 Case Report
The 45-year-old man was admitted for general weakness, blurred vision
and abdominal pain since Mar. 4, 2000. He is a patient of diabetes mellitus
and hypertension, but he did not receive regular medical control for years.
Besides, he had chronic alcohol consumption. He experienced loose stool
passage 7 to 8 times per day for about 10 days before admission. He drank
large amount of alcohol on Mar. 3, and the above complaint developed in
the next morning. There was no fever, abdominal pain or weight loss. He
visited the ES of NTUH where abdominal cramping and dyspnea occurred thereafter.
The patient denied any tobacco consumption. He had neither drug or food
allergy history nor operation history.
On physical examinations, he had clear consciousness. The body temperature
was 36.5°C. The blood pressure and the heart rate were 105/88 mmHg and
117 beat per minute respectively. The respiratory rate was 20 breaths per
minutes. His conjunctivae were not pale, and the sclera was anicteric.
The pupil was symmetric with prompt light reflex. There was no goiter,
jugular vein engorgement, or neck lymphadenopathy. His chest expanded symmetrically,
and his breath sound was clear. The heart rate was rapid but regular. The
abdomen was soft and flat. There was no any peritoneal sign. The bowel
sound was normoactive. No pitting edema or petechia was found over the
extremities. His peripheral pulses were symmetric. The skin and mucosa
were dry.
The plain abdominal film at ES showed small intestine gas. Abdominal
sonography revealed fatty liver, gall bladder stones, distension of stomach
and small intestine. Coffee-ground substance was drained out from the NG
tube. Therefore omeprazole was given. His chest X-ray image showed clear
lung field. But the blood gas showed pH 6.785, PCO2 15.5 mmHg, PO2 148.5
mmHg, HCO3 2.3 mmol/L, and base excess –32.6. The urine ketone was “1+”.
The lactate concentration was over 12 mmol/L. Leukocytosis without increasing
immature WBC was found. Sodium bicarbonate was administered for correction
of metabolic acidosis, and empiric antibiotics was given for possible sepsis.
Because the blood pressure declined soon (down to 86/32 mmHg), he was admitted
to ICU with inotropic agent using.
After admission, the dyspnea and hemodynamic state stabilized
under glucose and thiamine therapy. The CT showed swelling and thickening
of ascending colon. The initial serum ethanol concentration was 3 gm/dL
and the methanol concentration was less than 1 mg/dL. Panendoscopy revealed
superficial gastritis and duodenitis. Acute pancreatitis developed
two days later. Fortunately, the condition improved soon after supportive
care. He was discharged on Mar. 13, 2000
His serial laboratory results were showed below
| |
Day1
|
Day2
|
Day3
|
Day4
|
|
WBC (K/mL)
|
22.92
|
11.62
|
|
6.6 |
|
A/G (g/dL)
|
|
3.2/2.4
|
|
|
|
Bilirubin (mg/dL)
|
|
1.4
|
|
|
|
GOT/GPT (U/L)
|
|
16/27
|
|
|
|
BUN (mg/dL)
|
8.3
|
|
|
|
|
Creatinine (mg/dL)
|
1.0
|
|
|
|
|
T-CHO (mg/dL)
|
|
61
|
|
|
|
Triglyceride (mg/dL)
|
|
101
|
|
|
|
Glucose (mg/dL)
|
80
|
|
|
|
|
Amylase (IU/L)
|
108
|
|
423
|
492
|
|
Lipase (IU/L)
|
201
|
|
756
|
3481
|
|
PH
|
6.785
|
7.389
|
7.440
|
|
|
PCO2
|
15.5
|
29.1
|
39.0
|
|
|
HCO3
|
2.3
|
17.6
|
26.6
|
|
|
Na (mmol/L)
|
136
|
|
|
|
|
K (mmol/L)
|
3.1
|
|
|
|
|
Cl (mmolL)
|
99
|
|
|
|
病案分析
45歲男性, underlying disease為高血壓 糖尿病 以及chronic alcoholism這次來院的主訴為
來院前一天大量飲酒後發生腹痛 全身無力 及視力模糊 若考慮患者的腹痛與飲酒是否有關
則應將急性胰臟炎 急性胃炎 或急性消化性潰瘍列入鑑別診斷 因患者糖尿病未接受規則治療
應注意有無糖尿病酮酸血症或HHNK之可能 少數酒癮患者突然減少酒精攝取 會發生alcoholic
ketoacidosis其臨床表現亦類似 此外drug(如salicylate) 及toxic alcohol(如methanol,
ethylene glycol)中毒應加以排除
又 患者為CAD之高危險群 部份下壁心肌梗塞患者以上腹痛表現也是應值得注意的
所以腹痛的病人應該要考慮做心電圖的需要性
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