Inpatient department management – An alcoholic man with acute exacerbation of pancreatitis

Pathogenesis

In acute alcoholic pancreatitis, there is precipitation of protein plugs, which serve as niduses for subsequent calculi obstructing the ductal system. Early pancreatitis features hypersecretion of enzyme proteins by the acinar cells, without concomitantly increased fluid. Due to this, protein plugs precipitate in the small branches of the pancreatic ducts, which then enlarge to form laminar aggregates through accretion of amorphous material. Repeated episodes of necroinflammation may trigger the activation of pancreatic stellate cells, which are usually inactive in the normal pancreas.^[3]

Clinical features

Abdominal pain located in the epigastrium and periumbilical region, radiating to the back and lower abdomen, along with nausea, vomiting, and abdominal distention.^[3]

Physical examination

Hypotension, tachycardia, and low-grade fever with jaundice. Pulmonary findings: Basilar rales, pleural effusion (left-sided). Abdominal tenderness and muscle rigidity present. Bowel sounds: Diminished or absent. Positive Cullen’s sign and Turner’s sign indicate severe necrotizing pancreatitis.^[4]

Complications

Essential imaging studies

Ultrasound examination may demonstrate the underlying cause, for example, gallstones or pancreatic calcification, as evidence of pre-existent chronic pancreatitis.

Contrast-enhanced computed tomography is an essential tool for determining the presence and extent of necrosis.

Magnetic resonance cholangiopancreatography allows proper visualization of pancreatic and biliary duct anatomy.

Background information

The patient had initially reported to the casualty ward of the hospital on 20-07-13 (4.35 pm). The chief complaint was epigastric pain for 7–8 days with tightness of abdomen and sour eructation. The stool was watery, sticky, and occasionally blackish. On arrival, the patient had not passed stool for 2 days. He had nausea with 1 episode of vomiting and occasional mild cough with white sticky expectoration for 2 days. As the patient was not willing for admission, an injectable (antispasmodic) was administered and the patient went home.

On 21-07-13 (1.30 am), the patient returned to the casualty ward with the same complaints, but the intensity had increased.

Condition of the patient during admission

The patient reported considerable weakness due to nausea and vomiting. His pain was so intense that he was unable to eat anything and was forced to report to the casualty ward at 1.30 am. On examination, his vitals were stable. Random blood glucose level was 108 mg/ dL. Per abdomen examination yielded severe epigastric tenderness with rigidity; bowel sounds sluggish but present all over.

The patient and his relatives were reassured and oriented for homoeopathic treatment, after which the patient was admitted to the inpatient department (IPD).

Preliminary data

• Name: Mr. R K

• Age: 32 years

• Sex: Male

• Date of case taking: 21-07-13

• IPD no A – 256/ B – 2554.

Chief complaint:^[7] Chief complaint is written in the LSMC format for better clarity [Table 2]

Addictions

Alcoholic for 15 years, consumption upto 1 litre/day (4–5 times/week); chronic smoker (1 packet daily) for 15 years.

Medical history

Acute hepatitis, cholelithiasis, and chronic pancreatitis admitted in tertiary hospital with similar complaints 6 months earlier.

General examination

Vitals: Stable.

Systemic examination

Per abdomen: Epigastric tenderness with rigidity. Percussion: tympanic note. Bowel sounds: sluggish in all quadrants.

Bowel sounds: Diminished or absent due to gastric and transverse colonic ileus.

Rigidity: Involuntary response to prevent pain more pronounced in the upper abdomen.

Rest normal.

Investigations: (21-07-13)

Hemoglobin: 15.4 g/dl, total WBC count – 10,500 g/dl, platelets: Adequate; serum creatinine: 0.58 mg/dL, BUN: 7.7 mg/dL, bilirubin (total): 0.73 mg/dL, bilirubin (indirect): 0.30 mg/dL, SGOT – 52.5 U/L, SGPT – 33.6 U/L, serum amylase: 435 U/L, and serum lipase: 450 U/L.

USG abdomen: (22-07-13): Bulky pancreatic duct 3 mm, gallbladder 6 mm polyp.

The BISAP assessment: Treatment started in an early phase, considering the history of repeated episodes of pancreatitis. Therefore, the patient had a lower chance of developing complications.

On the basis of available signs and symptoms, the BISAP criteria were found most suitable for the assessment.

Probable diagnosis with understanding

The severity of pain with back radiation and associated features of nausea and vomiting with a history of recurrent episodes is highly suggestive of acute exacerbation of chronic pancreatitis. The history of alcohol abuse helped confirm the diagnosis. The investigation results, including the elevated serum lipase and amylase levels along with the ultrasonography findings favor acute pancreatitis.

Diagnostic criteria of acute exacerbation of alcoholic pancreatitis

The history of alcohol abuse with evidence of acute abdominal pain radiating to the back, raised serum amylase and lipase levels over 3 times the normal, and investigation findings suggest injury to the pancreas.

Stage of Pathology: Structural reversible disease

Totality:^[8] (Boger approach)

Time, pathogenesis (location and pathology), sensation, physical general, modalities, and mental state [Figure 1].

Close

Figure 1:

Repertorial totality of the case

Export to PPT

1. Acute exacerbation- pace- moderate

2. Abdomen - direction backward²⁺

3. Pancreas, glands

4. Colon

5. Inflammation – necrosis

6. Pain cramping

7. Burning

8. Thirstlessness³⁺

9. Discharge: Diarrhea changeable

10. <Lying on left side⁺²

11. <Bending forward⁺²

12. >Pressure⁺³

13. >Lying on right side⁺²

14. <Vomiting after²⁺

15. Irritable⁺².

Remedy differentiation: Pulsatilla/Nux Vomica/Phosphorus [Table 3]

Pulsatilla was selected as the final remedy considering the underlying pathology (glands, organs, and tissues), characteristic physical generals,^[9] and characteristic modalities as presented in the above table.^[10]

Planning and programming:^[11]

Potency selected was 200 as per the patient’s susceptibility assessed through planning and programming [Table 4].

Final remedy: Pulsatilla Nigricans Susceptibility: Moderate – Potency: 200

Follow-up criteria

Details are shown in [Table 5].

Remedy reaction

The patient was better with Pulsatilla 200, which signifies that remedy registration was seen but the potency was insufficient as pain and sleep were not improving further. Therefore, the potency was increased to 1 M, which resulted in a complete cure. The resident surgeon also examined the patient and advised continuing the ongoing line of treatment [Table 6].

Investigations before and after treatment

On the day of discharge, the patient was tolerating soft diet well. His vitals were stable. On 23-07-13, the patient was sent to Mumbai for endoscopy (further workup). He was advised to follow-up in the OPD with the endoscopy reports for further management.