E0158 - Could Sigmoid Diverticulitis, Drug-Induced Liver Injury and Drug-Induced Pancreatitis Occur Simultaneously?

Rutwik Pradeep Sharma, MD¹, Alexander Kusnik, MD², Divya Ravi, MD¹, Ahmed Shehadah, MD³, Jay Bapaye, MD³, Chengu Niu, MD³, Tausif Syed, MD¹, Michael Labuzetta, MD^1
1Rochester Regional Health/Unity Hospital, Rochester, NY; ²Rochester Regional Health - Unity Hospital, Rochester, NY; ³Rochester Regional Health, Rochester, NY

Introduction: Sigmoid diverticulitis, a common complication of diverticular disease, presents with abdominal pain, fever and elevated inflammatory markers. The prevalence is 10%-25%. Drug induced pancreatitis has a prevalence of 0.1-2% of all cases. It is often difficult to diagnose. Drug induced liver injury (DILI) is an uncommon adverse event. It is one of the common reasons for acute liver failure in the west. It is rare to see all these pathologies simultaneously. We present an interesting case with these pathologies.

Case Description/Methods: 72-year-old woman with past medical history significant of inflammatory arthritis and diverticulosis started on sulfasalazine. She began to have symptoms of fatigue and abdominal pain with bloody diarrhea few days after initiation of sulfasalazine. As per PCP recommendations patient had blood tests done which showed elevated- Lipase (600U/l), ALP (380U/L), AST (271U/l) and ALT (251U/L). Given these findings and ongoing abdominal pain, she was referred to the emergency department. Computerized tomography (CT) of the abdomen and pelvis with intravenous contrast showed evidence of sigmoid diverticulitis, normal pancreas, no biliary dilation and a simple liver cyst. On conservative management with intravenous piperacillin-tazobactum and intravenous fluids, she improved and was discharged home with oral antibiotics. Sulfasalazine was added to her allergy list. She recovered without complications and liver enzymes trended downwards at follow up.

Discussion: Diverticulitis occurs because of obstruction of diverticulum, chronic inflammation, alterations in the gut microbiome, micro perforations and alterations in neuromusculature. The gold standard for diagnosis is multidetector CT.
Drug induced pancreatitis can be proposed in the presence of an offending agent when common etiologies for acute pancreatitis have been ruled out. Criteria for acute pancreatitis should be met and re challenge with supposed offending drug could be attempted.
DILI can be either predictable or idiosyncratic. Pathogenesis remains unknown. Most cases resolve after withdrawal of the agent.
Patient presented with atypical abdominal pain for acute pancreatitis, elevated lipase and liver enzymes with recent initiation of sulfasalazine, which is known to cause pancreatitis. CT abdomen and pelvis showed sigmoid diverticulitis. On literature review, we could not find simultaneous presentation of diverticulitis, pancreatitis and drug induced liver injury.


Disclosures:


Rutwik Pradeep Sharma, MD¹, Alexander Kusnik, MD², Divya Ravi, MD¹, Ahmed Shehadah, MD³, Jay Bapaye, MD³, Chengu Niu, MD³, Tausif Syed, MD¹, Michael Labuzetta, MD¹. E0158 - Could Sigmoid Diverticulitis, Drug-Induced Liver Injury and Drug-Induced Pancreatitis Occur Simultaneously?, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.