scholarly journals A Treatable but Commonly Missed Etiology;An Unusual Presentation of Primary Hyperparathyroidism as Acute on Chronic Recurrent Pancreatitis- A Case Report

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A178-A179
Author(s):  
Randa Abdelmasih ◽  
Ramy Abdelmaseih ◽  
Elio Paul Monsour ◽  
Marines Faya ◽  
Hesham Nasser
Keyword(s):  
Acute Pancreatitis ◽  
Primary Hyperparathyroidism ◽  
Calcium Level ◽  
Alcoholic Pancreatitis ◽  
Definitive Treatment ◽  
Free Fluid ◽  
Recurrent Pancreatitis ◽  
Uncommon Presentation ◽  
Patient Reported ◽  
Unclear Etiology

Abstract Introduction: Acute pancreatitis is an identified, but uncommon presentation of Primary hyperparathyroidism with prevalence of 3.6%. Hypercalcemia is a rare but known cause of pancreatitis as it leads to premature intra pancreatic activation of protease and destruction of pancreatic tissue leading to pancreatitis. Here we present a case of primary hyperparathyroidism that went undiagnosed for years, and was finally diagnosed after recurrent episodes of pancreatitis of unclear etiology. Case Presentation: A 46-year-old female with history of recurrent pancreatitis presented to the emergency department due to constant epigastric pain for 6 hours associated with nausea and vomiting. Patient reported recurrent episodes of pancreatitis over the past 4 years. Patient was told that etiology of pancreatitis is unclear despite workup. Patient was frustrated that her pancreatitis attacks were usually labeled as alcoholic pancreatitis as she works as a bartender. She strongly states she only drinks alcohol occasionally. She underwent cholecystectomy 2 years ago in attempt to prevent further pancreatitis attacks. Her vital signs were stable. Physical exam was remarkable for epigastric tenderness. CT abdomen and pelvis with contrast showed chronic pancreatitis, pseudocyst and free fluid in the pancreatic bed characteristic of acute pancreatitis. Abdominal US showed post cholecystectomy changes, with no biliary dilatation or stones. Initial labs showed: lipase 2001 U/L, Alcohol level < 10 mmol/L, Calcium 11.5 mg/dl, ionized calcium 4.9 mg/dl, phosphate 2.7 mg/dl, and Triglycerides 52 mg/dl. Subsequently parathyroid hormone was checked and was 116.8 pg/ml. Vitamin D was normal. NM parathyroid scan showed increased tracer activity demonstrating parathyroid adenoma. Patient was given IVF and supportive treatment and her symptoms improved. Endocrinology recommended parathyroidectomy. Patient elected to be discharged and undergoes parathyroidectomy outpatient. Discusion: In this case we emphasize the importance of considering PHPT in acute pancreatitis of unclear etiology especially when Calcium level is elevated. PHPT was missed as a treatable etiology despite mildly elevated calcium level in prior hospitalizations. It is reported that pancreatitis is frequently associated with hypocalcemia with prevalence of 15–88%. Moreover, hypocalcemia is a component of Ranson’s scoring system for severity of pancreatitis. This is explained by precipitation of calcium soaps, hypoalbuminemia and increased calcitonin secondary to glucagon release. PTHT induced pancreatitis management has the same general principles of supportive management. All these patients, once stable, should undergo parathyroidectomy for definitive treatment. Data suggests nearly 100% improvement in pancreatitis symptoms and prevention of recurrent pancreatitis episodes after the cure of PHPT.

scholarly journals Acute Pancreatitis as an Initial Presentation of Primary Hyperparathyroidism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A179-A180
Author(s):  
Alexis Roberto Yamane Laforteza ◽  
Michael Lim Villa
Keyword(s):  
Acute Pancreatitis ◽  
Primary Hyperparathyroidism ◽  
Nasal Spray ◽  
Clinical Management ◽  
Calcium Level ◽  
Epigastric Pain ◽  
Initial Presentation ◽  
Ionized Calcium ◽  
Serum Lipase ◽  
Calcitonin Nasal Spray

