A 21-year-old African American female with noted obesity (basic metabolic index 40.34 kg/m2), without significant past medical history, presented with abdominal pain for 1 wk.\nHer abdominal pain was described as 7 out of 10 on a pain scale, diffuse, and non-radiating. It was associated with nausea, multiple episodes of non-biliary and non-bloody vomiting, anorexia, and myalgias. She denied any jaundice, pruritis, change in bowel habits, urinary symptoms, or extremity swelling. There was no history of fever, sick contacts, or recent blood transfusions.\nThere was no significant past medical illness.\nShe denied smoking tobacco, drinking alcohol, usage of illicit drugs, hormonal contraceptives, or energy drinks. She mentioned that she was taking a HS, GC (1400 mg daily), for weight loss since 4 wks. Family history was unremarkable.\nVital signs were notable for tachycardia (133 bpm). On examination, she had epigastric and right upper quadrant tenderness, without jaundice or hepatosplenomegaly.\nLaboratory workup (Table ) revealed elevated alanine aminotransferase (ALT) 981 U/L, aspartate aminotransferase (AST) 1062 U/L, alkaline phosphate 248 U/L, international normalized ratio (INR) 1.6, prothrombin time 19 s, and ammonia level 44 μmol/L. Acetaminophen and alcohol levels were negative, as was her urine toxicology. Testing for hepatitis A, hepatitis B, hepatitis C, human immunodeficiency virus, herpes simplex virus, cytomegalovirus, Epstein Barr virus, parvovirus, and rapid plasma regain were negative. Autoimmune work-up including antinuclear antibody, antimitochondrial antibody, and anti-smooth muscle antibody were also negative. Serologies for alpha-1 antitrypsin, ceruloplasmin, iron studies, alpha fetoprotein, and carcinoembryonic antigen were unremarkable.\nAbdominal ultrasound showed hepatosplenomegaly with heterogenous increased echogenicity compatible with fatty liver. Abdominal computer tomography (CT) scan showed hepatosplenomegaly with heterogeneous-appearing liver.
An 82-year-old man with a past medical history significant for obesity, AP secondary to cholelithiasis, prior cholecystectomy, hypertension, hyperlipidemia, diabetes mellitus, pulmonary embolism, and nonischemic cardiomyopathy presented to the emergency department with concerns of abdominal discomfort for two days. The patient reported discomfort in the epigastric region, which was non-radiating. He reported nausea but no vomiting. He reported at least two bouts of AP in the past. The patient denied any fevers, chills, lightheadedness, headaches, chest pain, shortness of breath, hematochezia, numbness, or melena. His medications included aspirin, apixaban, atorvastatin, metformin, metoprolol, spironolactone, and ramipril.\nThe patient reported taking GC as an appetite suppressant. On physical exam, tenderness was noted in the epigastric area, and bowel sounds were positive. His serum lipase was elevated to >600 U/L (reference range, 16 to 63 U/L), white blood cell count was 11.7 K/µL (reference range, 4.5 to 11 K/µL), hemoglobin was 13.4 g/dL (reference range, 13.5 to 17.5 g/dL), bilirubin was 0.5 mg/dL (reference range,0.1 mg/dl to 1.2 mg/dl), alkaline phosphatase was 66 IU/L (reference range 44 to 147 IU/L), alanine aminotransferase was 12 U/L (reference range, 10 U/L to 40 U/L), aspartate aminotransferase was 17 U/L (reference range, 10 to 40 U/L), and lactic acid was 0.9 mmol/L (reference range, 0.5 to 2.0 mmol/L). A computed tomography scan of the abdomen revealed fat stranding around his pancreas, which was concerning for AP (Figure ).\nThe patient denied any use of alcohol. Triglycerides levels were 146 mg/dL (reference range, <200 mg/dL). He was hospitalized and treated with adequate intravenous hydration, nothing by mouth, with remarkable improvement in his symptoms within 24 hours of presentation. He tolerated regular oral diet on discharge from the hospital. Due to his relatively recent consumption of GC and no recent changes in any other medications, a likely etiology of AP was thought to be secondary to the use of this herbal product. His care team recommended he avoid the use of GC in the future.