Gastro Case Challenge: A Coffee Drinker With Chronic Diarrhea, Epigastric Pain, and Fever

Sarah El-Nakeep, MD


November 09, 2022


The patient started antibiotic treatment (cefoperazone 2 g intravenously every 12 hours) and rehydration to prepare for endoscopic retrograde cholangiopancreatography (ERCP) after his condition stabilized. No radiologic study with contrast, including CT or magnetic resonance cholangiopancreatography, could be performed because of his dehydration, as evidenced by the elevation of the creatinine-to-BUN ratio to more than 1:20 (ie, prerenal disease).

Two days after the patient was admitted to the hospital, the abdominal pain shifted to the left side. He had severe tenderness, guarding, and associated dyspnea with every inspiration.

Once the dehydration resolved, an abdominal CT was performed. Imaging showed a splenic hematoma, with acute splenic vein thrombosis (Figure 7). The pancreas exhibited radiologic signs of chronic pancreatitis: irregular calcifications, loss of normal texture of the pancreas, and dilatation of the pancreatic duct, with no focal lesions.

Figure 7.

Further investigations showed these values:

  • Fecal elastase 1 level: 180 µg/g (reference range, > 200 µg/g)

  • Fecal fat level: 12 g/24 h (reference range, 2-7 g over a 24-hour period)

The patient in this case had chronic fibrotic pancreatitis complicated with acute cholangitis, which must be drained first through choledochojejunostomy combined with pancreaticojejunostomy because he had abdominal pain in addition to the obstructive jaundice symptoms. He also had splenic vein thrombosis and splenic hematoma.[1]

The abnormal texture and calcifications of the pancreas mandate drainage; intravenous antibiotics alone do not resolve the infection. Fibrosis of the pancreatic tissue occurs when the acini are atrophied but the ducts are not affected.[2] ERCP could relieve acute cholangitis alone; however, this patient had chronic pancreatic fibrotic tissue with associated splenic vein thrombosis and thus needed continuous drainage.

In patients who have chronic calcific pancreatitis, occult splenic rupture and hematoma have been reported. It is a rare life-threatening complication. The most common cause is splenic vein thrombosis, and in this patient, the acute sepsis caused by acute ascending cholangitis precipitated the splenic vein thrombosis.[3]

Pancreatic enzyme replacement is mandatory for the treatment of pancreatic insufficiency in this patient to avoid the long-term effects of malnutrition. Cholecystectomy has no role because this is a case of ascending cholangitis and not cholecystitis or gallbladder stone–related obstructive jaundice.


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