3014 A Rare Case of Fioricet-Induced Acute Pancreatitis

Abstract

INTRODUCTION: Acute pancreatitis is the inflammation of the pancreas leading to a very severe line of symptoms of which a very prominent one is excruciating abdominal pain; it is a common acute surgical presentation in the western world. The organ which has an important role in digestion due to hormone production including insulin (Santhi et al 2019). The annual incidence of acute pancreatitis is ∼20-40/100,000 population (Dhiraj Yadav et al 2014). About 40% are due to gallstones, 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP (Nesvaderani, M. et al 2015). Fioricet (Butalbital-Acetaminophen-Caffeine), a medication used in tension headaches due to the combination of acetaminophen for pain, caffeine to increase effects of acetaminophen and butalbital a sedative which helps to decrease anxiety and cause relaxation. We present a case of a female suspected to have acute pancreatitis due to fioricet. CASE DESCRIPTION/METHODS: A 46-year-old female with a BMI of 27 came to the ED with complaints of epigastric abdominal pain which had started the day before, radiates to back and right flank pain with the severity of 10/10 on the pain scale with associated nausea and with no vomiting. Previous history of Kidney stones, cholelithiasis (with a cholecystectomy), Hypothyroidism and Migraines for which she had been on Fioricet for over five years and takes the medication with the frequency of attacks. The patient denies any history of drinking and alcohol or drug abuse, with a known allergy to Hydrocodone. Ultrasound showed no acute pancreatitis, Ct Imagining with i.v contrast depicted acute pancreatitis, although labs showed; amylase-43, lipase-226, ast- 35, alt- 30, total bilirubin-0.3, WBC- 16.6 (left shift). To rule out autoimmune activity due to the history of hypothyroidism, Immuno-serology showed; Igg- negative, Ana- negative. An MRCP was performed showed no evidence of intra and extra-hepatic duct dilation, heterogeneous signal intensity was noted around the pancreas, compatible with pancreatitis. With all arrows pointing at the medication Fioricet. DISCUSSION: In conclusion, one of the active ingredients acetaminophen is documented as a class II medication (medications implicated in more than 10 cases of acute pancreatitis) (Trivedi CD et al 2005) due to the evidence stated above, we need to be cautious with long term therapy of fioricet in patients with chronic migraine and implement better screening techniques to avoid such complications which could lead to a more devastating outcome.