What are the next steps for a 34-year-old female diabetic patient on Jardiance (empagliflozin) with intermittent left upper quadrant (LUQ) pain, elevated amylase, and normal lipase, with a pending CT scan?

Management of LUQ Pain in a Diabetic Patient on Jardiance with Elevated Amylase

The most appropriate next step is to await the CT scan results while continuing to monitor the patient's clinical status, with serial amylase and lipase measurements every 6 hours to detect any rising trend. 1

Diagnostic Considerations

Current Clinical Picture

• 34-year-old female diabetic on empagliflozin (Jardiance)
• Intermittent left upper quadrant (LUQ) pain
• Elevated amylase (115) but normal lipase
• CT scan pending

Differential Diagnosis

The clinical presentation requires careful consideration of several possibilities:

1. Early or Mild Pancreatitis: Despite normal lipase, the elevated amylase may represent early pancreatic inflammation
2. SGLT2 Inhibitor-Related Complications: Jardiance can predispose to:
   • Volume depletion affecting renal function 2
   • Ketoacidosis (which can present with abdominal pain) 2
3. Non-pancreatic Causes of LUQ Pain: Splenic, gastric, or renal pathology

Diagnostic Approach

Laboratory Assessment

• Serial Enzyme Monitoring: Repeated measurements of serum amylase and lipase every 6 hours is recommended to detect any rising trend 1
• Additional Tests:
  • Complete metabolic panel to assess renal function
  • Urinalysis for ketones (given patient is on Jardiance)
  • Serum ketones and blood gas if concerned for SGLT2 inhibitor-associated ketoacidosis

Imaging

• Complete the Pending CT Scan: This is essential for diagnosing pancreatic and duodenal injuries/inflammation 1
• If CT is negative but clinical suspicion remains high:
  • Consider repeat CT in 12-24 hours if symptoms persist 1
  • MRCP may be considered as a second-line diagnostic modality if pancreatic ductal injury is suspected 1

Management Algorithm

1. Immediate Steps:

   • Continue NPO status until diagnosis is clarified
   • Maintain adequate IV hydration
   • Monitor vital signs and abdominal examination findings

2. After CT Results:

   • If CT shows pancreatitis:

     • Continue NPO
     • IV fluid resuscitation
     • Pain management
     • Consider temporary discontinuation of Jardiance 2

   • If CT is normal but symptoms persist:

     • Repeat CT in 12-24 hours 1
     • Continue serial amylase/lipase measurements
     • Consider MRCP if pancreatic ductal injury is suspected 1

   • If CT shows non-pancreatic pathology: Direct treatment accordingly

3. Jardiance Considerations:

   • Temporarily discontinue Jardiance if:
     • Acute pancreatitis is confirmed
     • Reduced oral intake is necessary
     • Signs of volume depletion or acute kidney injury develop 2

Important Caveats

• Mild Enzyme Elevations: An amylase of 115 (less than 3x upper limit of normal) has poor specificity for pancreatitis 3, 4
• Diagnostic Criteria: According to revised guidelines, diagnosis of acute pancreatitis requires at least 2 of 3 criteria:
  1. Abdominal pain consistent with pancreatitis
  2. Serum amylase/lipase >3 times upper limit of normal
  3. Characteristic findings on imaging 3, 5
• SGLT2 Inhibitor Risk: Jardiance can predispose to ketoacidosis even with normal blood glucose levels, which can present with abdominal pain 2
• Discordant Enzymes: Normal lipase with elevated amylase is less specific for pancreatitis than elevated lipase 3, 6

Pitfalls to Avoid

1. Premature Diagnosis: Don't diagnose pancreatitis based solely on mildly elevated amylase without other supporting evidence 3, 4
2. Missing DKA: Don't overlook the possibility of SGLT2 inhibitor-associated ketoacidosis, which can present with abdominal pain and normal glucose levels 2, 7
3. Overinvestigation: Extensive workup for mild enzyme elevations (<3x normal) has low diagnostic yield and poor cost-effectiveness 4
4. Delayed Repeat Imaging: If clinical suspicion remains high despite initial negative imaging, repeat CT within 12-24 hours 1