History
A 66-year-old gentleman with good past health presents with a 2-year history of steatorrhoea. He describes loose and foul-smelling stools that are difficult to flush. He also complains of epigastric pain. There is no weight loss. He is a chronic smoker and has drunk up to 5 cans of beer each day for the past 40 years. He is not on any medications. He also denies using over-the-counter drugs.
•Temperature 36.8°C, pulse 72 bpm, BP 133/78mmHg, SaO2 98-100% on RA.
•Hydration satisfactory, alcoholic smell.
•Examination of the hands reveals no clubbing, normal-appearing palmar creases and warm peripheries.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with mild epigastric tenderness. Murphy’s sign is negative.
•No signs of oedema.
Investigations
•CBC:
–WBC 9 x 109/L;
–haemoglobin 13g/dL;
–platelets 304 x 109/L.
•Total bilirubin 12μmol/L.
•ALP 35 IU/L.
•ALT 102 IU/L.
•Albumin 30g/L.
•Amylase normal.
What is your differential diagnosis?
•Chronic pancreatitis.
•Biliary obstruction.
•Peptic ulcer disease.
•Irritable bowel syndrome.
•Small bowel bacterial overgrowth.
•Celiac disease.
What further investigations would you perform?
•Abdominal X-ray.
•CT abdomen with contrast.
•Fasting glucose and HbA1C.
His fasting glucose is 13. A CT of the abdomen with contrast is performed (Figure 33.1).
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Please describe what you see
The pancreas is slightly small in size.
Multiple calcific foci are present in the body and tail of the pancreas (arrows).
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