Do Not Forget the Zebras in Acute Pancreatitis!

Presentation Number: MON 317
Date of Presentation: April 3rd, 2017

Ahmed Mohammed*1, Pranjali Sharma2, Yazan Samhouri2, Patricia Wilke2 and Manuel Matos2
1Unity Hospital, Rochester, 2Unity Hospital

Abstract

Introduction

It is well known that cholelithiasis and excessive alcohol intake are the dominating factors leading to acute pancreatitis. What rarely makes it into the differential for pancreatitis however, is hypercalcemia of primary hyperparathyroidism (PHPT). We report such a case of PHPT presenting as acute pancreatitis.

Case Description

A 75 year old male with a history of HTN (on amlodipine) and atrial fibrillation (on metoprolol/coumadin) presented with 2 days of altered mental status and abdominal pain. Exam revealed epigastric tenderness and normoactive bowel sounds. There was no guarding or rebound tenderness, and Murphy’s sign was negative. Initial blood tests showed lipase 7902 u/L (6-51 u/L), corrected serum calcium 17.2 mg/dL (8.6-10.2 mg/dL), serum phosphorus 1.2 mg/dL (2.5-4.5 mg/dL), serum magnesium 1.0 mg/dL (1.6-2.6 mg/dL), ALT 18 u/L, AST 25 u/L, ALP 71 u/L, and total bilirubin 1.1 mg/dL. Abdominal ultrasound showed no cholecystitis with an unremarkable common bile duct. He was admitted for acute pancreatitis secondary to hypercalcemia, and was placed on bowel rest, aggressive IV hydration, and pain management. Pamidronate 90 mg IV and calcitonin 400 IU SC were added to reduce calcium. Further work up revealed PTH 732 pg/mL (14-72 pg/mL) and a 24 hour urine calcium of 1831 mg (50-300 mg/24hr). After stabilization, a single parathyroid adenoma was found on sestamibi scintigraphy and was removed by parathyroidectomy.

Discussion

Acute pancreatitis is an inflammatory condition most frequently due to cholelithiasis or excessive alcohol intake (80-90%). Hypercalcemia is a rare etiology that accounts for about 1% of cases.

The proposed pathophysiologic mechanism behind hypercalcemia induced pancreatitis, is high calcium levels mediating the activation of trypsinogen to trypsin, which induces autodigestion of the pancreas.

PHPT and malignancy are the most common causes of hypercalcemia. A single gland adenoma accounts for 85% of PHPT cases, while hyperplasia of the four glands accounts for 10% of cases. Other rare causes include multiple adenomas, parathyroid cancer, or cysts - which occur in <5% of cases.

The first priority in treating patients with pancreatitis of PHPT is management of the pancreatitis, which can be fatal. While awaiting curative parathyroid therapy, serum calcium can be controlled with IV hydration, calcitonin, and bisphosphonates

It is essential to keep “the zebras” in mind when a patient presents with pancreatitis and no risk factors for the common etiologies. This case adds to the sparse literature about the association between PHPT and hypercalcemic pancreatitis.

 

Nothing to Disclose: AM, PS, YS, PW, MM