A 43-year-old man comes to the office due to a 6-month history of intermittent upper abdominal pain associated with nausea. The patient describes episodes of dull epigastric pain that are usually worse 15-30 minutes after meals and last for a few hours. Pain is not relieved with antacids but improves when leaning forward. He also has had occasional diarrhea. The patient has lost 6.8 kg (15 lb) over the last 12 months. Five years ago, he was hospitalized for 3 days with acute abdominal pain. He has no other medical problems and takes no medications. The patient smokes a pack of cigarettes a day and consumes alcohol almost daily. His family history is significant for diabetes mellitus in his mother and prostate cancer in his father. Which of the following will most likely indicate a diagnosis for this patient's condition?

Question

A 43-year-old man comes to the office due to a 6-month history of intermittent upper abdominal pain associated with nausea.  The patient describes episodes of dull epigastric pain that are usually worse 15-30 minutes after meals and last for a few hours.  Pain is not relieved with antacids but improves when leaning forward.  He also has had occasional diarrhea.  The patient has lost 6.8 kg (15 lb) over the last 12 months.  Five years ago, he was hospitalized for 3 days with acute abdominal pain.  He has no other medical problems and takes no medications.  The patient smokes a pack of cigarettes a day and consumes alcohol almost daily.  His family history is significant for diabetes mellitus in his mother and prostate cancer in his father.  Which of the following will most likely indicate a diagnosis for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d3df_5ba6_bc81_bd409f8d05bf_MD0003_00 This patient's presentation suggests chronic pancreatitis (CP), most commonly due to chronic alcohol consumption (including prolonged use of socially acceptable amounts). CP typically presents with chronic epigastric abdominal pain that can radiate to the back and is partially relieved by sitting upright or leaning forward. Patients can have intermittent pain-free intervals lasting from months to a year. Early CP can present with acute attacks that become continuous as the condition progressively worsens. Patients with CP develop progressive pancreatic inflammation that causes nonreversible exocrine and endocrine functional damage. Diarrhea, steatorrhea, and weight loss can develop due to fat malabsorption from reduced levels of exocrine pancreatic enzymes (eg, amylase, protease, lipase). CP eventually causes pancreatic endocrine failure with glucose intolerance or overt diabetes. Pancreatic calcifications seen on abdominal plain films or CT scan are helpful for establishing the diagnosis. In addition, CT scan helps exclude other etiologies (eg, pancreatic cancer, pseudocyst). Pancreatic calcifications (Choice A) Anti-tissue transglutaminase antibodies are typically positive in celiac disease, which can cause iron deficiency anemia, steatorrhea, and weight loss. However, celiac disease typically causes minor gastrointestinal (GI) symptoms; significant abdominal pain relieved by position change is extremely unlikely. (Choice B) Serum cancer-associated antigen (CA) 19-9 levels are elevated in pancreatic cancer, which usually presents with abdominal pain, weight loss, and jaundice. However, CA 19-9 levels should not be used to diagnose suspected pancreatic cancer (due to limited sensitivity and specificity). Abdominal CT scan is usually the first step. (Choice D) Mesenteric angiogram can diagnose chronic mesenteric ischemia, which can present with dull abdominal pain (usually after eating) and unintentional weight loss due to avoidance of food. Diarrhea and improvement in pain with position changes are uncommon. (Choice E) In contrast to widespread inflammation in acute pancreatitis, CP causes patchy inflammation and fibrosis (burned-out pancreas) and can present with normal or only slightly elevated serum amylase and lipase. Abdominal imaging showing pancreatic calcifications is the best way to confirm CP. (Choice F) Upper GI endoscopy is indicated for suspected peptic ulcer disease, gastritis, dysphagia, or hematemesis. The diagnosis of CP can often be made without invasive/endoscopic studies. Educational objective: Chronic pancreatitis is a progressive inflammatory disorder of the pancreas characterized by recurrent bouts of upper abdominal pain, diarrhea/steatorrhea, and weight loss. Diagnosis is established by the presence of pancreatic calcifications on CT scan or plain film. References: Chronic pancreatitis: a diagnostic dilemma. (http://www.ncbi.nlm.nih.gov/pubmed/26900292)

A 43-Year-Old Man Comes to the Office Due to a 6-Month