Mercy Catholic Medical Center Lansdowne, PA, United States
Sudheer Konduru, MD1, Vihitha Thota, MD1, Martha Dillon, BS2, Manaswitha Thota, BS3, Jayamohan Nair, MD4 1Mercy Catholic Medical Center, Lansdowne, PA; 2Drexel University College of Medicine, Philadelphia, PA; 3Virginia Commonwealth University School of Medicine, Ashburn, VA; 4Mercy Catholic Medical Center, Darby, PA
Introduction: Acute pancreatitis (AP) is a common gastrointestinal condition with numerous etiologies that is diagnosed through imaging and elevated pancreatic enzyme levels. We present a rare case of pancreatitis secondary to cannabis use with normal lipase and amylase in order to illustrate the diagnostic challenges an otherwise common condition can pose.
Case Description/Methods: A 44-year-old female with a history of hypertension presented to the emergency room with a one-day history of stabbing, 10/10 abdominal pain radiating to the back, and associated with intractable nausea and vomiting with inability to tolerate oral intake. The patient denied alcohol usage prior to this episode. The examination was notable for tachycardia and diffuse abdominal tenderness without rigidity or guarding. Bloodwork revealed no leukocytosis with normal liver function studies, lipase, and amylase. The toxicology screen was positive for cannabinoids. Contrast-enhanced computed tomography (CT) scan of the abdomen showed acute interstitial edematous pancreatitis with peripancreatic edema but no necrosis or loculated collections. Further workup was done to determine etiology, with autoimmune, infectious, and iatrogenic causes excluded. Furthermore, alcohol and triglyceride levels were normal. A review of old records showed recurrent admissions for AP, with unremarkable work-up including an MRCP which ruled out pancreatic divisum. Prior toxicology screens also were positive for cannabinoids; upon further questioning, she admitted to copious marijuana use prior to the current admission. She was medically managed for the AP with improvement in symptoms, at which point she was discharged and counseled on avoiding further cannabis use.
Discussion: The negative predictive value of lipase in diagnosing AP is very high (94-100%) with a normal lipase level in acute pancreatitis an extremely rare phenomenon. Normal pancreatic enzyme levels can be seen if there has been destruction of acinar tissue during prior episodes of pancreatitis. While there are many etiologies attributed to pancreatitis, approximately 15-20% of cases remain idiopathic after work-up. In cases of idiopathic pancreatitis, etiologies such as cannabis use must be considered. Though very rare, there has been an increasing amount of data suggesting a high probability of cannabis as a causative etiology of AP, especially in idiopathic and recurrent cases. Therefore, a toxicology screen should be considered in all patients with idiopathic pancreatitis.
Sudheer Konduru indicated no relevant financial relationships.
Vihitha Thota indicated no relevant financial relationships.
Martha Dillon indicated no relevant financial relationships.
Manaswitha Thota indicated no relevant financial relationships.
Jayamohan Nair indicated no relevant financial relationships.
Sudheer Konduru, MD1, Vihitha Thota, MD1, Martha Dillon, BS2, Manaswitha Thota, BS3, Jayamohan Nair, MD4. P0078 - Enduring Challenges in Establishing Etiology of Acute Pancreatitis With Normal Enzyme Levels: Cannabis to Blame?, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.