Walter Reed National Military Medical Center Bethesda, MD, United States
Opeyemi I. Oluyemi, DO1, Sylvester Luu, DO2, Henri Renom De La Baume, MD3, Franklin Goldwire, MD3 1Walter Reed National Military Medical Center, Bethesda, MD; 2Fort Belvoir Community Hospital, Bethesda, MD; 3Fort Belvoir Community Hospital, Fort Belvoir, VA
Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed medication for pain and inflammation, but are a leading cause of drug-induced liver injury (DILI). What is not well documented is ibuprofen-induced elevated carbohydrate antigen (CA) 19-9, which raises concern for pancreatic cancer. This case demonstrates liver injury and markedly elevated CA 19-9 in the 1000s, which resolved with cessation of ibuprofen use in the setting of negative endoscopic ultrasound (EUS) with fine needle aspiration (FNA).
Case Description/Methods: 45 year old male with no history of liver or biliary disease presented with painless jaundice. Status post hemorrhoidectomy with daily ibuprofen use (400mg, 8 tablets) for pain. New-onset upper extremity pruritus with 13 lbs. unintentional weight loss. Upon evaluation, patient had AST 217 U/L, ALT 157 U/L, alkaline phosphatase (ALP) 964 U/L, and bilirubin 13.6 mg/dL without leukocytosis, platelet dysfunction, coagulopathy, or systemic symptoms. Right upper quadrant ultrasound did not demonstrate any obstruction. Screening CA 19-9 of 1046 U/mL prompted diagnostic EUS-FNA of pancreas, which was normal. Interval liver function tests and CA 19-9 demonstrated marked downtrend with cessation of ibuprofen use—AST 25 U/L, ALT 21 U/L, ALP 152 U/L, bilirubin 2 mg/dL, and CA 19-9 84 U/mL.
Discussion: NSAIDs-induced DILI has an estimated incidence of 1-23 cases per 100,000 patient-years. Ibuprofen makes up ~10% of DILI cases in developed countries. Time to onset is 12 days. Serum CA 19-9 is the only validated tumor marker for pancreatic cancer, which has an annual incidence of 3.9 per 100,000. Higher CA 19-9 serum levels with cut off of 90 U/mL have a sensitivity of 86% and specificity of 39% for malignancy. Our patient had a CA 19-9 >1000 U/mL with weight loss, which required evaluation with EUS-FNA to rule out malignancy. Elevated CA 19-9 secondary to ibuprofen has only been noted on a single center retrospective study as a statistically significant incidence of 7.1% of 581 patients, p = 0.034 when compared to controls. However, the underlying mechanism has not been defined on literature review. Thus, this case is a rare presentation of elevated CA 19-9 secondary to ibuprofen instead of something more sinister as a pancreatic malignancy. Thorough evaluation is necessary to provide reassurance that this is a transient process that will resolve with cessation of the offending agent.
Figure: A. Fullness and rounded contour of the pancreatic head with dilated main pancreatic duct on CT B. EUS with no pancreatic duct dilation. C. EUS-FNA of pancreas
Opeyemi Oluyemi indicated no relevant financial relationships.
Sylvester Luu indicated no relevant financial relationships.
Henri Renom De La Baume indicated no relevant financial relationships.
Franklin Goldwire indicated no relevant financial relationships.
Opeyemi I. Oluyemi, DO1, Sylvester Luu, DO2, Henri Renom De La Baume, MD3, Franklin Goldwire, MD3. P2205 - Smoke but No Fire: A Case of Massive CA 19-9 Elevation From NSAID Use, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.