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

Sarah El-Nakeep, MD


November 09, 2022

In the patient in this case, diverticulosis of the colon was accidentally discovered. Duodenal diverticulum has been associated with recurrent attacks of clinical or subclinical pancreatitis, which could present as chronic pancreatitis.[4,5]

The pancreas, which consists of glandular tissue, has two important functions: endocrine and exocrine. The total weight of the organ is determined mainly by its exocrine portion because it composes 90%-99% of the pancreatic volume. The exocrine part consists of pancreatic acini and ducts.[2]

Pancreatic exocrine insufficiency can be a complication of alcoholic pancreatitis, celiac disease, diverticulosis of the duodenum, type 1 diabetes, or gastrointestinal or pancreatic surgery.[6] Asymptomatic pancreatic insufficiency is termed "subclinical pancreatic insufficiency." However, even in the patient in this case, deficiencies in fat-soluble vitamins and maldigestion of macronutrients could be present.[7] Chronic pancreatitis can present with epigastric pain (80% of cases), diabetes (40% of cases), weight loss, or gastrointestinal symptoms.[8]

Patients with chronic diarrhea tend not to lose weight because they eat more to avoid weight loss. This strategy stabilizes their weight; however, the abdominal pain may increase. Patients with pancreatic insufficiency tend to decrease their intake of food that causes steatorrhea, and their symptoms may improve because of this adjustment.[6] Abdominal pain can decrease with a low-fat diet, but the long-term complications and severity of the chronic pancreatitis are not affected.[9]

Although primary biliary cholangitis is associated with inflammatory bowel disease,[10] the association of diarrhea with fatty meals suggests pancreatic insufficiency. In addition, the fecal calprotectin level is normal, which tends to rule out any inflammatory process as the cause of the chronic diarrhea. The normal antiendomysial antibody IgA level excludes celiac disease. The mild elevation in the INR could be because of obstructive jaundice associated with direct hyperbilirubinemia[11] or the malabsorption of the coagulation factors activated by vitamin K as a result of chronic exocrine insufficiency of the pancreas.

Chronic pancreatitis can cause deficiencies in fat-soluble vitamins, including vitamins A, D, and E. In contrast, iron absorption is increased in patients with chronic pancreatitis.[12] Moreover, the chronic malnutrition and inflammatory state can affect the immune response and increase the risk for cardiovascular disease.[6]

The mild elevation in the amylase and lipase levels reduces the likelihood of acute pancreatitis but could result from the presence of acute cholangitis. The elevated liver enzyme levels are because of the inflammation of the hepatocytes and the acute cholangitis rather than chronic hepatitis. The absent Murphy sign makes the possibility of acute cholecystitis remote.[13]

The fecal elastase 1 is reduced in severe pancreatic exocrine insufficiency cases, not mild or moderate cases. It is commonly used in clinical practice because it is a noninvasive and cost-effective test. The enzyme comprises about 6% of the total secreted pancreatic enzymes.[14] The test differentiates between intestinal and pancreatic malabsorption syndromes (results are normal in intestinal malabsorption).

Other noninvasive tests include the measurement of total fat in stool to detect the amount of undigested fat and the 13C–mixed triglyceride breath test, which assesses the amount of digested fat. Both tests are used mainly after gastroduodenal resection surgeries.[6]

The secretin stimulation test is an invasive test for chronic pancreatitis and is used when the imaging of the pancreas is normal in a patient with suspected chronic pancreatitis (ie, at the early stages of the disease). The test has a negative predictive value of 97%.[15]

Endoscopic ultrasonography is another invasive procedure used in the advanced stages of chronic pancreatitis to detect complications of the disease (eg, malignant transformation, pseudocyst, or abscess formation); however, it is not specific for the early stages of the disease. Endoscopic ultrasonography is considered safer than ERCP.[16]

In this case, the patient's infection resolved with a choledochojejunostomy and meropenem (a carbapenem antibiotic) therapy because there was fear of an anaerobic intra-abdominal infection associated with the ascending cholangitis. The C-reactive protein level decreased, the leukocytosis and fever resolved, and the patient started eating with no vomiting or abdominal pain.


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