What is the best course of action for a patient with elevated lipase levels, epigastric abdominal pain, and a history of Ulcerative Colitis (UC), but no evidence of pancreatitis on computed tomography (CT) scan?

Management of Elevated Lipase with Epigastric Pain in UC Patient Without CT Evidence of Pancreatitis

This patient likely has drug-induced pancreatitis from UC medications (particularly aminosalicylates) or UC-associated pancreatitis that is not yet visible on CT, and should have UC medications discontinued immediately, be admitted for observation with supportive care, and undergo repeat imaging at 72-96 hours if symptoms persist or worsen. 1, 2, 3

Immediate Diagnostic Considerations

Why CT May Be Falsely Negative

• Early CT scanning (within 72 hours of symptom onset) will not show necrotic/ischemic areas and has only 90% overall detection rate early in the disease course. 1
• The optimal timing for contrast-enhanced CT assessment is 72-96 hours after onset of symptoms, when sensitivity approaches 100% for pancreatic necrosis. 1
• Your patient's negative CT does not rule out acute pancreatitis—it may simply be too early to visualize pancreatic changes. 1, 4

Alternative Causes of Elevated Lipase in UC

• Elevated lipase can occur in inflammatory bowel disease without true pancreatitis, as documented in infectious colitis and UC patients. 5
• However, with a lipase of 1000 (significantly above the diagnostic threshold of 3x upper limit of normal) combined with epigastric pain, pancreatitis remains the most likely diagnosis despite negative imaging. 1, 5

Critical Action: Medication Review

Drug-Induced Pancreatitis in UC

Immediately discontinue all aminosalicylate medications (sulfasalazine, mesalazine/5-ASA) as these are well-documented causes of acute pancreatitis in UC patients. 2, 3

• Sulfasalazine-induced pancreatitis has been reported with lipase levels of 1010-1080 units, remarkably similar to your patient's presentation. 2
• Mesalazine can cause acute pancreatitis with elevated lipase levels that resolve within days of discontinuation and recur upon rechallenge. 3
• Do not rechallenge with these medications even at lower doses, as recurrence is well-documented and can occur within 24 hours of reintroduction. 2, 3

Admission and Management Strategy

Severity Stratification

This patient requires hospital admission for observation and supportive care, even without CT evidence of pancreatitis. 6

• Monitor for development of organ failure over the next 48 hours using vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature. 6
• Check hematocrit (>44% indicates risk of pancreatic necrosis), urea (>20 mg/dL predicts mortality), and C-reactive protein at day 3 (≥150 mg/L indicates severe disease). 1
• If the patient remains stable without organ failure, this represents mild acute pancreatitis manageable on a general ward. 6

Supportive Care Protocol

Implement goal-directed fluid resuscitation aiming for urine output >0.5 mL/kg body weight. 6

• Provide multimodal pain control; consider dilaudid over morphine for non-intubated patients. 6
• Initiate early enteral nutrition rather than keeping the patient NPO—both gastric and jejunal feeding can be delivered safely even in acute pancreatitis. 6
• Do not administer prophylactic antibiotics in this mild case without evidence of infection. 6

Follow-Up Imaging Strategy

When to Repeat CT

Obtain repeat contrast-enhanced CT at 72-96 hours after symptom onset if:

• Pain persists or worsens 1
• Signs of organ failure develop 6
• Clinical deterioration occurs 6-10 days after admission 6
• Fever or signs of sepsis emerge 6

Alternative Imaging

• Perform ultrasound to evaluate for gallstones as a potential etiology, though less likely given UC history. 1
• If no clear etiology is identified after excluding drug-induced and biliary causes, consider MRCP or endoscopic ultrasound to screen for occult choledocholithiasis. 1

Common Pitfalls to Avoid

Do not dismiss this presentation based solely on negative CT imaging—clinical and biochemical findings of pancreatitis (lipase 1000 + epigastric pain) take precedence over early imaging. 1, 4

Do not continue UC medications pending "confirmation" of pancreatitis—the risk-benefit strongly favors immediate discontinuation given the well-established association and potential for rapid deterioration. 2, 3

Do not assume this is simply "elevated lipase from IBD" without true pancreatitis—while this phenomenon exists, a lipase of 1000 with characteristic pain warrants treatment as acute pancreatitis until proven otherwise. 5

Do not perform unnecessary surgical exploration—the absence of peritoneal signs and negative CT for perforation makes perforated viscus unlikely, and pancreatitis-related peritoneal fluid does not require surgical intervention. 4, 7