Elevated Lipase Case

[Guest Paula]

What would you do in this case?

 

20yo female, G1 P1 (child is one year old) presents to me with 1 year history of RUQ pain. It is intermittent. She had symptoms of mild occasional acid reflux, not worsened by food or beverages. Very rare alcohol intake. Nonsmoker. No nausea, vomiting, diarrhea, change in bowel/bladder habits, no dysuria, no hematochezia/melena. She stated it started soon after baby was born. She is on birth control patch. Generally healthy looking young lady, normal BMI.

 

Labs: H. pylori - negative. CBC - normal. CMP - mildly elevated lipase - 201. AST/ALT/Alk Phos - normal. Glucose - normal. Bili-normal. U/A - normal.

 

On exam: Mild RUQ tenderness. No hepatomegaly. I ordered RUQ ultrasound for gallbladder/pancreas/liver. Normal.

 

I started her on omeprazole with some improvement in symptoms. She has not returned for a repeat lipase.

 

My thought is the mildly elevated lipase is due to her birth control patch. I plan on first repeating lipase, then if still elevate, take her off the patch and repeat the lipase in 2 weeks (and hope she uses other birth control methods in the meantime). If lipase is normal, will consider starting her on depo-provera birth control.

 

Any thoughts?

 

P.S. She is livid that she now has a bill for the ultrasound. She thought it would be free since it was performed on-site at our tribal clinic and she is native american. Her insurance covers only reproductive/female issues, (medicaid0. I was not aware of what her insurance covered.

 

This begs the next question: Is it my responsibility to make sure each patient's insurance covers any tests I order? I say no. It is the patient's responsibility. I will have to incorporate the speech into my counseling that the patient must get their own approval for the test from their insurance company and then they can decline the test.

 

Part of this case involves CYA......

[Guest Paula]

P.S. Maybe there is no reason to jump through hoops to chase down a mildly elevated lipase? I am researching that question.......are there incidences of lipase elevation that do not need any further workup? I did review the case with my physician partner. He was in agreement of what I did and did not know some birth control options can cause an elevation of lipase. I didn't either until I looked up the patch and there is was on the side effects profile.

[rcdavis]

I think you are on the right track

The lipase, as are all labs, is only a small part of the whole picture, and needs to be evaluated as to whether it reflects a primary cause of her complaint, or is totally unassociated ( true true and associated.. True true and not associated).

 

Back to basics. The chief complaint. She appears to have a nebulous ruq ache which is non specific. In approaching the complaint you appropriately ruled out issues causing hepatocellular injury. You have also considered a pancreatic etio, which still may ge on the differential because of the lipase. You have thought about an inflammation of the stomach and duodenal tract by starting a poi, with some improvement.

You have investigated any solid or cystic masses in the area as a cause by the ( absolutely necessary) ultrasound.

 

All good.

 

Now the question is several fold.

 

1. What to do now?

 

A. Careful watching, seeing if the symptoms continue to improve with the and watching the lipase trend.

 

B. stopping the mini pill ( there does seem to be more side effects to these Meds than previously thought..I had a patient just recently who developed an FUO in concert with starting the pill) with the post that the pancreatic inflammation is due to that

 

C. Continuing the evaluation. Specifically setting up for an endoscopy/ercp to specifically Evaluate the gastric lining and outlet channel, the sphincters of odi and wirsund as a cause of her primary problem: the ruq ache. ( I would opt to do this if she did not completely improve, with normal labs, in 4 weeks of the ppi)

 

 

2. Whether or not is your responsibility to check insurance acceptability for studies you need.

This is the universal pain in the a$$ of practice.. Precertification of studies/labs in non-emergent patients. Usually the receiving study provider ( MRI, CT scan, ultrasound) has a listing of which insurance requires precertification and which does not. Unfortunately, you did the ultrasound in a clinic which did not check, and the patient is not happy.

Excluding the attitude that she has that everything done for her must be free, I guess the majority of practicing clinicians today would say that it is OUR Responsibility to determine what the insurance will, or will not, authorize. Many times the insurance companies will only authorize studies if done or ordered by a specialist. I think in the future, you should have your nurse call the insurance company and "precert" before progressing.

Which takes a monumental amount of time ( one time in a clinic I waited for 24 hours to get approval of a abdominal CT scan.. Which was DISAPPROVED, but didn't matter as the patient went to ED, had it done and had her appendix removed before I got the final response from the insurance company.

 

In summary I would watch for 2-4 weeks.

I would NOT take off pill until and unless lipase remains elevated at tat time..but would keep taking her off it high in my mind.

I would continue the ppi.

I would re-eval in 4 weeks.. If still symptomatic, I would both stop the mini pill, and set up for endoscopy/ERCP.

If no longer symptomatic, I would continue ppi for total 8-12 weeks, the stop the ppi, and see what happens. If sx return... Endoscopy

 

Maybe I would have a conversation with the patient and tell her your thinking process. Tell her you will check with her insurance company in the future. But emphasize that simetimes these tests HAVE to be done, and that not doing them can put her at risk for missing a serious problem.

 

Helpful?

[Guest Paula]

Helpful. Thanks. I do not have a specific nurse working with me but will ask the other two nurses working in the clinic to check. They are getting tired of checking everyone's insurance for outside orders. Part of the problem with the insurance issue is that typically any procedure, lab, or test that is done in the clinic is covered by Indian Health Service if the patient has no other insurance, and all co-pays, deductibles, etc are paid by IHS for those with insurance. The ultrasound capability is new to our clinic, and is contracted from a near-by hospital. THe tech comes twice monthly and the hospital has provided their old machine. My mistake was in assuming that IHS would pick up the payment since this was done "in-house". So, my bad and the administration here needs to notify us of these important issues, and I shouldn't have assumed!!!

