A woman with acute upper abdominal pain

Problem 14 A woman with acute upper abdominal pain

A 57-year-old woman is admitted with a 2-day history of increasingly severe upper abdominal pain, radiating through to the back. Although initially colicky in nature, the pain is now constant. She has lost her appetite and has vomited on several occasions. Over the preceding months she has suffered with intermittent bouts of colicky upper abdominal pain that have lasted a few hours at a time. She has no allergies and is a non-smoker. She has no other significant past medical history, including no previous abdominal surgery. On examination she is overweight and looks unwell and dehydrated, although she is apyrexial. Her heart rate is 115 bpm and regular and her blood pressure is 130/90 mmHg. Respiratory examination reveals decreased air entry and dullness to percussion at the left base. Her abdomen is mildly distended and tender in the epigastrium and peri-umbilically. There are no palpable masses and although present, bowel sounds are infrequent.

Q.1

Based on the history and examination, briefly discuss the differential diagnoses.

To refine your list of differential diagnoses you order some investigations.

Q.2

Which initial investigations would you order and why?

The patient’s ECG reveals a sinus tachycardia and no other changes. Her chest X-ray is shown in Figure 14.1 and her blood test results are shown in Investigation 14.1. Her BMI is calculated to be 34 kg/m².

Figure 14.1

Investigation 14.1 Summary of results

Q.3

What do the investigations show, what is the likely diagnosis and what other investigations would you like at this point?

The results of the arterial blood gas analysis on inspired room air and the C-reactive protein (CRP) are shown in Investigation 14.2.

Investigation 14.2 Summary of results

Q.4

How would you initially manage this patient? How would you assess potential disease severity?

Overnight, she remains stable and begins to feel better.

Q.5

What is the likely underlying cause of the pancreatitis and what investigation should be performed to investigate this?

An ultrasound scan shows gallstones in a distended gallbladder, with dilatation of the intrahepatic bile ducts. The extrahepatic biliary tree and the pancreas are obscured by bowel gas.

Over the next 24 hours the patient deteriorates. She develops a pyrexia of 38.8°C and becomes jaundiced. She is transferred to the high dependency unit and her repeat blood results are shown in Investigation 14.3.

Investigation 14.3 Summary of results

Q.6

What radiological investigation(s) would now be appropriate?

The magnetic resonance cholangiopancreatogram is shown in Figure 14.2. The MRCP shows dilated intra- and extrahepatic ducts and a solitary stone (arrow) impacted at the bottom of the common bile duct. The pancreatic duct is also visible passing to the right of the picture.