Atypical presentation of painless acute pancreatitis: A case report

Table 1 Laboratory blood work up

Labs	Value	Reference
Hemoglobin	15.1	13.0-17.0 g/dL
Hematocrit	44.1	38.6-49.2%
MCV	110.9	80.0-100.0 fL
Platelets	107 × 103	150-450 × 103/mcL
Sodium	125	133-144 mEq/L
Potassium	4.0	3.5-5.2 mEq/L
Chloride	82	98-107 mEq/L
HCO3	< 10	21-31 mEq/L
Creatinine	1.35	0.70-1.30 mg/dL
BUN	13	7-25 mg/dL
Calcium	9.1	8.6-10.3 mg/dL
AST	93	13-39 U/L
Total bilirubin	3.5	0.3-1.0 mg/dL
Glucose	210	70-99 mg/dL
Lactic acid	7.7	0.5-2.0 mmol/L
Troponin	377	0-20 pg/mL
Lipase	557	11-82 U/L
CPK	350	30-223 U/L
Cholesterol	218	< 200 mg/dL
Triglycerides	313	< 150 mg/dL

MCV: Mean corpuscular volume; BUN: Blood urea nitrogen; AST: Aspartate aminotransferase; CPK: Creatine phosphokinase.

Table 2 Acute pancreatitis scoring systems

Scoring System	Number of criterion	Criterion on Admission	Within 48 hours	Interpretation
Harmless Acute Pancreatitis Score (should not be used in isolation)	3	Peritonitis (rebound tenderness/guarding); Creatinine ≥ 2 mg/dL (177 µmol/L); Hematocrit ≥ 43% (male) or 39.6% (female)		Lower score suggests a more “harmless/ low-risk” course of pancreatitis
Ranson (Initially derived from Alcoholic Pancreatitis therefore prognosis is better for other types of pancreatitis)	11	WBC > 16k; Age > 55 years; Glucose > 200 mg/dL (> 11.1 mmol/L); AST > 250; LDH > 350	Hct drop > 10%; BUN increase > 5 mg/dL (> 1.79 mmol/L); Ca < 8 mg/dL (< 2 mmol/L); Arterial pO2 < 60 mmHg; Base deficit (24 - HCO3) > 4 mg/dL; Fluid needs > 6 L	Risk factors < 3: 1% mortality; Risk factors 3-4: 15% mortality; Risk factors 5-6: 40% mortality; Risk factors > 7: 100% mortality
Glasgow-Imerie	8	PaO2 < 59.3 mmHg (7.9 kPa); Age > 55 years; WBC > 15 × 10³/µL (109/L); Calcium < 8 mg/dL (2 mmol/L). BUN > 44.8 mg/dL (serum urea > 16 mmol/L); LDH > 600 IU/L. Albumin < 3.2 g/dL (32 g/L); Glucose > 180 mg/dL (10 mmol/L)	Serum Calcium < 2.0 mmol/L); Serum albumin < 32 g/L; LDH > 600 IU/L; AST/ALT > 200 IU/L	> 3 criteria present w/n first 48 hours of presentation qualifies for SAP
BISAP	5	BUN > 25 mg/dL (8.92 mmol/L); Impaired mental status; ≥ 2 SIRS criteria; Age > 60 years; Pleural effusion present on CT		Score 0 mortality 0.1%; Score 1 mortality 0.4%; Score 2 mortality 1.6%; Score 3 mortality 3.6%; Score 4 mortality 7.4%; Score 5 mortality 9.5%
APACHE II; Assess disease severity in Intensive Care unit patients (age > 16 years old)	15	History of severe organ failure or immunocompromised, age, temperature, mean arterial pressure, pH, heart rate/pulse, respiratory rate, serum sodium Serum potassium, serum creatinine, presence of acute renal failure, hematocrit, WBC count, glasgow coma scale, FiO2		Total score of > 30 increases non-operative and post-operative status to approximately 73%; total score: 0 to 4; non-operative status: 4% mortality; post-operative status: 1% mortality; total score: 5 to 9; non-operative status: 8% mortality; post-operative status: 3% mortality; total score: 10-14; non-operative status: 15% mortality; post-operative status: 7% mortality; total score: 15-19; non-operative status: 24% mortality; post-operative status: 12% mortality; total score: 20-24; non-operative status: 40% mortality; post-operative status: 30% mortality; total score: 25-29; non-operative status: 55% mortality; post-operative status: 35% mortality; total score: 30-34; non-operative status: 73% mortality; post-operative status: 73% mortality; total score: 35-100; non-operative status: 85% mortality; post-operative status: 88% mortality
CTSI (Balthazar Score + Necrosis Score)		Balthazar Score (CT Score: Grading); Score 0 Normal Pancreas (Grade A); Score 1 Edematous Pancreas (Grade B); Score 2 Edematous Pancreas and mild extrapancreatic changes (Grade C); Score 3 Severe extrapancreatic changes AND one fluid collection (Grade D); Score 4 Multiple or extensive fluid collections (Grade E). Necrosis Score (Extent of Necrosis), Score 0 No necrosis; Score 2 Necrosis < 33%; Score 4 Necrosis 33% to 50%; Score 6 Necrosis 50% or more		CTSI > 5 is associated with: Longer length of hospitalization; Mortality increased 15 fold

WBC: White blood cell; AST: Aspartate aminotransferase; LDH: Lactate dehydrogenase; BUN: Blood urea nitrogen; ALT: Alanine aminotransferase; SAP: Severe acute pancreatitis; CTSI: Computed Tomography Severity Index; APACHE II: Acute Physiology and Chronic Health Evaluation II.