Acute Pancreatitis in a Patient With Diabetic Ketoacidosis and Normal Lipase Levels

The diagnosis of acute pancreatitis requires clinical, biochemical, and occasionally imaging information. Biochemical criteria include serum lipase levels, which are considered both sensitive and specific for the diagnosis of acute pancreatitis. Patients with diabetic ketoacidosis often have abdominal pain that may be related to the ongoing metabolic derangement or to precipitating intra-abdominal pathology. The pain severity in diabetic ketoacidosis helps determine whether abdominal disease should be further investigated. We present a patient with diabetic ketoacidosis and acute pancreatitis who had no significant elevation of amylase and lipase. The patient had abdominal pain that persisted despite ongoing treatment with intravenous insulin for ketoacidosis. The pain was initially located in the epigastrium and then migrated to the right lower quadrant. An abdominal computed tomography scan was obtained to exclude acute appendicitis, and this study revealed peripancreatic fluid consistent with acute pancreatitis that extended into the right lower quadrant anterior to the psoas muscle. A literature review of previous case reports and possible explanations for normal lipase levels are discussed. In conclusion, normal lipase levels do not exclude the diagnosis of acute pancreatitis and imaging criteria may be needed. It is also important to recognize that laboratory studies have limitations, and these should be taken into account when confirming a diagnosis.