Eileen Chang, DO1, Marvin Vaishnani, MD1, Ian Chang, DO2, Whitney Jennings, MD, PharmD3
1Redmond Regional Medical Center, Rome, GA; 2University of California Irvine Medical Center, Orange, CA; 3Harbin Clinic, Rome, GA
Introduction: Acute pancreatitis is a relatively common condition in the hospital. About 75% of cases are associated with excessive alcohol use or gallstones, and only 0.1 to 2% are drug-induced. The clinical and pathologic findings are similar regardless of the inciting cause. We have suspicion that metronidazole-induced pancreatitis occurs at a significantly higher incidence, or maybe exclusively, in females.
Case Description/Methods: A 68 year old Caucasian female with history of hyperlipidemia, cardiomyopathy and hypothyroidism presents to the ED with chief complaint of epigastric pain. Symptoms started few days prior with back pain that progressed to epigastric tenderness and fullness. Associated symptoms include nausea and vomiting. She denies fever, chest pain, hematemesis, hematochezia, melena or recent injury. She denies alcohol or tobacco use. About 2 weeks ago, patient underwent upper endoscopy for ongoing epigastric pain and family history of sister who passed away in her 50s from gastric cancer. EGD showed numerous pedunculated and sessile hyperplastic appearing gastric polyps in the fundus and body; biopsy was obtained. Pathology report revealed no dysplasia or malignancy. She completed a short course of metronidazole for abdominal bloating and diarrhea 4 days prior to hospital presentation. On admission, lipase was 10,347 with normal triglyceride and calcium levels. CT imaging demonstrated stranding around the pancreatic head and uncinate process. She was placed on bowel rest, IV hydration and supportive care. MRCP was performed to assess the pancreatic duct; it revealed acute pancreatitis, but no cholelithiaisis, choledocholithiasis or other complicating features. Repeat lipase was 2,533. Patient recovered well and was discharged home.
Discussion: Metronidazole-induced acute pancreatitis has been reported in prior English literature; in which all 8 cases involved female patients (O'Halloran E, et al. HPB Surgery, pp. 1–4, 2010). Proposed mechanisms include free radical production and immune-mediated inflammatory response. In a population-based case control study, there was a significantly increased risk of acute pancreatitis within 30 days exposure to metronidazole, especially when used in combination with other agents for H. pylori eradication (Barbulescu A, et al. Clinical Epidemiology, pp. 1573–1581, 2018). Physicians should maintain a high index of suspicion when prescribing metronidazole and avoid rechallenge. Further investigation may help reduce morbidity related with this phenomenon.
Citation: Eileen Chang, DO; Marvin Vaishnani, MD; Ian Chang, DO; Whitney Jennings, MD, PharmD. P0063 - FEMALE PREDOMINANCE IN METRONIDAZOLE-INDUCED ACUTE PANCREATITIS: A CASE REPORT AND REVIEW OF LITERATURE. Program No. P0063. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.