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

Sarah El-Nakeep, MD


November 09, 2022

After the infection resolved, the gastroenterologist prescribed vitamin supplements and supplementary pancreatic enzymes to avoid malnutrition in the patient and to decrease his abdominal pain and steatorrhea. However, residual abdominal pain remained despite the enzymatic supplementation. A Cochrane review of the effect of enzymatic supplementation on relieving abdominal pain found that enteric-coated enzymes did not affect the daily pain score compared with placebo, whereas non–enteric-coated pancreatic enzymes improved the abdominal pain, with a very low certainty of evidence.[17,18]

Pancreatic enzyme replacement therapy (PERT) includes lipase, protease, and amylase. When a patient develops symptoms (as in this case), PERT is started at doses that range from 70,000 to 100,000 units of lipase per meal. In this dosage range, PERT can alleviate steatorrhea and prevent malnutrition.[19]

Pancreatic vitamin supplementation includes vitamins D, E, and A. The efficacy of vitamin K supplements is debatable, and higher doses of vitamin K may be needed to achieve normal levels.[20] Overall, the efficacy of calcium, vitamin, and antioxidant supplements remains unknown.[21]

Because patients are at increased risk for fractures, dual-energy radiographic absorptiometry is recommended every 1-2 years in addition to calcium and vitamin D supplementation.[19] Regular monitoring of albumin and vitamin D levels and the INR is required to assess the progress of the patient's condition.

The patient in this case is at high risk for infections and cardiovascular disease. Thus, close follow-up to monitor him for any signs of infection, ischemic heart disease, or stroke is mandatory. Education of patients about the first signs of these illnesses, as well as rapid access to a healthcare emergency facility, is highly important and could save their lives.

Patients with chronic pancreatitis, especially those with hereditary pancreatitis, are at an increased risk for pancreatic cancer, with an estimated rate of 3.6%.[22] Therefore, the patient should have a carbohydrate antigen 19-9 test. In addition, endoscopic ultrasound and/or an MRI is recommended every year until a lesion is detected in the pancreas. These screening tests are superior to a CT of the abdomen with contrast and are also not associated with radiation hazard.

The cumulative 5-year survival in patients with chronic pancreatitis is 59%, whereas the cumulative 3-year survival is 80%.[22]


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