 

Thanks for your input. I'm on vacation now and will be following up with the patient when I return, I'll post what happened when it's all said and done.

[bradtPA]

Difficult without insurance to run a HIDA scan but I have seen a lot of these cases come back with biliary hypokinesia....

[winterallsummer]

RUQ pain and lipase seems to more than justify the US even if her insurance doesn't cover.

[rcdavis]

RUQ pain and lipase seems to more than justify the US even if her insurance doesn't cover.

 

Which raises the question for comments:

 

In urgent care, general internal medicine, and family practice the problem of precertification is continuous. And often interfers with how we practice

 

YOU think the patient needs a study. The patient agrees.. sorta ..."only if my insurance will pay for it".. and the high school graduate answering the insurance company's phone notes that, by his algorfythm, the study is not warranted.

 

which means you now have to get involved.. in the process called "peer to peer", where in, after waiting for 10-30 minutes for the "peer" (usually a nurse) to pick up and "discuss " the case, the study may or may not be approved (in fairness.. if is reasonable, usually at this point, it is approved)..

 

So, you are taken away from the practice for 10-30 minutes while on hold (cuz, if the doc or the nurse DO pick up and you are not there, they move along, and you get to startall over again).

 

This time is non -compensatable, at least for now.. you cannot charge the patient for this.. and you have lost the revenue you might have generated if you were able to work.

 

 

raises several comments/questions:

 

-- As part of our daily practice, we have to learn how to carefully encourage the patient to get studies which we believe are necessary... and we have to learn how to practice "around" their declination of the studies...

We have to practice sometimes without the studies we need

 

- which means that we need to super document the patients refusal of the study, and reiterate the need for the study and re-document the declination at every visit, so as to avoid the inevitable patient or family saying(when the gallbladder has become gangrenous) "oh, I didn't think you REALLY wanted me to have the test," or " you didn't tell me that the test was THAT important"

 

--- and also means that there is a much higher level of shared accountability in taking care of the patient (something I am not used to ... even yet)

 

--- and means that there will be times that you THINK you know what is going on, but cannot prove it, and you will need to refer to a high level of specialty for care sooner than you would have otherwise, simply because you cannot adequately "work the patient up".

 

In these practices, I have found it helpful to try and risk stratify the need for a test:

 

Is the test necessary to make the diagnosis (am I using the test for confirmation of what I more than likely really "know " is wrong with the patient? or am I using the test to make the diagnosis, because I do not know what is wrong?)

 

Can I proceed safely without the test?

 

How will the test results influence my decisions? (eg, will I "believe" the test) (Bayes theorem)

 

If the test results will not influence my decisions about treatment, then, do I really need the test?

 

If I am "hunting", (eg am not sure what is wrong, and am using the test as an investigative tool), do I really need the test? And is the patient better served simply trying to localize the appropriate organ system and referring to that specialist?

 

And If I need the test, and the insurance company adamantly refuses it.. do I proceed with the test anyway?

 

All of this really comes into play, for example, with the issue of kids and acute abdominal pain. A kid with nausea, vomiting, right lower quadrant pain MAY WELL have an acute appy.. may also have gastritis, constipation, uti, stone, intessesepction, etc.

 

You want a CT.. radiology and the insurance company do not want to "unnecessarily irradiate the kid".

 

What now?

 

Consult? Observe? Refer? treat with abx? Is the kid "really" sick, or just uncomfortable? Parents may not want expense of CT or surgeon unless you REALLY need it.. Will you believe the appendicitis centered Ultrasound (porposed by rads) if negative?

 

ohh pooh.

 

but wait: with Obama care the PARB will soon be making these decisions for us ( at least as far as medicare goes).. ahhh. problem solved. there will be no appealing those rulings.. oops, sorry, wrong thread..

 

back to original comments.. yes, the symptoms do make the study reasonable.. but, was it necessary?

 

could paula have proceeded with a PPI and observation for a couple of weeks (as long as the patient did not become progressively sicker)?

 

hmmmm.

[bradtPA]

RUQ pain and lipase seems to more than justify the US even if her insurance doesn't cover.

Convincing the person to spend $250 on an ultrasound can be tough in this situation. What comes first, rent, food, or ultrasound? I face this daily with my Hispanic population who are making $8 an hour gutting hogs or turkeys and have no insurance.....

[Guest Paula]

Back to my patient....the cost of the test was $1000.00 I was shocked that it was that much. Apparently the tribe is picking up the tab...and just this week the council told us they are out of money in three weeks and may not make payroll...... oops.....off topic again. I cannot track down the patient. I sent her a letter to come in for a repeat lipase test. Her first one was actually 401 not 201 as I originally posted from memory......(which obviously was not working well and makes me wonder if I'm getting too old:=-0: for this stuff!). So the patients phone is not set up for voice mail. She won't answer texts from the healthy start program she is in. I am assuming she feels good and doesn't want to come in.

 

I probably could have waited a few weeks with the patient on the PPI. When she runs out of medicine and needs a refill she will be sure to call me hahaha.

 

I am re-registering with the locum company I worked for in urgent care/em just in case the tribe really runs out of money and then I have no income. It is the hazard of working for tribal.

 

Still an interesting job, though.