S3594 Gastric Ulcer Disease Presenting as Acute Pancreatitis

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Introduction: Acute pancreatitis is diagnosed based on the Atlanta criteria: i) typical pain, ii) serum lipase/amylase levels greater than 3 times, and/or iii) characteristic imaging findings. In addition to pancreatitis, lipase levels are also elevated in small-bowel, hepatobiliary and renal pathology in addition to other rare causes. We describe a case of a patient with elevated lipase with normal pancreas. Case Description/Methods: A 34-year-old man without any medical history presented with sharp epigastric pain aggravated by food for 2 days. This was associated with episodes of bilious emesis. He denied alcohol abuse or use of any new medicines. Patient had normal vitals and on exam he had epigastric and periumbilical tenderness. Laboratory studies showed leukocytosis of 18.1x109/L, hemoglobin 17 g/dL, hematocrit 51% and normal platelets. His liver chemistry was noted to be within normal range including aspartate aminotransferase 39 U/L, alanine aminotransferase 43 U/L, alkaline phosphatase 88 U/L and bilirubin 0.5 mg/dL. His lipase was elevated at 615 U/LA. Ultrasound revealed cholelithiasis without cholecystitis and normal bile ducts. The patient was managed with intravenous fluids for suspected acute gallstone pancreatitis and was scheduled to undergo cholecystectomy after surgical evaluation. A follow-up computed tomography scan showed normal pancreas but did note diffuse gastric antrum mucosal edema consistent with gastritis. Gastroenterology was consulted and upon further history, he reported daily ibuprofen use for months. Subsequent endoscopic evaluation revealed multiple gastric ulcers in the gastric antrum with the largest being nearly circumferential involving the incisura and extending into the greater curvature. Biopsy revealed acute gastritis with negative Helicobacter pylori. The patient was diagnosed with nonsteroidal anti-inflammatory drug induced gastric ulcers and discharged on twice-daily pantoprazole therapy with advice to follow up for repeat endoscopy to assess healing. Discussion: In our case, the patient was diagnosed with acute pancreatitis based on Atlanta criteria and planned for further surgical intervention due to his noted gallstones. Further diagnostic workup, which in this specific scenario was not strongly indicated, revealed gastric ulcers without any pancreatic disease or duodenal ulcers. Though lipase levels greater than 3 times the upper limit of normal are highly sensitive and specific for pancreatitis, it is important to obtain a thorough history to help guide diagnosis and provide appropriate management (see Figure 1).Figure 1.: A. Gastric antral ulcer B. Incisura.

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