENSORY SYTEM - NORMAL

GLASGOW SCALE- 15/15

REFLEXES  

BICEPS   TRICEPS  SUPINATOR  

RT 2+        2+             2+

LT  2+        2+             2+

KNEE ANKLE

RT     2+     2+

LT      2+     2+

Provisional diagnosis: ? Acute pancreatitis 

? Alcoholic hepatitis

Investigations: 

Chest x ray -  

Treatment: 

1.Nil per oral 

2.NS and RL 125ml/hr , DNS -25ml/hr

3.Inj . Thiamine 500mg in 100ml NS Over 20min OD 

4.Inj.optineuron 1amp IV /OD 

5.Inj.Tramadol 1amp in 100ml NS IV/sos

6.Tab. Lorazepam Po/TID 

Osce questions : 

1. What is the diagnostic criteria for acute pancreatitis? 

Ans : 1) symptoms of pancreatitis like epigastric pain 

          2) three fold rise of serum amylase and serum lipase .

           3) radiological features suggestive of pancreatitis 

2. How does alcoholic hepatitis can cause portal hypertension? 

Ans : there are various mechanisms which cause portal hypertension in alcoholic hepatitis patients including increased inflammation , increased intrahepatic vasoconstriction , increased portal inflow . 

For detailed explanation please visit below link - 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10075503/

3. Is this patient has increased risk of developing portal HTN ? 

Ans : Yes , because this is his 3rd episode in nearly 10 months . He doesn’t stop alcohol even after first 2 episodes which can aggravate his liver injury and can cause portal HTN by above mentioned mechanisms.

4.What are the key elements in the patient's history that raise suspicion for acute pancreatitis?How would you explore the patient's alcohol history further to assess the severity of alcohol use disorder?

1. Ans :
2. Key Elements in Patient's History: Sudden onset, gradually progressive epigastric pain radiating to the umbilical region, aggravated by food intake, history of alcohol consumption, previous admissions for similar complaints in Jan 2023 and Jul 2023.
3. Exploring Alcohol History: Further inquire about the patient's daily alcohol intake, any recent changes in drinking patterns, and any attempts at reducing alcohol consumption. Use validated screening tools like AUDIT (Alcohol Use Disorders Identification Test).

5.What other conditions would you consider in the differential diagnosis for a patient presenting with epigastric pain and a history of alcohol consumption?How would you differentiate between acute pancreatitis and alcoholic hepatitis based on the provided information?

1. Ans :
2. Conditions to Consider: Differential diagnoses include acute pancreatitis, alcoholic hepatitis, peptic ulcer disease, and biliary colic.
3. Differentiating Acute Pancreatitis and Alcoholic Hepatitis: Look for serum amylase and lipase levels, imaging findings (e.g., CT scan), and specific liver function tests. Acute pancreatitis often presents with elevated amylase and lipase, while alcoholic hepatitis shows elevated transaminases with a significant history of alcohol abuse.

5.Explain the rationale behind the medications prescribed, including thiamine, optineuron, tramadol, and lorazepam.How would you monitor the patient's response to treatment, and what criteria would indicate improvement?

Ans :

1. • Rationale for Medications:
     • Thiamine: To prevent Wernicke's encephalopathy, common in chronic alcohol users.
     • Optineuron: A combination of vitamins to address potential nutritional deficiencies.
     • Tramadol: For pain relief.
     • Lorazepam: To manage alcohol withdrawal symptoms.
   • Monitoring Response: Evaluate the resolution of pain, improvement in vital signs, and serial laboratory tests (e.g., amylase, lipase, liver function tests) to gauge treatment effectiveness. Consider imaging follow-up for further assessment.

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