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No account of the complications of acute pancreatitis (Gut 2005;54:426–36) would be complete without mention of diabetic ketoacidosis as an association, which is either fortuitous or one which exists as a complication in its own right. Recognition of this association has been inhibited by the complicated relationship between diabetic ketoacidosis, acute abdominal pain, and hyperamylassaemia, notwithstanding the fact that, as long ago as 1961, a patient with subsequent post mortem validation of acute pancreatitis did present with sudden deterioration of diabetic status, the latter being characterised by unequivocal diabetic ketoacidosis.1
Subsequently, it was also recognised that diabetic ketoacidosis could present with acute abdominal pain and elevation in serum amylase (even beyond four times the upper limit) without necessarily signifying acute pancreatitis.2 The relationship between the two disorders was clarified by a recent study comprising 100 consecutive episodes of diabetic ketoacidosis in which all patients with either abdominal pain or elevation in serum amylase to “more than three times normal” had an abdominal computerised tomography (CT) scan.3 Eleven per cent of patients had CT evidence of acute pancreatitis, and this was associated with abdominal pain in eight. Among the three without abdominal pain was one who was comatose on admission. Accordingly, although in the context of diabetic ketoacidosis and abdominal pain the presence of “pancreatitis levels” of serum amylase does not necessarily signify acute pancreatitis,2 it is nevertheless also true that unequivocal acute pancreatitis can be associated with diabetic ketoacidosis,3 the latter being either a complication or a coincidence. Either way, this is an association which has to be acknowledged rather than ignored, given the prevalence of the association (11% of 100 consecutive cases),3 the potential lethality of either of the two disorders, and the fact that, at least one of the complications of diabetic ketoacidosis, namely, acute respiratory distress syndrome,4 can be identical in its presentation with its counterpart in acute pancreatitis.5
Conflict of interest: None declared.
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