The first document describes a 45-year-old male presenting with abdominal pain rated 7/10 with nausea and vomiting who had consumed alcohol the night before. On examination, he had epigastric tenderness and a purple discoloration. The second document describes a 50-year-old female with sudden onset abdominal pain made worse by eating, fever, and jaundice on examination. The third document provides an overview of acute pancreatitis including causes, presentation, investigations, severity criteria, differential diagnoses, and management.

1. Scenario One
WHILE WORKING IN THE ED, A 45-YEAR-OLD MALE PRESENTS WITH ABDOMINAL PAIN.
HE DESCRIBES THE ABDOMINAL PAIN AS “SEVERE” AND GRADED IT A 7/10. THERE’S BEEN ASSOCIATED
EPISODES OF NAUSEA AND VOMITING.
HE MENTIONS THE PAIN RADIATED TO THE BACK BUT GETS BETTER WHEN HE LEANS FORWARD. HE HAD
JUST RETURNED FROM A PARTY THE NIGHT BEFORE WHERE HE HAD CONSUMED QUITE A LOT OF LAGERS.
ON EXAMINATION, THERE WAS EPIGASTRIC TENDERNESS, AND A PURPLE DISCOLORATION AROUND THE
PERIUMBILICAL REGION.

2. Scenario Two
 While in the ED, a 50-year-old female presents with sudden onset abdominal pain. She mentions
she felt warm to touch and her partner had noticed her eyes looked a bit yellow.
 She had taken paracetamol to help with the pain, but it wasn’t helping. She explained that the pain
seemed to be worse after eating meals.
 On examination, there was epigastric pain, radiating to the back, sclerus icterus, and a temperature
of 37.9

3. Acute Pancreatitis
By Dr. Gboneme Sandra
Junior Clinical Fellow in Medicine
George Eliot NHS Trust

4. Outline
 Introduction
 Theory
 Etiology
 History and Exam
 Investigations
 Criteria
 Treatment options
 Differentials
 Summary
 Questions ?

5. Introduction
 Acute Pancreatitis is an acute inflammation and hemorrhaging of the pancreas due to its own
digestive enzymes.
 It is a common cause of acute abdominal pain .
 Grouped into Mild, Moderate, Severe
 Mild: No systemic complications , or organ involvement
 Moderate; associated systemic complications or transient organ failure, resolves in 48 hours .
 Severe: resolves in greater than 48 hours.

6. Theory
 Pancreas is located retroperitoneally in the epigastric region.
 Pancreas plays both endocrine and exocrine role;
 Exocrine role: Acinar cells produce digestive enzymes that help digest food
 The pancreas protects itself by producing enzymes in their inactive form
 These enzymes are called zymogens/tripsinogen and are kept in zymogen granules.
 Usually, zymogens are activated by Proteases.

7. Etiology
Alcohol misuse
Gallstone migration
Middle aged women
Young to middle aged men
Hypertriglycerides
Use of causative drugs
Trauma
Hypercalcemia
Mumps
Family history of pancreatitis
Autoimmune Conditions
Pancreatic Cancer

8. History and Examination
 Mid-Epigastric Pain or Left upper quadrant
pain radiating to the back
 Nausea and Vomiting
 Signs of hypovolemia ( decreased skin turgor,
hypotension, oliguria)
 Signs of pleural effusion 9especially due to
pulmonary dysfunction)
 Anorexia/ Lack of appetite
 ABDOMINAL EXAM: Tender abdomen with
voluntary guarding
 Signs of SIRS: Tachypnoea, tachycardia,
temperature spikes
 Jaundice
 Cullen’s/Grey turner sign

10. Investigations
 SERUM TRYPSIN: Most accurate but not routinely available
 LIPASE
 AMYLASE
 ROUTINE BLOODS; FBC, U and E, LFT, CRP
 Calcium: Hypercalcemia and Hypocalcemia
 Serum Triglycerides ( if not gallstone or alcohol ) consider if >11.3 mmol
 IMAGING; Contrast Enhanced CT Abdo ( not necessary for diagnosis)

11. Bedside Index of Severity in Acute Pancreatitis
(BISAP) Score
 BUN > 8.9mmol/L (1 point)
 Abnormal mental status with a GCS of <15 (1 point)
 Evidence of SIRS (1 point )
 Patient age > 60 years old ( 1 point)
 Imaging Study reveals pleural effusion ( 1 point )
 0 to 2 points: Lower Mortality
 3 to 5 points: Higher Mortality

12. APACHE II

13. Treatment
 ABC of Resuscitation
 FLUID RESUSCITATION
 Pain control
 Antiemetic
 Alcohol related: Replace Thiamine and other vitamins
 Antibiotics if infection is implicated
 Early nutritional support, parenteral if neccessary

14. Differentials
 PUD
 Intestinal obstruction
 Cholecystitis
 Hepatitis

15. Summary
 In Summary, Acute pancreatitis is a common presentation in
the ED, and is one that should not be missed.
 It requires a high index of suspicion with alcohol and
gallstones being the most common causes .
 With regards to investigations; Serum Lipase/Amylase is the
key investigation and tends to be 3x the higher normal
 Fluid resuscitation is important, as well as pain control.

16. Scenario three
 A 60-year-old man comes to the emergency complaining of severe epigastric abdominal pain that
radiates to the back. Pain improves when he leans forward. It is worse when he breathes in deeply.
He also complains of nausea, vomiting and loss of appetite. He smokes 10 cigarettes and drinks 14
units of alcohol per day.
 On examination, he has tachycardia, tachypnoea and low blood pressure. There are decreased
breath sounds over the base of his left lung.
 His routine Bloods showed: BUN 9.9mmol, WBC; 14,000, CRP: 117, Neut: 11,000, adjusted calcium:
2.0
 What is his BISAP score ?
 What extra tests would you request?
 What management would you recommend ?

17. Questions?
Thank you very much.