beathricce
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10. A previously healthy 47-year-old woman comes to the emergency department because of a 36-hour history of nausea, vomiting, and abdominal pain that radiates to her back. Over the past 3 years, she has had intermittent episodes of cramping abdominal pain 1 to 2 hours after meals; the pain lasts for several hours and resolves spontaneously. She does not smoke and drinks one to two glasses of wine each evening. There is a family history of coronary artery disease and hypertension. Her temperature is 37 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 20/min. Abdominal examination shows moderate epigastric and right upper quadrant tenderness with no guarding or rebound; bowel sounds are decreased. Laboratory studies show:
Hematocrit 45%
Leukocyte count 9000/mm3 with a normal differential
Serum
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 120 U/L
Aspartate aminotransferase (AST, GOT) 78 U/L
Amylase 365 U/L
Lipase 1223 U/L (N=1–160)
Triglycerides 300 mg/dL
Which of the following is the most likely diagnosis?
A) Acute cholecystitis
B) Alcoholic hepatitis
C) Alcoholic pancreatitis
D) Ascending cholangitis
E) Gallstone pancreatitis
F) Hepatitis A
G) Pancreatic cancer
H) Peptic ulcer disease
I) Triglyceride-induced pancreatitis
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| study_ing
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C alcoholic pancreatitis
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| study_ing
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clinical picture is supported by high amylase and lipase levels
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| frank100
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I woul say E, gallstone pancreatitis, because HFT´s are elevated and also lipase is elevated. and explains previous episodes.
AST/ALT ration is not >2, so it is not (b)
(I) cannot explain elevated liver enzimes
(h) doesn´t fit the presentation
(g) if they want us to think PC, weight loss, or family history, would have been in the question.
(f) no travel history, no fever, etc...
(d) patient is afebrile, and AC is scarry...
(c) if that´s the answer, why I´m not the hospital?
(a) could be, but...I don´t like it.
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| achilles
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E
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| study_ing
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AST ALT ratio is firstly not calculable...i tot ALP are given rather than ALT...secondly arent they imp for acute hepatitis rather than acute panreatitis...unfortunately what i found predictive of gallstone pancreatitis was ALT >150 ( which is not mentioned in the Q)
interesting ..will post later
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| study_ing
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ALP was ok so me tot of a non obstructive pahtology..nice q
please comment on whether u think it is acute vs chronic pancreatitis with an acute attack...that wud help
or maybe its GB pathology with pancreatitis....
me tot chronic pancreatitis ( hence alcoholic more likely) as pain radiated to the back
Edited by study_ing on 08/11/06 - 12:17 AM
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| frank100
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oh my I don´t know what I was thinking when calculated the AST/ALT ratio...perhaps the early morning...
but I still woud choose (e).
ok, hummm...ahhh...not alcoholic stuff because CAGE questionare wasn´t done in the question.
and, no abdominal X-rays with pancreatic calcification...
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| achilles
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the pt's history points towards stone as the likely pathology ( cramping pain after meals ) and ALT>AST and both amylase and lipase are increased which is indicative of pancreatitis. increase in lipase is more specific of pancreatitis.
we can also rule out other options by the given information. frank has already done it and as for acute cholecystitis, this pt is afebrile and does not have the clinical picture of cholecystits and the last option can also be ruled out as triglycerides should be close to 1000 to cause pancreatitis.
and one of the most common causes of pancreatitis is gall stones.
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| MILF
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beathricce wrote:
10. A previously healthy 47-year-old "woman" comes to the emergency department because of a 36-hour history of nausea, vomiting, and abdominal pain that radiates to her back. Over the past 3 years, she has had intermittent episodes of cramping abdominal pain 1 to 2 hours after meals; the pain lasts for several hours and resolves spontaneously. She does not smoke and drinks one to two glasses of wine each evening. There is a family history of coronary artery disease and hypertension. Her temperature is 37 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are 20/min. Abdominal examination shows moderate epigastric and right upper quadrant tenderness with no guarding or rebound; bowel sounds are decreased. Laboratory studies show:
Hematocrit 45%
Leukocyte count 9000/mm3 with a normal differential
Serum
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 120 U/L
Aspartate aminotransferase (AST, GOT) 78 U/L
Amylase 365 U/L
Lipase 1223 U/L (N=1–160)
Triglycerides 300 mg/dL
Which of the following is the most likely diagnosis?
A) Acute cholecystitis
B) Alcoholic hepatitis
C) Alcoholic pancreatitis
D) Ascending cholangitis
E) Gallstone pancreatitis
F) Hepatitis A
G) Pancreatic cancer
H) Peptic ulcer disease
I) Triglyceride-induced pancreatitis
47 y/o woman=gallstones (10-15% have gallstones)
2 glasses of wine is the normal intake of most American so it will not be alcoholic pancreatitis !
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| juanma0
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I agree E is the answer, the pain after eating is classic for gallstone pathology. Similar q in kaplan had that in the answer. Remember think most common!!!!!!!
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| study_ing
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"Over the past 3 years, she has had intermittent episodes of cramping abdominal pain 1 to 2 hours after meals; the pain lasts for several hours and resolves spontaneously"
due to gall stones
and
36-hour history of nausea, vomiting, and abdominal pain that radiates to her back
so its more likely acute panreatitis with h/o gallstones, rather than the chronic pancreatitis i was thinking abt, i guess.
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| cbenitesch
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I would say Alcoholic pancreatitis...but there are several studies demonstrate the disease is observed on heavy drinking people and they need around 15 year of heavy drinking to develop the disease in fact they need to consume 40 to 50g of pure alcohol per day to develop disease.
Patient has 3 of 4 F´s, is Female, Forty, Fertile I don´t know if she´s fat... so cramping pain after meals, maybe sha has gallstones... and accordying to lab... I´l go for E)Gallstone pancreatitis.
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