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"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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What caused the pancreatitis?
17 Aug2009
The patient is a 68-year-old man who presented with abdominal pain, nausea and vomiting. He described his pain as 10/10 sharp and mid-epigastric without radiation. He denied any lower gastrointestinal symptoms. Around 2 months previously he had a bout of pancreatitis, but his physicians did not find an etiology.
He had type II diabetes mellitus, hypertension, coronary artery disease (stent), and a known right kidney mass. His medication list included simvastatin, januvia, aspirin, cilostazol, famotidine, actos, lisinopril, plavix, lasix prn and metformin.
Social history was negative for alcohol, tobacco or illegal drugs.
He was afebrile, BP 139/64, heart rate 101, respirations 18. He had mild epigastric tenderness without guarding or rebound. His stool was heme negative and rectal exam showed no tenderness.
Complete blood count showed a slightly elevated WBC – 11. Liver tests:
| Destruction | Obstruction | Factory | |||
| AST | 396 | alk phos | 88 | albumin | 4 |
| ALT | 290 | T. Bili. | 1.3 | INR | n/a |
His lipase was 1056.
RUQ ultrasound showed no stones on this admission as well as his previous admission. The radiologist did note some gallbladder wall thickening.
Consider the differential diagnosis of acute pancreatitis. How would you evaluate the patient further?
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11 Responses to What caused the pancreatitis?
david
August 17th, 2009 at 1:24 pm
Most likely the acute pancreatitis is from microlithiasis from the gallbladder. The elevated AST and ALT support a passed stone despite the normal alk phos and bilirubin. He needs the gallbladder resected. Could also do an ERCP or MRCP to evaluate the biliary ducts though even if negative he would still need the gallbladder taken out.
That said, I would do an MRCP first to evaluate for a peripancreatic mass that may be obstructing the CBD. Perhaps this “renal mass” may be playing a role.
Certainly meds like the ACE-I could cause acute pancreatitis but would be unliklely to simultaneously cause a hepatitis. Either way it would be a diagnosis of exclusion.
Plan:
1. do MRCP
2. if negative then remove gallbladder. If it shows a mass or other abnormality then proceed appropiately.
Daniel Cardenas
August 17th, 2009 at 2:27 pm
Elevated liver enzymes could be due to simvastatin.
D/C furosemide.
What caused the pancreatitis? : Trends
August 18th, 2009 at 6:23 am
[...] and a known right kidney mass. His medication list included simvastatin, januvia, aspirin, cilostaz click for more Published: August 18, 2009 Filed Under: Uncategorized Leave a Comment Name: [...]
Happy Hospitalist
August 18th, 2009 at 7:08 pm
Just about every medicine he’s on could cause either hepatitis or pancreatitis. I’d find out if any of them were recent additions. For the time being stop the statin, metformin, ace, lasix, ASA, januvia. I’m not sure about the others. Check for Hep B and C.
And ERCP would be helpful to look for local structural abnormalities (diverticula).
At any rate, I’m not sure about the GB being the cause. Perhaps a PIPIDA scan is warranted.
Check a triglyceride level, of course. Maybe he needs lipopharesis and has hepatitis from NASH.
Oh, and just because he says he doesn’t drink, doesn’t mean he doesn’t. I’d admit him to a rehab place against his will.
Happy Hospitalist
August 18th, 2009 at 7:29 pm
I forgot to add, I have no idea what chemo is used to treat RCC, but if i’ts 6-MP, you have your answer.
david
August 18th, 2009 at 7:32 pm
This man need his gallbladder out ASAP before he gets another potentially fatal case of pancreatitis.
david
August 18th, 2009 at 7:34 pm
Also would perform an intra-op cholangiogram at the time of the ccy.
Daniel Cardenas
August 18th, 2009 at 8:05 pm
Any crazy surgeon?
Hospital Survivor
August 19th, 2009 at 11:10 pm
Dear “Happy Hospitalist”
I had acute pancreatitis 16 years ago and I didn’t drink alcohol. Sometimes patients tell THE TRUTH!
Anonymous
August 20th, 2009 at 11:24 am
It was a joke Truth Teller
Bohdan A. Oryshkevich, MD, MPH
August 20th, 2009 at 9:07 pm
I have not looked at the answer yet. But searching for medications that cause simultaneous pancreatitis and hepatitis I came across saw palmetto. This man is in the age when he could have BPH. But I am just beginning my work on this.
This is early and easy thing to check. Just ask the patient before ordering any fancy tests or removing the gall bladder.
Bohdan A. Oryshkevich, MD, MPH