CLINICAL BIOCHEMISTRY & HEMATOLOGY (BIO3CBH)

CASE STUDY 1
VINOEDH NAIDU JENNY LIM HO ZHI YIN SOOI CHENG YING LECTURER : 15991723 15953846 15987839 15990706 MR. PRASAD

A 51 years old woman with a history of alcoholism, now admitted with an acute central abdominal pain radiating to the back.

 Alcoholism : Is the addiction to or dependency upon drinking excessive amounts of alcohol. Central Abdominal Pain: Pain occurring in any area about a hand's breadth around the umbilicus or belly button

Analyte Plasma

Result

Unit

Reference Range

Ca
PO4 Albumin ALP Creatinine

1.88
1.22 47 75 0.091

mmol/L
mmol/L g/L U/L mmol/L

2.15-2.55
0.60-1.25 37-52 30-120 0.06-0.12

Amylase 2400

U/L

< 70

HYPOCALCAEMIA
An electrolyte imbalance and is indicated by a low level of calcium in the blood. Normally the body is able to keep the blood level within a narrow range (2.15-2.55 mmol/L). Calcium is important for healthy bones and teeth, as well as for normal muscle and nerve function.

Symptoms muscles tighten up painful muscle cramps and "pins and needle" sensations may develop.

CAUSES OF HYPOCALCEMIA
Vitamin D deficiency Chronic renal failure Magnesium deficiency Alcoholism

HYPERAMYLASEMIA
An excess of the pancreatic enzyme - amylase in the blood. Digestion of dietary intake of carbohydrates and fat relies on the action of amylase, found in the saliva, to begin the digestion of starches. At the same time, lipase from gastric secretions breaks down the fat in food.

 Symptoms of Hyperamylasemia : Pain, nausea, sweating and weakness. Things to do to avoid hyperamylasemia: Avoiding alcohol, taking all the prescribed medications.

Not to be confused with . . .

A Cute Abdomen

With any patient presenting with pain . . . REMEMBER!

SOCRATES
S O C R A T E S ite nset haracter adiation ssociated Symptoms iming xacerbating and relieving factors everity

Right Hypochondrion Acute Cholecystitis Biliary colic Cholangitis Hepatomegaly (congestive) Hepatitis Basal pneumonia Right Lumbar Renal / ureteric colic Renal infarct Pyelonephritis

Epigastric Peptic ulcer

Left Hypochondrion Ruptured spleen Splenic infarct Splenomegaly Subphrenic abscess Basal pneumonia

Acute pancreatitis
MI AAA Dissecting aortic aneurysm Oesophagitis Perforated oesophagus Umbilical

Left Lumbar Renal / ureteric colic Renal infarct Pyelonephritis

Acute pancreatitis
Early appendicitis AAA Dissecting arotic aneurysm Bowel obstruction Ischaemic bowel Gastroenteritis Suprapubic Cystitis / UTI Urinary retention

Right Iliac Fossa Appendicitis Meckels diverticulitis Perforated caecal carcinoma Renal / ureteric colic Terminal ileitis Crohns disease Ectopic pregnany Testicular torsion

Left Iliac Fossa Diverticulitis Colitis Renal / ureteric colic Ectopic pregnancy Testicular torsion Other gynae pathology

CHEMICAL PATHOLOGY

HYPOCALCAEMIA*
Hypoalbuminuria** Renal failure* Acute pancreatitis* Increased bone uptake* Drug therapy Malnutrition*
U.S. NATIONAL INSTITUTES ON AGING

MILD HYPOCALCAEMIA (1.8-2.0 MMOL/L)

X (RENAL FAILURE: PO4 & Cr)

X (severe hypocalcaemia 1.4-1.8 mmol/L)

PANCREATITIS (fall occurs within 36h of pain onset, rarely below 1.8mmol/L). RARE CASES ( tumor lysis, osteoblastic metastates) DRUGS(anticonvulsant, calcitonin)

HYPERAMYLASAEMIA*
Gut obstruction/perforation Renal failure* Acute pancreatitis* Macroamylasaemia Drugs* Salivary glands*

CONCLUSION
Hypocalcemia and high amylase level renal failure and pancreatitis Lab values of renal failure:creatinine level rises, high level of phosphates,microalbuminuria,low level of serum albumin,elevated BUN level Phosphates,albumin creatinine level of patient :normal range Conclusion, renal failure , pancreatitis

Pancreatitis
Pancreas gland located behind the stomach. releases hormones insulin and glucagon, digestive enzymes

Pancreatitis:inflammation of the pancreas. occurs when the enzymes that digest food are activated in the pancreas instead of the small intestine. When these enzymes somehow become active inside the pancreas, they eat (and digest) the tissue of the pancreas. causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels.

