Case Presentation: The following case describes the excessive use of calcium carbonate (Tums) as a cause of recurrent episodes of pancreatitis. A 39-year-old female presented to the emergency department with severe epigastric pain radiating to her back. The pain was exacerbated by oral intake and was associated with nausea, vomiting, and constipation. Her past medical history includes gastroesophageal reflux disease (GERD), tobacco use and sleeve gastrectomy with cholecystectomy. She had two episodes of acute pancreatitis within the last eight months. Her home medications included Ibuprofen and Tums. She admitted that she was taking up to twelve tablets of Tums per day for the past eight months to alleviate her GERD symptoms. She denied any family history of pancreatitis, cancer, alcohol or drug use. Physical examination was positive for epigastric tenderness. Laboratory findings were pertinent for lipase greater than 3000 U/L and calcium 14.7mg/dl, bicarbonate 32 mmol/L, and elevated creatinine 1.53 mg/dl (from a baseline of 0.8 mg/dl). Further work up revealed low parathyroid hormone and Vitamin D levels. Her bilirubin, liver enzymes and lipid panel were all within normal limits. Computed tomography scan of the abdomen reported pancreatic and peripancreatic edema. She was treated with aggressive hydration and pain medication. She received Calcitonin and Pamidronate to treat her severe hypercalcemia. Over the course of eight days her symptoms resolved.
Discussion: Acute pancreatitis is a significant cause of hospitalization in the United States. Both pancreatic duct and acinar injury ensue from sudden inflammation of the pancreas due to pancreatic enzyme activation. Common etiologies include gallstones, alcohol abuse and hypertriglyceridemia. Infrequently, it has been associated with hypercalcemia and medications. The safety profile of over the counter medicines (OTC) is reassuring, but they are not harmless. Abuse and misuse of OTC medicines can cause adverse clinical outcomes. This patient had hypercalcemia, metabolic alkalosis and acute kidney injury, consistent with Milk-Alkali Syndrome secondary to excessive Tums ingestion. Calcium-containing products are the third leading cause of hypercalcemia, with rare instances linking hypercalcemia to pancreatitis through calcium deposition in the pancreatic duct. Although several studies have reported hypercalcemia as a cause of acute pancreatitis, few cases have reported association between calcium carbonate and pancreatitis.
Conclusions: Heartburn is one of the most common symptoms treated with OTC medications. This delves into a further systemic issue that must be addressed. With the escalating shortage of primary care physicians, an increasing number of patients are resorting to self-treatment using OTC medications. Its use and misuse could lead to life-threatening complications, such as in this case of recurrent hypercalcemia-related pancreatitis. Further emphasis should be given to health care providers to accurately reconcile home medications including OTCs. It is vital to empower patients by educating them on the medications they take, so they know when to seek help when complications arise.