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Left flank pain as the sole manifestation of acute pancreatitis: a report of a case with an initial misdiagnosis
  1. J-H Chen1,
  2. C-H Chern1,
  3. J-D Chen2,
  4. C-K How1,
  5. L-M Wang1,
  6. C-H Lee1
  1. 1Department of Emergency Medicine, Veterans General Hospital-Taupei, Taiwan, ROC, National Yang-Ming University of Medicine, Taipei, Taiwan, ROC
  2. 2Department of Radiology, Veterans General Hospital-Taipei, Taiwan, ROC, National Yang-Ming University of Medicine, Taipei, Taiwan, ROC
  3. 3
  1. Correspondence to:
 Chii-Hwa Chern
 MD, Emergency department, Veterans General Hospital-Taipei, Taiwan, ROC; chchern2002yahoo.com.tw

Abstract

Acute pancreatitis is not an uncommon disease in an emergency department (ED). It manifests as upper abdominal pain, sometimes with radiation of pain to the back and flank region. Isolated left flank pain being the sole manifestation of acute pancreatitis is very rare and not previously identified in the literature. In this report, we present a case of acute pancreatitis presenting solely with left flank pain. Having negative findings on an ultrasound initially, she was misdiagnosed as having possible “acute pyelonephritis or other renal diseases”. A second radiographic evaluation with computed tomography showed pancreatitis in the tail with abnormal fluid collected extending to the left peri-renal space. We performed a literature review and discussed this rare occurrence of acute pancreatitis. We also discussed the clinical pitfalls in this case.

  • pancreatitis
  • renal colic
  • ultrasound

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In physcians’ clinical experiences, pancreatitis can manifest solely as left flank pain, but very rarely. However, in a review of the literature, we were unable to identify a report specifically mentioning “left flank pain” as an isolated finding. We present a case of pancreatitis presenting solely with left flank pain. Due to a negative ultrasound report and the misinterpretation of clinical presentations, the on-duty physician missed the diagnosis initially.

CASE REPORT

A 63 year old female patient visited our ED with a complaint of back pain on her left side for 5 days. The patient had no fever, abdominal pain, chest pain, dyspnea, or symptoms related to the urinary system. No recent trauma was noted. A review of her medical history revealed that she had a 5 year history of hypertension and type 2 diabetes mellitus with regular treatment, but no history of cardiac disease, stroke, or renal disease (including urolithiasis). She did not smoke or consume alcohol. A physical examination revealed prominent left flank pain with percussion, but was otherwise unremarkable.

Laboratory data were as follows: white blood cells 7,970/mm3; hemoglobin 12.4 gm/dL; platelet count 280,000/mm3; blood urea nitrogen 9 mg/dL; serum creatine 0.6 mg/dL; serum glucose 280 mg/dL; and C-reactive protein (CRP) 10.3 mg/dL. A urinary analysis was normal and abdominal plain films did not reveal a radiopaque lesion or other significant abnormal findings. Due to the elevated CRP level and marked flank pain, an ultrasound was performed to evaluate the left kidney or surrounding organs. The ultrasound report by radiology suggested there were no abnormal findings in the areas of the kidneys, spleen, pancreas, or hepatobiliary system. Given this report, the on-duty senior resident decided to treat the patient in the ED-attached observation room.

On further review of the patient’s case 2 hours after the ultrasound examination, a decision was made to obtain a computed tomography (CT) scan due to concern over the limitation of ultrasound studies in some clinical conditions. The CT showed abnormal fluid collection over the peri-renal space and pancreatic tail as well as necrotic changes and swelling of the pancreatic tail (fig 1). Serum pancreatic enzymes revealed a normal amylase (90 u/L) and a slightly elevated lipase level (336 u/L). The patient was diagnosed to have acute pancreatitis and admitted for supportive treatment and monitoring. During her admission she was also noted to have hyperlipidemia (triglyceride 980 mg/dL and cholesterol 319 mg/dL). The left flank pain was resolved after a 7 day treatment and she was discharged with the recommendation that she needed to follow up as an outpatient for long-term the lipid management.

Figure 1

 The computed tomography demarcated the lesion and showed a necrotic change over the pancreatic tail and abnormal fluid collection over the pancreatic tail and peri-renal space (arrowhead). The ultrasound showed fluid collection over the peri-renal spaces. A thick fluid collection (arrow) might have been misinterpreted as bowels by an inexperienced hand. (PT: pancreatic tail, S: spleen, LK: left kidney)

DISCUSSION

The clinical manifestations of acute pancreatitis can include upper abdominal pain, nausea, vomiting, and elevated levels of amylase and lipase.1 Although there are no disease-specific signs or symptoms for acute pancreatitis,2 making the diagnosis is usually not difficult, using a combination of clinical, laboratory, and imaging findings. Combinations of both upper abdominal and left flank pain are common in the presentation of pancreatitis. However, presenting solely with left flank pain is rare in the clinical experience. After reviewing the literature, we were unable to identify a report specifically mentioning the incidence of left flank pain as sole manifestation of acute pancreatitis. A few reports have described this rare clinical manifestation indirectly. Dalla Palma et al, reported using CT to diagnose urolithiasis in patients with flank pain and suggested its usefulness in detecting extraurinary lesions that can mimic renal colic.3 Romano et al, also reported incidental findings of panceatitis, diverticulitis, and renal tumor in patients with suspected renal colic by using CT.4 As early as 1975, Hodges et al, suggested that pain typical of reno-ureteral diseases could emanate from any adjacent organs or any organs with the same innervations. Pancreatitis is listed in the differential diagnoses.5 According to the literature, from 0.47% to 3.1% of patients with a flank pain were determined to have pancreatitis during their evaluation for the possible urolithiasis.4,6,7

This case report presents several points of interest in recognizing an unusual presentation of a common clinical problem. First, the causes of flank pain should not include only renal-ureteral diseases, but a wide range of clinical conditions. Pancreatitis should be included in the differential diagnosis, especially when renal-ureteral causes fail to adequately explain the clinical picture. Second, ultrasound may have limitations in identifying pancreatitis or other lesions around the pancreatic tail. Additionally, thick fluid collection in peri-renal space and the pancreatic tail (fig 1 in the same patients after retrospective review, arrowhead) may be confused with bowel on an ultrasound examination. Understanding this limitation and making use of CT may be necessary. Another interesting finding in this report is the level of the CRP. Although it is a nonspecific finding, an elevated CRP should raise the physician’s suspicion to look for serious disease in the light of initially negative findings (for example, negative ultrasound). The CRP level has been shown to be well correlated with the severity of acute pancreatitis.8

REFERENCES

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