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  #1  
Old 05-01-2013
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Default GI question

A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:
WBC 8.0K/ÁL
Hemoglobin 10.5gm%
Serum amylase 200 IU/L ( N = 25 to 160 U/L)
Serum Lipase 150 IU/L (Normal = 25 to 80U/L)
AST 30 IU/L
ALT 40 IU/L
Total bilirubin 0.6gm%
Alkaline Phosphatase 80IU/L .
Which of the following is indicated in this patient at this time?
A) Ultrasound of the Gall Bladder
B) Nothing by mouth and IV hydration
C) No further investigations or treatment
D) Endoscopic Retrograde Cholangio Pancreatography
E) CT scan of the Abdomen
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  #2  
Old 05-01-2013
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Quote:
Originally Posted by mbbs2010 View Post
A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:
WBC 8.0K/ÁL
Hemoglobin 10.5gm%
Serum amylase 200 IU/L ( N = 25 to 160 U/L)
Serum Lipase 150 IU/L (Normal = 25 to 80U/L)
AST 30 IU/L
ALT 40 IU/L
Total bilirubin 0.6gm%
Alkaline Phosphatase 80IU/L .
Which of the following is indicated in this patient at this time?
A) Ultrasound of the Gall Bladder
B) Nothing by mouth and IV hydration
C) No further investigations or treatment
D) Endoscopic Retrograde Cholangio Pancreatography
E) CT scan of the Abdomen
ercp????????????
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Old 05-01-2013
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Quote:
Originally Posted by mbbs2010 View Post
A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:
WBC 8.0K/ÁL
Hemoglobin 10.5gm%
Serum amylase 200 IU/L ( N = 25 to 160 U/L)
Serum Lipase 150 IU/L (Normal = 25 to 80U/L)
AST 30 IU/L
ALT 40 IU/L
Total bilirubin 0.6gm%
Alkaline Phosphatase 80IU/L .
Which of the following is indicated in this patient at this time?
A) Ultrasound of the Gall Bladder
B) Nothing by mouth and IV hydration
C) No further investigations or treatment
D) Endoscopic Retrograde Cholangio Pancreatography
E) CT scan of the Abdomen

I really wouldnt know what this patient has... but for the sake of it I would pick E
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  #4  
Old 05-01-2013
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Age above 45 so prolly needs endoscopy. Nothing by mouth and iv hydration ?
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Old 05-01-2013
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Correct answer is C. The patient is asymptomatic currently and has a pain that is completely relieved by antacids. Yes, he has an epigastric paiin which is most likely gastritis or peptic ulcer disease since it completely responds to antacids. Acute pancreatitis pain does not respond to antacids and does not follow a course like this. Chronic pancreatitis can cause pain after eating however, response to antacids is unusual. Panccreatic enzymes are often normal in Chronic pancreatitis. Liver function tests and total bilirubin are normal excluding the possibility of gallstone pancreatitis which often occurs due to a stone in the common bile duct. Clinically, he does not have pancreatitis but laboratory investigations show increased amylase and lipase. When clinical picture does not match lab values one should always think of other conditions that could elevate the lab values. Chronic dialysis patients can have amylase and lipase up to three times upper limit of normal but never above three times the upper limit. This is because Lipase and amylase are eliminated by glomerular filtration and when GFR reduces, these values increase. Another reason for elevated lipase is that heparin which is often used during hemodilaysis increases the lipo-protein lipase levels. Therefore, in the absence of a typical clinical picture, a value of lipase or amylase < 3xULN is considered benign in hemodilaysis patients.
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The above post was thanked by:
docwedsengr27 (05-01-2013), medisid (05-09-2013), qurat21 (05-01-2013), stepdoc1 (05-01-2013), XpaezX (05-02-2013)



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