From the Guidelines
The patient's presentation of right-sided abdominal pain after cholecystectomy with mildly elevated lipase (127) and total bilirubin (1.3) is not diagnostic of acute pancreatitis, as the lipase level is less than 3 times the upper limit of normal, according to the AGA Institute medical position statement on acute pancreatitis 1. The patient's symptoms and laboratory results suggest post-cholecystectomy syndrome or possible bile duct injury.
- Initial management should include pain control with acetaminophen 650-1000mg every 6 hours and/or ibuprofen 400-600mg every 6-8 hours if not contraindicated.
- The patient should undergo an abdominal ultrasound to evaluate for bile duct dilation and an MRCP (magnetic resonance cholangiopancreatography) to assess for bile duct injury, stricture, or retained stones.
- While awaiting imaging, the patient should maintain a low-fat diet to minimize digestive discomfort.
- Laboratory tests including complete liver function tests, amylase, and a complete blood count should be obtained to further evaluate the cause of pain. If imaging reveals bile duct obstruction or injury, referral to gastroenterology for possible ERCP (endoscopic retrograde cholangiopancreatography) would be indicated.
- The mildly elevated lipase suggests pancreatic inflammation, possibly from transient obstruction at the ampulla, while the slightly elevated bilirubin points to potential biliary obstruction. The diagnosis of acute pancreatitis should be established within 48 hours of admission, based on compatible clinical features and elevations in amylase or lipase levels, as stated in the AGA Institute medical position statement on acute pancreatitis 1. However, in this case, the lipase level is not significantly elevated, and other causes of abdominal pain should be considered.
- Computed tomography (CT) of the abdomen using intravenous contrast enhancement may be considered if the diagnosis is still unclear after initial evaluation, but it is not the first line of imaging in this scenario.
From the Research
Patient Presentation
- The patient is status post cholecystectomy with right side abdominal pain
- Lipase level is 127, which is slightly elevated
- Bilirubin total is 1.3, which is within normal limits
Possible Causes of Abdominal Pain
- According to 2, biliary calculi and alcohol abuse are the most common causes of acute pancreatitis
- However, the patient is status post cholecystectomy, which may suggest that the biliary calculi have been removed
- Other possible causes of abdominal pain include iatrogenic factors, sphincter of Oddi dysfunction (SOD), and eating disorders, as mentioned in 2
Diagnosis of Acute Pancreatitis
- According to 3, the diagnosis of acute pancreatitis requires two of the following: upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings
- The patient's lipase level is slightly elevated, but it is not clear if it meets the criteria for acute pancreatitis
- Further imaging and laboratory tests may be necessary to confirm the diagnosis, as suggested in 3
Role of Biliary Pancreatic Reflux
- According to 4, biliary pancreatic reflux may initiate acute pancreatitis, especially if there is previous biliary hypertension, temporary pancreatic duct obstruction, and bacterial infection of choledochal secretions
- However, the patient is status post cholecystectomy, which may reduce the risk of biliary pancreatic reflux
Treatment and Management
- According to 3, initial priorities for treating acute pancreatitis include intravenous fluid resuscitation, analgesia, and enteral nutrition
- Further management may involve critical care and organ support, parenteral nutrition, antibiotics, and pancreatic exocrine and endocrine replacement therapy, as necessary
- Patients with local complications should be referred to specialist tertiary centers for further management, as suggested in 3