Alcohol Induced Pancreatitis with a Fatal Complication

Expectation from this E log :

 This is online E log book to discuss our patient's de-identified health data shared after taking signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

About the patient :

The patient is a 32 year old man hailing from the southern part of India , who is a Lorry driver by occupation presented to the casualty on 25/May/2021 with complaints of

Pain Abdomen since 3 days which has become extreme with passing time

constipation since 3 days

Vomiting Episodes since 2 Days

Shortness of Breath since 1 day

Elaborating on his Chief Complaints :

The Patient is a heavy alcoholic for the past 15 years, he was apparently fine 5 years ago when he had an attack of Acute Pancreatitis , from which he recovered with treatment .

He did not bring any changes to his Alcohol intake ;

began experiencing Abdominal Pain since the past 3 days

Pain is in the upper abdomen (Epigastric Pain) , dull in nature , radiating to the back 

Vomiting Episodes have been 2-3 times a day for the past 2 days, contents of Vomitus is Food.

Shortness of Breath is of Grade 1 ; since the past day.

Past History :

The patient has a history of pacreatitis 5 years ago.

Not a known case of DM , HTN .

Has not had TB, Epilepsy , Asthma 

Personal History :

He has Normal Appetite ,

takes mixed Diet

His Bowel and Bladder movements are normal and regular ( but patient complains of having constipation since the past 3 days )

no known Allergies.

 

Hand Written Notes on History :

ADDICTION DETAILS :

The patient uses chewable Tobacco.

He is an alcoholic for the last 15 years.

Consumes 5-6 full bottles of alcohol in a week.

volume of intake :  ( 750 * 6 ) ml

Initial Assessment Notes: 

FINDINGS OF THE PATIENT ON PRESENTATION 

Vitals :

Pulse : 

Rate : 130 bpm

Rythm : regular

Volume : Adequate

Condition of Vessel : Normal

Delays : absent.

Blood Pressure :

Value : 130/90 mm Hg recorded on the Right Arm ( Brachial Artery )

Postion : Supine

Respiratory Rate:

24 cps

Spo2 : 97 % on room air

Pain : Present

( 8 on Wong Baker Faces Pain scale )

GENERAL EXAMINATION  :

Mild Dehydration

Systemic Examination :

Abdomen : Tenderness and rigidity in the epigastric and hypochondriac region ;Sluggish Bowel Sounds.

SIGNS:  Cullen's Sign ; Fox's Sign , Grey turner 's Sign were negative.

REPORTS SHOWN  AT THE TIME OF PRESENTATION :

CECT :

Pancreatitis

Mild Ascites

B/L Mild pleural Effusion

with Consolidative lesions in B/l lower lung lobes.

CTS :8/10

USG : Grade 1 Fatty Liver ; Pancreatitis

Blood Works :

Hb : 14.6

TLC : 17500

Platelet : 2.32

Serum Amylase :271

Serum Lipase :137

Chest X Ray @ time of Admission

ECG @ time of Admission

INTERVENTIONS DONE IMMEDIATELY AFTER THE PATIENT PRESENTED :

Analgesia

Fluid Rescusitation

Ultrasonogram Findings ( done after admission ) :

• Body of Pancreas Edematous with Altered Echotexture 
•  Peripancreatic Fluid Accumuation seen

• Mild Ascites
• B/L Pleural Effusion
• Grade 1 Fatty Liver

2D Echo :

OTHER CRISIS  EVENTS WHICH FOLLOWED IN THE PATIENT : 

TIMELINE :

25/May /2021  12:30 pm :

Patient began having Tachycardia , Tachypneoa , with Hypoxia.

Diagnosed with Supraventricular Tachycardia.

Refractory to Vagal Manouvres 

Refractory to Adenosine

Patient was electively intubated in view of ARDS and administered Amiodarone.

Plain Chest Radiograph : Post Intubation

25/May/2021   6:30 pm :

Patient developed Hypotension

Ionotropic support given.

Amiodarone infusion continued in lieu of Arrythmia .

D Dimers levels elevated .

Anticoagulation started .

26/May/2021  1:00 am :

Patient suddenly developed Bradycardia with fall in Oxygen Saturation ( 48 % )

Central Pulses not felt

CPR done in accordance with ACLS guidelines inspite of which he could not be rescusitated ,

Declared dead at 1:53 am.

