INTRODUCTION
Emergency departments are healthcare facilities where any citizen who perceives themselves in need of urgent medical attention can present with any complaint at any time of the day. Especially in recent years, there has been a significant increase in emergency department visits in our country. Due to the high number of visits, there is also an increase in critical diagnoses that emergency department physicians must not overlook. Within the daily practice of emergency departments, these vital diagnoses can sometimes be identified simultaneously in certain cases.
Abdominal pain is one of the reasons for presenting to the emergency department, with a frequency of 5-8% (1). Acute pancreatitis, on the other hand, is one of the differential diagnoses in patients with abdominal pain, with a frequency ranging from 5 to 80 per 100,000 (2). Subdural hematoma (SDH) is another clinical diagnosis, more commonly seen in elderly patients and rarely in young individuals, posing a life-threatening condition, although its true incidence remains unknown (3).
Here, we present a case of a patient who presented to the emergency department with complaints of abdominal pain and altered consciousness, where diagnoses of acute pancreatitis and subdural hematoma were concurrently identified.
CASE
A 90-year-old male patient was brought to our emergency department complaining of inability to pass gas or stool for one day, abdominal pain, and 2-3 episodes of black-colored vomiting. His medical history revealed benign prostatic hyperplasia (BPH) as his only comorbidity, and he reported irregular use of aspirin for treatment purposes. Upon arrival, the patient was found to be somnolent with limited cooperation and orientation. Vital signs at presentation were blood pressure 193/82 mmHg, heart rate 66 beats per minute, oxygen saturation 95% on room air, and temperature 36.7°C. Physical examination revealed abdominal distension without any other specific findings.
A nasogastric tube was inserted, and during the initial two-hour observation, approximately 300cc of dark black fluid and 300cc of bilious fluid were drained. Electrocardiography showed a normal sinus rhythm. Laboratory investigations revealed elevated white blood cell count (18.37 x 10^3/μL), AST (aspartate aminotransferase) 308 U/L, ALT (alanine aminotransferase) 180 U/L, GGT (gamma-glutamyl transferase) 194 U/L, total bilirubin 1.39 mg/dL, amylase 1699 U/L, and lipase 3200 U/L. Computed tomography scans of the brain and abdomen were requested. Brain CT demonstrated a hyperdense appearance consistent with an acute-chronic subdural hematoma measuring approximately 25mm in thickness at the right parietal region (Image 1). Abdominal CT revealed fluid collection at the level of the pancreatic head and enhancement of the pancreatic duct, leading to a preliminary diagnosis of acute pancreatitis (Image 2).
The patient was consulted to the Departments of Neurosurgery and Gastroenterology for further management. He was admitted to the Intensive Care Unit under the care of Neurosurgery for advanced monitoring and treatment.
Image 1. Subdural hematoma on brain computed tomography
Image 2. The appearance of the pancreatic area on abdominal computed tomography.
DISCUSSION
Acute pancreatitis (AP) is a clinical diagnosis that should be considered in cases presenting with abdominal pain, nausea, and vomiting. The clinical symptoms and signs vary depending on age and the severity of the attack. Sudden onset of abdominal pain, nausea, vomiting, and abdominal distension are common symptoms and signs. In etiology, gallstones and alcohol are responsible for about 90% of cases. Other causes include abdominal trauma, hypertriglyceridemia, pancreatic or ampullary tumors, medications, hypothermia, infectious causes, procedures, and surgical interventions. In about 10% of cases, no cause can be identified. In our case, neither stones nor alcohol were found as etiological factors.
In AP, blood and urine amylase, serum lipase, serum elastase 1, serum trypsin, serum phospholipase A2, CRP, interleukin 6-8, and procalcitonin levels may increase. However, the commonly used diagnostic methods in AP are serum amylase and lipase determination, along with imaging techniques such as ultrasound and CT scans. The sensitivity of serum amylase in diagnosing AP ranges from 67% to 100%, with a specificity of 85% to 98%, while the sensitivity of lipase ranges from 82% to 100%, with a specificity of 82% to 100%. In our case, elevated serum amylase and lipase levels were detected, and the preliminary diagnosis of acute pancreatitis was reported based on the abdominal CT scan.
CT is the gold standard for diagnosing AP and evaluating cases. It provides better anatomical delineation and can reveal complications such as pancreatic inflammation and necrosis. Additionally, CT assists in determining the clinical severity and prognosis (2). In our case, the diagnosis of AP was confirmed by CT.
Subdural hematoma (SDH) typically occurs as a result of tearing of the bridging veins that connect the dural sinuses to the superficial veins of the brain (5). It can also occur due to arterial bleeding (6). It is commonly seen in the elderly, alcoholics, individuals with brain atrophy, those with intracranial aneurysms, those taking anticoagulant medications, and those who have experienced trauma (7). A study examining 100 patients with SDH found a history of trauma in 80% of patients, medication causing coagulation disorders in 22%, and alcoholism in 11% (8). Another study of 322 patients aged 65 and older reported a history of head trauma in over half of the patients and a history of anticoagulant medication use in one-third (7). In our case, there was no history of trauma. Non-traumatic spontaneous SDH is rare. In a study by Koç et al., five patients aged 61-75 without a history of trauma were reported to have SDH based on brain CT results. Four of these patients had a history of hypertension (6). When examining cases of spontaneous SDH in the literature, patients presenting with symptoms such as headache, nausea, and vomiting without facilitating factors such as trauma and alcohol have been reported (9).
SDH is classified as acute, subacute, or chronic based on the time of onset (10). In our case, SDH was reported as acute-chronic based on the brain CT findings.
When consulting the Departments of Neurosurgery and Internal Medicine for our case, both departments declined to admit the patient under their care due to accompanying pathologies. The patient was admitted to the Intensive Care Unit under the care of Neurosurgery based on the decision of the Emergency Medicine Specialist.
CONCLUSION
Acute pancreatitis (AP) can present as a significant clinical challenge with potentially fatal outcomes in cases presenting to emergency departments with symptoms of abdominal pain, nausea, and vomiting. Additionally, in patients with altered consciousness in the emergency department, it should not be forgotten that cerebrovascular events such as subdural hematoma (SDH) may play a role in the etiology, even in the absence of a history of trauma, alcohol, or anticoagulant medication use. In the chaotic environment of emergency departments, the possibility of a secondary life-threatening diagnosis in patients should be kept in mind.
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