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Re: Diagnostic pitfalls

Dear Editor,

The case report [1] by Chen et al was very informative and explains how an unusual presentation of acute pancreatitis can be a challenge in a busy Emergency Department (ED).

Recently we came across an interesting case of a 59 year old, male patient with right sided flank pain and fever which very well fitted with a diagnosis of pyelonephritis. While assessing a patient with flank pain all possibilities should be considered which are relevant anatomically.

Our patient presented to the ED with right loin pain for 2 days associated with vomiting on and off. He described the pain as a dull ache and was also associated with sweating and shivering. Initial blood tests showed a raised white cell count 18.9 (Normal-3.8-11) and CRP >200 (Normal-0-10 mg/l). Urine dipstick was positive for nitrite and blood. With a tentative diagnosis of pyelonephritis patient was referred to the medical team, but the surgical team was also involved to rule out intraabdominal pathology

Serum amylase was 1808 (Normal-30-125), and a diagnosis of acute pancreatitis was made. Though an elevated amylase in acute setting does not have a diagnostic implication, subsequent ultrasound and CT of the abdomen showed gallstones with normal biliary tract and extensive inflammatory stranding around the entire pancreas with moderate peripancreatic free fluid. Patient was treated conservatively with a plan for a laparoscopic cholecystectomy.

Acute Pancreatitis was last of the possibilities in the initial evaluation, as he did not have any epigastric pain, back pain, history of alcohol consumption, jaundice or gallstones. He was a known diabetic started on insulin recently because of poor control of diabetes and hypertensive

This, we believe is quite an unusual presentation compared to the case report by J-H Chen et al. as patient with left flank pain can have a possibility of pancreatitis with involvement of tail of pancreas. Our patient had a totally obscure picture where the right flank was involved with urinalysis in favour of infection although blood and urine cultures did not show any growth. Both these cases emphasize the need to keep an open mind in an emergency setting, to astute clinicians examining patients with abdominal pain in grey areas such as flank, loin and groin. Also it would be interesting to know if the amylase levels in the reported patient were raised on subsequent blood tests.

References

1) J-H Chen et al, Emerg Med J 2005; 22:452-453

Authors:

A.B. Reddy, Senior House Officer, General Surgery

C. Kaliaperumal, Senior House Officer, ED