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Transcript
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.