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A 52-year-old male was admitted to the hospital complaining of severe epigastric pain with radiation to his back. The pain started on the day before admission and was associated with nausea and vomiting. On examination he was found to be dehydrated and to have only mild epigastric midline tenderness and guarding. He denied a recent alcohol debauch. Because of previous symptoms, the patient had undergone an ultrasound of the gallbladder, the results of which were normal.
Studies Results Routine laboratory studies Within normal limits (WNL) except for the following: White blood cells (WBCs), p. 526 15,000/mm3 (normal WBC: 5000-10,000/mm3) Serum amylase test, p. 61 640 International units/L (normal: 56-190 International units/L) Urine amylase test, p. 909 1240 International units/hour (normal: 3-35 International units/hour) Serum lipase test, p. 339 240 units/L (normal: 0-110 units/L) Ultrasound examination of pancreas, p. 887 Edematous and enlarged head of the pancreas Computed tomography (CT ) scanning of abdomen, p. 1020 Diffusely edematous and enlarged pancreas Endoscopic retrograde cholangiopancreatography (ERCP), p. 605 Normal pancreatic duct
The diagnosis of pancreatitis was certain in light of the elevation of both the serum and urine amylase levels and also of the serum lipase level. Alcohol and gallstones are the two most common causes of pancreatitis; however, the patient denied drinking alcohol, and previous ultrasound of the gallbladder excluded gallstones. Because cancer of the pancreas also can cause distal pancreatic inflammation, tumor had to be ruled out as a cause of this pancreatic episode. Ultrasonography, which is occasionally inaccurate for pathologic pancreatic conditions, indicated an enlarged head of the pancreas that could be compatible with a tumor. However, CT scanning and ERCP results eliminated the possibility of cancer.
The patient was treated with nasogastric (NG) suction and IV infusions until his gastrointestinal function returned to normal. His pancreatitis was subsequently found to be drug induced (by hydrochlorothiazide). The drug was stopped, and he had no further problems.
Critical Thinking Questions
Case Studies 2Copyright 2014 by Mosby, Inc., an imprint of Elsevier Inc.1. Why was it important to question this patient about binge drinking? 2. What advantage is achieved by obtaining urine amylase levels in addition to serum amylase levels?
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