A 54-year-old man comes to the office for evaluation of chronic diarrhea and weight loss. He has had bulky, foul-smelling stools for the past 8 months, which usually occur shortly after eating. There have been no nocturnal bowel movements, and he denies fecal incontinence. The patient also experiences dull, epigastric abdominal pain that is exacerbated by eating and unrelieved by antacids. He drinks 6 or 7 beers a day but denies tobacco or illicit drug use. Vital signs are within normal limits. The abdomen is tender to palpation in the epigastrium without distension, rebound, or guarding. Sudan staining of a fecal specimen is positive, and fecal occult blood testing is negative. Blood testing reveals normal hemoglobin. Which of the following pathophysiologic changes are most likely present in this patient?

Question

A 54-year-old man comes to the office for evaluation of chronic diarrhea and weight loss.  He has had bulky, foul-smelling stools for the past 8 months, which usually occur shortly after eating.  There have been no nocturnal bowel movements, and he denies fecal incontinence.  The patient also experiences dull, epigastric abdominal pain that is exacerbated by eating and unrelieved by antacids.  He drinks 6 or 7 beers a day but denies tobacco or illicit drug use.  Vital signs are within normal limits.  The abdomen is tender to palpation in the epigastrium without distension, rebound, or guarding.  Sudan staining of a fecal specimen is positive, and fecal occult blood testing is negative.  Blood testing reveals normal hemoglobin.  Which of the following pathophysiologic changes are most likely present in this patient?

Quizplus · Accepted Answer

This patient with a history of alcohol use disorder who has chronic epigastric pain, weight loss, and steatorrhea (ie, bulky, fatty stools) likely has chronic pancreatitis, a progressive inflammatory disease that ultimately leads to pancreatic fibrosis. Major risk factors include alcohol abuse, recurrent episodes of acute pancreatitis, and smoking. Patients classically have epigastric pain that worsens with meals; pain is initially intermittent but may become constant in advanced disease. Other signs and symptoms of chronic pancreatitis are due to the following pathophysiologic changes: Elastase is derived from a zymogen produced by pancreatic acinar cells and activated by trypsin in the duodenum; levels correlate with pancreatic exocrine activity. Therefore, low fecal elastase can help diagnose pancreatic insufficiency and supports a diagnosis of chronic pancreatitis. Other useful tests include Sudan staining (which identifies fecal fat) and hemoglobin A1c (which diagnoses diabetes mellitus). (Choice A) Bile acid synthesis, which occurs in the liver, is not affected by chronic pancreatitis. Bile acids are necessary for proper biliary flow; therefore, bile acid synthesis disorders usually present with cholestasis, jaundice, and hepatic failure in neonates. (Choice C) Autoimmune gastritis occurs due to autoantibodies directed at parietal cells and intrinsic factor, resulting in reduced intrinsic factor production. Although patients may have postprandial abdominal pain, they also typically have macrocytic anemia (due to vitamin B₁₂ deficiency). Steatorrhea (due to fat malabsorption) is unexpected. (Choice D) The pancreas normally produces a bicarbonate-rich fluid that neutralizes stomach acid. Chronic pancreatitis results in progressive pancreatic destruction, leading to decreased pancreatic bicarbonate production. (Choice E) Villous atrophy of the small bowel is characteristic of celiac disease. Although patients can have steatorrhea and abdominal pain, celiac disease also usually causes iron deficiency anemia. In addition, chronic pancreatitis is more likely in this patient with heavy alcohol use. Educational objective: Chronic pancreatitis is an inflammatory disorder leading to pancreatic fibrosis and atrophy, resulting in endocrine (ie, insulin) and exocrine (eg, lipase, elastase, amylase, trypsin, chymotrypsin) insufficiencies. Patients typically have postprandial steatorrhea (ie, bulky diarrhea that is difficult to flush) and epigastric pain with meals. Low fecal elastase, positive Sudan staining, and elevated hemoglobin A1c support the diagnosis. __________ References: Chronic pancreatitis: an international draft consensus proposal for a new mechanistic definition. (http://www.ncbi.nlm.nih.gov/pubmed/26924663) Management of chronic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23622138)

A 54-Year-Old Man Comes to the Office for Evaluation of Chronic