Abstract Background: Acute pancreatitis secondary to hypercalcemia is may be the initial presentation of a patient with primary hyperparathyroidism. However, because of its infrequency as a cause of pancreatitis, it can be easily missed during clinical management. Clinical Case: A 56-year old woman initially presented with epigastric pain with radiation to the back. She had no previous comorbidities, did not drink alcohol, and had no previous history of cholelithiasis, nephrolithiasis nor pathologic fractures. The diagnosis was confirmed by an elevated serum lipase level (59117 U/L, reference interval (RI): 73–393 U/L) and contrast-enhanced MRI findings suggestive of acute pancreatitis with hemorrhagic component in the pancreatic body and tail. Hypercalcemia was documented on two separate occasions during her confinement with a serum total calcium level of 10.5 mg/dL (RI: 8.5–10.1 mg/dL) and an ionized calcium level of 1.45 mmol/L (RI: 1.09–130 mmol/L), however, no further workup was done at that time. She was managed conservatively and was sent home with plans to do an ERCP and possible laparoscopic cholecystectomy once her condition had stabilized. However, she had recurrence of the epigastric pain about one month after her initial episode. Her serum lipase showed an interval increase from her last result (1426 U/L from 933 U/L) and contrast-MRI now showed the development of areas of walled-off necrosis in the body and tail of the pancreas. Serum ionized calcium was again elevated (2.17 mmol/L); she also had an elevated intact PTH level (780.6 pg/ml, RI: 18.5–88.0 pg/ml). Parathyroid SPECT-CT showed a sestamibi-avid lesion inferoposterior to the right thyroid lobe, indicating a probable parathyroid adenoma. She was given 1 dose of Denusomab 120 mg subcutaneously and started on Calcitonin nasal spray 200 IU twice a day. She underwent ultrasound-guided drainage of the pancreatic necrosis and was subsequently discharged. Due to difficulty in procurement of the Calcitonin nasal spray, she was maintained on Cinacalcet 30 mg/tablet, 1 tablet once a day upon discharge with plans to undergo parathyroidectomy once she was had fully recovered from her pancreatitis. Conclusion: Primary hyperparathyroidism should always be considered when hypercalcemia is noted during the clinical management of acute pancreatitis. Reference: Misgar RA, Bhat MH, Rather TA, Masoodi SR, Wani AI, Bashir MI, Wani MA, Malik AA. Primary hyperparathyroidism and pancreatitis. J Endocrinol Invest. 2020 Oct;43(10):1493–1498.

scholarly journals Primary Hyperparathyroidism Presenting as Recurrent Pancreatitis Due to Parathyroid Adenoma

2020 ◽  
Vol 3 (S 01) ◽  
pp. S68-S72
Author(s):  
Vigneshraja Kumar ◽  
Anil Kumar Nethikoppula ◽  
N. Pallavi ◽  
Nukala Anusha ◽  
Shrinivas B. Somalwar ◽  
...  
Keyword(s):  
Acute Pancreatitis ◽  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Young Women ◽  
Surgical Excision ◽  
Recurrent Pancreatitis ◽  
Initial Manifestation

AbstractRecurrent attacks of acute pancreatitis as initial manifestation of primary hyperparathyroidism is rare. We report two cases of young women presenting with recurrent attacks of pancreatitis due to parathyroid adenoma. After surgical excision of the parathyroid adenoma, symptoms of pancreatitis resolved, and serum parathormone and calcium levels returned to normal.

scholarly journals A Case of Acute Pancreatitis as a First Presentation of Primary Hyperparathyroidism

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A170-A170
Author(s):  
Ahmed Elmaaz ◽  
Alberto Antonio Franco Akel ◽  
Regina Belokovskaya
Keyword(s):  
Acute Pancreatitis ◽  
Primary Hyperparathyroidism ◽  
Parathyroid Adenoma ◽  
Calcium Level ◽  
Urinary Stones ◽  
Thyroid Lobe ◽  
Ureteric Stone ◽  
Serum Lipase ◽  
Left Thyroid Lobe

