Case Presentation
A 43 years old gentleman, presented to the Emergency department of our hospital with severe periumbilical abdominal pain, fever and recurrent vomiting for the past 2 days. He is a smoker and imbibes alcohol occasionally with no known comorbidities or regular medications. He had consumed alcohol 4 days prior to presentation to the hospital. He had mild diffuse abdominal discomfort and nausea after consuming alcohol. The symptoms worsened over the next few days until he presented to the hospital with severe symptoms. His fever was of low grade. The abdominal pain was limited to the periumbilical area and had no radiation. Vomiting was non-projectile. The initial vomitus contained food particles while later he vomited scanty amounts of green fluid only. He claims to have vomited 10-13 times per day prior to presentation.
He had no chills, rigors, dysuria, diarrhea, cough, breathlessness, chest pain or throat pain.
On physical examination, he was tachycardic (HR:123/mt) and had high BP (144/103 mmHg). His respiratory rate was 21/mt and SpO2 was 96% on room air. He was afebrile (Temp: 37.1°C). His weight was 64kg. He had no pallor, icterus, cyanosis, clubbing or edema. His chest was clear with no added or adventitious sounds. No abnormality was detected in the cardiovascular system.
Abdominal examination revealed mild upper abdominal tenderness only. No visceromegaly, guarding, or evidence of free fluid was detected. Examination of the nervous system was also within normal limits.
The findings of the imaging tests done as part of management and the x-ray chest (PA view) showed bilateral accentuation of vascular markings in the lung fields with no obvious pneumonic consolidation. The mediastinal and cardiac shadows were normal. There was no pleural effusion. The thoracic cage was normal. The x-ray of the abdomen showed nonspecific bowel gas pattern and no air-fluid fluid levels or free intraperitoneal gas.
Abdominal ultrasound (USG) of the showed only fatty liver. But the pancreas was obscured by bowel gas. There were no sonographic features of acute cholecystitis or cholelithiasis. Liver appeared normal in size measuring 14.9 cm, and it showed increased echogenicity. No focal lesions or intrahepatic biliary radicles dilatation was seen. Common bile duct (CBD) was not dilated - measuring 3mm in diameter. Gallbladder was well distended. No wall thickening, cholelithiasis or pericholecystic fluid.
The patient was diagnosed with acute alcoholic pancreatitis based on the history, examination and the high lipase level. The patient received two liters of normal saline followed by another two liters of 5% dextrose in normal saline (DNS) as continuous infusion. The serum phosphate was assayed on the 2nd day and it was at a critical value (0.25 mmol/L). Phosphate replacement was started initially with 20 mmol of sodium glycerophosphate as an intravenous slow infusion over 8 hours which was followed by oral potassium/sodium phosphate tablet (Neutra ®) at a dose of 250mg 3 times a day. This led to progressive correction of phosphate levels. He was discharged on the 4th day of admission with the serum phosphate level and the other laboratory tests having returned to normal values.