SAT129 Clinical Conundrum Of Suspected Pancreatitis Masking Diabetic Ketoacidosis
Authors: Sood Aayushi , Syed Omar , Sood Akshit , Patel Preya , Alosiyus Mark M , Physician Attending 
Published: October 2023

Abstract
Disclosure: A. Sood: None. O. Syed: None. A. Sood: None. P. Patel: None. M.M. Alosiyus: None.
​​Abstract: Patients with End-Stage-Renal-Disease (ESRD) have poor renal excretion which can cause false elevation in pancreatic enzymes. We present a case of a pregnant woman on hemodialysis (HD) with elevated lipase levels concerning for acute pancreatitis. Case Presentation: A 25-year-old African American female with history of type 1 diabetes mellitus, ESRD secondary to diabetic nephropathy, diabetic gastroparesis, hypertension presented to the hospital with diffuse severe abdominal pain following HD. Lab showed Anion gap 15, Glucose 304 mg/dL, Creatinine 4.6 mg/dL, Triglyceride 130 mg/dL, Lipase 390 mg/dL, with urine negative for ketones. The abdominal US was negative for gallstones, and revealed a normal size common bile duct. CT scan was deferred due to a positive urine pregnancy test. She was started on IV fluids for suspected pancreatitis. Patient had worsening blood glucose levels as well as anion gap despite being on Humalog and correctional scale insulin. Patient was started on an insulin drip with resolution of the anion gap. Discussion: Patient met 2 of 3 criteria for pancreatitis, with CT and MRI deferred in this case due to pregnancy and low suspicion secondary to negative US result.[5] Pancreatic enzymes can be falsely elevated in ESRD patients. Lipase can be elevated in HD[3] patients due to the lipolytic effect of heparin used during dialysis, while elevation of lipase in DKA remains unclear[2]. Acidosis is common in ESRD patients, thus masking the diagnosis of DKA which also presents with abdominal pain, nausea, vomiting, which can potentially cause a delay in the treatment. The mimicking and masking of these conditions by each other can thereby result in a diagnostic dilemma, which is why a prompt diagnosis of pancreatitis should be made in a patient presenting with DKA. Conclusion: Elevated levels of amylase and lipase are concerning for pancreatitis, however, metabolic processes could also be masked by underlying chronic diseases. While fluid resuscitation is the mainstay treatment for DKA and pancreatitis, it is extremely important to be cautious when a patient has an underlying ESRD. The diagnostic dilemma due to the overlapping diagnosis should be taken into consideration early during the hospitalization, and a high index of clinical suspicion can prevent the unnecessary delay in the treatment.
References: Baker S. Diagnosis and Management of Acute Pancreatitis. Critical care and Resuscitation 2004;6:17-27Collen MJ, Ansher AF, Chapman AB, Mackow RC, Lewis JH. Serum amylase in patients with renal insufficiency and renal failure. Am J Gastroenterol. 1990 Oct;85(10):1377-80. PMID: 1699413.Shibasaki T, Matsuda H, Ohno I, Gomi H, Nakano H, Misawa T, Abe S, Ishimoto F, Kisugi R, Ikeda K, Machida K, Sakai O. Significance of serum lipase in patients undergoing hemodialysis. Am J Nephrol. 1996;16(4):309-14. doi: 10.1159/000169015. PMID: 8739284.Vaziri ND, Chang D, Malekpour A, Radaht S. Pancreatic enzymes in patients with end-stage renal disease maintained on hemodialysis. Am J Gastroenterol. 1988 Apr;83(4):410-2. PMID: 2450453.Zhao, K., Adam, S. Z., Keswani, R. N., Horowitz, J. M., & Miller, F. H. (2015). Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging. American Journal of Roentgenology, 205(1), W32-W41. https://doi.org/10.2214/ajr.14.14056
Presentation: Saturday, June 17, 2023