# Clinical Cases: Pancreatic Disorders

## Case 1: Acute Gallstone Pancreatitis

### Patient Presentation
**Demographics:** 52-year-old female

**Chief Complaint:** Severe epigastric pain radiating to the back for 12 hours

**History of Present Illness:** The patient developed severe, constant epigastric pain after eating dinner last night. The pain is "boring" in quality and radiates straight through to her back. She reports that leaning forward provides some relief. She has had multiple episodes of nausea and vomiting. She notes that she has had similar but milder episodes of right upper quadrant pain after fatty meals over the past year that typically resolved within a few hours.

**Past Medical History:** Obesity, hyperlipidemia, type 2 diabetes mellitus, known gallstones (found incidentally 2 years ago)

**Social History:** Non-smoker, occasional alcohol (1-2 glasses of wine weekly)

### Physical Examination
- **Vital Signs:** Temperature 38.2C, BP 105/68 mmHg, HR 108 bpm, RR 20/min
- **General:** Uncomfortable female lying still, appears distressed
- **Abdomen:** Significant epigastric tenderness with voluntary guarding; no rebound tenderness; hypoactive bowel sounds; no palpable masses

### Workup and Results
- **CBC:** WBC 15,200 with 82% neutrophils
- **BMP:** Glucose 245 mg/dL, BUN 28 mg/dL, Creatinine 1.2 mg/dL
- **Liver Function Tests:** AST 186 U/L, ALT 312 U/L (elevated, suggesting biliary etiology), ALP 185 U/L, Total bilirubin 2.8 mg/dL
- **Lipase:** 1,842 U/L (greater than 3x upper limit of normal)
- **Triglycerides:** 180 mg/dL (normal)
- **Right Upper Quadrant Ultrasound:** Multiple gallstones; gallbladder wall thickening; common bile duct 8 mm (mildly dilated); no definite choledocholithiasis visualized
- **CT Abdomen with IV Contrast (obtained at 72 hours):** Diffuse pancreatic enlargement with peripancreatic fat stranding and small peripancreatic fluid collection; pancreas enhances uniformly without evidence of necrosis

![Autoimmune Pancreatitis CT](case_01_image.jpg)
*CT scan demonstrating diffuse pancreatic enlargement with loss of normal lobular contour ("sausage pancreas" appearance), consistent with pancreatic inflammation. While this particular image shows autoimmune pancreatitis, similar diffuse enlargement can be seen in acute pancreatitis of various etiologies.*

**Image Source:** Wikimedia Commons. Hellerhoff, CC BY-SA 3.0

### Diagnosis
**Acute Gallstone Pancreatitis - Mild (Revised Atlanta Classification)**

### Clinical Correlation
This case illustrates classic gallstone pancreatitis, the most common cause of acute pancreatitis (40% of cases). The diagnosis is established when two of three criteria are met: (1) characteristic epigastric pain radiating to the back, (2) serum lipase greater than 3 times the upper limit of normal, and (3) characteristic imaging findings. This patient meets all three criteria.

Several features point to gallstones as the etiology: the classic "4 F's" risk factors (Female, Forty-plus, Fertile, Fat), known cholelithiasis, and elevated ALT (an ALT greater than 3 times normal has a positive predictive value exceeding 85% for gallstone pancreatitis). The mechanism involves transient obstruction of the pancreatic duct at the ampulla of Vater by a passing stone, causing premature activation of pancreatic enzymes and autodigestion.

The BISAP score helps risk-stratify patients at presentation: BUN > 25 (present), Impaired mental status (absent), SIRS criteria (present - fever, tachycardia, tachypnea), Age > 60 (absent), Pleural effusion (absent). This patient's BISAP score of 2 indicates moderate risk.