Abstract Introduction: Alcohol use and biliary stones cause the majority of cases of acute pancreatitis (AP). Hypercalcemia is considered a relatively uncommon sole reason for AP. The incidence of hypercalcemia induced AP is about 1.5%. AP as the first presentation of primary hyperparathyroidism (PHPT), in the absence of any other precipitating factors, is extremely rare. We present a case of AP combined with obstructive uropathy as the first clinical manifestations of occult PHPT. The clinical and biochemical recovery of the patient followed parathyroidectomy suggested the correlation between AP and PHPT. Case Presentation: A 63-year-old patient with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease presented to the emergency room with progressive abdominal pain that started two days prior. The pain radiated to his back and was associated with nausea and vomiting. Additionally, he reported black urine and dysuria. He did not report any alcohol or illicit drug use. His surgical history was significant for cholecystectomy. Physical examination showed elevated blood pressure and severe epigastric tenderness. Laboratory findings were significant for calcium level 14.3 mg/dL (8.5–10.5 mg/dL), serum lipase level 679 U/L (13–60 U/L), serum amylase 327 U/L (28–100 U/L), serum PTH 239 pg/mL (15–65 pg/mL), and leukocytosis 11.9K (4-11K) with neutrophilia of 86.4 %, Hemoglobin 13.3 g/dL, and normal platelet count. Vitamin D 25 (OH) level was 12.5 ng/mL (30–80 ng/mL). Urine analysis had moderate hematuria. Lipid panel showed normal triglycerides and cholesterol concentrations. HbA1c was 6.1 % (4–5.6%). Normal levels of metanephrines were found. CT of the abdomen showed acute pancreatitis with peripancreatic edema and right ureteric stone. Thyroid ultrasound revealed a hypervascular mass posterior to the left thyroid lobe. Sestamibi scan further demonstrated abnormal retention of activity in the neck near the left thyroid lobe consistent with parathyroid adenoma. After hydration and a short course of calcitonin, Cinacalcet was started as a bridge to parathyroidectomy. The patient clinically improved with normalization of Calcium levels. The ureteric stone was removed and elective left parathyroidectomy was performed two weeks later. The histopathological exam confirmed a parathyroid adenoma. Postoperatively, intact PTH level was 26 pg/mL with Calcium level of 10.4 mg/dL. The patient was completely asymptomatic. Conclusion: Although AP is a rare presentation of a silent PHTP, it should warrant the measurement of serum calcium and PTH levels in absence of more common causes of AP, especially if combined with urinary stones. Furthermore, MEN type 2 should be considered in the setting of the thyroid mass with PHPT. Medical therapy could improve the clinical condition of the patient; however, the surgical resection of a parathyroid adenoma remains the curative treatment.

scholarly journals Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis

2021 ◽  
Vol 8 (1) ◽  
pp. e000538
Author(s):  
Alejandra Tepox-Padrón ◽  
Rafael Ambrosio Bernal-Mendez ◽  
Gilberto Duarte-Medrano ◽  
Adriana Fabiola Romano-Munive ◽  
Milton Mairena-Valle ◽  
...  
Keyword(s):  
Acute Pancreatitis ◽  
Chronic Pancreatitis ◽  
Endoscopic Ultrasound ◽  
Complete Resolution ◽  
Diagnostic Yield ◽  
Recurrent Pancreatitis ◽  
Mucinous Neoplasm ◽  
Possible Cause ◽  
Symptoms And Signs

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP.ObjectivesTo determine the diagnostic yield of EUS in IARP.DesignA retrospective study was performed in patients with IARP evaluated by EUS between January 2009 and December 2016. Follow-up assessments of acute pancreatitis recurrence were carried out.ResultsSeventy-three patients with 102 EUS procedures were included. EUS was able to identify the cause of IARP in 55 patients (75.3%). The most common findings were chronic pancreatitis in 27 patients (49.1%), followed by lithiasic pathology in 24 patients (43.6%), and intraductal papillary mucinous neoplasm in four patients (7.3%). A directed treatment against EUS findings had a protective tendency associated with the final resolution of recurrence. There were no complications reported.ConclusionEUS performed in patients with IARP helped to identify a possible cause in 2/3 of the cases. The majority of patients have a treatable disease.

