Tuesday, October 4, 2011

Family Medicine: Pancreatitis, Gallstones and the Differential Diagnosis

The patient has severe abdominal pain and nausea after supper.  It's unbearable so they get the spouse to drive them to the local ER.  In the ER, the patients pulse rate is 110, BP is 136/82, Temperature is 99.4,  weight 152.  The 46 year old patient appears to be uncomfortable, holding the upper abdomen and moaning intermittently.  The physician notes a normal physical exam except for some perspiration on the forehead and upper lip, the tachycardia (without gallop or murmurs) and epigastric tenderness without rebound or guarding.  Rectal exam is negative for occult blood.  Past Medical History is significant for Rheumatoid Arthritis, currently on Sulfasalazine (ssz) orally and  Methotrexate but recently tapered off prednisone over a prolonged period of time.

The ED physician orders some lab tests, IV fluids and opiates (as needed for pain),  and an abdominal CT scan.

IV morphine relieves the pain from 9/10 to 3/10.  Lab results include elevated amylase, lipase, ALT, AST, BUN and WBC (13,500).

The examining physician gets the CT report from the physician in Australia who reads night imaging studies from this hospital.  The report notes several normal elements and comments on several gallstones present in a normal appearing gallbladder without thickening of its walls or other evidence of inflammation of the gallbladder.  The pancreas appears normal, but the mid-portion is blocked from view by overlying intestine.

The patient is admitted to the hospital and undergoes evaluation by a gastroenterologist, a general surgeon and a hospitalist, who was the admitting physician. The rheumatologist does not come to the hospital, but was called by the hospitalist to discuss the status and treatment of the RA.

Five days later, the patient sees the family physician in the office and relates the story of the hospitalization.  "Have you ever had an NG tube in your nose, Doctor?"  The patient begins.  "And people analyzing everything coming out of your body for exact fluid content?  Do you know how inefficient hospitals are?  Three different people asked me the same questions on the night of my admission.  It was like the clipboards from Hell.

The doctors said I had pancreatitis.  I survived and got the tube out of my nose.  The surgeon wanted to blame my gallbladder for the pancreatitis, but the gastroenterologist gave it a clean bill of health, at least for now.  The surgeon suggested surgery and the gastroenterologist suggested changing one of my RA drugs.

I'm not excited about surgery and I feel horrible if I don't get that drug.  The rheumatologist said there was an extremely low likelihood that the drug caused the pancreatitis.  What do you think?"

Health System time out: The Family Doctor used to do all their own admitting, but the hospitalist movement and increasing employment of family physicians by hospitals has dramatically decreased the percent of doctors admitting their own patients.  So the patient doesn't know the admitting physician or the consultants.
    
This decreases the patient's trust and belief in the information received.  The stress of the situation from abdominal pain, the NG tube in the nose and down the throat, the loss of privacy with the counting of intake and output of fluids, the excessive repetition of the same administrative/billing questions, and the general sense of uncertainty about what's going to happen is overwhelming, increasing the patient's discomfort and fear.

So how does the personal family physician of this patient respond?  First is to show respect for the human who is also the patient and to reaffirm the patient-physician relationship which already includes an element of trust because of past interactions.  Next is to listen to the patient's story, honoring their humanity and recognizing their suffering.  Responding to the feelings expressed during the story helps to protect the patient from flashbacks to loneliness and fears experienced initially in the hospital and validates their view of their experience.

The family physician has already seen the hospital reports and the discharge medication list in the fax or EMR via the hospital relationship.  They now think of the natural history of all the pathologic processes and phenomena noted in the hospital as well as the RA.  They seek to detect where the patient is on those natural history time lines, determining further information needed by way of further history, physical exam, laboratory testing and imaging if indicated.  They know that it's not over for this episode of sickness.

While the pancreas has calmed down, the gallstones aren't going to disappear, so the physician will inquire about the patients impression of the surgeon's comments about the cholelithiasis (gallstones) and gallbladder, later comparing that information with the final discharge summary dictated by the hospitalist. "Cholelithiasis" is added to the patients problem list by the family physician for future reference.

All of this information is filtered through the patients personal values, goals and dreams in their living, learning and working worlds.  Yes, it is complex, challenging and even fun.  The patient gets to make the decisions, so the family doctor has to do this medical mental work (including the development of an ongoing differential diagnosis for both the pancreatitis and the cholelithiasis- maybe using SPIT) in the overall context of the patient via the biopsychosocial model, explained in a post last year.  Using the Biopsychosocial model to detect.

The family physician has seen thousands of patients and filters the patient situation through many similar experiences and their understanding of the medical literature to offer their best insights about what may happen with each of the patient's options relative to this illness.  Their knowledge and experience becomes a resource for the patient, whose interaction with the physician in the context of a trusting relationship enables a refreshed perspective on their options.

Human to human, patient to physician communication enables the dyad to move ahead to develop a follow-up plan.  What do you think?


4 comments:

  1. Awesome! I might be your only follower laughing while reading the opening of this post :)

    I could write a book in response, but will restrain myself. Thank you for some very good information and things to consider as I prepare for my appointment with my family physician later this week and we figure out the next step.

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  2. Thanks for your comment, Socks. Your posts about your hospital stay inspired this post. No other physicians responded with comments yet, so they didn't comment about various probabilities and HIDA scans of the gallbladder and radiation safety, etc. The SPIT on pancreatitis could include Malignancy, Gallstones, viral infection, cholecystitis, hypertryglyceridema, medication side effects, etc.
    Good Luck. Dr J

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  3. Your hypothetical case sounded somewhat familiar :D

    Thank you for the SPIT list. It's incredibly reassuring to discover all the things that aren't problems I have to deal with.

    I really wish I had known all this stuff years ago, because my direction in college would have been very different. The human body is fascinating.



    For your amusement, now that my ordeal is in the past: WBC 16200, glucose 168, lipase >400, no amylase unless "lipase reflex" is another name for that, in which case it was 1041, ALT/AST/BUN all wnl. Interesting CT findings, which I will probably blog about at some point.

    Blog on!

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  4. maggie.danhakl@healthline.comOctober 14, 2014 at 7:33 AM

    Hi,

    Healthline.com recently launched a free interactive "Human Body Maps" tool. I thought your readers would be interested in our body map of the Gallbladder: http://www.healthline.com/human-body-maps/gallbladder

    It would be much appreciated if you could include this tool on http://drsynonymous.blogspot.com/2011/10/family-medicine-pancreatitis-gallstones.html and / or share with friends and followers. Please let me know if you have any questions.

    Thank you in advance.
    Warm Regards,

    Maggie Danhakl- Assistant Marketing Manager
    p: 415-281-3124 f: 415-281-3199

    Healthline Networks, Inc. * Connect to Better Health
    660 Third Street, San Francisco, CA 94107 www.healthline.com

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