WBR1491

Author	PageAuthor::William J Gibson
Exam Type	ExamType::Surgery Shelf
Main Category	MainCategory::Pancreatic and Hepatic
Sub Category	SubCategory::Diagnosis
Prompt	[[Prompt::A 58 year old man presents to the emergency department with upper abdominal pain. He was playing poker and drinking whiskey with his friends when the pain began. He describes the pain as radiates to the back, 8/10 and colicky. On physical exam, the patient exhibits unintentional guarding and the abdomen is rigid. Laboratory evaluation reveals the following: Sodium: 135 Potassium: 4.1 Chloride: 100 Calcium: 10.1 Hematocrit: 40% Hemoglobin: 13 mg/dL WBC: 20,000 cells/mm3 Neutrophils: 15,000 Amylase: 500 mg/dL Lipase: 1,000 mg/dL LDH: 385 mg/dL AST: 400 mg/dL ALT: 250 mg/dL Which of the following is not a component of the criteria typically used for risk assessment in this patient's condition?]]
Answer A	AnswerA::WBC count
Answer A Explanation	AnswerAExp::A white blood cell count greater than 16,000 is one of the Ranson's criteria on initial presentation.
Answer B	AnswerB::Serum amylase
Answer B Explanation	AnswerBExp::Serum amylase is not one of Ranson's criteria. Nonetheless, serum amylase is highly sensitive for diagnosing acute pancreatitis.
Answer C	AnswerC::Serum LDH
Answer C Explanation	[[AnswerCExp::Serum LDH > 350 is one of Ranson's criteria. LDH is released from dying liver cells and is a sensitive measure of liver injury that can be secondary to leakage of pancreatic digestive enzymes.]]
Answer D	AnswerD::Serum glucose
Answer D Explanation	[[AnswerDExp::Serum glucose >200 is one of Ranson's criteria. Hyperglycemia can occur in she pancreatitis due to a decrease in insulin secretion from pancreatic beta cells.]]
Answer E	AnswerE::Age
Answer E Explanation	[[AnswerEExp::Age >55 is one of Ranson's criteria.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::The patient in this vignette has pancreatitis. Patients typically present with severe, colicky abdominal pain that gets worse with ingestion of food. Risk factors for pancreatitis include alcohol (35%), gallstones (45%), hypertriglycerideemia, obesity and family history. Ranson's criteria is used for prognosis in pancreatitis. There are two sets of criteria that compose Ranson's criteria: criteria on admission and criteria at 48 hours. Ranson's criteria on admission: 1. Glucose > 200 2. Age > 55 3. LDH> 350 4. AST > 250 5. WBC > 16,000 These criteria can be remembered with the mnemonic GA LAW. The criteria at 48 hours are: 1. Calcium < 8 mg/dL 2. Hematocrit drop > 10% (absolute % drop) 3. O2 < 60 (PaO2) 4. Base deficit > 4 5. BUN increase > 5 6. Sequestration > 6L These criteria can be remembered with the mnemonic C HOBBS (like Calvin and Hobbes). Ranson's criteria predict mortality in acute pancreatitis as summarized in figure 1. Acute medical treatment for pancreatitis consists of aggressive fluid administration, and narcotics for pain. Once discharged, patients should be advised to avoid any alcohol consumption. Occasionally, patients may have recurrent unrelenting pain for which surgical treatment is indicated. Figure 1. Ranson's score vs mortality. Educational Objective: Serum amylase is not part of Ranson's criteria. References: Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139(1):69-81.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Pancreatitis, WBRKeyword::Prognosis, WBRKeyword::Ranson's criteria, WBRKeyword::Pancreas
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::