scholarly journals Advances in the diagnosis and the management of primary hyperparathyroidism

2021 ◽  
Vol 12 ◽  
pp. 204062232110159
Author(s):  
Ana Kashfia Islam
Keyword(s):  
Renal Function ◽  
Parathyroid Hormone ◽  
Bone Loss ◽  
Primary Hyperparathyroidism ◽  
Kidney Stones ◽  
Parathyroid Glands ◽  
Definitive Treatment ◽  
Indications For Surgery ◽  
Musculoskeletal Complaints ◽  
Parathyroid Cancer

The parathyroid glands, one of the last organs to be discovered, are responsible for maintaining calcium homeostasis, and they continue to present the clinician with diagnostic and management challenges that are reviewed herein. Primary hyperparathyroidism (PHPT) comprises the vast majority of pathology of the parathyroid glands. The classic variant, presenting with elevated calcium and parathyroid hormone levels, has been studied extensively, but the current body of literature has added to our understanding of normocalcemic and normohormonal variants of PHPT, as well as syndromic forms of PHPT. All variants can lead to bone loss, kidney stones, declining renal function, and a variety of neurocognitive, gastrointestinal, and musculoskeletal complaints, although the majority of PHPT today is asymptomatic. Surgery remains the definitive treatment for PHPT, and advances in screening, evolving indications for surgery, new imaging modalities, and improvements in intra-operative methods have greatly changed the landscape. Surgery continues to produce excellent results in the hands of an experienced parathyroid surgeon. For those patients who are not candidates for surgery, therapeutic advances in medical management allow for improved control of the hypercalcemic state. Parathyroid cancer is extremely rare; the diagnosis is often made intra-operatively or on final pathology, and recurrence is common. The mainstay of treatment is normalization of serum calcium via surgery and medical adjuncts.

scholarly journals Sialendoscopy With Intraductal Steroid Irrigation in Patients With Sialadenitis Without Sialoliths

2019 ◽  
Vol 98 (5) ◽  
pp. 291-294 ◽  
Author(s):  
Saudamini J. Lele ◽  
Mickie Hamiter ◽  
Torrey Louise Fourrier ◽  
Cherie-Ann Nathan
Keyword(s):  
Treatment Option ◽  
Case Series ◽  
Complete Response ◽  
Definitive Treatment ◽  
Invasive Technique ◽  
Effective Treatment Option ◽  
Patient Reported ◽  
History Of ◽  
The Mean

Sialendoscopy has emerged as a safe, effective and minimally invasive technique for management of obstructive and inflammatory salivary gland disease. The aim of our study was to analyze outcomes of sialendoscopy and steroid irrigation in patients with sialadenitis without sialoliths. We performed a retrospective analysis of patients who underwent interventional sialendoscopy with steroid irrigation from 2013 to 2016, for the treatment of sialadenitis without sialolithiasis. Twenty-two patients underwent interventional sialendoscopy with ductal dilation and steroid irrigation for the treatment of sialadenitis without any evidence of sialolithiasis. Conservative measures had failed in all. Eleven patients had symptoms arising from the parotid gland, 4 patients had symptoms arising from the submandibular gland, while 6 patients had symptoms in both parotid and submandibular glands. One patient complained of only xerostomia without glandular symptoms. The mean age of the study group which included 1 male and 21 females was 44.6 years (range: 3-86 years). Four patients had autoimmune disease, while 7 patients had a history of radioactive iodine therapy. No identifiable cause for sialadenitis was found in the remaining 11 patients. The mean follow-up period was 378.9 days (range: 16-1143 days). All patients underwent sialendoscopy with ductal dilation and steroid irrigation. Twelve patients showed a complete response and 9 patients had a partial response, while 1 patient reported no response. Only 3 patients required repeat sialendoscopy. The combination of sialendoscopy with ductal dilation and steroid irrigation is a safe and effective treatment option for patients with sialadenitis without sialoliths refractory to conservative measures. Prospective studies with a larger case series are needed to establish its role as a definitive treatment option.

scholarly journals Imaging of the parathyroid glands in primary hyperparathyroidism

