Gastro Case Challenge: Pain, Vomiting in a 48-Year-Old on Levothyroxine, Metformin

Bashar Sharma, MD; John W. Birk, MD


September 23, 2022

Physical Examination and Workup

Upon examination, the patient is alert and oriented. He lies sideways in bed in mild distress due to the pain. He is afebrile, but his heart rate is tachycardic at 108 beats/min. His blood pressure is 88/59 mm Hg. His respiration rate is 24 breaths/min, and his oxygen saturation is 98% on room air. The results of cardiac and respiratory examinations are normal. The abdominal examination is significant for epigastric tenderness and decreased bowel sounds, but his abdomen is otherwise soft, without any guarding or rebound tenderness.

Laboratory investigations reveal these values:

  • Hemoglobin level: 15 g/dL (reference range, 13.2-17.1 g/dL)

  • Hematocrit: 47% (reference range, 40%-54%)

  • White blood cell count: 14,200 cells/µL (reference range, 5000-10,000 cells/µL)

  • Platelet count: 420,000 cells/µL (reference range, 135,000-337,000 cells/µL)

  • Creatinine: 1.5 mg/dL (reference range, 0.8-1.5 mg/dL)

  • Blood urea nitrogen: 34 mg/dL (reference range, 7-20 mg/dL)

  • Calcium: 9.9 mg/dL (reference range, 8-10 mg/dL)

  • Lactic acid: 3.7 mg/dL (reference range, 4.5-19.8 mg/dL)

  • Glucose: 466 mg/dL (reference range, 65-110 mg/dL)

  • Alanine aminotransferase: 54 U/L (reference range, 20-60 U/L)

  • Aspartate aminotransferase: 43 U/L (reference range, 6-34 U/L)

  • Alkaline phosphatase: 96 U/L (reference range, 44-147 U/L)

  • Bilirubin: 0.4 mg/dL (reference range, 0.1-1.2 mg/dL)

  • Lipase: 874 U/L (reference range, 8-51 U/L)

  • Amylase: 364 U/L (reference range, 25-125 U/L)

  • Antinuclear antibody: positive with 1:40 titer

  • Immunoglobulin G4 (IgG4): 187 mg/dL (reference range, 8-140 mg/dL)

  • Total cholesterol: 278 mg/dL (reference range, < 200 mg/dL)

  • Triglycerides: 921 mg/dL (reference range, < 150 mg/dL)

A CT of the abdomen and pelvis with intravenous (IV) contrast shows moderate peripancreatic edema, consistent with acute pancreatitis (Figure 1 and Figure 2). A 3 × 2 × 2.5 cm septated cyst is present in the tail of the pancreas. No pancreatic ductal dilatation is noted. The gallbladder is normal, without biliary ductal dilation.

Figure 1.

Figure 2.


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