S1905 A Rare Case of Acute Pancreatitis With Normal Lipase

Abstract

Introduction: Acute pancreatitis (AP) is an inflammatory disease of the pancreas that usually presents with epigastric pain radiating to the back. AP is a critical condition that can lead to multi-organ failure if not diagnosed early. It is diagnosed with 2 of the following: characteristic abdominal pain, imaging consistent with acute pancreatitis, and lipase levels greater than 3 times the upper limit of normal. The negative predictive value of lipase for diagnosing acute pancreatitis is between 94% and 100%. We present a rare case of acute pancreatitis with normal serum lipase levels. Our findings highlight the vital utility of imaging for diagnosing acute pancreatitis in the setting of normal lipase levels. Case Description/Methods: An 80-year-old female presented with a 1-day history of epigastric pain radiating to her back associated with nausea, vomiting, and loss of appetite. Her past medical history was significant for hypertension, NIDDM II, and atrial fibrillation. She had no recent medication changes and took amlodipine, metformin, metoprolol, and apixaban. Previous surgeries included cholecystectomy and appendectomy. She abstained from alcohol, tobacco, or recreational drug use. She reported abdominal trauma from bicycle collision one week prior to arrival. Vital signs were remarkable for T 101.2 F. She did not appear in acute distress. Her physical exam was remarkable for epigastric tenderness on palpation. Murphy, Cullen, and Grey-Turner signs were absent. Laboratory evaluation revealed WBC 12.8 k/uL, lipase 29 U/L, amylase 52 U/L, AST 13 U/L, ALT 21 U/L, ALP 58 U/L (Table). Lipid profile and EtOH levels were within normal limits. CT of the abdomen and pelvis revealed interstitial edematous pancreatitis (Figure). She was started on aggressive intravenous fluid resuscitation, metoclopramide for nausea, and intravenous acetaminophen for pain. Her abdominal pain progressively resolved, and she tolerated a full diet by day 3. Discussion: AP is a critical condition that requires early diagnosis. The negative predictive value of elevated lipase levels for diagnosing AP ranges from 94% to 100%. Our patient was diagnosed with acute pancreatitis due to trauma in the setting of normal lipase levels. We demonstrate the utility of imaging in diagnosing acute pancreatitis in the setting of normal serum lipase levels.Figure 1.: CT scan of the abdomen revealed peripancreatic fat stranding and interstitial edema consistent with findings of pancreatitis. Table 1. - Laboratory trends are displayed here. Lipase remained within normal limits through the 4 days measured. Admission Day 1 Day 2 Day 3 Day 4 Normal Range Hemoglobin 8.8 7.8 9.3 8.6 9.0 12.0 - 15.0 g/dL WBC 12.8 7.4 5.9 5.7 6.2 3.4 - 11.0 10*3/uL Amylase 52 39 29 - 103 U/L Lipase 29 12 13 - 60 U/L Calcium 8.9 8.1 8.9 8.8 8.4 8.4 - 10.2 mg/dL Alkaline Phosphatase 58 44 46 59 54 40 - 129 U/L ALT 21 16 29 17 11 10 - 50 U/L AST 13 10 14 12 16 13 - 39 U/L