Clinical Case Summary

A 43 year-old man presented at emergency department due to acute epigastric pain radiating to the back. He had personal history of transient ischemic attack 7 years ago. No relevant family history. On observation, fever (T38ºC), tachycardia (115 bpm) and epigastric pain with tenderness was noticed. The initial study showed: 1) blood test: leukocytosis 10 x10^9/L, C reactive protein (CRP) 2.12 mg/dL, amylase 639 U/L ; 2) abdominal ultrasound: mild hepatic steatosis, without other changes. However, pancreas wasn’t visualized. A diagnosis of acalculous mild acute pancreatitis (2 of 3 Atlanta criteria) with a BISAP score of 1 (SIRS criteria) was admitted. Intravenous hydration and analgesia were instituted. The etiological study revealed hypercalcemia (11.3 mg/dL), elevation of parathyroid hormone (214 pg/mL) and severe vitamin D deficit (8.98 ng/ml). Cervical ultrasound identified a nodule of the parathyroid gland suggestive of an adenoma. Due to an episode of unilateral flank pain and haematuria, an CT urogram was requested which identified bilateral radiopaque renal lithiasis. After discussion with Endocrinology and Urology Departments, adequate oral hydration (1.5-2L/day), oral vitamin D and tamsulosin were initiated. The patient is still waiting for bone densitometry and surgical treatment of the adenoma. A favourable clinical evolution of AP was noticed and the patient was discharged after 8 days of hospitalization with abdominal CT scan scheduled for pancreatic evaluation at week 4.
Primary hyperparathyroidism (PHP) is a frequent cause of hypercalcaemia and is mostly asymptomatic. AP is one of the possible gastrointestinal manifestations (prevalence 1-12%). However, hypercalcemia is a rare cause of AP (prevalence 1.5-7%). We present an illustrative case of AP due to hypercalcemia in association with other PHP manifestations and its multidisciplinary approach.

References

• Abdominal CT scan – related with pancreatic alterations as well as renal lythiasis
• Cervical Ultrasound images – parathyroid adenoma
• If held before the congress – bone densitometry and scintigraphy bone densitometry and Tc99 scintigraphy.

Introduction

Acute pancreatitis (AP) is one of the most common gastroenterological diseases requiring admission to the hospital. The main etiological factors of AP are gallstones and excessive alcohol consumption, but rarer causes, such as hypercalcemia, should keep on mind. Only few cases are reported in the literature, and the severity of hypercalcaemia-induced acute pancreatitis is not known.

Aims & Methods

We aim to assess the occurrence and severity of hypercalcaemia-induced AP and compare it with the clinical characteristics of AP caused by other etiological factors. We collected patients from the Hungarian Acute Pancreatitis Registry, Hungarian GOULASH study and the Europe-wide EASY study, who had AP and had a serum calcium level above 2.6 mmol/l. Patients were divided into three groups: hypercalcemia-induced AP, where no other etiology than hypercalcemia were present, mixed etiology group, where both hypercalcemia and other etiologies were revealed and the control group with normal serum calcium level. Propensity score matching adjusted by age, sex, diabetes, lipid disorder, previous pancreatic disease was made and several outcome parameters were analyzed during the statistical analysis. Hypercalcemic cases were divided into 3 subgroups based on the level of serum calcium: mild (2.6< >3.0 mmol/l), moderate (3.0 < >3.5 mmol/l) or severe hypercalcemia (>3.5 mmol/l).

Results

1.02% of our AP patients (19/1867) had clear hypercalcemic etiology and 3.75 % (70/1867) of the patients had mixed etiology, 1778 patients were in the control group. There was no difference in the mean ages of the patients in the three groups (57.3± 16.3 and 56.1 ± 20.1 vs. 55.1 ± 14.6 years). Severe AP was significantly more frequent in patients with hypercalcemia-induced AP compared to the control group [21.05% (4/19) vs 6.13% (109/1778); odds ratio: 4.08 (95% CI, 1.08-15.38)]. Renal failure was more frequent in hypercalcemic etiology compared to AP patients with normal serum calcium level [27.27% (3/11) vs 5.35% (95/1776); odds ratio: 6.63, (95% CI, 1.36-32.35)]. There was no significant difference in CRP, amylase, lipase, WBC, creatinine, length of hospital stay, mortality, intensive care admission, the presence of pancreatic necrosis, pseudocysts, and other organ failure between the hypercalcemic or mixed etiology and the control groups. There was no significant difference in the severity of AP between the mixed etiology and normal serum calcium groups. The outcome of acute pancreatitis was not influenced by the severity of hypercalcemia within the hypercalcemic group.

Conclusion

Hypercalcemia-induced AP has a higher risk for developing into severe AP and renal failure compared to other etiology.

Introduction

Acute pancreatitis (AP) is one of the most common diseases leading to admission in Gastroenterology departments. The aging population is contributing to an increasing number of hospitalizations among elderly patients. Our study aims to evaluate different clinical outcomes in patients across different age groups.

Aims & Methods

A retrospective analysis was conducted using a prospective database consisting of a cohort of patients with AP consecutively enrolled from March 2017 to June 2019 at a tertiary care hospital. Clinical management followed standard clinical practice guidelines, including routine abdominal ultrasound upon admission and CT scans in cases of diagnostic uncertainty or clinical deterioration. Diagnosis and classification were based on the revised 2012 Atlanta classification. Patients were divided into three age groups: <50 years, 50–75 years, and >75 years. Initially, a univariate analysis using the chi-square test was performed, followed by binary logistic regression to assess the influence of age on different clinical aspects of the disease.

Results

465 patients with AP were recruited. Overall, 48.6% of the patients were women; however, in the >75 age group, up to 64% were female. Older patients presented with more comorbidities, a greater need for antibiotic therapy, higher rates of severe AP, and an increased likelihood of mortality. These associations were confirmed in the multivariate analysis. Notably, patients over 75 years old had a higher risk of requiring antibiotic therapy (OR 2.73) and death (OR 7.42), while those aged 50–75 years had a higher risk of developing severe AP compared to younger patients (OR 8.05). No significant differences were found between age groups regarding the occurrence of necrotizing pancreatitis.

Table 1. Binary logistic regression analysis showing the increased risk of each variable by age group, using the youngest group (< 50 years old) as the reference category.

Conclusion

Our study presents the distribution of epidemiological and clinical variables across different age groups (<50 years, 50–75 years, and >75 years). We found that women over 75 years had a higher risk of developing AP compared to men, which could be influenced by an increased prevalence of biliary etiology with advancing age. Interestingly, patients over 75 years required antibiotic therapy more frequently, although the rates of necrotizing pancreatitis did not differ between age groups. This may suggest a higher incidence of other types of infections in older patients. Notably, patients over 75 years accounted for 80% of the deaths in our cohort, while no clear increase in mortality risk was observed in the 50–75 age group compared to younger patients. Finally, the risk of severe AP increased progressively with age, peaking in patients over 75 years. In conclusion, female sex was predominant among patients over 75 years, who also showed a significantly higher risk of severe AP and mortality, as well as a greater need for antibiotic therapy.