6_diabetes and pancreatic disease case study by xuyuzhu


									     Case Study

El Hadidy Mohamad El Hadidy
   Professor of Internal Medicine & Endocrinology
 MIS is a non smoker Egyptian male patient
  66 years old from Mansoura suffered from
  hypertension since 10 years and was well
  controlled on Natrilex SR once daily.
 He developed diabetes mellitus since one
  year and was well controlled on Amaryl 3
  mg once daily.
He presented with gradual loss of weight
 since the appearance of diabetes with loss
 of appetite.
He also had food induced abdominal
 discomfort with all varieties of food.
There was constipation since one year. There
 was no other GIT symptoms.
There was no other symptoms referable to
 other systems.
There was no FH of DM or HTN.
           On examination
The patient appeared cachectic , fully
 conscious, well oriented. Pulse 90/min
 regular, RR 15/min. temp. 37 C, BP 130/75
 mmHg. Height 184 cm, weight 70 kgm.
 There was pallor. There was apparent
 decrease of muscle mass and prominent
 bones of shoulder and pelvic girdles.
 General examination was otherwise
Abdominal examination revealed
Enlarged mildly tender liver with liver span of
 about 16 cm.
There was deep epigastric mass of more or
 less firm consistency with mild tenderness
 over the epigastrium.
There was no other remarkable abdominal
Chest and heart examination revealed
 unremarkable findings.
Clinical impression and DD ??

Ask for investigations?

Radiologic study revealed:
   Spiral triphasic multislice CT
        abdomen revealed:
 Diffusely swollen pancreas with
  heterogeneous hypodensity with areas of
  degeneration and dilated main pancreatic
  duct with encasement of celiac trunk, main
  portal vein, SMV and SMA. Also infiltrating
  the surrounding fat. No calcification.
   Multiple enlarged LNs in porta hepatic,

aortocaval and para aortic regions.
 Dilated CBD 18 mm diameter, common
  pancreatic duct 10mm diameter
 Marked dilataion of intrahepatic biliary
 radicles with gas density inside.
 Enlarged non cirrhotic liver with multiple well
  defined enhancing areas in both lobes. On
  triphasic study they show arterial
  enhancement…..likely cholangitis with
  starting chalngitic abcesses.
 NO ascites.
Ct abdomen
   Laboratory work up revealed:

 Urinalysis : no abnormal findings.
 CBC: Hb 11gm% microcytic hypochromic morphology.
       TLC 23000/cmm ( N 49%, E 3%, B 1%, L 43%
  M2%, Band 2% Platelets 434000/cmm.
 ESR 105/ 130 mm ( 1st/2nd h).
 FBS 116 mg %
 SGOT, SGPT : 55u, 47 u/L
 Bilirubin 1.3 mg %
 s. creatinin 1.4 mg %
                 Lab. cont
   Serum Ca : 6.2 mg%
   Serum lipase 91 u/l ( N less than 200 )
   Serum amylase 72 u/l ( N less than 86)
   CEA 0.2 ng/ml ( N lees than 3.4 )
   CA 19.9 27 u/ml (N 0-39 ).
              Cont. lab
 Ig G 1529 mg % ( N 700- 1600 mg
 Ig G4 128 mg% ( 8-140 mg%).%)
 ANA negative.
Diagnosis & management
      strategy ??
The patient was advised to see a surgeon.
But the patient refused any intervention.
The patient was given conservative
   Cefotaxim 2gm\day
   Oral digestive enzymes
   Prednisolone oral 30mg\day
   Alphachemotripsin IM daily
   Premixed insulin MDI
  Response to conservative ttt:
The patient resumed good appetite with no
 more food induced abdominal discomfort.
 He started to gain body weight with fair
 improvement of the general conditions.
The epigastric mass becomes hardly
Abdominal Ct and laboratory work up were
 asked after one month of the conservative
          Follow up Ct Report :
 Large well defined hypodense soft tissue mass
  7x5 cm. with hererogenous enhancement after
  contrast and air density inside. The mass infiltrates
  head and neck of pancreas encasing splenic and
  hepatic arteries without attenuating their lumin.
  Dilated CBD & pancreatic ducts. Evidence of air in
  IHBR ( suggesting fistula formation ). Multiple
  porta hepatic LNs.
 Conclusion : infiltrating mass mostly malignant, for
  further assessment.
Follow up ct abdomen:
Cont.Ct. abdomen follow up:
        Follow up Lab Report:

   TLC 27000/mm with PMN 47%
   s. creatinine 0.9 mg%
   SGPT 29 u/ml
   SGOT 87 u/ml
    S.albumin 3.4 gm%
   S.bilirubin 0.8 mg %
   INR 1.0
       Diagnosis ( suggested ):
 Auto immune pancreatitis ?
 ( inflammatory pseudotumor )
            associated with
Cholangitis with biliary enteric fistula
Abdominal lymphadenopathy
Retroperitoneal fibrosis

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