A 54-year-old man comes to the office after a year of progressive fatigue and frequent loose stools. He describes voluminous, foul-smelling stools that float and are difficult to flush. The patient has lost about 9 kg (20 lbs) in the past 6 months. He was hospitalized on multiple occasions several years ago for epigastric pain radiating to the back, nausea, and vomiting. Lately, the patient has had intermittent episodes of similar pain lasting for 15-30 minutes after meals. He has had no hematemesis, hematochezia, or melena. The patient stopped drinking alcohol several years ago and does not use tobacco or recreational drugs. Temperature is 37 C (98.6 F), blood pressure is 118/80 mm Hg, and pulse is 78/min. BMI is 19.5 kg/m². Abdominal examination shows epigastric tenderness on deep palpation. Bowel sounds are normal. Which of the following is most likely to improve this patient's symptoms?

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11ec25c8_d819_f7d6_bc81_095f1936c768_MD0003_00 This patient's presentation of weight loss and loose, greasy, malodorous stools that float in the toilet and are difficult to flush is consistent with fat malabsorption (steatorrhea), which can be caused by various conditions. This patient's steatorrhea is most likely due to chronic pancreatitis related to long-standing alcohol abuse. His previous hospitalizations for vomiting and epigastric pain that radiates to the back raise suspicion for recurrent episodes of acute alcoholic pancreatitis. Repeated pancreatic injury causes progressive inflammation and fibrosis and results in impaired endocrine and exocrine (loss of digestive enzymes) functions. Patients with chronic pancreatitis may initially be asymptomatic, but disease progression ultimately leads to malabsorption, steatorrhea, and postprandial epigastric pain that can become continuous. Symptomatic improvement can be achieved with alcohol cessation and pancreatic enzyme supplementation. (Choice A) Antimicrobial therapy (eg, rifaximin) should be considered in patients with small intestinal bacterial overgrowth syndrome, which can present with abdominal pain/bloating and symptoms of malabsorption. However, this condition is typically associated with anatomical abnormalities (eg, surgical blind loop) or motility disorders (eg, scleroderma) of the gastrointestinal tract. (Choice B) Cholecystectomy and stone removal should be considered in patients with biliary colic, which typically presents with postprandial right upper quadrant/epigastric pain associated with nausea/vomiting. Steatorrhea and malabsorption are not characteristic. (Choice C) A gluten-free diet is appropriate for individuals with celiac disease, which can present with diarrhea, malabsorption, and nutritional deficiencies. However, this patient's history of alcohol use and epigastric abdominal pain that radiates to the back is more consistent with chronic pancreatitis. (Choice D) Helicobacter pylori infection is a common cause of peptic ulcer disease, which can present with postprandial epigastric pain, nausea/vomiting, and weight loss due to food aversion. However, peptic ulcer disease does not usually cause steatorrhea. (Choice E) Mesenteric angioplasty should be considered in patients with chronic mesenteric ischemia, which can present with postprandial abdominal pain (intestinal angina) and weight loss due to food aversion. However, steatorrhea is not characteristic. (Choice G) Restriction of dairy products may be considered in patients with lactose intolerance, which typically presents with abdominal pain/cramping, bloating, flatulence, and frothy/watery diarrhea after dairy product consumption. However, steatorrhea and malabsorption are not characteristic. Educational objective: Steatorrhea occurs due to fat malabsorption and generally presents with voluminous, greasy, and foul-smelling stools that are difficult to flush. It is commonly caused by pancreatic exocrine insufficiency (loss of digestive enzymes) in patients with chronic alcoholic pancreatitis. Alcohol cessation and pancreatic enzyme supplementation can improve symptoms in such patients. References: Chronic pancreatitis. (http://www.ncbi.nlm.nih.gov/pubmed/21397320) Diagnosis and treatment of pancreatic exocrine insufficiency. (http://www.ncbi.nlm.nih.gov/pubmed/24259956)

A 54-Year-Old Man Comes to the Office After a Year