Case 33


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.

Physical examination

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.



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).


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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Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 33

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