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PUID: 52 || PLAB 2 Mock :: Medicine Symptomatic Differentials: Acute On Chronic Pancreatitis


Summary:

This PLAB 2 case scenario involves managing a patient presenting with a sudden worsening of chronic abdominal symptoms due to acute on chronic pancreatitis. The case tests the candidate's ability to recognize pancreatic insufficiency, provide appropriate emergency management, and educate the patient on lifestyle modification, especially in the context of alcohol use.



Key Points:


Gastrointestinal System

  • Recognize chronicity through history: symptoms like foul-smelling, floating stools indicate fat malabsorption due to lipase deficiency.

  • Identify risk factors: chronic alcohol use is a major contributor.

  • Understand the role of pancreatic enzymes in digestion.


Acute Presentation

  • Characterized by sudden worsening of abdominal pain on a background of chronic symptoms.

  • May be precipitated by alcohol or obstruction (tumour, gallstones).


Endocrine System

  • Monitor blood glucose levels for signs of endocrine dysfunction.

  • Refer to diabetes team for possible glycaemic control issues.


Diagnostic Approach

  • Stool elastase test to assess exocrine insufficiency.

  • Blood tests: FBC, U&E, LFT, CRP, amylase, lipase, blood glucose.

  • Imaging: Abdominal ultrasound, followed by CT or MRCP if needed.

  • Explore for signs of obstruction (e.g., jaundice).



Important Considerations:

  • Confirm full name and age.

  • Always assess for malabsorption signs and red flags like jaundice or persistent vomiting.

  • Establish previous history of pancreatitis or abdominal surgeries.

  • Always link symptoms to physiology when explaining to patients.



Diagnostic Approach:

  1. Take detailed history including alcohol intake, stool characteristics, and pain description (SOCRATES).

  2. Physical examination focusing on vitals, dehydration, jaundice, and abdominal tenderness.

  3. Request initial investigations: bloods and abdominal imaging.

  4. Use stool elastase to evaluate pancreatic function.

  5. Consider differential diagnoses: gallstone pancreatitis, tumour-induced obstruction, etc.



Management:

  • Immediate:

    • Admit the patient.

    • Start IV fluids, analgesia, antiemetics, and make the patient nil by mouth.

  • Investigations:

    • Imaging and blood tests to confirm diagnosis and extent of inflammation.

  • Ongoing:

    • Refer to gastroenterology and diabetes team.

    • Start Pancreatic Enzyme Replacement Therapy (e.g., Creon).

    • Provide nutritional support and involve a dietitian.

  • Lifestyle Advice:

    • Strongly advise alcohol cessation.

    • Educate on healthy diet and medication adherence.



Communication Skills:

  • Use open-ended questions to explore symptoms fully.

  • Avoid medical jargon; explain in layman’s terms (e.g., “Your pancreas helps you digest food and manage sugar levels…”).

  • Provide empathy and reassurance.

  • Include safety netting and follow-up: when to return, what symptoms to watch for, and diabetic nurse input.

  • Provide patient education leaflets.



Ethical Considerations:

  • Respect patient autonomy while guiding them on alcohol cessation.

  • Ensure confidentiality and professional boundaries in sensitive discussions.

  • Discuss all findings and management plans transparently.

  • Follow GMC Good Medical Practice in communication, decision-making, and consent.



Additional Resources:

  • NICE Guidelines on Chronic Pancreatitis

  • GMC Good Medical Practice

  • NICE CKS: Pancreatitis (Acute and Chronic)

  • Turing Med School AI tools for case practice

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