Not All Hyperlipasemia Is Pancreatitis

Abstract

Purpose: We commonly encounter situations where we see elevation of pancreatic enzymes. We present two unlikely causes of elevated lipase. Methods: Case review Results: Case 1: A 55 yo AAM presented with complaints of intermittent abdominal pain associated with nausea/vomiting for the past year. Past medical history included acute pancreatitis and hypertension. Social history was significant for past heavy alcohol and tobacco abuse. Physical exam was normal. Labs were significant for elevated amylase (176 u/L) and lipase (264 u/l). CT abdomen showed heterogenous enlargement of pancreatic head with a possible low density nodule in it, soft tissue mass in medial wall of second portion of duodenum, marked CBD dilatation and mild intrahepatic ductal dilatation. Enlarged celiac and peripancreatic lymph nodes and multiple hypervascular liver lesions were seen as well. ERCP was attempted. There was a mass like structure in second portion of duodenum through which the scope could not traverse. Biopsy revealed carcinoid tumor. PET scan showed increased FDG uptake in the head of pancreas and duodenum and none in the liver. Octreotide scan revealed increased activity in the mass suggestive of neuroendocrine tumor. Patient underwent Whipple's procedure and is doing well currently. Case 2: A 40 yo AAM presented with abdominal pain, nausea and hematemesis. Diffuse abdominal tenderness was present on exam. Labs were significant for mildly elevated LFTs and a lipase of 800 u/l. CT abdomen showed mild bulkiness of head of pancreas with mutilobulated mass measuring 12.5 cm × 5.6 cm encasing the second and third portion of duodenum. Filling defects in proximal jejunum were identified. Enlarged mesenteric and retroperitoneal lymph nodes were seen. SBE showed a 1 cm gastric ulcer in fundus, an ulcer in duodenal bulb with abnormal appearing tissue around it as well as a friable mass like lesion with narrowing distal to the third portion of duodenum preventing GIF 160 scope passage. Biopsies revealed diffuse large B-cell lymphoma. He later tested positive for HIV. PET scan showed increased FDG uptake in neck, chest and abdomen with diffuse involvement of small bowel with multiple strictures. Patient was started on chemotherapy. His hospital course was complicated by pulmonary embolism for which he received anticoagulation. He developed hematochezia. He left AMA before further GI work up could be completed. Conclusion: These cases illustrate that amylase and lipase are non-specific and need detailed work up before diagnosing a patient as having pancreatitis; especially since the first patient was misdiagnosed as having acute pancreatitis on a prior admission. Malignant etiologies should be entertained particularly in patients with persistent hyperlipasemia.