109) A 35 year old HIV positive male patient comes to your office with complaint of anorexia, nausea and vomiting and abdominal pain. His anti-retroviral medications include Stavudine and Didanosine. On physical examination, his temperature is 100F. His abdomen is tender in the epigastric area. Laboratory results reveal WBC count of 20k/µl, Serum amylase 500 IU/L ( N = 25 to 160 U/L) , Lipase 590 units/liter (Normal = 25 to 300U/L), AST 120 IU/L, ALT 200 IU/L, Total bilirubin 3.6gm% and Alkaline phosphatase 200IU/L . Ultrasound reveal gallstones with no cystic duct obstruction and no evidence of cholecystitis and a common bile duct diameter of 1.5cm. The most appropriate step that would address the etiology of his acute pancreatitis is:
a) Intravenos Imipinem/ Cilastatin
b) Supportive care followed by Endoscopic Retrograde Cholangiopancreatography ( ERCP)
c) Stop Didanosine
d) Stop Stavudine
e) Exploratory Laporotomy
c.Stop Didanosine
S/E-Didanosine cause Pancreatitis
c
bbbbbbbbbbbbbbbbbbbbb
Yes agree is B! CBD >1.5–> obstructive cause
b
B.
cbd > 7 mm. is diagnostic of obstruction
amylase and lipase elevated… Suggests pancreatitis…
Stop didanosine…
b
The cause is but obvious- Didanosine! It causes mitochondrial damage and disrupts the pancreas. The CBD can be normal upto 10 mm as well. Only when the CBD thickness is more than 7, physicians tend to explore and that too there should be evidence of hepatobiliary disease. One more give away, Pancreatitis 99% of the time gives you epigastric tenderness. There could be a lot of other pathology going on in the GI which could give you pain abdomen but tenderness with an elevated lipase, amylase is acute pancreatitis. Here, stones are not the cause because there’s no obstruction to the cystic duct. So, how in the world can the stones reach the pancreatic duct area and cause further blockage and pancreatitis?
One important point- The most common cause of pancreatitis in USA is gallstones and not alcohol!