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Presumed Pancreatitis in the Setting of Renal Impairment

We present a patient misdiagnosed with acute pancreatitis in the setting of acute kidney injury. Misdiagnosis delayed the treatment of his underlying illness and resulted in misuse of resources and prolonged hospital stay.

Case Report

A 60-year-old nonverbal male with a history of quadriplegia, diabetic nephropathy, and nephrolithiasis with left ureteral stent placement was referred for evaluation of failure to thrive, episodic abdominal pain with nausea and vomiting, and low blood pressure. On examination he was found to have epigastric and suprapubic tenderness on palpation.

Initial laboratory results demonstrated acute reduction in glomerular filtration rate (GFR) to 14 mL/min/1.73m2 and a lipase level of 506 u/L. He was admitted to the intensive care unit for management of pancreatitis. Renal ultrasound demonstrated left-sided hydronephrosis. Subsequent lipase and GFR remained abnormal despite high volume crystalloid therapy, with no resolution of his abdominal pain.

Noncontrast abdominal computed tomography (CT) demonstrated left-sided ureter calculi with ureteral dilation and an unremarkable pancreas. Foley catheter placement with ureteroscopy was performed with subsequent resolution of abdominal pain and improvement in GFR and lipase.

Discussion

The diagnosis of acute pancreatitis is based on the presence of any 2 of the following 3 criteria: clinical examination demonstrating epigastric pain often radiating to the back; elevation of serum amylase and lipase levels to at least 3 times of upper limit of normal (ULN); or characteristic findings of acute pancreatitis on imaging. Serum lipase levels 3 times the ULN has a reported sensitivity and specificity for acute pancreatitis from 64%-100% and 99%-100%, respectively.1

However, serum lipase clearance is dependent on glomerular filtration, with subsequent tubular reabsorption and intrarenal degradation.2 We question if serum lipase 3 times the ULN retains its diagnostic relevance in diagnosing acute pancreatitis in the setting of concurrent acute kidney injury. Indeed, significant lipase elevations have been observed in patients with acute and chronic renal impairment. Hameed et al found studies that stated that a correlation between the etiology of acute kidney injury and an elevated serum lipase level did not exist.1

Conclusion

Application of diagnostic criteria can lead to misdiagnosis and mistreatment if not applied in the correct clinical setting. To avoid this clinical error, clinicians should be aware of alternative diagnoses with similar presentations. Lipase elevations to 3 times the ULN for the diagnosis of pancreatitis may sometimes be a false positive depending on the clinical context. Significant lipase elevations may be seen with renal impairment and other intra-abdominal nonpancreatitis pathology, and obstructive nephropathy may present with abdominal pain leading to a misdiagnosis of pancreatitis.

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-Muhammad Khan, MD, Abdurraoof Patel, MD, Reza Samad, MD

This article originally appeared in the May 2019 issue of The American Journal of Medicine.

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