19 Case 3-2017: A 40-year-old female with epigastric pain, nausea and vomiting

Acute Pancreatitis: An Atypical Presentation. Case reports in gastroenterology, 2017, 11(2), 359–363. https://doi.org/10.1159/000475920

Nadhem, O., & Salh, O.

Case Summary 1

A 40-year-old woman is presented with severe, sharp epigastric  pain radiating to the back with symptoms of nausea and vomiting. She has a medical history of hypertension and cholecystectomy three years prior to this hospital admission. Upon examination epigastric tenderness was present. Lab investigations showed whole blood cell counts were high (22.1 × 103/μL with neutrophils 87%) while serum amylase and lipase level were normal. To exclude further diagnosis an abdominal computed tomography (CT) scan was done which showed fat stranding in the pancreatic head.  

 


Learning Objectives

  • Investigating the clinical history of the patient and selecting appropriate examinations for the diagnosis of acute pancreatitis.
  • Understanding the atypical presentation of acute pancreatitis and identifying those presented in the patient.
  • Familiarizing and defining new medical terminology associated with acute pancreatitis.

Clinical History 1

  • Age:  40 years old
  • Sex:  Female

Medical History 1

  • Hypertension
  • Bipolar disorder
  • Cholecystectomy (three years prior to this hospital admission)

Symptoms 1

  • Severe, sharp epigastric abdominal pain radiating to the back.
  • Nausea and vomiting.

 

Examinations (Clinical Assays/Tests/Imaging) 1

Physical Examination 1

  • Heart rate – 105 beats/min
  • Blood pressure – 132/84 mm Hg
  • Severe epigastric tenderness- present.

Blood Investigations 1

  • WBC: 22.1 × 103/μL with neutrophils 87%, (normal range: 4000-10,000/μL, 45%-75% neutrophils)6
  • Hemoglobin: 14.0 g/dL (normal range:12.0-15.5g/dl)8 
  • Platelets: 380 × 103/μL. (normal range:150×109-400×109/L)7
  • Potassium level: 2.7 mEq/L (normal range: 3.5-5.5 mEq/L)2 
  • Triglyceride level: 53 mg/dL (normal range: <150 mg/dL)3 
  • Serum amylase: 31 IU/L (normal range: 20–160)1 
  • Serum lipase: 14 IU/L (normal range: 8–78)1 

Abdominal Computed Tomography (CT) Scan 1

Abdominal CT image
Figure 1: Abdominal CT scan with intravenous contrast- white arrows in the figure shows fat stranding in the pancreatic head consistent with pancreatitis and reactive thickening in the duodenum.1

 

Question & Answers Leading to Diagnosis: 

Question 1: Based on the physical, imaging and laboratory investigations, what results would support this patient’s diagnosis? Does she meet all the criteria for this diagnosis?

Question 2: If this were a clear acute pancreatitis case, what lab results would we expect to see?

Question 3: What factors would lead to normal amylase and lipase levels in acute pancreatitis?

** For answers please check the next chapter.

 

Medical terminology/Abbreviations: 

  • AP (Acute pancreatitis) – Acute pancreatitis means inflammation of the pancreas that develops quickly.10
  • CT scan – Computerized Tomography scan. (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels, and soft tissues inside your body. 11
  • Cholecystectomy – Cholecystectomy is a surgical procedure to remove the gallbladder. 4
  • Epigastric region – Epigastric region is the upper central region of the abdomen.5 

References

  1. Nadhem, O., & Salh, O. (2017). Acute Pancreatitis: An Atypical Presentation. Case reports in gastroenterology, 11(2), 359–363. https://doi.org/10.1159/000475920
  2. Rastegar, A. (2021). Serum Potassium. Retrieved 21 May 2021, from https://www.ncbi.nlm.nih.gov/books/NBK307/
  3. Lee, Y., & Siddiqui, W. (2021). Cholesterol Levels. Retrieved 21 May 2021, from https://www.ncbi.nlm.nih.gov/books/NBK542294/
  4. (2021). Retrieved 21 May 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/cholecystectomy.
  5. epigastric region. (2021). Retrieved 21 May 2021, from https://medical-dictionary.thefreedictionary.com/epigastric+region
  6. Blumenreich, M. (2021). The White Blood Cell and Differential Count. Retrieved 21 May 2021, from https://www.ncbi.nlm.nih.gov/books/NBK261/
  7. Daly, M. (2010). Determinants of platelet count in humans. Haematologica, 96(1), 10-13. doi: 10.3324/haematol.2010.035287
  8. Hemoglobin test – Mayo Clinic. (2021). Retrieved 21 May 2021, from https://www.mayoclinic.org/tests-procedures/hemoglobin-test/about/pac-20385075#:~:text=The%20normal%20range%20for%20hemoglobin,to%2015.5%20grams%20per%20deciliter
  9. Banks PA, Freeman ML: Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101:2379–400.
  10. Knott, D. (2021). Acute Pancreatitis | Symptoms, Causes and Treatment | Patient. Retrieved 28 May 2021, from https://patient.info/digestive-health/gallstones-and-bile/acute-pancreatitis
  11. CT scan – Mayo Clinic. (2021). Retrieved 28 May 2021, from https://www.mayoclinic.org/tests-procedures/ct-scan/about/pac-20393675

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Creative Commons License

This post is adapted for the Health & Medical Case Studies created by the Master of Medical Biotechnology program of the University of Windsor. This work is licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC-ND) 4.0 International License.

 

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Case 3-2017: A 40-year-old female with epigastric pain, nausea and vomiting Copyright © by Nadhem, O., & Salh, O. is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

Digital Object Identifier (DOI)

https://doi.org/10.1159/000475920

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