A 68-year-old man comes to the office because of diarrhea for the past 2 months. His stools are postprandial, watery, foul-smelling, and difficult to flush. They never awaken him at night. Prior to this, the patient's stools were always regular and solid. He also has intermittent, epigastric, postprandial abdominal pain that has not improved with a trial of lansoprazole. The patient has no melena, hematochezia, or vomiting, although he has unintentionally lost 7 kg (15.4 lb). Medical history is significant for a prolonged hospitalization 3 years ago for acute necrotizing pancreatitis due to alcohol use. He does not take any medications. The patient smokes a pack of cigarettes daily and occasionally drinks alcohol. Temperature is 37.1 C (98.8 F), blood pressure is 147/82 mm Hg, pulse is 82/min, and respirations are 15/min. Physical examination shows anicteric sclera, moist mucous membranes, and normal heart and lung sounds. The abdomen is mildly tender to palpation in the epigastrium but without distension, rebound, or guarding. Laboratory results are as follows: Which of the following is most likely to be present in this patient?

Question

A 68-year-old man comes to the office because of diarrhea for the past 2 months.  His stools are postprandial, watery, foul-smelling, and difficult to flush.  They never awaken him at night.  Prior to this, the patient's stools were always regular and solid.  He also has intermittent, epigastric, postprandial abdominal pain that has not improved with a trial of lansoprazole.  The patient has no melena, hematochezia, or vomiting, although he has unintentionally lost 7 kg (15.4 lb).  Medical history is significant for a prolonged hospitalization 3 years ago for acute necrotizing pancreatitis due to alcohol use.  He does not take any medications.  The patient smokes a pack of cigarettes daily and occasionally drinks alcohol.  Temperature is 37.1 C (98.8 F), blood pressure is 147/82 mm Hg, pulse is 82/min, and respirations are 15/min.  Physical examination shows anicteric sclera, moist mucous membranes, and normal heart and lung sounds.  The abdomen is mildly tender to palpation in the epigastrium but without distension, rebound, or guarding.  Laboratory results are as follows:  Which of the following is most likely to be present in this patient?

Quizplus · Accepted Answer

11ec25c8_d3df_f7e8_bc81_8525f143b002_MD0003_00 This patient with a history of necrotizing acute pancreatitis has weight loss, abdominal pain, and steatorrhea (characterized by bulky, postprandial diarrhea that is difficult to flush). This presentation suggests chronic pancreatitis, a progressive inflammatory disease that ultimately leads to pancreatic fibrosis. Major risk factors include recurrent episodes of acute pancreatitis, alcohol abuse, smoking, and family history (eg, hereditary pancreatitis). Patients classically have epigastric pain that radiates to the back and worsens with meals; pain is initially intermittent but may become constant in advanced disease. As the disease progresses, destruction of pancreatic islet and acinar cells leads to endocrine (ie, diabetes) and exocrine insufficiency, resulting in protein and fat malabsorption, steatorrhea, weight loss, and fat-soluble vitamin deficiencies. Fecal elastase is a noninvasive test with high sensitivity and specificity for severe pancreatic exocrine insufficiency. Elastase is a proenzyme (zymogen) produced in pancreatic acinar cells and activated by trypsin in the duodenal lumen; low levels indicate severe exocrine insufficiency. An alternate noninvasive test is serum trypsinogen, which would also be low in this setting. Treatment involves pancreatic enzyme replacement, which includes lipase to aid in fat digestion and improve steatorrhea. (Choice A) Lactose intolerance, which can be diagnosed with a lactose breath test, typically leads to bloating and osmotic diarrhea after lactose ingestion (eg, milk) due to carbohydrate malabsorption; fat malabsorption and steatorrhea do not occur. In addition, weight loss is atypical. (Choices C and D) An increase in both fecal calprotectin and fecal leukocytes occurs in patients with inflammatory bowel disease, which causes abdominal pain but is associated with severe, watery diarrhea or hematochezia, not steatorrhea. (Choice E) Tissue transglutaminase antibodies are elevated in celiac disease. Although steatorrhea and weight loss can result from malabsorption in celiac disease, patients typically have iron deficiency anemia and other autoimmune comorbidities (eg, autoimmune thyroiditis). Chronic pancreatitis is more likely in this patient with a history of necrotizing pancreatitis from alcohol abuse. Educational objective: Chronic pancreatitis is a progressive inflammatory disease that leads to pancreatic fibrosis; destruction of pancreatic islet and acinar cells results in endocrine (ie, diabetes) and exocrine insufficiency. Pancreatic exocrine insufficiency is characterized by protein and fat malabsorption, steatorrhea, weight loss, and fat-soluble vitamin deficiencies; low fecal elastase is diagnostic. Treatment involves pancreatic enzyme replacement.

A 68-Year-Old Man Comes to the Office Because of Diarrhea