PUID: 55 || PLAB 2 Mock :: Medicine Symptomatic Differentials: Acute Pancreatitis

Practice a case with the AI patient 🤖

Summary

A patient presents to A&E with severe upper abdominal pain, nausea, and vomiting. The history and examination point toward acute pancreatitis, most likely alcohol-induced. Rapid identification, early supportive management, and preventive education are key to optimal care and to preventing recurrence.

Key Points

Gastrointestinal – Acute Pancreatitis

• Severe epigastric pain radiating to the back, associated with nausea/vomiting.

• Risk factors: alcohol binge, gallstones, hypertriglyceridemia, certain drugs, post-ERCP, idiopathic.

• Differential diagnoses to consider: perforated peptic ulcer, Mallory-Weiss tear, acute cholecystitis, bowel obstruction, MI.

History Taking & Data Gathering

• Use open questions early to let the patient elaborate (covers elements of SOCRATES).

• Ask targeted questions to confirm diagnosis and exclude emergencies.

• Explore alcohol history in detail: quantity, frequency, binge episodes, previous complications.

• Assess for gallstone symptoms: RUQ pain, relation to fatty meals.

• Rule out obstruction: bowel habit changes, vomiting of faeculent material.

• Screen for relevant PMHx, medications, allergies, previous surgeries, family history.

Physical Examination

• General appearance, vitals.

• Abdominal exam: tenderness, guarding, rebound tenderness, Murphy’s sign, signs of peritonitis.

• Systemic exam to exclude other acute abdominal or cardiac causes.

Important Considerations

• Prioritise identifying and ruling out emergencies before moving to management.

• In the exam, focus on relevant questions; avoid wasting time on irrelevant or exhaustive checklists.

• Always mention diagnosis, key investigations, and management to the examiner – it demonstrates clinical reasoning.

• Balance time: roughly 4 minutes for history/exam, 4 minutes for management.

• Avoid overuse of stock phrases; maintain natural, empathetic conversation.

Diagnostic Approach

1. Clinical suspicion from history and exam.

2. Key Investigations:

   • Serum lipase (≥3× upper normal limit confirms diagnosis; remains elevated for 3–4 days).

   • Amylase (less specific).

   • FBC, U&E, LFTs, CRP, calcium, triglycerides.

3. Imaging:

   • Abdominal ultrasound – assess gallbladder and biliary tree.

   • CXR – exclude perforation.

4. Severity Assessment: Glasgow-Imrie or Modified Marshall score for prognosis.

Management

Immediate (A&E)

• Admit to hospital.

• Keep nil by mouth (NPO) to rest pancreas.

• IV fluid resuscitation with isotonic fluids.

• Analgesia – escalate quickly to opioids (e.g., morphine) for severe pain.

• Antiemetics for nausea/vomiting.

• Monitor: vitals, urine output, O2 saturation.

• NG tube if persistent vomiting.

Further Inpatient Management

• Identify and address underlying cause (alcohol cessation, gallstones).

• Early input from gastroenterology/surgical team.

• Consider prophylactic antibiotics only if infected necrosis is confirmed.

Long-Term & Preventive Care

• Alcohol cessation advice, signposting to support services.

• Leaflets/pamphlets on pancreatitis and alcohol risks.

• Follow-up with GP post-discharge.

• Safety-netting – warning signs (worsening pain, fever, vomiting, confusion).

Communication Skills

• Use layman’s terms when explaining diagnosis and link with alcohol use.

• Check understanding and invite questions.

• Signpost changes in questioning to keep patient engaged.

• Provide reassurance but avoid over-promising services or outcomes.

Ethical Considerations

• Respect patient dignity and avoid judgment when discussing alcohol use.

• Maintain confidentiality but share relevant info with healthcare team for safety.

• Obtain informed consent for examinations/investigations.

• Treat patient holistically – address both acute condition and lifestyle risk factors.

Additional Resources

• NICE Clinical Guideline [CG84] – Acute pancreatitis diagnosis and management.

• GMC Good Medical Practice – domains on clinical care, communication, and professionalism.

• RCS & BSG Guidelines – surgical and gastroenterological aspects.