A 55-year-old man comes to the physician for follow-up after an episode of acute pancreatitis. Four weeks ago, he presented to the hospital with severe epigastric pain and vomiting after an episode of binge drinking. Ultrasound revealed no evidence of gallstones. He was hospitalized for 3 days and tolerated oral feeds on the day of discharge. He currently feels well and has a good appetite. The patient reports mild fullness in the abdomen but no nausea or vomiting. He has refrained from alcohol consumption. His other medical problems include hypertension and gout.
Vital signs are within normal limits. There is mild tenderness in the epigastric region on deep palpation. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 55-year-old man comes to the physician for follow-up after an episode of acute pancreatitis.  Four weeks ago, he presented to the hospital with severe epigastric pain and vomiting after an episode of binge drinking.  Ultrasound revealed no evidence of gallstones.  He was hospitalized for 3 days and tolerated oral feeds on the day of discharge.  He currently feels well and has a good appetite.  The patient reports mild fullness in the abdomen but no nausea or vomiting.  He has refrained from alcohol consumption.  His other medical problems include hypertension and gout.
Vital signs are within normal limits.  There is mild tenderness in the epigastric region on deep palpation.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Persistently elevated lipase and abdominal fullness following a resolved attack of acute pancreatitis suggest pancreatic pseudocyst. Pancreatic pseudocysts are more common in alcoholic than non-alcoholic pancreatitis and usually occur 4-6 weeks after the initial pancreatitis episode. About 10% of patients with acute pancreatitis and 30%-40% with chronic pancreatitis develop pseudocysts. Patients may be asymptomatic or present with abdominal pain or fullness. Fever indicates infected pseudocyst. Pseudocyst expansion can result in gastric outlet or biliary obstruction, vascular occlusion, or fistula formation into adjacent viscera (eg, pleura). Serum lipase usually increases within 4-8 hours of acute pancreatitis, peaks at 24 hours, and returns to normal within 8-14 days. Lipase levels are not necessary for monitoring the course of pancreatitis, but persistent elevation can indicate complications (eg, pancreatic duct blockage, pseudocyst) in symptomatic patients. Diagnosis is confirmed via abdominal computed tomography scan showing a thick-walled, rounded, fluid-filled mass adjacent to the pancreas. Endoscopic ultrasound with fine-needle aspiration can help differentiate pancreatic pseudocyst from other cystic pancreatic lesions. Most pseudocysts resolve spontaneously, and asymptomatic cysts do not require intervention. Symptomatic or complicated pseudocysts (infection, duodenal or biliary obstruction) can be drained via percutaneous, surgical, or endoscopic procedures (preferred). computed tomography scan (Choice A) Chronic pancreatitis usually presents with abdominal pain and pancreatic insufficiency (steatorrhea, malabsorption, diabetes). Serum lipase levels are typically normal ("fibrosed" pancreas) or may be only mildly elevated. (Choice B) This patient's history of acute pancreatitis due to alcohol use and the absence of weight loss and constitutional symptoms make pancreatic cancer less likely. (Choice D) Peptic ulcer disease can present with postprandial epigastric discomfort and fullness, early satiety, burning pain, and reflux. However, it typically does not elevate the serum lipase to the degree seen in this patient. (Choice E) Acute pancreatitis usually presents with abdominal pain, nausea, and vomiting. This patient's absence of these typical symptoms makes acute pancreatitis less likely. Educational objective: Pancreatic pseudocyst should be suspected after an attack of resolved acute pancreatitis in patients with persistently elevated lipase, abdominal fullness, or early satiety. Diagnosis is confirmed via abdominal computed tomography scan. Most pseudocysts resolve without intervention. __________ References: Pancreatic pseudocysts: prognostic factors for their development and their spontaneous resolution in the setting of acute pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/22487516) Pancreatic pseudocyst. (http://www.ncbi.nlm.nih.gov/pubmed/19115466)

A 55-Year-Old Man Comes to the Physician for Follow-Up After