A 34-year-old man is admitted to the hospital with sudden onset of severe epigastric pain and vomiting. He has no significant medical history. The patient smokes half a pack of cigarettes a day. He takes no medications and does not use alcohol or illicit drugs. His father died of a heart attack at age 42. The patient is married but has no children. His blood pressure is 144/92 mm Hg and pulse is 110/min. On examination, there is marked epigastric tenderness. Bowel sounds are decreased. Crops of yellow-red papules are seen on the extensor surfaces of his arms and shoulders. Laboratory results are as follows: An abdominal ultrasound reveals no evidence of gallstones. The common bile duct appears normal. Which of the following is most likely to reveal the cause of this patient's current condition?

Question

A 34-year-old man is admitted to the hospital with sudden onset of severe epigastric pain and vomiting.  He has no significant medical history.  The patient smokes half a pack of cigarettes a day.  He takes no medications and does not use alcohol or illicit drugs.  His father died of a heart attack at age 42.  The patient is married but has no children.  His blood pressure is 144/92 mm Hg and pulse is 110/min.  On examination, there is marked epigastric tenderness.  Bowel sounds are decreased.  Crops of yellow-red papules are seen on the extensor surfaces of his arms and shoulders.  Laboratory results are as follows:  An abdominal ultrasound reveals no evidence of gallstones.  The common bile duct appears normal.  Which of the following is most likely to reveal the cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d3d4_10f2_bc81_9f5c183d13f0_MD0003_00 This patient's epigastric pain, vomiting, and markedly elevated lipase are consistent with acute pancreatitis. The most common causes of acute pancreatitis include alcohol (which this patient does not use) and gallstones (which were not seen on the ultrasound). Other possible causes include hypertriglyceridemia (third most common), medications (eg, azathioprine, valproic acid, thiazide diuretics), infections (eg, cytomegalovirus [CMV]), recent endoscopic retrograde cholangiopancreatography (ERCP), and trauma. The serum triglyceride level generally must be >1,000 mg/dL to be considered a potential cause of pancreatitis. The yellow-red papules on this patient's arms and shoulders suggest eruptive xanthomas, which are due to subcutaneous fat deposition. Eruptive xanthomas are usually associated with marked hypertriglyceridemia (>1,000 mg/dL), typically due to familial hypertriglyceridemia (which may also explain the patient's father's myocardial infarction at age 42). A fasting serum lipid profile can determine if hypertriglyceridemia is the underlying cause of this patient's xanthomas and pancreatitis. (Choice A) Abnormalities in the CFTR gene lead to cystic fibrosis (CF), which is a potential cause of pancreatitis. However, this patient likely would have had pulmonary manifestations of CF long before age 34. In addition, CF does not typically cause eruptive xanthomas. (Choice B) ERCP is usually done to evaluate biliary pancreatitis. Although patients with biliary pancreatitis may sometimes have a normal ultrasound (especially if the stone is passed), they typically have an elevated alanine aminotransferase (ALT) level (>150 U/L). This patient's normal ALT level makes biliary pancreatitis less likely. ERCP should also be considered in patients with >1 episode of acute pancreatitis of unknown cause. (Choice D) Acute pancreatitis has been associated with viruses (eg, mumps, hepatitis B, HIV, coxsackievirus, CMV, herpes simplex virus), but patients often develop other characteristic findings of particular viral infections. Viral serology is generally not recommended as the significance of a positive result is unknown, and there is no potential treatment for most of these viruses. (Choice E) Cannabis use has been associated with case reports of acute pancreatitis, but it would not cause eruptive xanthomas. Other illicit drugs usually do not cause acute pancreatitis. Educational objective: Acute pancreatitis is most commonly due to chronic alcohol use and gallstones. Marked hypertriglyceridemia (>1,000 mg/dL) can lead to acute pancreatitis and can cause eruptive xanthomas. The diagnosis can be confirmed with a fasting serum lipid profile. References: Acute pancreatitis: etiology, clinical presentation, diagnosis, and therapy. (http://www.ncbi.nlm.nih.gov/pubmed/18570947) Current knowledge of hypertriglyceridemic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25269432) Issues in hypertriglyceridemic pancreatitis: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24172179)

A 34-Year-Old Man Is Admitted to the Hospital with Sudden