ECG @ 26/May/2021 1:53 am

ECG STRIPS : 

25/May/21  1:30 pm

25 May 2021 2:37 pm

 25/May/21  2:38 pm

25/May/2021 

7:00 pm

no electical activity

26/May/2021

1:53 am

OUTCOME : 

 Immediate Cause of Death : Pulmonary Embolism

Antecent Cause of Death : Severe Acute Pancreatitis ; ARDS

Corelation Of Pulmonary Embolism in Patients of Pancreatitis :

DISSEMINATED INTRAVASCULAR COAGULOPATHY 

What Could Have Been Found on Autopsy :

• Discussion :

Why were the signs ( indicating Coagulopathy ) absent in the patient who developed a massive coagulopathic crisis later ?  

What could have been done pro actively to forsee the DIC ?

What could have been the appropriate Ventilator Settings used in this patient ?

 

 

A 65-year old man with a Cluster of Symptoms

 Introduction :

The patient is a 65 year old retired man hailing from a small hilly village.

A note on Consent and De identification : 

All identifiers have been adequately removed so as to protect the privacy of the concerned patient . Consent has been obtained after thorough counselling.

I thank Dr. Rishik who is in charge of this patient of ours , for providing me with all details about the patient . 

Source of the image above : 

(updated )

It has been taken from the e log of the General Medicine  Monthly Assessment Scheme ( for the month of May made by me ; link to the same shall be mentioned here in )

https://drsaranyaroshni.blogspot.com/2021/05/assignment-patient-centred-learning.html?m=1

The gentleman complains of -

Loss of appetite

Unintentional Significant Weight Loss

Being extremely tired

Indigestion

Acidity issues.

A Past Background

A quick background of his past issues before elaborating his present problems: 

About 6 years ago, he used to have hemorrhoids which had been successfully operated upon, and since then it has not disturbed him again. ( evaluation done in 2015 ; Surgery done in 2019 )

He used to be anaemic when he had the problem of hemorrhoids but it got corrected after the surgery 

.

Presently the patient has ..

His gastrointestinal symptoms ( complaint of "indigestion" , flatulence ) began about a decade ago and have remained in him since then but have aggravated of late ( i.e. 6 months ago)

Other problems which began 6 months back

He began feeling very weak and tired , felt like staying in bed all day long , he noticed that his appetite had decreased. 

And he complains of a 'dark discolouration of his skin'

About two months back, because these symptoms were not getting relieved ,he had taken a consultation with a local physician

Who suggested him to get a complete blood picture done.

In the reports , hemoglobin came out to be 7g / dl

The physician suggested a transfusion

He recieved 2 units of blood 

And the test done after the transfusion showed  Hb of 7 g/dl again.

Patient mentions having less tolerance to heavy,spicy food to a certain extent.

He also complains of burps and belches and a tendency to have flatulence and indigestion.

His bowel and bladder movements are normal except for some occasional bouts of constipation which get relieved on consumption of fibre rich food and natural fibre husk supplements.

Please Note : The gastrointestinal symptoms have been there in him ,on and off over the years (got aggravated of recent )

Patient cannot recall any particular reason which led to the precipitation of these problems.

He does not complain of

Nausea

Vomiting episodes

Fever

Cough

Blood in stools

Blood in vomitus

Abdominal pain

Some more details about the patient :

He is a chronic smoker since 40 years ,smokes about 12 cigarettes per day.

He used to be an alcoholic but got rid of the addiction 15 years back.

He admits of being around 70 kg ,6 months ago, but as of today he weighs 58 kg

Making it a loss of 17% of his total body weight within a span of 6 months which is quite significant.

He is not a known case of hypertension , diabetes mellitus, thyroid disorders.

He has truncal obesity , and had been diagnosed to have Fatty liver earlier.

He does not have any history of past tuberculosis .

A Few Reports: 

Hemoglobin : 7 g/dl

MCV: 109 ( slightly elevated )

ESR : 34mm/hr

Renal Parameters within limits.

Lipid profile 

Summary by a physician who evaluated him 6 years back :

 

A Clinical Look at the Patient :

UPDATE :

A Few More Investigation Reports :

UPDATED : REPORTS ( 9 JUNE 2021 )

UPDATES ( 11/june/2021 )

The Need of the Hour :

Presently the patient is keen on getting rid of his fatigue,wants to get his appetite back as it used to be and maybe to find a reason of his significant unwanted weight loss so that he can regain his fit self once again.

Questions :

Why is he suffering from anemia ?

Why did his Hb levels not increase even right after 2 units of transfusion?

Any active bleeding going on? 

If yes ,then what is the source of pathology?

What is causing his loss of appetite and the significant weight loss ?

What investigations can help us move towards the underlying cause?

All your valuable inputs and differentials are warmly welcomed such that the patient can be healed optimally.