Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Vita Jaspan; Verity Schaye; Andrew S. Parsons; David Kudlowitz

doi:10.1515/dx-2021-0035

Article

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Vita Jaspan , Verity Schaye , Andrew S. Parsons and David Kudlowitz

Published/Copyright: December 7, 2021

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From the journal Diagnosis Volume 9 Issue 2

Abstract

Objectives

Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome.

Case presentation

This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome.

Conclusions

Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

Keywords: clinical reasoning; diagnostic schema; illness script; metacognitive checklist; problem representation

Corresponding author: David Kudlowitz, MD, Assistant Professor of Medicine (Clinical), Department of Medicine, NYU Grossman School of Medicine, 550 First Avenue, New York, NY 10016, USA, E-mail: David.Kudlowitz@nyulangone.org

Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: The local Institutional Review Board deemed the study exempt from review.

References

1. Banks, PA, Bollen, TL, Dervenis, C, Gooszen, HG, Johnson, CD, Sarr, MG, et al.. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102. https://doi.org/10.1136/gutjnl-2012-302779.Search in Google Scholar PubMed

2. Murphy, MJ, Sheng, X, MacDonald, TM, Wei, L. Hypertriglyceridemia and acute pancreatitis. JAMA Intern Med 2013;173:162–4. https://doi.org/10.1001/2013.jamainternmed.477.Search in Google Scholar PubMed

3. Painter, K, Sticco, KL. Auto-brewery syndrome (gut fermentation) StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513346/.Search in Google Scholar

4. Malik, F, Wickremesinghe, P, Saverimuttu, J. Case report and literature review of auto-brewery syndrome: probably an underdiagnosed medical condition. BMJ Open Gastroenterol 2019;6:e000325. https://doi.org/10.1136/bmjgast-2019-000325.Search in Google Scholar PubMed PubMed Central

5. Mishra, A, Seril, DN. Suspected gut fermentation syndrome (Auto-Brewery syndrome): 2519. Am J Gastroenterol 2017;112:S1373. https://doi.org/10.14309/00000434-201710001-02520.Search in Google Scholar

6. Saverimuttu, J, Malik, F, Arulthasan, M, Wickremesinghe, P. A case of auto-brewery syndrome treated with micafungin. Cureus 2019;11. https://doi.org/10.7759/cureus.5904.Search in Google Scholar PubMed PubMed Central

7. Welch, BT, Coelho Prabhu, N, Walkoff, L, Trenkner, SW. Auto-brewery syndrome in the setting of long-standing Crohn’s disease: a case report and review of the literature. J Crohn’s Colitis 2016;10:1448–50. https://doi.org/10.1093/ecco-jcc/jjw098.Search in Google Scholar PubMed

8. Jansson-Nettelbladt, E, Meurling, S, Petrini, B, Sjölin, J. Endogenous ethanol fermentation in a child with short bowel syndrome. Acta Paediatr 2006;95:502–4. https://doi.org/10.1080/08035250500501625.Search in Google Scholar PubMed

9. Spinucci, G, Guidetti, M, Lanzoni, E, Pironi, L. Endogenous ethanol production in a patient with chronic intestinal pseudo-obstruction and small intestinal bacterial overgrowth. Eur J Gastroenterol Hepatol 2006;18:799–802. https://doi.org/10.1097/01.meg.0000223906.55245.61.Search in Google Scholar PubMed

10. Akhavan, BJ, Ostrosky-Zeichner, L, Thomas, EJ. Drunk without drinking: a case of auto-brewery syndrome. ACG Case Rep J 2019;6:e00208. https://doi.org/10.14309/crj.0000000000000208.Search in Google Scholar PubMed PubMed Central

11. Guo, X, Zhang, W, Huang, R, Ma, J, Liu, Z, Hu, D, et al.. Case Report the case study of one patient with gut fermentation Syndrome: case report and review of the literature. Int J Clin Exp Med 2018;11:4324–9.Search in Google Scholar

12. Cordell, B, Kanodia, A. Auto-brewery as an emerging syndrome: three representative case studies. J Clin Med Case Rep 2016;2:5.10.13188/2332-4120.1000013Search in Google Scholar

13. Pallier, G, Wilkinson, R, Danthiir, V, Kleitman, S, Knf∼evi, G, Stankov, L, et al.. The role of individual differences in the accuracy of confidence judgments. J Gen Psychol 2002;129:257–99. https://doi.org/10.1080/00221300209602099.Search in Google Scholar PubMed

14. Berner, ES, Graber, ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:S2–23. https://doi.org/10.1016/j.amjmed.2008.01.001.Search in Google Scholar PubMed

15. Dreiseitl, S, Binder, M. Do physicians value decision support? A look at the effect of decision support systems on physician opinion. Artif Intell Med 2005;33:25–30. https://doi.org/10.1016/j.artmed.2004.07.007.Search in Google Scholar PubMed

16. Jaspan, O, Wysocka, A, Sanchez, C, Schweitzer, AD. Improving the relationship between confidence and competence: implications for diagnostic radiology training from the psychology and medical literature. Acad Radiol 2022;29:428–38. https://doi.org/10.1016/j.acra.2020.12.006.Search in Google Scholar PubMed

17. Potchen, EJ. Measuring observer performance in chest radiology: some experiences. J Am Coll Radiol 2006;3:423–32. https://doi.org/10.1016/j.jacr.2006.02.020.Search in Google Scholar PubMed

18. Podbregar, M, Voga, G, Krivec, B, Skale, R, Parežnik, R, Gabršček, L. Should we confirm our clinical diagnostic certainty by autopsies? Intensive Care Med 2001;27:1750–5. https://doi.org/10.1007/s00134-001-1129-x.Search in Google Scholar PubMed

19. Mamede, S, van Gog, T, van den Berge, K, Rikers, RMJP, van Saase, JLCM, van Guldener, C, et al.. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 2010;304:1198–203. https://doi.org/10.1001/jama.2010.1276.Search in Google Scholar PubMed

20. Mamede, S, Schmidt, HG, Penaforte, JC. Effects of reflective practice on the accuracy of medical diagnoses. Med Educ 2008;42:468–75. https://doi.org/10.1111/j.1365-2923.2008.03030.x.Search in Google Scholar PubMed

21. Martin, M, Sedighi Manesh, R, Henderson, MC, Critchfield, JM. Diagnostic scheming. J Gen Intern Med 2015;30:1874–8. https://doi.org/10.1007/s11606-015-3478-0.Search in Google Scholar PubMed PubMed Central

22. Snape, M. Psych-out error. In: Raz, M, Pouryahya, P, editors. Decision making in emergency medicine: biases, errors and solutions. Singapore: Springer Singapore; 2021:301–6 pp.10.1007/978-981-16-0143-9_47Search in Google Scholar

Received: 2021-03-11

Accepted: 2021-11-17

Published Online: 2021-12-07

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Articles in the same Issue

https://doi.org/10.1515/dx-2021-0035

Keywords for this article

clinical reasoning; diagnostic schema; illness script; metacognitive checklist; problem representation