Acute pancreatitis as the presenting manifestation of primary hyperparathyroidism due to parathyroid adenoma

A 61-year-old overweight man, active smoker and with an unremarkable medical history presented to the Emergency Department with a 24-h history of epigastric pain that had intensified 2 h earlier. The pain radiated to the back and was unresponsive to positional changes. He denied fever, nausea, vomiting, gastrointestinal bleeding or changes in bowel habits. On examination, he was hemodynamically stable but dehydrated. His vital signs were normal except for elevated blood pressure (160/85 mmHg). The patient was alert, oriented and exhibited moderate mesogastric tenderness without rebound. Bowel sounds were normal, and no masses were detected. Electrocardiogram showed normal sinus rhythm at 90 bpm. Laboratory investigations (Table 1) revealed lipase and amylase were elevated to more than three times the upper limit of normal. Abdominal ultrasound and contrast-enhanced computed tomography demonstrated diffuse pancreatic enlargement with inflammatory fat stranding and peripancreatic fluid collections in the lesser sac, left anterior renal fascia and peri-splenic region (Figure 1A). A 20-mm fluid collection consistent with a small peripancreatic abscess was identified near the pancreatic head, but drainage was deemed unnecessary. The biliary tree and pancreatic duct were normal, and no gallstones were found.