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44 Chronic Pancreatitis Gaurav Aggarwal and Suresh T. Chari Questions and Answers 1. A 72-year-old gentleman with recently diagnosed chronic pancreatitis comes to establish care with you in the geriatrics clinic. His past medical history is signiﬁcant for heavy alcohol abuse, although he has been abstinent for the last 10 years. He complains of having foul-smelling stools that are difﬁcult to ﬂush. He has lost 5 lb in the last 6 months. He denies abdominal pain, nausea, vomiting, fevers. On examination, he appears well. You decide to order a 72-h fecal fat quantitation to evaluate the patient for steatorrhea. In addition, you tell the patient which of the following: A.“You must fast the night before the test.” B.“You must consume a high protein (2 mg/kg), low fat diet(<20 g/day) the day before the test.” C.“You must consume a high fat diet(100 g/day) the day before the test.” D.“You must consume a high fat diet (100 g/day) for 2 days before the test and for the 3 days you will collect stools.” E.“No dietary changes are necessary for this test.” Answer: D. Patients undergoing a stool fat quantitation must be counseled about consuming a high fat (100 g/day) diet for 2 days before beginning the collection for the test. In healthy adults, daily fat excretion is <7 g even if fat intake is increased to 100–125 g/day. In individuals with malabsorption, false negative results can be seen if this instruction is not followed. A 72-h collection is preferred because it reduces variability. Enemas and laxatives (especially mineral oil) can increase stool fat and should be avoided during the collection. Metamucil, barium, and alcohol can all affect test results and need be avoided. While interpreting the results of the test, it is important to bear in mind that fecal fat excretion can be increased (up to 14 g/day) in diarrhea, in the absence of fat malabsorption. Thus, a modest increase in fecal fat excretion in a patient with diarrhea does not necessarily indicate malabsorption as the primary cause and other tests should be performed to identify the cause of the diarrhea. Patients with pancreatic steatorrhea usually have more than 20 g/day. 2. A 64-year-old lady with a history of idiopathic chronic pancreatitis returns for a follow up visit. She denies abdominal pain, weight loss or steatorrhea. She is taking enteric-coated lipase 30,000 IU with each meal. She does not smoke cigarettes or drink alcohol. You decide to make no changes to her medical regimen since she is doing well. As you are leaving the room, her granddaughter who is a medical student points out that she has recently learned that patients with chronic pancreatitis are at increased risk of pancreatic cancer. She wonders what they should do to ensure that her grandmother does not have cancer. Which of the following do you recommend for surveillance? A.Pancreas protocol CT scan. B.Endoscopic ultrasound. C.Reassurance, no further testing at this time. D.Increase pancreatic enzyme dose to reduce risk of cancer. Answer: C. While pancreatic cancer can mimic chronic pancreatitis, the presence of chronic pancreatitis is an established risk factor for the development of pancreatic cancer. The risk increases with increasing duration of disease from an estimated 2% at 10 years to 4% at 20 years. There is no evidence to suggest that increasing pancreatic enzyme dosage has an impact on the risk of malignancy. Current guidelines do not recommend surveillance for pancreatic cancer in patients with chronic pancreatitis, in the absence of clinical symptoms to suggest malignant transformation. Unfortunately, relying on clinical symptoms alone is insufﬁcient since there is an overlap in the presenting symptoms of pancreatic cancer and chronic pancreatitis. Both entities can present with epigastric pain, weight loss C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology, DOI 10.1007/978-1-4419-1623-5_44, © Springer Science+Business Media, LLC 2012 477 478 and jaundice. Findings that should raise concern for pancreatic cancer in a patient with chronic pancreatitis include worsening abdominal pain, older age, ongoing unexplained weight loss, and other constitutional symptoms. CA 19-9 is helpful if elevated, but a normal level does not exclude cancer. A pancreatic duct stricture greater than 10 mm on ERCP should again raise suspicion for malignancy. 3. A 76-year-old gentleman with a history of chronic alcoholic pancreatitis returns to see you in clinic. He is distraught over the fact that he continues to have greasy, foul-smelling diarrhea despite arduously following your instructions regarding a low fat diet, abstinence from alcohol and taking all his medications. You review his medication list and note that at his last visit you prescribed non-enteric-coated lipase 40,000 IU with each meal and Omeprazole 20 mg twice daily. Which of the following is the next best step in the management of the patient? A.Explain that a high dose of lipase can cause diarrhea and recommend reducing the dose to 30,000 IU with each meal. B.Discontinue Omeprazole since it might be causing diarrhea and start Ranitidine 150 mg at bedtime. C.Switch to an enteric-coated formulation of lipase. D.Ask the patient to describe exactly how he takes the lipase in relation to his meals. E.Add medium chain triglycerides (MCTs) to his current regimen. Answer: D. One of the most common causes of failure of pancreatic enzyme replacement in treating steatorrhea is inappropriate use of the medication. While this patient is taking the lipase tablets with each meal, it is important to make sure that he is taking it spread out over the course of the meal, to ensure available enzymes in the duodenal lumen during the course of the meal. Reducing the dose of the lipase would not help and might actually worsen his diarrhea. While Omeprazole can cause diarrhea, it is unlikely to be the case here since the patient had diarrhea before starting the medication. There would be no beneﬁt to switching to ranitidine. Likewise, switching to an enteric-coated formulation would not help in this situation. While MCTs might help with the steatorrhea, they are reserved for patients who lose weight despite using pancreatic enzymes appropriately. 