Intermittent abdominal pain

Chief Complaint A 38 yo female came with intermittent abdominal pain for 5 days. History The pain is constant and radiated to the back & is associated with diarrhea, nausea, and vomiting. Initially, the pain was 7 out of 10. Now reached to 9 out of 10 from 2 days & is causing cramping. Pain is relieved a bit while lying in the prone position. She is taking Valsartan for the 6-7 months. Not on any other medicines. Vitals BP: 138/66 mmHg, Temperature: 99.8°F, HR: 113 beats per minute RR: 19 /minute. Investigation WBC: 14.7 103 U/L (4.5-11.0 103U/L) HB: 12.7 g/dL (12.0-17.0 g/dL), Hematocrit 38.8% (35-45%), Total bilirubin 3.2 mg/dL (<1.3 mg/dL), Alkaline phosphatase 199 U/L (20-120 U/L), BUN 17 mg/dL (8-25 mg/dL), Creatinine 1.15 mg/dL (0.60-1.10 mg/dL), Calcium 9.0 mg/dL (8.4-10.3 mg/dL) Triglycerides 90 mg/dL (< 150mg/dL). Diagnosis Please comment on the diagnosis & management



Very nicely illustrated and documented case CT scan is suggestive of bulky pancreas with peripancreatic fat stranding suggestive of ascite pancreatitis as diagnosis Sonography is showing gall bladder stone with typical posterior acoustic shadowing, which is black Shadow seen below gall stones on sonography - so it is Gall stone induced pancreatitis Bilirubin is raised, so there is likely possibility of stone in CBD causing obstructive jaundice MRCP may further clarify stone induced obstructive jaundice Treatment of pancreatitis involves Fluid therapy Vital monitoring and correction No Antibiotic in first week Early enteral nutrition In this case ERCP and stenting if stone in common bile duct is documented

History well described pain abd with vomiting radiating back gradually leaning forward and prone to get relief of pain indicating initially started with acute cholecystitis with with acoustic shadow in USG . When the infection is severe of gall bladder usually spreads to the surrounding organs like liver and pancreas . Due to infection there is oedematous change causing oedema of CBD causing obstruction of bile flow causes jaundice and also causes oedema of the pancreatic duct obstructing the flow of pancreatic juice as a result of which there is swelling if pancreas leading pacreas bulky and pancreatitis with fatty striae well demonstrated in CT Treatment NPm IV drip to contue for High antibiotic parenteral Inj PPI IV daily Jaundice may be stone in CBD When the patient settles MRCP to see any stone in CBD causing jaundice or not May be planned for cholecytectomy and stone CBD.

Thanks Dr Ved Prakash Sharma

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*GAll bladder STONE with ACUTE PANCREATITIS Inj ceftam 1gm iv bd Inj metrgyl 100mg TDS I v maintain for electrolytes infusion and pumping of medicine. Iv Multivitamin Iv PPI od Inj diclo or fortwin or phenergan im for pain vomiting and sedation. When acute phase of over and after evaluation and assessment surgical intervention.

Thanks Dr Mrinal kantil pal

Acute pain abdomen with radiation to back along with nausea, vomiting and USG showing acoustic shadowing and CT showing pancreatic edema and peripancreatic fat stranding with necrosis in the head region. The diagnosis is acute biliary necrotising pancreatitis. Pain management, IV fluid and early enteral nutrition are the cornerstone of management. Monitor for development of severe pancreatitis or peripancreatic fluid collections and manage accordingly.

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