ID: 33: ACUTE PANCREATITIS WITH NORMAL LIPASE AND AMYLASE ENZYMES

Case ReportA 44 year-old Male with no significant past medical history presented to the Emergency Department complaining of nausea, vomiting, diarrhea, upper abdominal pain and fever. For the past one week prior to presentation, patient developed pressure-like epigastric pain, radiating to the back, worsened with lying down, and associated with non-bloody, non-bilious vomiting, followed by anorexia, nausea and fever to 102F. Patient had not eaten several days prior to arrival to the hospital; hence he was brought in by his family for evaluation. Notably, two months prior to presentation, patient was evaluated in an outside hospital for abdominal pain similar in quality, but not in intensity, and reportedly had normal blood tests and imaging.Physical examination: vital signs significant for hypertension of 150/90, tachycardia to 108 and fever of 101.5; abdomen notable for tenderness to palpation over epigastrium, with mild guarding, but no rebound or Murphy's sign; the rest of the exam, including cardiovascular, pulmonary, integumentary and neurological exam, unremarkable. Initial laboratory findings are: WBC of 10.1, with 81% neutrophils, amylase of 47 (N 28–100 U/L), lipase level of 14 (N 11–82 U/L), and unremarkable basic metabolic panel. Liver function tests notable for normal AST and ALT, elevated GGT to 277 (N <50 U/L), LDH: 681 (N 90–225 U/L), Total bilirubin: 0.9(N 0–1.5 mg/dl). Lipid panel: Total Cholesterol 201 (N<200 mg/dL), Triglycerides 80 (N<150 mg/dL), LDL 68 (<100 mg/dL). Chest X-ray showed a small left-sided pleural effusion.Patient was admitted to medicine service for treatment of gastroenteritis, and was started on intravenous fluids and symptomatic management. On day three of hospitalization, patient developed worsening abdominal pain, associated with inability to tolerate per oral intake secondary to vomiting of food contents, and due to worsening abdominal pain, underwent further workup. CBC revealed leukocytosis with a left shift, WBC count of 15.3, with 81.5% neutrophils. Basic metabolic panel notable for sodium of 124, potassium of 3.2, calcium of 7.4, magnesium of 1.7, phosphate of 1.9. Repeat lipase was 67(N 11–82 U/L). An abdominal CT scan (figure 1) with IV and oral contrast was performed, and showed extensive pancreatic edema, especially involving the pancreatic head and uncinate process, and peripancreatic stranding; these changes deemed consistent with acute pancreatitis; no calcifications or pseudocysts were observed on the CT. Abdominal ultrasound showed multiple gallbladder stones, however, common bile duct was of normal diameter (2.5 mm), and no intrabiliary duct dilatation was noted.Based on clinical presentation and radiological findings, the diagnosis of acute pancreatitis was made. The patient started on aggressive intravenous fluid hydration, pain management and bowel rest, with good improvement in symptoms. On day 5, patient was able to tolerate a regular diet, and noted an almost complete resolution of pain, and therefore was discharged home.Abstract ID: 33 Figure 1