Title : Dilemma of the diagnostic criterion with an atypical presentation of pancreatitis
Abstract:
Acute Pancreatitis (AP) is a medical condition that requires prompt diagnosis and treatment. Its diagnosis requires at least two of the following three criteria: Acute abdominal pain, serum lipase/amylase ≥ 3 times of normal, and imaging consistent with pancreatitis. High morbidity and mortality is associated with delay in diagnosis and management in patients who do not meet this criteria.
This case reports a 55 years old male who presented to the Emergency department (ED) with left upper quadrant pain, lipase in a normal range, and Computed Tomography (CT) Scan findings non-consistent with pancreatitis. In following ED visits, he presented with Right upper, left upper and epigastric pain. Lipase level remained in a normal range. On admission, he was tachycardic and hypertensive. Basic labs were normal. Liver function test were slightly elevated. Hepatitis panel was normal. Lipase trended up to 173 U/L. Serial CT scans to establish the etiology of the abdominal pain were read to be unremarkable. Later, Magnetic resonance cholangiopancreatography showed findings of acute pancreatitis. The patient died within two days due to multi-organ failure secondary to pancreatitis despite aggressive resuscitation. AP has mortality rate of 5% and can be potentially fatal if misdiagnosed. While diagnosis of AP requires meeting a certain criteria, it can be missed or delayed in patients with either nonspecific abdominal pain, normal levels of lipase and unrevealing CT imaging for pancreatitis. It is suggested that patients that do not fit well into criterion be monitored very closely in a hospital setting using other severity or predictability scores like APACHE and RANSONS’ criteria.
