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500: DIAG-“NA”-STIC HICCUPS OF PANCREATITIS

Introduction: Hiccups, are rarely clinically significant. When persistent, whether asleep or awake, they tend to be associated with more toxic-metabolic causes. Here, we describe a case of persistent hiccups with associated hyponatremia in a case of severe pancreatitis. Description: A 28 year old male with a past medical history of GERD presented with 3 days of persistent hiccups associated with abdominal discomfort and bloating. He reported drinking excessive amounts of fluids, particularly pedialyte, with no solid food ingestion. He presented to the emergency department with marked sinus tachycardia at a rate of 150 bpm, mild renal impairment (creatinine of 1.28 mg/dl) and sodium of 112 mmol/l. Other notable labs included hyperkalemia to 5.4 mmol/L and hypochloremia to 82 mmol/l, hemoglobin of 17.9 g/dl with leukocytosis to 14K/uL. A chest x-ray revealed hypoventilation and opacification of the left lung base. He was admitted to the medical intensive care unit with persistent tachycardia and hypertension. Hiccups were refractory to treatment with compazine and baclofen. His abdominal pain improved after bowel movement but distension persisted. Given concern for abdominal pathology leading to diaphragmatic irritation a CT abdomen and pelvis was ordered which revealed extensive peripancreatic fat stranding, areas of necrosis, portal venous thrombus and small thrombus in the superior mesenteric vein. Lipase was elevated at 332 IU/L. Conservative management was recommended and high intensity heparin was started for venous thrombosis. Hyponatremia, attributed to hypovolemia was slowly corrected with intravenous fluid. He was found to have mild hypertriglyceridemia to 274 mg/dl. His stay was complicated by overcorrection of his sodium, need for DDAVP, and transient confusion. Hiccups eventually improved with baclofen and he was discharged on Eliquis. Discussion: Hiccups are an uncommon presentation of pancreatitis. Our case highlights the importance of considering intraabdominal pathologies causing diaphragmatic irritation when hiccups persist. Hyponatremia is associated with pancreatitis caused by hyperlipidemia. The literature surrounding the association with pancreatitis of other etiologies is sparse. However, extremes of sodium may be associated with increased disease severity.