A 54-year-old man comes to the emergency department complaining of several days of persistent abdominal pain. He also complains of nausea, vomiting, low-grade fever, and appetite loss. He does not drink alcohol. The patient is being treated for seizure disorder; his last seizure was 3 months ago. Chest and abdominal x-rays reveal no abnormalities. The patient's abdominal CT scan is shown below. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 54-year-old man comes to the emergency department complaining of several days of persistent abdominal pain.  He also complains of nausea, vomiting, low-grade fever, and appetite loss.  He does not drink alcohol.  The patient is being treated for seizure disorder; his last seizure was 3 months ago.  Chest and abdominal x-rays reveal no abnormalities.  The patient's abdominal CT scan is shown below.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d3d4_d444_bc81_1b82dfa32f3c_MD0003_00 This patient's presentation suggests acute pancreatitis. Most cases of acute pancreatitis are caused by alcohol ingestion or gallstones, but drug-induced pancreatitis accounts for 5% of cases. This patient's anti-seizure medication is the most likely cause of his drug-induced pancreatitis. In particular, valproic acid is a commonly-used anti-seizure medication that is associated with acute pancreatitis. Other common drugs associated with pancreatitis include: Diuretics (furosemide, thiazides)Drugs for inflammatory bowel disease (sulfasalazine, 5-ASA)Immunosuppressive agents (azathioprine)HIV-related medications (didanosine, pentamidine)Antibiotics (metronidazole, tetracycline) Diuretics (furosemide, thiazides) Drugs for inflammatory bowel disease (sulfasalazine, 5-ASA) Immunosuppressive agents (azathioprine) HIV-related medications (didanosine, pentamidine) Antibiotics (metronidazole, tetracycline) Drug-induced pancreatitis is usually mild. Patients typically develop nausea, vomiting and abdominal pain radiating to the back. Laboratory results usually show elevated serum amylase and lipase. The CT scan reveals swelling of the pancreas with prominent peripancreatic fluid and fat-stranding (red arrow). Supportive treatment with fluids and electrolyte replacement is recommended. (Choice A) Gallstones migrating into the bile duct or the ampulla of Vater can obstruct the pancreatic duct and cause gallstone pancreatitis. However, this patient's abdominal CT does not reveal an enlarged gallbladder shadow or gallbladder inflammation/stones. (Choice B) Liver disease (eg, metastatic malignancy such as colon cancer, nodules, abscess, hemangiomas) can cause abdominal discomfort, nausea, vomiting, and jaundice. However, this patient's CT scan does not reveal any significant liver lesions. (Choice C) Acute mesenteric ischemia typically presents with periumbilical abdominal pain (often out of proportion to examination findings) that can be associated with nausea and vomiting. However, this patient's absence of risk factors (eg, advanced age, atrial fibrillation) makes this less likely. In addition, mesenteric ischemia does not usually cause the abnormal pancreatic findings seen on this patient's abdominal CT scan. (Choice E) Peptic ulcer disease can present with midepigastric pain and can sometimes be relieved with food or antacids. However, it would not cause this patient's abnormal CT findings. Educational objective: Acute pancreatitis is most often due to alcohol use, gallstones, or medications. Commonly implicated drugs include diuretics, anti-seizure drugs (eg, valproic acid), and antibiotics (eg, metronidazole). An abdominal CT scan can reveal diffuse or focal parenchymal changes, edema, necrosis, or liquefaction. Drug-induced pancreatitis is usually mild and resolves with supportive care. References: Drug-induced pancreatitis: A potentially serious and underreported problem. (http://www.ncbi.nlm.nih.gov/pubmed/23946630)

A 54-Year-Old Man Comes to the Emergency Department Complaining of Several