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Abstract
Background: Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, accounting for approximately 300,000 emergency department visits annually. It is characterized by parenchymal and peripancreatic fat necrosis accompanied by inflammation. The clinical diagnosis of AP is based on elevated serum amylase and lipase levels, characteristic imaging findings, and epigastric pain often radiating to the back. While gallstones and alcohol use are the most common causes of AP, drug-induced pancreatitis (DIP) is a rare but increasingly recognized etiology, contributing to 0.1–5% of cases. DIP is typically diagnosed by excluding other causes and is often associated with over 500 implicated drugs, including mesalamine, valproate, proton pump inhibitors, and metronidazole. Potential mechanisms of DIP include pancreatic duct constriction, toxic metabolite accumulation, hypersensitivity reactions, and localized angioedema. The management of DIP focuses on the withdrawal of the offending agent and supportive care, with timely recognition being critical to preventing severe complications.
Case Presentation: We present the case of a 53-year-old female with a history of hypothyroidism, type 2 diabetes, chronic kidney disease (CKD) stage 3, hypertension, and erosive gastritis, who presented with persistent upper abdominal pain, nausea, and vomiting. A computed tomography scan revealed an enlarged pancreas with peripancreatic fluid and fat stranding. Despite normal serum lipase levels, her clinical presentation and imaging findings were consistent with acute pancreatitis. Laboratory workup revealed leukocytosis, mild hyperglycemia, and elevated creatinine (2.51 mg/dL, slightly above baseline). Her GI history included chronic and acute-on-chronic gastritis, and she was noted to be taking mesalamine (800 mg PO BID) prior to admission.
Further evaluation excluded other common etiologies of AP, such as gallstones, hypertriglyceridemia, and ethanol abuse. Workup, including antibody and serology tests, was unremarkable. Given the temporal relationship between mesalamine use and the onset of symptoms, mesalamine was discontinued during her hospitalization, leading to resolution of symptoms. An esophagogastroduodenoscopy revealed mild gastritis but no significant findings to account for her symptoms. The patient was managed with supportive care, including pain and nausea control, hydration, and adjustments to her CKD medications. She was discharged in stable condition with outpatient follow-up recommended.
Conclusion: Drug-induced pancreatitis (DIP) is a rare but significant cause of acute pancreatitis (AP), with an estimated incidence of 2–3.6%. The diagnosis is challenging, as DIP presents similarly to other forms of AP and is primarily a diagnosis of exclusion. Symptoms range from mild epigastric pain and nausea to severe cases with systemic manifestations and complications like pseudocysts or sepsis. In this case, the patient's polypharmacy and mesalamine use complicated the diagnostic process, but discontinuation of the suspected drug resulted in symptom resolution, strengthening the diagnosis of DIP. This case highlights the importance of early recognition, careful medication review, and prompt withdrawal of the offending agent to improve outcomes and prevent complications in patients with complex medical histories. Clinician awareness of DIP is essential, particularly in those on multi-drug regimens.
Recommended Citation
Arellano Villanueva, Elias; Lopez, Miguel; Asaad, Alhasan; and Campo Maldonado, Jose, "A Peculiar Pancreatitis: Investigating the Adverse Effects of Mesalamine" (2025). Research Symposium. 57.
https://scholarworks.utrgv.edu/somrs/2025/posters/57
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Chemical and Pharmacologic Phenomena Commons, Gastroenterology Commons, Hematology Commons, Internal Medicine Commons, Patient Safety Commons
A Peculiar Pancreatitis: Investigating the Adverse Effects of Mesalamine
Background: Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, accounting for approximately 300,000 emergency department visits annually. It is characterized by parenchymal and peripancreatic fat necrosis accompanied by inflammation. The clinical diagnosis of AP is based on elevated serum amylase and lipase levels, characteristic imaging findings, and epigastric pain often radiating to the back. While gallstones and alcohol use are the most common causes of AP, drug-induced pancreatitis (DIP) is a rare but increasingly recognized etiology, contributing to 0.1–5% of cases. DIP is typically diagnosed by excluding other causes and is often associated with over 500 implicated drugs, including mesalamine, valproate, proton pump inhibitors, and metronidazole. Potential mechanisms of DIP include pancreatic duct constriction, toxic metabolite accumulation, hypersensitivity reactions, and localized angioedema. The management of DIP focuses on the withdrawal of the offending agent and supportive care, with timely recognition being critical to preventing severe complications.
Case Presentation: We present the case of a 53-year-old female with a history of hypothyroidism, type 2 diabetes, chronic kidney disease (CKD) stage 3, hypertension, and erosive gastritis, who presented with persistent upper abdominal pain, nausea, and vomiting. A computed tomography scan revealed an enlarged pancreas with peripancreatic fluid and fat stranding. Despite normal serum lipase levels, her clinical presentation and imaging findings were consistent with acute pancreatitis. Laboratory workup revealed leukocytosis, mild hyperglycemia, and elevated creatinine (2.51 mg/dL, slightly above baseline). Her GI history included chronic and acute-on-chronic gastritis, and she was noted to be taking mesalamine (800 mg PO BID) prior to admission.
Further evaluation excluded other common etiologies of AP, such as gallstones, hypertriglyceridemia, and ethanol abuse. Workup, including antibody and serology tests, was unremarkable. Given the temporal relationship between mesalamine use and the onset of symptoms, mesalamine was discontinued during her hospitalization, leading to resolution of symptoms. An esophagogastroduodenoscopy revealed mild gastritis but no significant findings to account for her symptoms. The patient was managed with supportive care, including pain and nausea control, hydration, and adjustments to her CKD medications. She was discharged in stable condition with outpatient follow-up recommended.
Conclusion: Drug-induced pancreatitis (DIP) is a rare but significant cause of acute pancreatitis (AP), with an estimated incidence of 2–3.6%. The diagnosis is challenging, as DIP presents similarly to other forms of AP and is primarily a diagnosis of exclusion. Symptoms range from mild epigastric pain and nausea to severe cases with systemic manifestations and complications like pseudocysts or sepsis. In this case, the patient's polypharmacy and mesalamine use complicated the diagnostic process, but discontinuation of the suspected drug resulted in symptom resolution, strengthening the diagnosis of DIP. This case highlights the importance of early recognition, careful medication review, and prompt withdrawal of the offending agent to improve outcomes and prevent complications in patients with complex medical histories. Clinician awareness of DIP is essential, particularly in those on multi-drug regimens.
