What is the most likely cause of this patient's acute pancreatitis, given his symptoms of persistent epigastric pain radiating to the back, elevated serum amylase and lipase levels, and presence of yellow-brown papules on the extensor surfaces of the arms?

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Last updated: April 1, 2025 • View editorial policy

Differential Diagnosis for Acute Epigastric Pain and Pancreatitis

The patient presents with acute epigastric pain radiating to the back, elevated serum amylase and lipase, and a history of intermittent abdominal pain since childhood. The presence of yellow-brown papules over the extensor surfaces of the arms is also noted. Based on these findings, the differential diagnosis can be categorized as follows:

  • Single Most Likely Diagnosis

    • Hereditary Pancreatitis: This condition is characterized by recurrent episodes of pancreatitis, often starting in childhood, and is associated with mutations in the PRSS1 gene. The patient's history of intermittent abdominal pain since childhood and the absence of common causes of pancreatitis (e.g., alcohol consumption, gallstones) make this diagnosis likely. The presence of yellow-brown papules, possibly consistent with lipomas or other skin manifestations associated with hereditary conditions, further supports this diagnosis.
  • Other Likely Diagnoses

    • Chronic Pancreatitis: Given the patient's history of recurrent abdominal pain, chronic pancreatitis is a possible diagnosis. However, the acute presentation and lack of specific risk factors (e.g., long-term alcohol use) make it less likely than hereditary pancreatitis.
    • Hypertriglyceridemia-induced Pancreatitis: Although the patient does not report recent intake of fatty foods, hypertriglyceridemia could be a primary cause of pancreatitis. The presence of lipomas or other signs of lipid metabolism disorders could be related to this condition.
  • Do Not Miss Diagnoses

    • Gallstone Pancreatitis: Although the patient does not report recent fatty food intake, gallstones are a common cause of pancreatitis and must be considered. The absence of ecchymoses does not rule out this diagnosis.
    • Abdominal Aortic Aneurysm or Dissection: Severe abdominal pain radiating to the back could be indicative of an aortic emergency. Although less likely given the patient's age and the presence of elevated pancreatic enzymes, this diagnosis is critical not to miss due to its high mortality rate.
    • Peptic Ulcer Disease: Although the patient's pain pattern and elevated pancreatic enzymes suggest pancreatitis, peptic ulcer disease can cause severe epigastric pain and must be considered, especially if there are any signs of gastrointestinal bleeding.
  • Rare Diagnoses

    • Autoimmune Pancreatitis: This is a rare form of pancreatitis characterized by an autoimmune mechanism. It could be considered if other causes are ruled out and there are specific imaging or serological findings suggestive of this condition.
    • Genetic Disorders Affecting Lipid Metabolism: Conditions such as familial combined hyperlipidemia or other rare genetic disorders affecting lipid metabolism could potentially lead to pancreatitis and might explain the skin findings. However, these are less common and would require specific diagnostic testing for confirmation.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.