A Case of Periodic Marathon Pancreatitis: Smaller Electricity but a Bigger Medical Bill

Abstract

Purpose: In October 2006, a 41-year-old man was admitted to hospital with 3 days of epigastric pain, nausea and vomiting. He had just finished cutting and storing “two vans' worth” of firewood for upcoming winter in order to save on electricity bill by burning firewood. He was not taking any medications. There was no history of alcohol use or trauma. Physical examination showed blood pressure 98/57 mmHg and epigastric tenderness. Based on suggestive symptoms, elevated lipase (251 IU/L) and positive CT findings, a diagnosis of acute pancreatitis (AP) was made. Liver panel, serum calcium and triglycerides, and abdominal ultrasound were normal. An ERCP was normal and he underwent biliary and pancreatic sphincterotomy and cholecystectomy. In October 2008 he was re-admitted with another episode of unexplained acute pancreatitis while cutting firewood which was treated as previously. Another sphincterotomy for possible sphincter of Oddi dysfunction was performed. Unfortunately, he developed “post-ERCP pancreatitis” from which he recovered after an 8-day hospitalization. Three years later, in October 2011, he was admitted to hospital once again with epigastric pain and vomiting after cutting firewood. CT scan showed acute edematous pancreatitis. His liver profile, serum calcium and triglyceride level were normal. Serum IGg-4, ESR, CEA, CA 19-9 were also normal. His condition improved with analgesia and hydration. Based on periodic nature of AP immediately following heavy exertion, “marathon (ischemic) pancreatitis” was diagnosed. In retrospect, the patient informed that he did not cut firewood in years 2007, 2009 and 2010 and had no problems in those years. CT angiography showed no significant mesenteric atherosclerosis or aberrancy of pancreatic perfusion (Figure 2). Establishing a cause of acute pancreatitis (AP) is crucial in preventing recurrence and associated morbidity. In most cases, etiology can be determined with basic clinical evaluation including history, physical examination, laboratory data and abdominal imaging. A significant number of remaining cases require advanced testing; however, a detailed and accurate history may prove invaluable in the work-up for unexplained AP, potentially avoiding the need for multiple invasive procedures associated with complications and expense.Figure: [832] CT abdomen showing acute pancreatitis (A) and CTA showing normal pancreatic blood supply (B).