Lydia Lutz: A 24-Year-Old Bartender With the Acute Onset of Severe Abdominal Pain That Radiates Through to Her Back

Learning Objectives

•

Learn the common causes of abdominal pain.
•

Develop an understanding of the unique anatomy of the pancreas.
•

Develop an understanding of the causes of acute pancreatitis.
•

Develop an understanding of the differential diagnosis of acute pancreatitis.
•

Learn the clinical presentation of acute pancreatitis.
•

Learn how to examine the abdomen.
•

Learn how to use physical examination to identify acute pancreatitis.
•

Learn how to use laboratory evaluation to identify acute pancreatitis.
•

Develop an understanding of the treatment options for acute pancreatitis.

Lydia Lutz

One look at Lydia and you could see that she was really sick. Lydia was always blasting in and out of the office for this and that, never anything big, sore throats, earaches, one time a Bartholin cyst. This time was different. Lydia Lutz is a 24-year-old bartender with the chief complaint of, “I feel like I’m dying.” Lydia stated that over the past several days, she has had increasing upper abdominal pain that is boring through to her back. “Doctor, at first I thought I just had the ‘brown bottle flu.’ I hit it pretty hard last weekend. My bestie was in town, and it was nonstop fun. I thought it would go away. I took PeptoBismol and Tums, but I just got sicker and sicker. Now it’s hard to lie flat in bed. I feel best when I prop myself up on the couch and hug my knees. Don’t worry, Doc, I’m not pregnant. I just finished my period. This really sucks.” Lydia went on to say that she would probably lose her job if she didn’t get back to work within the next couple of days. I asked Lydia if she ever had anything like this before, and she said, “Now that I think about it, I’ve had a kind of queasy feeling in my tummy in the center up high a couple of times, but I really didn’t give it much thought. I’d take some Tums and a swig of PeptoBismol and head into work. Sometimes a Brandy Alexander or two would set things right. I can make a mean Brandy Alexander. I like it with Baileys and a dash of cinnamon—it’s really soothing. You should come into the bar and I’ll make you one, and you’ll see what I mean. It’s just what the doctor ordered.” With that, Lydia rolled over on her side on the exam table, moaned and pulled her knees up to her abdomen. “Doc, I am sicker than a dog. Please get me better! I feel like somebody is drilling a big hole all the way through my gut. Like they are digging to China! I think this is something more than the flu.”

I asked Lydia what made the pain worse, and she said even though she didn’t have much of an appetite, any time she tried to force herself to eat, she got really nauseated. She said that her stomach was really “off.” She reported having diarrhea that was “really gross, really smelly.” Her roommate had been giving her a hard time until she realized how sick she was. “She took off work to bring me in today. Oh, Doctor, I feel like I am going to die.” As I started to examine Lydia, I began to think she was right and asked my nurse to get me a liter of lactated Ringer and an intravenous start kit. “Lydia, I think we ought to get you over to the hospital because you are pretty sick.”

I asked Lydia to use one finger to point to the spot where it hurt the most, and she pointed to her epigastrium and said that it felt like someone was drilling a hole in her gut.

On physical examination, Lydia was febrile with a temperature of 100.4°F. Her respirations were 20, her pulse ox was 96 on room air, and her pulse was 92 and regular. Her blood pressure was 100/62, and she appeared acutely ill. Lydia had mild scleral icterus, which I ascertained was not good. On fundoscopic examination, her retina looked okay, and nothing else appeared abnormal about her head, eyes, ears, nose, throat (HEENT) exam, except that her breath smelled of alcohol. She was tachycardic, and I thought I could hear rales in the base of her left lung. Her thyroid was normal, and there was no adenopathy. Her abdominal examination was markedly abnormal. Even gentle palpation caused Lydia to moan. She was most tender in her epigastrium, and she was guarding her abdomen. Lydia had no localized pain with palpation of McBurney point, and there was no real rebound tenderness. Bowel sounds were markedly diminished. Visual inspection of the abdomen revealed mild distention, but I was unable to identify the presence of either the Cullen or Grey-Turner sign. There was mild costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination revealed some tenderness to deep palpation of the paraspinous musculature. A quick neurologic examination was normal, with no evidence of Chvostek or Trousseau sign. I asked my nurse to call an ambulance for Lydia.

Key Clinical Points—What’s Important and What’s Not

The History

■

Onset of severe epigastric pain that bores through to the back after a bout of heavy drinking
■

Patient feels very ill
■

Patient tried to manage the pain with antacids, bismuth-containing solution, and alcohol
■

Patient is anorexic
■

Pain is improved with flexion of the spine and bringing the knees up to the abdomen

The Physical Examination

■

Patient is febrile and tachycardic
■

Patient appears acutely ill
■

Patient has mild scleral icterus
■

Patient is guarding the abdomen
■

Diffuse tenderness in the epigastrium without rebound
■

Decreased bowel sounds
■

No Cullen or Grey-Turner sign identified
■

Fundoscopic examination normal
■

Chvostek or Trousseau sign not present

Other Findings of Note

■

Tenderness to deep palpation of the lumbar paraspinous muscles
■

No peripheral edema

What Tests Would You Like to Order?

The following tests were ordered:

■

Chest x-ray to identify pathology above the diaphragm responsible for the patient’s symptoms as well as to identify pleural effusion
■

Abdominal x-ray series with the patient in upright position to identify free air in the abdomen
■

Computed tomography (CT) of the abdomen to identify occult intraabdominal pathology and to assess the severity of the acute pancreatitis
■

Serum amylase
■

Serum lipase
■

Comprehensive metabolic profile, including liver enzymes, triglycerides, blood urea nitrogen (BUN), creatinine, and serum calcium
■

Complete blood count (CBC)
■

C-reactive protein as a prognostic test for the severity of acute pancreatitis
■

Ultrasound of abdomen with special attention to the gallbladder

Test Results

Chest x-ray reveals a small pleural effusion on the left as evidenced by blunting of the left costophrenic angle consistent with an inflammatory process below the diaphragm ( Fig. 12.1 ).

Abdominal x-ray series with the patient in upright position did not identify any free air in the abdomen, suggesting that a perforated viscus is not the cause of the patient’s acute abdominal pain ( Fig. 12.2 ).

CT of the abdomen revealed diffuse edema of the pancreas and moderate peripancreatic fluid consistent with acute pancreatitis ( Fig. 12.3 ).

Serum amylase was over three times normal at 265 U/L.

Serum lipase was elevated at 188 U/L.

Comprehensive metabolic profile revealed a slightly elevated aspartate aminotransferase and serum glutamic-oxaloacetic transaminase; BUN and creatinine were normal, as was serum calcium.

CBC revealed a hemoglobin of 12.4 with an elevated white count to 12,800 with a left shift.

C-reactive protein was elevated at 12, suggesting moderately severe acute pancreatitis.

Ultrasound of abdomen with special attention to the gallbladder revealed no evidence of gall bladder disease, but peripancreatic inflammation was noted ( Fig. 12.4 ).