A 55-year-old woman comes to the emergency department due to acute-onset midepigastric pain that radiates to her back. She also has nausea and vomiting. Medical history is significant for plantar fasciitis and hypertension, for which she takes amlodipine. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 37.1 C (98.8 F), blood pressure is 117/76 mm Hg, pulse is 102/min, and respirations are 16/min. Examination shows tenderness to deep palpation in the epigastrium. The remainder of the examination is within normal limits. Laboratory test results are as follows:
| Liver studies | |
| Albumin | 4.2 g/dL |
| Alkaline phosphatase | 148 U/L |
| Aspartate aminotransferase (SGOT) | 111 U/L |
| Alanine aminotransferase (SGPT) | 160 U/L |
| Amylase | 940 U/L |
| Lipase | 2,155 U/L |
| Complete blood count | |
| Hemoglobin | 12.8 g/dL |
| Platelets | 220,000/mm3 |
| Leukocytes | 13,200/mm3 |
Abdominal ultrasonography is notable for revealing several stones within the gallbladder without gallbladder wall thickening. The patient is admitted to the hospital and given supportive care with pain control, intravenous fluids, and nothing by mouth. She recovers rapidly and can eat within 2 days. Her enzyme levels begin to trend down, and the patient says she feels normal. Which of the following is the best next step in management of this patient?
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This patient has epigastric pain radiating to the back and amylase/lipase levels >3 times the upper limit of normal, meeting diagnostic criteria for acute pancreatitis. Acute pancreatitis is most commonly due to alcohol or gallstones. Given this patient's lack of alcohol use and the presence of several gallstones on ultrasonography, gallstones are the most likely etiology; in addition, some studies have shown that ALT >150 U/L has a high (~90%) positive predictive value for diagnosing gallstone pancreatitis.
Initial management of gallstone pancreatitis requires determining whether urgent intervention with endoscopic retrograde cholangiopancreatography (ERCP) is indicated. The presence of pancreatitis is not itself an indication for ERCP (Choice B). Instead, urgent ERCP (for stone removal and/or sphincterotomy) is indicated if either of the following is present:
In the absence of these indications, patients with gallstone pancreatitis are treated using supportive care (eg, IV fluids, analgesics). Most stones pass spontaneously from the CBD into the duodenum, so the condition of patients, such as this one, often improves without further intervention. Following the resolution of pancreatitis (eg, improved symptoms, normalization of laboratory values), early elective cholecystectomy is recommended because it significantly reduces the incidence of recurrent attacks.
(Choice A) Antihypertensives commonly associated with drug-induced pancreatitis include thiazides and ACE inhibitors. However, calcium channel blockers (eg, amlodipine) do not commonly cause pancreatitis. In addition, this patient's findings of gallstones and elevated ALT are more consistent with gallstone pancreatitis.
(Choice C) The HIDA scan uses a nuclear tracer that is excreted in bile to evaluate the patency of the cystic duct; it can evaluate for cholecystitis when there is a high suspicion based on history and physical examination but indeterminate ultrasonography. Acute cholecystitis is unlikely in this patient whose condition has improved and who now feels normal, so a HIDA scan is unnecessary.
(Choice E) Ultrasonography can be repeated in 4 weeks in patients with biliary colic symptoms who do not have gallstones on the initial ultrasonography. However, this patient has gallstones complicated by acute pancreatitis and requires treatment at this time.
Educational objective:
Gallstone pancreatitis should be suspected in patients who have acute pancreatitis with elevated alanine aminotransferase levels >150 U/L and gallstones on ultrasonography. Urgent endoscopic retrograde cholangiopancreatography (ERCP) is indicated if common bile duct obstruction or acute cholangitis is present. Patients without these indications for ERCP are usually treated with supportive care followed by early cholecystectomy.