This is a patient with a medical history of neuroendocrine carcinoma of the pancreas status post Whipple complicated by pancreaticojejunostomy stricture followed by leak, recurrent pancreatitis requiring multiple endoscopic retrograde cholangiopancreatographies with stent placements; she also had gastroesophageal reflux disease (GERD) and iron-deficiency anemia. She presented to the emergency department on with a history of progressive worsening constant right upper quadrant abdominal pain, weakness, nausea, and one episode of emesis. Her pain was similar to prior episodes of pancreatitis, and worse on lying flat, and improved when bending forward. She had attempted Tylenol and Advil without improvement.
Physical examination was notable for right upper quadrant and epigastric abdominal tenderness and bilateral costovertebral angle tenderness. Lab results were notable for anemia with hemoglobin of 10.9 grams per deciliter (g/dL), elevated potassium of 5.3 millimoles per liter (mmol/L), and normal lipase of 20 units per liter (U/L). A computed tomography scan of the abdomen and pelvis showed hepatomegaly and prior Whipple procedure; there were no acute findings. A computed tomography scan of the chest showed multiple bilateral pulmonary nodules measuring up to 3 millimeters (mm), unchanged since a prior scan. The health plan's determination is upheld. The patient had possible acute pancreatitis, as the lipase may be normal during pancreatitis after a Whipple procedure [1-4]. Notably, imaging did not show pancreatitis or complications of pancreatitis such as peripancreatic fluid collections. The patient was appropriately treated, with intravenous fluid administration and gradual advancement of diet [5]. However, there was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute continued inpatient care, and the treatment provided could have been provided without the acute inpatient level of care [6]. The Gastroenterology consultation did not recommend further inpatient workup for pancreatitis and signed off on the day of admission with a recommendation for advancing diet as tolerated and Pain Management consultation. Pain management recommended resumption of home oral pain medications, which could have been completed by the second day of admission and did not require the inpatient level of care.