Review Question - QID 213811

This woman with a history of peptic ulcer disease and bipolar disorder, who presents with a CT scan and symptoms suggesting pancreatitis, was most likely taking valproic acid, which is both a common treatment for bipolar disorder and a cause of acute pancreatitis.

Acute pancreatitis is inflammation of the pancreas, often involving release of pancreatic enzymes and autodigestion of the pancreas. The most common causes are heavy alcohol use (alcoholic pancreatitis) and gallstone blockage of the pancreatic duct (gallstone pancreatitis). It can also be caused by several medications, including valproic acid, antibiotics (especially sulfa antibiotics), antivirals (especially protease inhibitors and nucleoside reverse transcriptase inhibitors, both which are treatments for HIV), statins, and antihypertensives (especially thiazides and ACE inhibitors), among others. Classic symptoms include acute onset epigastric abdominal pain and tenderness, nausea, vomiting, and fever. Labs show elevated pancreatic enzymes (amylase and lipase) in the serum. The diagnosis is made based on the combination of classic symptoms plus either elevated lipase (> 3x the normal limit) or a CT scan showing pancreatitis. Treatment involves suspending the offending agent and supportive care (NPO, IV fluids, and pain medications).

Figure/Illustration A is an abdominal CT scan demonstrating an enlarged pancreas (red arrow) with indiscriminate margins (due to inflammation), which suggests pancreatitis.

Incorrect Answers:
Answer 1: Amoxicillin is not known to cause pancreatitis. It is part of the triple therapy treatment regimen for peptic ulcer disease caused by Helicobacter pylori, a disease which can be asymptomatic or present with recurrent post-prandial epigastric pain and nausea.

Answer 2: Lithium (a treatment for bipolar disorder) can cause renal failure, hypothyroidism, and nephrogenic diabetes insipidus, and can accumulate to toxic levels (as it has a narrow therapeutic window). However, it is not known to cause pancreatitis.

Answer 3: Pantoprazole is a proton pump inhibitor that is used to treat GERD, gastritis, and peptic ulcer disease. It may lead to an increased incidence of GI and respiratory infections and may lead to the malabsorption of some nutrients such as vitamin B12 with frequent use.

Answer 5: Simvastatin (and statins in general) can cause acute pancreatitis. However, this patient's medical history does not suggest any indication for her to be on a statin (e.g., hyperlipidemia or a prior myocardial infarction).

Bullet Summary:
Acute pancreatitis can be caused by heavy alcohol use, gallstones, or numerous medications (including valproic acid), and classically presents with epigastric pain, vomiting, fever, and enlarged and inflamed pancreas on CT.