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Severe acute pancreatitis: case report A 21-year-old man developed severe acute pancreatitis during treatment with valproic acid for epilepsy. The man had developed suppurative meningitis at the age of one month, followed by hydrocephalus and cerebral palsy accompanied by epilepsy as sequelae. A ventriculo-peritoneal shunt was placed for hydrocephalus. At the age of 11 years, he had undergone laparoscopic fundoplication for gastroesophageal reflux disease (GERD). At the age of 18 years, he had undergone gastrostomy and bilateral orchiopexy. At presentation at the age of 21 years, he had been receiving valproic acid 8.6 mg/kg/day for epilepsy [route not stated] along with lamotrigine. He needed total assistance in the activities of daily living. A semi-digestible nutritional formula three times a day was started. He was referred to gastrointestinal surgery department. At the time of admission, BP was 156/73mm Hg; pulse was 84 bpm and body temperature was 38.6°C. Additionally, contracture of the limbs and severe scoliosis were also noted. He had distended abdomen and tympanitic sounds. Gastrostomy was noted in the left upper quadrant. Haematological-biochemical examination exhibited an inflammatory response with a WBC count of 15 060 cells/µL and CRP of 27.6 mg/dL, which caused fever. He had amylase level of 233 IU/L. An abdominal radiography showed intestinal dilation in the upper abdomen and gas retention. Also, displaced and dilated large intestine at the splenic flexure was noted. Abdominal and pelvic CT scan exhibited pancreatic enlargement from the body to the tail. Increased intensity in the surrounding adipose tissue up to the inferior pole of the left kidney was noted, without obvious poor contrast enhancement of the pancreatic body. Barium enema study showed narrowing of the intestinal tract, which was thought to be the cause of obstruction. Under the Japanese Ministry of Health, Labour, and Welfare Acute Pancreatitis Severity Criteria, his prognostic score was two points, and the CT grade was three. Based on these findings, severe acute pancreatitis was diagnosed [time to reaction onset not stated]. The man was put on fasting. Fluid replacement, unspecified antibiotics and protease inhibitors were started. Continuous hemodiafiltration was performed to decrease cytokine levels. As the possibility of drug-induced pancreatitis secondary to valproic acid could not be ruled out, valproic acid was stopped and levetiracetam was initiated. On hospital day 2, abdominal CT scan showed an increase in the adipose tissue intensity around the pancreas and necrosis in the pancreatic tail was suspected. Worsening of pancreatitis was determined, and unspecified antibiotics and protease inhibitors were promptly initiated. Additionally, narrowing of the intestinal tract and intestinal dilation from the stomach to the upper jejunum was noted on CT scan. Hence, complicated adhesive intestinal obstruction was suspected. Operative treatment for the adhesive intestinal obstruction was planned following stabilisation of the p