Pancreatitis

Acute chronic

sudden and lasts for a few days sudden swelling and inflammation of the pancreas.

occurs over many years. inflammation of the pancreas that does not heal or improve, gets worse over time, and leads to permanent damage.

Signs and Symptoms

symptoms Severe upper abdominal pain, with radiation through to the back Nausea and vomiting Clay-colored stools Gaseous abdominal fullness Hiccups Indigestion jaundice Skin rash or sore Swollen abdomen signs Abdominal tenderness or lump (mass) Fever Low blood pressure Rapid heart rate Rapid breathing (respiratory) rate Lab test Increased blood amylase level Increased serum blood lipase level Increase urine amylase level

Causes

The most common cause of acute pancreatitis is the presence of gallstones small, pebble-like substances made of hardened bilethat cause inflammation in the pancreas as they pass through the common bile duct.

Excessive alcohol use is the most common cause of chronic pancreatitis and can also be a contributing factor in acute pancreatitis. The most common cause is overconsumption of alcohol.

Chronic pancreatitis can result if certain medications continue to be taken, alcohol intake continues to be high, and eating habits do not change.

Elevated amylase level

In acute pancreatitis, amylase in the blood often increases to 4 to 6 times higher than the highest reference value, sometimes called upper limit of normal.

Hypocalcemia

caused primarily by precipitation of calcium soaps in the abdominal cavity, but glucagon-stimulated calcitonin release and decreased PTH secretion may play a role. When the pancreas is damaged, free fatty acids are generated by the action of pancreatic lipase. Insoluble calcium salts are present in the pancreas, and the free fatty acids avidly chelate the salts, resulting in calcium deposition in the retroperitoneum.

TREATMENT OF ACUTE PANCREATITIS

The mortality of patients with acute pancreatitis is about 15%; so it is important to seek immediate hospital treatment. The length of hospital stay is around 5 to 14 days for uncomplicated pancreatitis. For complicated ones, the length of stay can last up to 65 days.

How is the treatment like?

Pain management Pancreatitis can cause severe pain so pain medication is usually given to reduce the pain. Fasting Food intake will be stopped for a few days to let the pancreas recover. Once the inflammation in the pancreas is under control, clear liquids and bland food may be taken. If pancreatitis persists and pain is felt when eating, nasogastric tube may be recommended to provide nutrients.

 Intravenous (IV) fluids As energy and fluid is needed to repair the pancreas, dehydration may occur; so fluid is inserted intravenously during the hospital stay. This is also to maintain the blood pressure.  Eg. Normal saline and Ringers lactate Antibiotics Antibiotic is only given when there is infection

 Once oral intake is tolerated, patient can be discharged from hospital. Before leaving the hospital, the patient should be advised to avoid smoking, alcohol and fatty food. Since this patient has a history of alcoholism, she should be counselled and encouraged to participate in a detoxification and rehabilitation program . If the condition of the patient does not improve after 7 days, referral should be made to a medical centre with a team experienced in caring for severe pancreatitis.

References
Mayo Clinic, 2011, Pancreatitis: Treatments and Drugs, retrieved on 6 August 2011 from http://www.mayoclinic.com/health/pancreatitis/DS00371/ DSECTION=treatments-and-drugs WebMD, 2011, Pancreatitis: Treatment Overview, retrieved on 6 August 2011 from http://www.webmd.com/digestivedisorders/tc/pancreatitis-treatment-overview MedicineNet, 2011, Pancreatitis, retrieved on 6 August 2011 from http://www.medicinenet.com/pancreatitis/page3.htm SSAT, 2011, Treatment of Acute Pancreatitis, retrieved on 6 August 2011 from http://www.ssat.com/cgibin/acupanc6.cgi http://www.chemocare.com/managing/hyperamylasemiahigh-amylase.asp