Nonpancreatic Elevations in Serum Lipase: A Case Report

Authors' Affiliations

Charu Bajracharya MD, Department of Internal Medicine, Guthrie Clinic, Sayre, PA Madeline Mylod OMS-III, Lake Erie College of Osteopathic Medicine, Elmira, NY Jefferson Thompson DO, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Blair Reece MD, Department of Internal Medicine, East Tennessee State University, Johnson City, TN

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

31

Name of Project's Faculty Sponsor

Blair Reece

Faculty Sponsor's Department

Internal Medicine

Classification of First Author

Medical Resident or Clinical Fellow

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

An 18-year-old female with a past medical history of asthma, vitamin D deficiency, acne, and migraine headaches presented to her pediatrician’s office with a chief complaint of nausea, vomiting, and epigastric pain for three weeks. Further history revealed that her symptoms resolved from self-administered esomeprazole 20 mg daily and returned once stopping the medication. Laboratory tests conducted during this initial clinic visit revealed an elevated lipase level of 893 units/L, a normal complete blood count (CBC), a normal complete metabolic panel (CMP), and a negative urine pregnancy test. The elevated lipase level prompted concern for pancreatitis for which she was referred to the emergency department. A right upper quadrant ultrasound showed no abnormalities and an abdominal magnetic resonance imaging without and with contrast did not reveal pancreatitis or any other abnormality. Ultimately, omeprazole 20 mg daily was prescribed, leading to symptom resolution. Due to a recent family history of Helicobacter pylori (H. pylori) infection, a stool antigen test for H. pylori was recommended but the patient did not have a bowel movement prior to discharge. The patient was instructed to continue omeprazole for eight weeks if the H. pylori antigen returned negative, with an esophagogastroduodenoscopy with tissue sampling for H. pylori if symptoms persisted or recurred post-treatment with omeprazole. The most likely etiology of her symptoms was a presumed diagnosis of peptic ulcer disease due to the finding of an elevated lipase level without evidence for pancreatitis on multiple imaging studies and brisk resolution of symptoms on omeprazole. Lipase measurement, a critical diagnostic tool for gastrointestinal disorders, particularly acute pancreatitis, may present diagnostic challenges due to its elevation in a variety of non-pancreatic conditions. Although traditionally deemed more specific than amylase for identifying pancreatitis, lipase can be found elevated in conditions such as peptic ulcer disease, hepatobiliary disorders, renal insufficiency, malignancies, diabetic ketoacidosis, and among asymptomatic HIV positive patients, challenging its diagnostic specificity. This broad spectrum of lipase elevation is partly due to its presence not only in the gastrointestinal tract but also in the liver, heart, lungs, and leukocytes, necessitating methodological adjustments in lipase assays to enhance pancreatic specificity. Furthermore, an array of medications, including cholinergics, DPP4-inhibitors, furosemide, methylprednisolone, metronidazole, narcotics, oral contraceptives, and thiazides, have been implicated in causing lipase abnormalities. The extensive evidence of hyperlipasemia in extrapancreatic conditions and medication-induced alterations underscores the importance of careful consideration of alternative etiologies when elevated lipase levels are observed, highlighting the need for a comprehensive clinical evaluation to accompany laboratory findings to avoid misdiagnosis and ensure accurate patient management. This case highlights the importance of considering extrapancreatic causes of lipase elevation in order to encourage obtaining a thorough history and physical examination, reduce unnecessary diagnostic testing, reduce over utilization of the emergency department, and to avoid misdiagnosing patients with pancreatitis when another potential etiology is present that may lead to elevated serum lipase levels.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

Nonpancreatic Elevations in Serum Lipase: A Case Report

D.P. Culp Center Ballroom

An 18-year-old female with a past medical history of asthma, vitamin D deficiency, acne, and migraine headaches presented to her pediatrician’s office with a chief complaint of nausea, vomiting, and epigastric pain for three weeks. Further history revealed that her symptoms resolved from self-administered esomeprazole 20 mg daily and returned once stopping the medication. Laboratory tests conducted during this initial clinic visit revealed an elevated lipase level of 893 units/L, a normal complete blood count (CBC), a normal complete metabolic panel (CMP), and a negative urine pregnancy test. The elevated lipase level prompted concern for pancreatitis for which she was referred to the emergency department. A right upper quadrant ultrasound showed no abnormalities and an abdominal magnetic resonance imaging without and with contrast did not reveal pancreatitis or any other abnormality. Ultimately, omeprazole 20 mg daily was prescribed, leading to symptom resolution. Due to a recent family history of Helicobacter pylori (H. pylori) infection, a stool antigen test for H. pylori was recommended but the patient did not have a bowel movement prior to discharge. The patient was instructed to continue omeprazole for eight weeks if the H. pylori antigen returned negative, with an esophagogastroduodenoscopy with tissue sampling for H. pylori if symptoms persisted or recurred post-treatment with omeprazole. The most likely etiology of her symptoms was a presumed diagnosis of peptic ulcer disease due to the finding of an elevated lipase level without evidence for pancreatitis on multiple imaging studies and brisk resolution of symptoms on omeprazole. Lipase measurement, a critical diagnostic tool for gastrointestinal disorders, particularly acute pancreatitis, may present diagnostic challenges due to its elevation in a variety of non-pancreatic conditions. Although traditionally deemed more specific than amylase for identifying pancreatitis, lipase can be found elevated in conditions such as peptic ulcer disease, hepatobiliary disorders, renal insufficiency, malignancies, diabetic ketoacidosis, and among asymptomatic HIV positive patients, challenging its diagnostic specificity. This broad spectrum of lipase elevation is partly due to its presence not only in the gastrointestinal tract but also in the liver, heart, lungs, and leukocytes, necessitating methodological adjustments in lipase assays to enhance pancreatic specificity. Furthermore, an array of medications, including cholinergics, DPP4-inhibitors, furosemide, methylprednisolone, metronidazole, narcotics, oral contraceptives, and thiazides, have been implicated in causing lipase abnormalities. The extensive evidence of hyperlipasemia in extrapancreatic conditions and medication-induced alterations underscores the importance of careful consideration of alternative etiologies when elevated lipase levels are observed, highlighting the need for a comprehensive clinical evaluation to accompany laboratory findings to avoid misdiagnosis and ensure accurate patient management. This case highlights the importance of considering extrapancreatic causes of lipase elevation in order to encourage obtaining a thorough history and physical examination, reduce unnecessary diagnostic testing, reduce over utilization of the emergency department, and to avoid misdiagnosing patients with pancreatitis when another potential etiology is present that may lead to elevated serum lipase levels.