A 53-year-old man comes to the office due to intermittent abdominal pain for the past 6 months. He describes the pain as sharp, located across his mid-abdomen, and relieved with sitting upright. The patient also describes postprandial bloating and discomfort during these episodes. He has observed that the pain is more noticeable shortly after meals. The painful episodes last minutes to hours at a time and then spontaneously resolve. His symptoms are becoming progressively more severe and frequent, but currently he is not experiencing pain. The patient has frequent large, loose stools that require multiple flushes. He reports being hospitalized multiple times in the past for abdominal pain but does not recall a specific diagnosis, and no records of these hospitalizations are available. The patient has no dysphagia, odynophagia, vomiting, black stools, or blood in the stool. He reports a 6.8-kg (15-lb) weight loss over the last 6 months. The patient drinks 4 or 5 bottles of beer daily and occasionally liquor. He does not smoke or use illicit drugs. Medications include over-the-counter antacids and acetaminophen. Temperature is 36.4 C (97.5 F) , pulse is 86/min, blood pressure is 122/78 mm Hg, and respirations are 12/min. BMI is 21 kg/m². The lungs are clear to auscultation. The abdomen is tender to palpation, but soft and nondistended. There is no rebound tenderness, rigidity, hepatomegaly, or splenomegaly. The remainder of the physical examination is normal. Laboratory results are as follows:

Which of the following tests is most likely to provide the diagnosis?

Question

A 53-year-old man comes to the office due to intermittent abdominal pain for the past 6 months. He describes the pain as sharp, located across his mid-abdomen, and relieved with sitting upright. The patient also describes postprandial bloating and discomfort during these episodes. He has observed that the pain is more noticeable shortly after meals. The painful episodes last minutes to hours at a time and then spontaneously resolve. His symptoms are becoming progressively more severe and frequent, but currently he is not experiencing pain. The patient has frequent large, loose stools that require multiple flushes. He reports being hospitalized multiple times in the past for abdominal pain but does not recall a specific diagnosis, and no records of these hospitalizations are available. The patient has no dysphagia, odynophagia, vomiting, black stools, or blood in the stool. He reports a 6.8-kg (15-lb) weight loss over the last 6 months. The patient drinks 4 or 5 bottles of beer daily and occasionally liquor. He does not smoke or use illicit drugs. Medications include over-the-counter antacids and acetaminophen. Temperature is 36.4 C (97.5 F) , pulse is 86/min, blood pressure is 122/78 mm Hg, and respirations are 12/min. BMI is 21 kg/m². The lungs are clear to auscultation. The abdomen is tender to palpation, but soft and nondistended. There is no rebound tenderness, rigidity, hepatomegaly, or splenomegaly. The remainder of the physical examination is normal. Laboratory results are as follows:

Which of the following tests is most likely to provide the diagnosis?

Quizplus · Accepted Answer

Explanation: This patient's presentation of significant weight loss combined with bulky, foul-smelling stools that are difficult to flush is consistent with fat malabsorption and steatorrhea. Given his history of high daily alcohol intake and multiple hospitalizations for abdominal pain, chronic pancreatitis (CP) is the most likely diagnosis. CP tends to cause epigastric abdominal pain that radiates to the back. The pain may be relieved by sitting up or leaning forward, positions that displace the other abdominal organs away from the inflamed pancreas. CP can be episodic or continuous, and may be exacerbated by meals. Unlike acute pancreatitis, which can be effectively diagnosed in the appropriate setting by elevations in serum lipase or amylase, CP does not regularly result in laboratory abnormalities. Consequently, a magnetic resonance cholangiopancreatography (MRCP) of the abdomen would be the most appropriate test. Pancreatic calcifications are the hallmark of CP. Pancreatic enlargement, ductal dilation, and pseudocysts may also be seen. MRCP has a higher sensitivity and specificity for CP compared to plain radiographs or ultrasound, and is becoming the test of choice for the diagnosis of CP. An abdominal CT scan is an acceptable alternative. Pancreatic calcifications ductal dilation (Choice A) Upper gastrointestinal endoscopy would not evaluate the pancreas unless an endoscopic retrograde cholangiopancreatography was performed as well. Endoscopic retrograde cholangiopancreatography can be used when the diagnosis is unclear after noninvasive imaging or if an intervention is necessary. (Choice B) Voluminous and difficult-to-flush stool is more commonly seen with fat malabsorption and not carbohydrate malabsorption (eg, lactose intolerance). Carbohydrate malabsorption typically causes flatulence and watery diarrhea, and the associated pain is not positional or not severe enough to warrant hospitalization. (Choice D) Celiac disease is an important consideration in patients with malabsorption; however, abdominal pain is usually not a prominent complaint. This patient's alcohol history is more suggestive of CP. (Choice E) Serum amylase and lipase may be mildly elevated in CP but are frequently normal, as the levels of these enzymes are decreased within the scarred, fibrotic pancreas. These studies would be reasonable if acute pancreatitis were suspected, but they lack sensitivity in CP and, consequently, have no role in its diagnosis. Educational objective: Abdominal pain accompanied by fat malabsorption should raise suspicion of chronic pancreatitis, particularly in patients with a history of heavy alcohol intake. The diagnosis can be confirmed with magnetic resonance cholangiopancreatography or an abdominal CT scan, which can identify pathognomonic findings (eg, pancreatic calcifications). References: Chronic pancreatitis: a diagnostic dilemma. (http://www.ncbi.nlm.nih.gov/pubmed/26900292) Chronic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23852141)

A 53-Year-Old Man Comes to the Office Due to Intermittent