### Treatment
- NPO initially; early enteral nutrition when pain improves (within 24-48 hours)
- IV fluid resuscitation with Lactated Ringer's (250-500 mL/hour initially), goal-directed to urine output 0.5-1 mL/kg/hour
- Pain management with IV opioids (morphine or hydromorphone)
- **No prophylactic antibiotics** - sterile necrosis does not benefit from antibiotics
- MRCP or endoscopic ultrasound to evaluate for retained CBD stones given elevated liver enzymes
- **Cholecystectomy during the same admission** (after clinical improvement) to prevent recurrent pancreatitis
- ERCP only if concurrent cholangitis or persistent biliary obstruction

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## Case 2: Chronic Pancreatitis with Exocrine Insufficiency

### Patient Presentation
**Demographics:** 48-year-old male

**Chief Complaint:** Chronic abdominal pain, weight loss, and greasy stools for 6 months

**History of Present Illness:** The patient has a long history of recurrent episodes of epigastric pain requiring hospitalization, diagnosed as acute pancreatitis. Over the past 6 months, he has developed persistent, gnawing epigastric pain that worsens after eating. He reports unintentional weight loss of 25 pounds despite maintaining appetite. He describes his stools as loose, foul-smelling, greasy, pale, and difficult to flush. He has also developed new-onset diabetes requiring insulin therapy 3 months ago.

**Past Medical History:** Multiple hospitalizations for acute pancreatitis (5 episodes over 10 years), new-onset diabetes mellitus, hypertension

**Social History:** 30-year history of heavy alcohol use (8-10 beers daily); quit alcohol 6 months ago; 1 pack-per-day smoker for 25 years

### Physical Examination
- **Vital Signs:** Temperature 36.8C, BP 118/72 mmHg, HR 78 bpm
- **General:** Thin, cachectic male appearing older than stated age
- **Abdomen:** Epigastric tenderness without peritoneal signs; no organomegaly
- **Extremities:** Thin muscle bulk, no edema

### Workup and Results
- **CBC:** Hemoglobin 10.8 g/dL, MCV 102 fL (macrocytic anemia)
- **BMP:** Glucose 285 mg/dL, normal creatinine
- **Liver Function Tests:** Normal
- **Lipase:** Normal (burned-out gland)
- **HbA1c:** 9.8%
- **Fecal Elastase:** 85 micrograms/g (severely reduced; normal > 200)
- **Fat-Soluble Vitamins:** Vitamin D 12 ng/mL (low), Vitamin A 18 mcg/dL (low)
- **CT Abdomen:** Diffuse pancreatic calcifications throughout the gland; main pancreatic duct dilation (7 mm) with "chain of lakes" appearance; glandular atrophy
- **MRCP:** Dilated main pancreatic duct with strictures and dilations consistent with chronic pancreatitis

### Diagnosis
**Chronic Pancreatitis with Pancreatic Exocrine Insufficiency (TIGAR-O: Toxic-Metabolic - Alcohol)**

### Clinical Correlation
This case demonstrates the progression from recurrent acute alcoholic pancreatitis to chronic pancreatitis with irreversible structural damage. Alcohol accounts for approximately 70% of chronic pancreatitis cases in Western countries. The classic clinical triad includes chronic epigastric pain, steatorrhea (when > 90% of exocrine function is lost), and diabetes mellitus (due to islet cell destruction).

Key diagnostic findings include:
- **Fecal elastase < 200 micrograms/g**: Confirms exocrine insufficiency (< 100 indicates severe insufficiency)
- **Pancreatic calcifications on CT**: Highly specific for chronic pancreatitis
- **Chain of lakes appearance on MRCP**: Alternating strictures and dilations of the main pancreatic duct
- **New-onset "brittle" diabetes**: Results from destruction of both beta cells (insulin deficiency) and alpha cells (glucagon deficiency), causing unpredictable glycemic swings

The "burned-out" gland phenomenon explains the normal lipase: progressive fibrosis destroys acinar cells, reducing enzyme production even during inflammatory episodes.

### Treatment
- **Absolute alcohol abstinence and smoking cessation** - essential to slow progression
- **Pain management**: Start with non-opioids; consider pancreatic enzyme supplementation for pain (may reduce CCK-mediated pancreatic stimulation); avoid opioid dependence
- **Pancreatic Enzyme Replacement Therapy (PERT)**:
  - Starting dose: 40,000-50,000 lipase units with meals, 25,000 with snacks
  - Take at the beginning of or during meals
  - Add PPI to optimize enzyme activity
- **Dietary modifications**: Low-fat diet (< 20 g fat per meal); frequent small meals
- **Fat-soluble vitamin supplementation**: Vitamins A, D, E, K
- **Diabetes management**: Insulin therapy; close monitoring due to brittle nature
- **Endoscopic therapy consideration**: ERCP with dilation and stenting for dominant strictures
- **Surgical consultation**: Lateral pancreaticojejunostomy (Puestow procedure) for dilated duct disease if medical management fails