2016 ◽  
Vol 174 (1) ◽  
pp. D1-D8 ◽  
Author(s):  
Salvatore Minisola ◽  
Cristiana Cipriani ◽  
Daniele Diacinti ◽  
Francesco Tartaglia ◽  
Alfredo Scillitani ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Minimally Invasive ◽  
Invasive Procedure ◽  
Parathyroid Glands ◽  
Definitive Treatment ◽  
Preoperative Imaging ◽  
Disease Etiology ◽  
Minimally Invasive Surgical ◽  
Asymptomatic Patients ◽  
Surgical Expertise

Primary hyperparathyroidism (PHPT) is one of the most frequent endocrine diseases worldwide. Surgery is the only potentially curable option for patients with this disorder, even though in asymptomatic patients 50 years of age or older without end organ complications, a conservative treatment may be a possible alternative. Bilateral neck exploration under general anaesthesia has been the standard for the definitive treatment. However, significant improvements in preoperative imaging, together with the implementation of rapid parathyroid hormone determination, have determined an increased implementation of focused, minimally invasive surgical approach. Surgeons prefer to have a localization study before an operation (both in the classical scenario and in the minimally invasive procedure). They are not satisfied by having been referred a patient with just a biochemical diagnosis of PHPT. Imaging studies must not be utilized to make the diagnosis of PHPT. They should be obtained to both assist in determining disease etiology and to guide operative procedures together with the nuclear medicine doctor and, most importantly, with the surgeon. On the contrary, apart from minimally invasive procedures in which localization procedures are an obligate choice, some surgeons believe that literature on parathyroidectomy over the past two decades reveals a bias towards localization. Therefore, surgical expertise is more important than the search for abnormal parathyroid glands.

scholarly journals The role and importance of biochemical markers in diagnosis of alcoholic acute pancreatitis

2012 ◽  
Vol 65 (3-4) ◽  
pp. 152-157
Author(s):  
Snezana Tesic-Rajkovic ◽  
Biljana Radovanovic-Dinic ◽  
Tatjana Jevtovic-Stoimenov
Keyword(s):  
Acute Pancreatitis ◽  
Aspartate Aminotransferase ◽  
Alanine Aminotransferase ◽  
Biochemical Markers ◽  
Biochemical Parameters ◽  
Serum Amylase ◽  
Alcoholic Pancreatitis ◽  
Serum Lipase ◽  
Acute Alcoholic Pancreatitis ◽  
Biochemical Analyses

Introduction. Alcoholic acute pancreatitis occurs in 10% of alcoholics, who take more than 80g alcohol daily. Different biochemical markers are used to diagnose acute pancreatitis, and some of them may help in establishing etiology of acute pancreatitis. Material and Methods. This study is a prospective review of 21 patients. All patients were hospitalized at the Department for Gastroenterology and Hepatology or at the Department for Surgery of the Clinical Centre of Nis in the period from August 1st 2009 to March 1st 2010 with diagnosis of acute alcoholic pancreatitis. Detailed anamnesis, clinical examination, biochemical analyses and ultrasonography of the upper abdomen were done in all patients. All patients provided data on alcohol abuse. Results. The analysis of the corresponding biochemical parameters revealed a statistically significant correlation between the following values: serum amylase and serum lipase (R=0.964674; p<0.001), cholesterol and triglycerides (R=0.93789; p<0.001), total and direct bilirubin (R=0.857899; p<0.001) and between aspartate aminotransferase and alanine aminotransferase (R=0.824461, p<0.001) in patients with alcoholic acute pancreatitis. In addition, there was a statistically significant correlation between the values of serum amylase and urinary amylase (R=0.582742, p<0.001). Discussion. The analysis of biochemical markers showed that some of them were significant for beforehand diagnosis of alcoholic acute pancreatitis, which is in accordance with other studies. Conclusion Some biochemical parameters can be potential predictors of alcoholic acute pancreatitis (lipase/amylase ratio >2, greater ratio of aspartate aminotransferase/ alanine aminotransferase, enhanced triglycerides and values of mean corpuscular volume.

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