4. A 60-year-old, native American male presents with abdominal pain, nausea, and vomiting for 12 h. The pain is located in the epigastric region and radiates to the back. He has never experienced similar symptoms in the past. His other medical history is signiﬁcant for hyperlipidemia and hypertension. His medications include lovastatin, G. Aggarwal and S.T. Chari aspirin, atenolol, and hydrocholorthiazide. His brother was recently diagnosed with autoimmune pancreatitis (AIP). He does not drink alcohol or smoke tobacco. On exam, he is obese and visibly jaundiced. Laboratory studies show the following (normal values in parentheses): WBC count 15,000/mL (4,000–11,000), Hemoglobin 17 g/dL (12.5–16), ALT 300 IU/L (10–40), AST 246 IU/L (12–42), alkaline phosphatase 210 U/L, total bilirubin 4 mg/dL (0.4–0.7), direct bilirubin 3 mg/dL (0.1–0.4), lipase 400 U/L (20–70), creatinine 2 mg/dl (0.5–1.2), calcium 8.7 mg/dL (8–10), triglycerides 300 mg/dL (<150). Abdominal USG shows a dilated bile duct, peripancreatic edema, and gall stones. Which of the following is the next best step in managing this patient’s acute pancreatitis? A.No further testing necessary, start ﬂuid resuscitation. B.No further testing necessary, start ﬂuid resuscitation and steroids for presumed autoimmune pancreatitis. C.No further testing at present, start ﬂuid resuscitation and check plasma IgG4 level once the patient’s acute pancreatitis resolves. D.Check plasma IgG4 level and start ﬂuid resuscitation. Answer: A Several facts would argue against AIP as an explanation for acute pancreatitis in this patient. Acute pancreatitis is rarely seen in type 1 AIP, the subtype that generally affects older men. In contrast, 20–30% patients with type 2 AIP present with acute pancreatitis but this subtype affects younger patients. AIP is a rare disease when all causes of acute pancreatitis are considered. A rare manifestation of a rare disease would be even unusual. Obstructive jaundice can be a presenting symptom of AIP, however in this gentleman with evidence of gallstones and a dilated bile duct this is likely due to choledocholithiasis. This patient’s presentation is most consistent with gallstone pancreatitis given elevated liver enzymes, dilated bile duct and gallstones on ultrasound. While IgG4 levels can be useful to diagnose AIP, especially type 1 disease, checking an IgG4 level in this patient who likely has gallstone pancreatitis would be inappropriate. 5. A 69-year-old gentleman presents to the clinic with complaints of paraesthesias in both feet. His wife is worried that he might have colon cancer since he has been having frequent “accidents” for the last several months. His stools have a foul odor and are difﬁcult to ﬂush. He has also lost about 10 lb since his last visit 1 year ago. His medical history is signiﬁcant for type 2 diabetes, hypertension, coronary artery bypass grafting, emphysema, peripheral vascular disease, and hyperlipidemia. He denies alcohol use and has smoked 1 pack per day for the last 50 years. On examination, he has impaired perception of vibration and diminished deep tendon reﬂexes. CT scan of the 44 Chronic Pancreatitis abdomen and pelvis shows sigmoid diverticuloses. His last colonoscopy 5 years ago was normal. Which of the following tests is LEAST likely to be useful in evaluating this patient further? A.Methylmalonic acid level. B.Fecal elastase. C.Vitamin E level. D.Upper endoscopy with small bowel aspirate. E.Flexible sigmoidoscopy with random biopsies. Answer: E. This patient likely has late-onset idiopathic chronic pancreatitis based on his age, symptoms of steatorrhea and weight loss. The neurological ﬁndings are likely related to concomitant vitamin B12 deﬁciency since pancreatic secretions are needed for the cleavage of Vitamin B12 from R-factor, so B12 can ultimately be absorbed in the 479 small intestine. Thus, checking a methylmalonic acid level would be useful to determine if this patient has Vitamin B12 deﬁciency. A fecal elastase is useful for the diagnosis of chronic pancreatitis in patients with steatorrhea, which this patient has by history. Patients with steatorrhea are often deﬁcient in fat-soluble vitamins (A, D, E, and K). Steatorrhea and vitamin B12 deﬁciency can also be seen with small bowel pathology. With a history of long-standing diabetes, this patient is at risk of developing bacterial overgrowth which can be assessed with a small bowel aspirate. Flexible sigmoidoscopy with random biopsies is unlikely to be useful for the evaluation of this patient’s symptoms. While colonic pathology that causes diarrhea (e.g., microscopic colitis) could result in increased stool fat loss, it would not explain this patient’s neurologic ﬁndings.