Q&A Medicine>>>>>Gastroenterology
Question 3#

A 39-year-old woman presents with epigastric pain that has radiated to her back for the last 8 hours. She endorses nausea and vomiting. Her past medical history is significant for hyperlipidemia; however, she does not take any medications other than a multivitamin. She denies alcohol or drug use. On examination, the patient is slightly febrile at 38.4°C, with a blood pressure of 114/83 mmHg, a heart rate of 98 beats per minute, and a respiratory rate of 22 breaths per minute. The patient has decreased bowel sounds and guarding in the midepigastrium.

Which of the following results is the most specific finding in this condition?

a. Elevated amylase
b. Elevated ALT
c. Elevated lipase
d. Positive fecal fat test

Correct Answer is C

Comment:

Elevated lipase. The patient in this question is presenting with signs and symptoms of acute pancreatitis (epigastric abdominal pain radiating to the back, nausea, and vomiting). The vast majority of cases (80%) result from gallstones and alcohol. However, other causes of acute pancreatitis can be remembered with the mnemonic GET SMASHED (Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hyperlipidemia, ERCP, Drugs [specifically diuretics, gliptins, azathioprine, salicylates, steroids]).

Acute pancreatitis can be diagnosed through several modalities: physical examination demonstrating epigastric pain radiating to the back, elevated amylase and lipase levels (typically 3× higher than the normal limit), and abdominal imaging (CT) showing pancreatic enlargement with heterogeneous enhancement with IV contrast. Ultrasound is also helpful in diagnosing gallstone pancreatitis by visualizing gallstones in the gallbladder. Lipase has the greatest specificity of all possible tests and is usually more elevated than amylase in acute pancreatitis.

(A) Amylase can sometimes be normal in acute pancreatitis (particularly if the etiology is hyperlipidemia). Furthermore, amylase is not specific to the pancreas as there is not only pancreatic amylase but also salivary amylase. (B) Although elevated ALT is very useful in suggesting gallstone pancreatitis, it does not encompass all the causes of acute pancreatitis and therefore is not a specific test. (D) Positive fecal fat test is typically positive (>7 g/d) in chronic pancreatitis; however, chronic pancreatitis presents with symptoms of malabsorption (as opposed to pain) and is typically due to alcohol use (neither of which this patient endorses).