ASCITES CASE: active case discussion

[20/06/20, 7:29:30 PM] Trishaala Reddy: Good evening sir


[20/06/20, 7:52:56 PM] Trishaala Reddy: Sir in this case could the diagnosis be pancreatic tuberculosis?

[20/06/20, 8:24:22 PM] Dr Rakesh Biswas Sir: What are your points in favor of that possibility?

[20/06/20, 8:28:10 PM] Trishaala Reddy: Elevated lipase and  amylase levels?

[20/06/20, 8:32:08 PM] Dr Rakesh Biswas Sir: When was that done and was it repeated? What was the ascitic fluid amylase? What is the role of ascitic fluid amylase in the diagnosis of pancreatic ascites?

[20/06/20, 8:36:55 PM] Trishaala Reddy: Sir it was done at a local hospital before coming to our hospital where they suspected pancreatitis due to raised enzyme levels

[20/06/20, 8:39:28 PM] Trishaala Reddy: Ascitic fluid amylase is over 1000 IU /L in pancreatic ascites with SAAG less than 1.1 g/dl

[20/06/20, 8:59:16 PM] Dr Rakesh Biswas Sir: So what did we find on repeating it here?

[20/06/20, 9:21:22 PM] Trishaala Reddy: Ascitic fluid amaylase-15 ?

SAAG- 0.5 g/dl

[20/06/20, 9:50:33 PM] Dr Rakesh Biswas Sir: Then clearly she didn't have pancreatitis?

[20/06/20, 9:55:51 PM] Trishaala Reddy: Yes sir

[20/06/20, 9:56:06 PM] Trishaala Reddy: But how do we explain the raised enzyme levels?

[20/06/20, 10:06:35 PM] Dr Rakesh Biswas Sir: You mean initially in her blood? What is the specificity of those raised enzyme levels and what other disorders is it known to occur?

[20/06/20, 10:13:06 PM] Trishaala Reddy: Neoplastic disorders of pancreas

[20/06/20, 10:14:12 PM] Dr Rakesh Biswas Sir: I think there are many more sources of those enzymes other than pancreas?

[20/06/20, 10:21:53 PM] Trishaala Reddy: Sir do u mean increased levels of pancreatic enzymes in conditions unrelated to the pancreas?

[20/06/20, 10:24:04 PM] Trishaala Reddy: Sir I came across an article which says about the altered levels of pancreatic lipase in tuberculosis without involvement of pancreas

[20/06/20, 10:24:36 PM] Trishaala Reddy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637765/


[20/06/20, 10:28:35 PM] Dr Rakesh Biswas Sir: Quote the relevant portion

[20/06/20, 10:31:03 PM] Trishaala Reddy: “We measured lipase and amylase activity levels in MTB-infected individuals and normal controls. Lipase and amylase activity levels were significantly higher in the MTB patient group. Moreover, lipase correlated with severity of inflammation as estimated by the ESR, leading us to infer that lipase is conceivably causally related to the underlying inflammatory process.”

[20/06/20, 10:31:58 PM] Dr Rakesh Biswas Sir: Mtb infected pancreas?

[20/06/20, 10:32:48 PM] Trishaala Reddy: No sir

[20/06/20, 10:33:08 PM] Trishaala Reddy: Increased levels of enzymes without involvement of pancreas
[20/06/20, 11:21:26 PM] Trishaala: Sir so in this particular case can we attribute increased enzyme levels to chronic inflammation ( mostly Tuberculosis) which was evident on biopsy?

[20/06/20, 11:22:31 PM] Dr Rakesh Biswas Sir: Yes possibly. Or can we attribute it to just an immune mediated inflammation of her peritoneum?

[20/06/20, 11:22:51 PM] Trishaala: Yes sir





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